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Androgen Deprivation Therapy: A Survival Benefit or Detriment in Men With High-Risk Prostate Cancer?Androgen deprivation therapy (ADT) has been used in the management of prostate cancer for more than four decades. Initially, hormone therapy was given largely for palliation of symptomatic metastases. Following several randomized trials of patients with intermediate- to high-risk prostate cancer that demonstrated improvements in biochemical control and survival with the addition of ADT to external beam radiotherapy, there was a dramatic increase in the use of hormone therapy in the definitive setting. More recently, the safety of ADT has been questioned, as some studies have suggested an association of hormone therapy with increased cardiovascular morbidity and mortality. This is particularly worrisome in light of practice patterns that show ADT use extrapolated to situations for which there has been no proven benefit. In the setting of dose escalation with modern radiotherapy, in conjunction with the latest concerns about cardiovascular morbidity with ADT, the magnitude of expected benefit along with potential risks of ADT use must be carefully considered for each patient.
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Intravenous Itraconazole in the Management of Fungal Infections in Bone Marrow TransplantationThe frequency of major fungal infections continues to increase, whether in association with increasing numbers of patients at risk due to under lying disease or its treatment, selection pressures related to increased use of broad-spectrum antimicrobials
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Plastic Surgery: A Component in the Comprehensive Care of Cancer PatientsPlastic surgery represents a small but critical component of the comprehensive care of cancer patients. Its primary role in the treatment of cancer patients is to extend the ability of other surgeons and specialists to more
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Irradiation in Early-Stage Breast Cancer: Conventional Whole-Breast, Accelerated Partial-Breast, and Accelerated Whole-Breast Strategies ComparedGiven their greater convenience and, in most cases, decreased costs, APBI and AWBI are becoming increasingly popular alternatives to conventional WBI for early-stage breast cancer patients who desire BCT. However, given the protracted time to local recurrence and complications following BCT, definitive results from randomized clinical trials comparing conventional WBI vs AWBI or APBI are limited.
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Translation Requires Evidence: Does Cancer-Specific CGA Lead to Better Care and Outcomes?he field of geriatric assessment is crowded by a variety of assessment domains, a plethora of assessment tools, and research spanning diverse care settings. In their article published in this issue of the journal ONCOLOGY, Schubert, Gross, and Hurria have synthesized the evidence and propose a subset of commonly used functional assessment tools for assessing older adults with cancer.[1]
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The Last-Dose-of-Chemo BluesSome patients go through the end of treatment without a hint of emotional distress. But for many others, ending acute treatment becomes an emotional “pothole” on the cancer journey.
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Psychological Complications of Prostate CancerPirl and Mello carefully review the current state of knowledge about the psychological complications of prostate cancer. Their discussion is worth reading, particularly by those who treat patients with the disease. To put this knowledge in context for the general reader, we should give some thought to what this review illustrates about all patients with a serious life-threatening illness.
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Quality-Adjusted Life-Years, Comparative Effectiveness in Cancer CareRecently, the American Recovery and Reinvestment Act (ARRA) set aside $1.1 billion for comparative effectiveness research (CER) to investigate what healthcare strategies and interventions offer the greatest benefits to individual patients and the population as a whole. The Institute of Medicine has identified CER in cancer care as a high priority research focus for ARRA funding. The ability to measure quality of life will be central to CER in oncology because survival and disease-free survival do not adequately capture outcomes important to policy makers, physicians, and patients. There are two ways to measure quality of life: descriptive health status and patient preference weights (utilities). However, only patient preference weights can be incorporated into the economic analysis of medical resources and be used in the calculation of quality-adjusted life-years (QALYs). Some of the advantages and limitations inherent in measuring quality of life with descriptive health status and patient preference weights are discussed. Both types of measurements face health literacy barriers to their application in underserved populations, an important concern for CER in all medical fields.
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Commentary (Stenson): Indications for Selective Neck Dissection: When, How, and WhySelective neck dissection is a procedure that is primarily indicated in patients with clinically negative nodal disease in which there is a high risk of occult metastases. Others have advocated its use for patients with
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Continuous Low-Dose GM-CSF as Salvage Therapy in Refractory Recurrent Breast or Female Genital Tract CarcinomaGranulocyte-macrophage colony-stimulating factor (GM-CSF,sargramostim [Leukine]) is a powerful cytokine that is able to stimulatethe generation of dendritic cells. Adjuvant treatment with continuous lowdoseGM-CSF has been shown to prolong survival of stage III/IV melanomapatients. Data on continuous low-dose GM-CSF therapy in tumorsother than prostate cancer are still lacking.
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Optimizing the Benefit of CNS Radiation Therapy in the Pediatric Population-PART 1: Understanding and Managing Acute and Late ToxicitiesMinimizing late treatment toxicities in these patients remains an important priority due to both the young age of the patients and the high cure rate that can be achieved.
