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A 55-Year-Old Woman With New Triple-Negative Breast Mass, Less Than 2 cm on Both Mammogram and UltrasoundA 55-year-old perimenopausal woman presented with a palpable lump in her left breast. Diagnostic mammogram showed a 1.8-cm spiculated mass with scattered microcalcifications within the mass. Comparison with her most recent prior mammogram (about 9 months earlier) showed this to be a new mass.
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Are Bisphosphonates Ready for the Adjuvant Setting?A majority of the more than 190,000 women diagnosed with breast cancer each year in the US[1] will receive some form of adjuvant therapy. Many breast cancer treatments cause decreases in circulating estrogen levels, which in turn can have a significant effect on bone mineral density; this condition is known as cancer treatment-induced bone loss (CTIBL). In this issue of ONCOLOGY, Reeder and Brufsky review the role of bisphosphonates in the setting of adjuvant breast cancer treatment. Both oral and intravenous bisphosphonates are effective in the prevention and treatment of CTIBL, and emerging data suggest that adjuvant bisphosphonate therapy may also affect breast cancer recurrence and survival. In considering the role of these medicines in early stage breast cancer, however, a number of important questions remain.
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ACR Appropriateness Criteria® Adjuvant Management of Early-Stage Endometrial CancerAfter a review of the published literature, the panel voted on three variants to establish best practices for the utilization of imaging, radiotherapy, and chemotherapy after primary surgery for early-stage endometrial cancer.
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PSA After Radiation for Prostate CancerThe introduction of prostate-specific antigen (PSA) as a reliabletumor marker for prostate cancer brought significant changes in theend points used for outcome reporting after therapy. With regard to adefinition of failure after radiation, a consensus was reached in 1996that took into account the particular issues of an intact prostate aftertherapy. Over the next several years, the consensus definition issued bythe American Society for Therapeutic Radiology and Oncology(ASTRO) was used and studied. Concerns and criticisms were raised.The sensitivity and specificity of this definition vs other proposals hasbeen investigated, and differences in outcome analyzed and compared.Although the ASTRO definition came from analysis of datasets on external-beam radiation and most of the work on this topic has been withthis modality, failure definitions for brachytherapy must be exploredas well. The concept of a universal definition of failure that might beapplied to multiple modalities, including surgery, should also be investigated,at least for comparative study and research purposes.
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Surgical Staging in Endometrial CancerEarly presentation of endometrial cancer permits effective managementwith excellent clinical outcome. The addition of hysteroscopy todilatation and curettage (D&C) in the evaluation of postmenopausalbleeding adds little to the detection of malignancy. Imaging studies suchas computed tomography, magnetic resonance imaging, and positronemissiontomography may be of use in determining the presence ofextrauterine disease in patients medically unfit for surgical staging.However, these studies are not sufficiently sensitive to replace surgicalstaging and have little role in routine preoperative evaluation. Clinicalstaging alone is clearly inadequate, as 23% of preoperative clinicalstage I/II patients are upstaged with comprehensive surgical staging.Preoperative tumor grade from D&C or office biopsy may be inaccurateand lead to an underestimate of tumor progression if used to determinewhich patients should be surgically staged. Clinical estimationof depth of invasion, with or without frozen section, is inaccurate andmay lead to underestimation of disease status when surgical staging isnot performed. The practice of resecting only clinically suspicious nodesshould be discouraged as it is no substitute for comprehensive surgicalstaging. Comprehensive surgical staging provides proper guidance forpostoperative adjuvant therapy, avoiding needless radiation in 85% ofclinical stage I/II patients. Finally, resection of occult metastasis withsurgical staging may improve survival.
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Gynecologic Malignancies in Older WomenThe demographics of the US population continue to change dramatically, as the absolute number and proportion of older people relative to the remainder of the population increases. Last year, the number of persons older than 65 years was estimated to be 35 million, representing almost 13% of the overall population; by 2030, the older population is expected to double. Along with the general aging of the population, the percentage of persons older than 85 years is also growing rapidly, as is the ethnic and racial diversity within the older population.
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Alternative Dosing Schedules for IrinotecanMost of the clinical experience with irinotecan (CPT-11 [Camptosar]) has been with either a weekly or an every-3-week schedule. Recent phase I trials have explored new routes and schedules of administration. One approach
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Is There a Role for Octreotide in the Treatment of Hormone-Refractory Prostate Cancer?Normal and hyperplastic prostate glandular epithelium does not express somatostatin receptors. Neuroendocrine prostatic cells contain bioactive secretory products such as chromogranin A, serotonin, and neuron-specific enolase. The stromal smooth muscle cells around glandular epithelium and ganglion cells of the prostatic plexus are positive for somatostatin subtype 2 receptors (sst 2).[1] In prostate cancer, however, there is nonhomogeneous distribution of sst 1. In the peritumoral veins of prostate cancer, sst 2 receptors were found by Reubi et al in 14 of 27 samples.[2]
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ACR Appropriateness Criteria® Nonsurgical Treatment for Locally Advanced Non–Small-Cell Lung Cancer: Good Performance Status/Definitive IntentThe treatment of inoperable stage III non–small-cell lung cancer (NSCLC) remains a challenge due to high rates of distant metastasis, local recurrence, and toxicity associated with definitive therapy.
