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Treatment of Advanced Non–Small-Cell Lung Cancer in Special PopulationsOnly a minority of elderly patientswith advanced non–small-cell lung cancer(NSCLC) have been offered palliativechemotherapy, as indicated by clinicalsurveys beginning in the 1980s.Lilenbaum’s thorough review of thetreatment of locally advanced and metastaticNSCLC studies in two specialpopulations (elderly and Eastern CooperativeOncology Group [ECOG]performance status [PS] 2 patients)highlights a new trend seen with theadvent of better-tolerated chemotherapyregimens.
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Small- and Large-Cell Neuroendocrine Cervical CancerSmall- and large-cell neuroendocrine tumors of the cervix are exceedingly rare and exceedingly aggressive.
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Commentary (Herman/Wharam): Current Techniques in Three-Dimensional CT Simulation and Radiation Treatment PlanningStephenson and Wiley demonstrate that three-dimensional (3D) CT-based simulation is an improvement in the simulation process. The growing importance of CT in radiation oncology treatment planning has been discussed previously [1] and is further emphasized in this article. The advantages of geometric optimization in three dimensions for radiation therapy treatment planning also are described. These results are applicable to both 3D and two-dimensional (2D) dose planning, because the treatment team can visualize and delineate structures on axial or reconstructed CT planes in greater detail than is possible with conventional simulation projected radiographs.
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Commentary (Sarr/Farnell): Combined-Modality Treatment for Operable Pancreatic AdenocarcinomaPisters and colleagues from theM. D. Anderson Cancer Centeroffer a state-of-the-art discussionof the staging and treatment ofpancreatic cancer. Their treatise addressesmost of the current issues ofcontroversy surrounding this diseasefrom a largely nonparochial standpoint,and should serve as a primerfor the multidisciplinary approach tothe treatment of pancreatic ductal cancer.Their call for and justification ofregionalization of treatment in patientswith potentially resectable diseaserings true with virtually all nationaland international studies that have examinedthis topic from the aspect ofmorbidity, mortality (and thus survival),duration of hospitalization, andof course in our current economic climate,cost.[1-7] This topic should nolonger be considered controversial.
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Cutaneous T-Cell Lymphoma: Pathogenesis and TreatmentCutaneous T-cell lymphoma (CTCL) is a malignancy of a distinctive subset of T-helper cells designated “cutaneous T cells” because of their central role in the normal functioning of the skin immune system. Guided by
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Pancreatic Cancer: Recognizing an Hereditary PredispositionAlthough candidate genes for hereditary pancreatic cancer have been identified (Figure 1), namely p16 and BRCA2, pancreatic cancer patients having an inherited predisposition will not be easy to recognize on clinical grounds.
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Integration of Palliative Care Into Comprehensive Cancer Care: Accountable Collaborationn their article, Dennis et al call for timely integration of palliative care into standard oncology care and sustained collaboration between these two specialties, to provide comprehensive, individualized care for patients with advanced, incurable cancer and their families.[
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New Menus for CLL TreatmentChronic lymphocytic leukemia (CLL) is a heterogeneous disease with an extremely variable course. Survival after diagnosis can range from months to decades. As the pathogenesis of the disease is increasingly understood, we begin to unfold the molecular patterns that define the different prognostic subgroups and to develop strategies to predict the clinical course.
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Phase II Study of Rituximab in Combination With Fludarabine in Patients With Chronic Lymphocytic LeukemiaThis phase II trial investigated the safety and efficacy of a combined-modality treatment with rituximab (Rituxan) and fludarabine (Fludara) in patients with fludarabine- and anthracycline-naive chronic lymphocytic lymphoma (CLL).
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Reassessments of ESAs for Cancer Treatment in the US and EuropeAnemia is a widely prevalent complication among cancer patients. At the time of diagnosis, 30% to 40% of patients with non-Hodgkin lymphoma or Hodgkin lymphoma and up to 70% of patients with multiple myeloma are anemic; rates are higher among persons with myelodysplastic syndromes. Among patients with solid cancers or lymphomas, up to half develop anemia following chemotherapy. For almost 2 decades, erythropoiesis-stimulating agents (ESAs) were the primary treatment for cancer-related anemia. However, reassessments of benefits and risks of ESAs for cancer-associated anemia have occurred internationally. We reviewed guidelines and notifications from regulatory agencies and manufacturers, reimbursement policies, and utilization for ESAs in the cancer and chronic kidney disease settings within the United States, Europe, and Canada. In 2008 the US Food and Drug Administration (FDA) restricted ESAs from cancer patients seeking cure. Reimbursement is limited to hemoglobin levels < 10 g/dL. In the United States, ESA usage increased 340% between 2001 and 2006, and decreased 60% since 2007. The European Medicines Agency (EMEA) recommended that ESA benefits do not outweigh risks. In Europe between 2001 and 2006, ESA use increased 51%; since 2006, use decreased by 10%. In 2009, Canadian manufacturers recommended usage based on patient preferences. In Canada in 2007, approximately 20% of anemic cancer patients received ESAs, a 20% increase since 2004. In contrast to Europe, where ESA use has increased over time, reassessments of ESA-associated safety concerns in the United States have resulted in marked decrements in ESA use among cancer patients.