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Performing Economic Evaluations Alongside of Cancer Clinical TrialsHealth care providers and financing organizations have become more aware of the resource constraints on the provision of medical services, thus increasing the importance of economic evaluations within the health care industry.[1,2] This has carried over to the evaluation of new, therapeutic strategies for cancer, which have traditionally been evaluated exclusively for safety and clinical efficacy.
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The Past, Present, and Future of Melanoma TherapyWe will absolutely need to continue our endeavors to evaluate reliable predictive biomarkers for both targeted drugs and immunotherapeutic agents to achieve a truly personalized melanoma therapy with the maximal clinical benefit.
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Attacking a Moving Target: Understanding Resistance and Managing Progression in EGFR-Positive Lung Cancer Patients Treated With Tyrosine Kinase InhibitorsIn this article, we review the available literature addressing the competing treatment strategies in EGFR-Positive Lung Cancer and attempt to clarify best treatment practices, including the emerging role of T790M-directed therapies.
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Surgical Management of Pancreatic CancerAdenocarcinoma of the pancreas remains a lethal malignancy: The majority of patients with pancreatic cancer continue to present with advanced disease and die within a year of diagnosis. Despite this grim fact, some progress has been made over the past decade, particularly in the surgical management of patients with resectable and advanced disease. This well-constructed review by Drs. Ahrendt and Pitt succinctly details the advances that have been made and highlights many of the unresolved issues.
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The Biodistribution and Pharmacokinetics of Stealth Liposomes in Patients with Solid TumorsLiposomes have been proposed as potential vehicles for drug therapy targeted to solid tumors, in particular, because of the increased permeability of these tumors to macromolecules. The recent development of Stealth
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Anorexia/Cachexia in Patients with HIV: Lessons for the OncologistEarly intervention and attention to nutritional status are essential in patients with cachexia. Identification of reversible causes of decreased energy intake and/or weight loss is the first step in treatment. When such factors
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Docetaxel and Vinorelbine Plus GM-CSF in Malignant MelanomaPatients having locoregional or metastatic melanoma have a poorprognosis, with 50% to 100% of patients dying from the disease within5 years. Current chemotherapy regimens offer limited benefits to thesepatients, and more effective and less toxic treatments are needed. Wetherefore piloted a study of docetaxel (Taxotere), vinorelbine(Navelbine), granulocyte-macrophage colony-stimulating factor(GM-CSF, sargramostim [Leukine]), or the DVS regimen, in patientswith stage IV melanoma. Eight patients were treated after previousbiochemotherapy and two patients were given the regimen as an initialtreatment. The DVS regimen consisted of docetaxel at 40 mg/m2 IVover 1 hour, vinorelbine at 30 mg/m2 IV over 6 to 10 minutes every 14days, and GM-CSF at 250 mg/m2 SC on days 2 to 12. No grade 3 or 4toxicities were encountered. Of the 10 patients evaluable for response, 5were partial responders (50% response rate). Time to progression for the10 cases ranged from 2 to 26+ months (median: 8 months). The DVSregimen was active against advanced melanoma in both previously treatedand untreated patients. A larger study to confirm the activity of the DVSregimen for stage IV melanoma is currently under way.
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The Sentinel Node in Colorectal CarcinomaOne of the most important prognostic factors in colorectal cancer is the presence or absence of regional lymph node metastases. In many instances, micrometastatic disease may not be found on routine pathologic analysis using hematoxylin and eosin staining, but may be discovered only with immunohistochemical methods or polymerase chain reaction assay.
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Unknown Primary Carcinomas: Diagnosis and ManagementUnknown primary carcinomas are a significant health problem, constituting 3% to 10% of all tumors diagnosed in the United States each year [1,2]. While the majority of patients with metastatic carcinoma of unknown primary origin have short survival times and disease resistant to treatment, recent findings suggest that certain subsets of patients have tumors that are responsive to chemotherapy. Others can be successfully treated with regional therapy.
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Non-Small-Cell Lung Cancer Adjuvant Therapy: Translating Data Into RealitySurgery remains the initial treatment for patients with early-stage non-small-cell lung cancer (NSCLC). Additional therapy is necessary because of high rates of distant and local disease recurrence after surgical resection. Early trials of adjuvant chemotherapy and postoperative radiation were often plagued by small patient sample size, inadequate surgical staging, and ineffective or antiquated treatment. A 1995 meta-analysis found a nonsignificant reduction in risk of death for postoperative cisplatin-based chemotherapy. Since then, a new generation of randomized phase III trials have been conducted, some of which have reported a benefit for chemotherapy in the adjuvant setting. The role of postoperative radiation therapy remains to be defined. It may not be beneficial in early-stage NSCLC but still may have utility in stage IIIA disease. Improvement in survival outcomes from adjuvant treatment are likely to result from the evaluation of novel agents, identification of tumor markers predictive of disease relapse, and definition of factors that determine sensitivity to therapeutic agents. Some of the molecularly targeted agents such as the angiogenesis and epidermal growth factor receptor inhibitors are being incorporated into clinical trials. Preliminary results with gene-expression profiles and lung cancer proteomics have been promising. These techniques may be used to create prediction models to identify patients at risk for disease relapse. Molecular markers such as ERCC1 may determine response to treatment. All of these innovations will hopefully increase cure rates for lung cancer patients by maximizing the efficacy of adjuvant therapy.