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Cancer Stem Cells, EMT, and Seeding: A Rose Is a Rose Is a Rose?The brief review by Federici et al in the current issue of this journal is a cogent restatement of an argument that has accompanied the cancer stem cell (CSC) hypothesis almost from its inception.
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Novel peptide vaccine promising in myeloid leukemiaATLANTA-In a phase I/II randomized trial, a novel leukemia vaccine, PR1 peptide, produced immune responses that correlated with a longer event-free survival.
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Metastatic Papillary Adenocarcinoma in a 22-Year-Old: Is Her History of Mayer-Rokitansky-Küster-Hauser Syndrome Causative or Incidental?A 22-year-old college student with primary amenorrhea due to Müllerian agenesis presented with a headache, dysarthria, nausea, vomiting, and left upper extremity weakness. MRI of the brain showed numerous intracranial lesions.
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Neoadjuvant Chemotherapy for Resectable Non–Small-Cell Lung CancerLung cancer is the most common cancer diagnosed in men and women in the United States, and is the leading cause of cancer death.Over 160,000 individuals died as a result of lung cancer in 2008.[1] This number amounted to more than the number of deaths from colon, breast, and prostate cancers combined. The majority of lung cancer cases are non–small-cell lung cancer (NSCLC), and the poor outcomes are attributed to the high rate of metastases associated with this disease.
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Incidence and Management of AIDS-Related LymphomaOver time, the spectrum of the acquired immune deficiency syndrome (AIDS) epidemic has changed, especially with the advent of highly active antiretroviral therapy (HAART). The goal of this article is to delineate changes
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Breast Cancer Screening: The Evolving EvidenceIn this paper, the historic and recent evidence supporting the value of breast cancer screening will be described, along with the underpinnings of the current debate over the relative and absolute benefit of regular mammography screening.
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Speech and Swallowing Rehabilitation for Head and Neck Cancer PatientsHead and neck cancer and its treatment frequently cause changes in both speech and swallowing, which affect the patient's quality of life and ability to function in society. The exact nature and severity of the post-treatment changes depend on the location of the tumor, the choice of treatment, and the availability and use of speech and swallowing therapy during the first 3 months after treatment. This paper reviews the literature on speech and swallowing problems in various types of treated head and neck cancer patients. Effective swallowing rehabilitation depends on the inclusion of a video-fluorographic assessment of the patient's oropharyngeal swallow in the post-treatment evaluation. Pilot data support the use of range of motion (ROM) exercises for the jaw, tongue, lips, and larynx in the first 3 months after oral or oropharyngeal ablative surgical procedures, as patients who perform ROM exercises on a regular basis exhibit significantly greater improvement in global measures of both speech and swallowing, as compared with patients who do not do these exercises. [ONCOLOGY 11(5):651-659, 1997]
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Surviving the Stresses of Clinical Oncology by Improving CommunicationArmstrong and Holland’s articleprovides a clear and concisediscussion of many ofthe problems oncologists face in thehigh-pressure/high-stakes world of21st century medicine. Physicians ingeneral, and oncologists in particular,are overburdened with demandson their time, energy, and emotions.The authors present suggestions forrelieving these stresses in the formof a “survival kit.” The survival kit isinteresting because it provides an educationon how to communicate withpatients and deal with the emotionalaspects of practicing medicine.
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Cancer Stem Cells: Implications for Cancer TherapyThis review will focus on properties of cancer stem cells; will compare and contrast the cancer stem cell model with the clonal evolution model of tumorigenesis; will discuss the role of cancer stem cells in the development of resistance to chemotherapy; and will review the therapeutic implications and challenges of targeting cancer stem cells, with an assessment of the potential such an approach holds for improving outcomes for patients with cancer.
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Further Thoughts on Adjuvant Treatment for Older Breast Cancer PatientsThe adjuvant treatment of breast cancer is facing a challenging phase due to the increasing knowledge of breast cancer biology and consequent need to personalize treatments. Medical oncologists are asked to practice evidence-based medicine, but their approach is often based on results of trials conducted in extremely heterogeneous populations.
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Lymph Node Staging in Localized Breast CancerIn this interview we discuss the current guidelines for lymph node staging in breast cancer and dive into the debate surrounding sentinel node biopsies.
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Management of Pain in Special Populations of Cancer PatientsChildren, the elderly, AIDS patients, and former narcotic drug abusers pose special problems in pain management that may lead to undermedication even more frequently than occurs in the general population of cancer patients with pain. A multidisciplinary panel of six pain experts with clinical experience in caring for these special groups met in Santa Fe, New Mexico, to discuss assessment methods and pharmacologic approaches to the treatment of pain in these patients. A summary of the roundtable discussion follows.
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Early-Stage BRCA2-Linked Breast Cancer Diagnosed in the First Trimester of Pregnancy Associated With a Hypercoagulable StateThis feature examines the case of a patient with newly diagnosed breast cancer in the setting of a first-trimester pregnancy presenting to our multidisciplinary breast cancer clinic.
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Ground-Glass Opacity Lung Nodules in the Era of Lung Cancer CT Screening: Radiology, Pathology, and Clinical ManagementThis review focuses on the radiologic and pathologic features of ground-glass opacity nodules, along with the clinical management of these lesions.
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Management of DeliriumMs. B is a 44-year-old married African-American female who was diagnosed with locally advanced right breast cancer in 2002. Immunohistochemistry in the original tumor was estrogen- and progesterone-receptor-negative, HER2-positive. Her past medical history is significant for hypertension and miscarriage in 1995.
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Are We Overtreating DCIS?With evidence from a number of studies, this presentation delves into the controversy surrounding the treatment, or overtreatment, of ductal carcinoma in situ (DCIS), and discusses whether or not these lesions should indeed be classified as breast cancer.
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Laura Esserman and Ian Thompson Discuss Strategies for Screening and Treatment of Early-Stage Cancers, and How Clinicians Can Learn From Each Other’s ExperiencesIn this interview we review recent breast cancer screening guidelines from the ACS and USPSTF, and discuss the changing way that early-stage breast and prostate cancers are being treated.
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Mathematical Modeling for Breast Cancer Risk AssessmentWomen at increased risk of breast cancer have important opportunities for early detection and prevention. There are, however, serious drawbacks to the available interventions. The magnitude of breast cancer risk is a crucial factor in the optimization of medical benefit when considering the efficacy of risk-reduction methods, the adverse effects of intervention, and economic and quality-of-life outcomes. Breast cancer risk assessment has become increasingly quantitative and is amenable to computerization. The assembly of risk factor information into practical, quantitative models for clinical and scientific use is relatively advanced for breast cancer, and represents a paradigm for broader risk management in medicine. Using a case-based approach, we will summarize the major breast cancer risk assessment models, compare and contrast their utility, and illustrate the role of genetic testing in risk management. Important considerations relevant to clinical oncology practice include the role of risk assessment in cancer prevention, the logistics of implementing risk assessment, the ramifications of conveying risk information with limited genetic counseling, and the mechanisms for genetics referral. Medical professionals can embrace new preventive medicine techniques more effectively by utilizing quantitative methods to assess their patients’ risks. [ONCOLOGY 16:1082-1099, 2002]
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ONS: Infection Risk, Prevention, and ManagementIn this interview, Laura Zitella will be discussing challenges and considerations for management and prevention of infection in the oncology setting-in both patients with solid tumors and those with hematologic malignancies.
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Discovery, Development, and Clinical Applications of BortezomibProteasome inhibition is a novel, targeted approach in cancertherapy. Both natural and synthetic proteasome inhibitors selectivelypenetrate cancer cells, disrupting the orderly destruction of key regulatoryproteins involved in tumorigenesis and metastasis. Disrupting theorderly destruction of regulatory proteins causes an imbalance of theseproteins within the cell, which interferes with the systematic activationof signaling pathways required to maintain tumor cell growth and survival;therefore, cellular replication is inhibited and apoptosis ensues.
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Anastrozole: A New Selective Nonsteroidal Aromatase InhibitorEndocrine therapy has long been a mainstay in the therapy of metastatic breast cancer and in the adjuvant setting. The introduction of anastrozole (Arimidex) to the market in 1996 has provided another option for such treatment. Drs. Goss and Tye provide a thorough review of anastrozole and outline its advantages over other aromatase inhibitors as adjuvant therapy for breast cancer and its potential use in the treatment of early breast cancer. The authors delineate many important issues regarding the use of anastrozole; an understanding of these issues is imperative for the optimal utilization of this therapy. The paper has two shortcomings: (1) It focuses almost solely on aromatase inhibitors, to the neglect of other endocrine therapies. (2) Many references are unconventional and represent data on file with various drug manufacturers, which are not easily accessible to readers.