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Optimizing Outcomes With Bevacizumab by Better Targeting Patients and TumorsNumerous preclinical and clinical studies have demonstrated a role for angiogenesis in the growth and progression of breast cancer. Elevated vascular endothelial growth factor (VEGF) levels have been demonstrated in association with poor outcomes, and thus, this finding is an attractive target for therapeutic intervention.
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Optimizing Outcomes of Chemoradiation in the Management of Squamous Cell Carcinoma of the Anal CanalDr. Fakih and colleagues provide a detailed and thoughtful review of the role of chemoradiation in anal cancer treatment. They have included a comprehensive description of the epidemiology and risk factors for the development of squamous cell carcinoma of the anal canal, including the strong association with human papillomavirus (HPV) infection and increased incidence in human immunodeficiency virus (HIV)-positive individuals.
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What’s New in Genetic Testing for Cancer Susceptibility?The dilemma for clinicians is how best to understand and manage this rapidly growing body of information to improve patient care. With millions of genetic variants of potential clinical significance and thousands of genes associated with rare but well-established genetic conditions, the complexities of genetic data management clearly will require improved computerized clinical decision support tools, as opposed to continued reliance on traditional rote, memory-based medicine.
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Cancers of the Gallbladder and Biliary DuctsNeoplasms of the biliary tract tree are uncommon and have a poor overall prognosis. Although numerous risk factors have been identified, little is known about the pathogenesis of these tumors, and no effective screening
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Second-Line Therapy for Gemcitabine-Refractory Pancreatic Cancer: Is There a Standard?Pancreatic cancer is the fourth leading cause of cancer mortality in the United States. According the American Cancer Society, about 37,680 new cases are anticipated in the year 2008, and 34,290 patients will die from the disease.[1] This malignancy is a very aggressive tumor, and patients often present with advanced-stage disease. Surgical resection, when possible, provides the only opportunity for cure. Even with R0 resection, pancreatic cancer still carries an overall dismal prognosis, and therefore adjuvant treatment is offered.
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Biphasic Tumors of the Female Genital TractIn this installment of Second Opinion, we are presenting two cases of tumors of the female genital tract, specifically, the ovary and uterus, which contain both epithelial and mesenchymal components and therefore have unique diagnostic and therapeutic implications. The first has an unusually poor prognosis and the second is notoriously difficult to diagnose.
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Commentary (Corry et al): The Role of Neck Dissection Following Definitive ChemoradiationIn this issue of ONCOLOGY, Kutleret al eloquently address the concept,application, and controversiesof a planned neck dissection inpatients with head and neck carcinomaand nodal metastasis who receivenonsurgical therapy to the primary tumor.As stated lucidly in the article,planned neck dissection arose in thehistorical context of low rates of completeresponse in patients with N2/3neck disease treated with conventionallyfractionated radiotherapy, coupledwith low surgical salvage ratesamong patients who failed in the neck.Hence, the concept evolved that allpatients with N2/3 neck disease shouldundergo a planned neck dissection regardlessof response to radiotherapy.
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Invasive Candida Infections: The Changing EpidemiologyCandida is recognized as the fourth most common cause of bloodstreaminfection in the United States, with a high attributable mortalityrate. While Candida albicans remains the most common pathogen, nonalbicansCandida species, including Candida glabrata and Candidakrusei, with greater resistance to triazoles are being increasingly isolated.These epidemiologic changes are attributable to a combinationof factors, such as the use of fluconazole prophylaxis, changes in patientdemographics and underlying diseases, and use of therapeuticstrategies that may pose unique risks. Of particular concern is the increasedprevalence of species that are resistant to the azole antifungals.Candida glabrata, for example, is often resistant to fluconazole,and its ability to become cross-resistant to newer azole antifungals is arecent concern. Increasing evidence underscores the need to carefullyevaluate antifungal treatment options, according to both host and therapeuticrisks for drug resistance.
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Treatment Strategies in Primary Mediastinal B-Cell LymphomaIn this interview, we discuss the biology and the therapeutic strategies for primary mediastinal B-cell lymphoma.