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Treatment Approaches for Therapy-Related AML, MDS Based on Mutation ProfilesThis video examines different mutational profiles of therapy-related myeloid neoplasms and how they can affect approaches to treatment.
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Chemotherapeutic Prophylaxis of Superficial Bladder TumorsIn a recent issue of ONCOLOGY (15:85-88, 2001), Drs. Edgar C. Baselli and Richard E. Greenberg presented a brief
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Sequencing of Agents for Castration-Resistant Prostate CancerIn this review we will outline an approach to sequencing new therapies for metastatic castration-resistant prostate cancer (CRPC), with particular attention paid to the biology of CRPC.
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Preventing Prostate Cancer Overdiagnosis From Becoming OvertreatmentThe controversy surrounding PSA screening is one of the most heated in oncology. The potential benefits include prevention of prostate cancer morbidity and mortality, but the men potentially harmed through overdiagnosis and overtreatment outnumber those who benefit.
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Use of Transcription Factors as Agents and Targets for Drug DevelopmentCells respond to external signals by either activating or inhibiting key regulatory proteins of gene expression called transcription factors (TFs). Abnormal expression of these factors plays a critical role in many human
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Book Review: Euthanasia is Not the Answer-A Hospice Physician's ViewRecent broad interest in euthanasia and assisted suicide by society at large has prompted this review of euthanasia. This fine,
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Commentary (Droller): Prostate-Specific Antigen as a Marker of Disease Activity in Prostate CancerThis second installment on prostate specific antigen (PSA) as a marker of disease activity and cancer cell viability in prostate cancer focuses on its role in monitoring the effects of a variety of therapies at different stages of the disease. In addition, the authors propose guidelines for studying the efficacy of new treatments in this setting.
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Hypofractionation for Breast Cancer: Lessons Learned From Our Neighbors to the North and Across the PondIn this review we discuss the rationale and underlying radiobiologic concepts for hypofractionation, and review the clinical trials and ASTRO guidelines supporting hypofractionated radiation in the treatment of breast cancer.
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Quick Reference for Oncology CliniciansAs a midcareer academic medical oncologist, I have found that some books are especially useful as a pocket reference. Some books are small enough for a briefcase, but not ideal for a coat pocket. Others are best sequestered on a bookshelf. Where a book is placed often influences how one will (or won't) use it or read it.
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Principles of Radiation TherapyThis chapter provides a brief overview of the principles of radiation therapy. The topics to be discussed include the physical aspects of how radiation works (ionization, radiation interactions) and how it is delivered (treatment machines, treatment planning, and brachytherapy).
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Concurrent Chemotherapy and Radiotherapy in Patients With Brain TumorsBecause treatment for most brain tumors remains inadequate, there has been a sustained interest in using concurrent chemotherapy and radiotherapy to improve local control, prolong overall survival, and reduce
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Transoral Robotic Surgery (TORS): The Natural Evolution of Endoscopic Head and Neck SurgeryThe article presented by Bhayani, Holsinger, and Lai thoroughly evaluates the emergence of transoral robotic surgery (TORS) as a technique in the field of otolaryngology. Transoral approaches to the upper aerodigestive tract, whether for diagnostic or therapeutic purposes, represent core tenets of the discipline and formed one of the bases for the inception of the specialty. Innovations and refinements in optics and materials have steadily increased the view, reach, and, consequently the effectiveness of the endoscopic surgeon with each passing decade. In the past thirty years, the introduction of the laser has further enhanced the capabilities of the surgeon, augmenting treatment options beyond open tumor resection and chemoradiation. The introduction of the daVinci robot is an incremental step in the development of techniques that have been evolving over the past one hundred and twenty years.
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Managing CLL: A New Level of SophisticationFor decades, initial therapy for chronic lymphocytic leukemia (CLL) consisted of alkylators such as chlorambucil (Leukeran). The introduction of nucleoside analogs such as fludarabine and monoclonal antibodies such as rituximab (Rituxan) markedly changed the initial therapy of CLL, particularly in the United States. Fludarabine and combination regimens such as fludarabine/cyclophosphamide (FC) have achieved higher complete response (CR) rates and progression-free survival (PFS) than chlorambucil in previously untreated CLL, but long-term overall survival has not improved, due to concurrent improvement in salvage therapy of relapsed CLL patients. Upfront chemoimmunotherapy regimens such as fludarabine/rituximab (FR) and fludarabine/cyclophosphamide/rituximab (FCR) have similarly improved CR rates and PFS in previously untreated CLL patients, but it is unclear whether overall survival is improved. Advances in cytogenetic analysis and other biologic prognostic factors have greatly enhanced clinicians' ability to risk-stratify newly diagnosed CLL patients, and knowledge of such prognostic factors is necessary to properly interpret results of clinical treatment studies. The choice of initial therapy for an individual patient should depend upon the patient's age and medical condition, cytogenetic and other prognostic factors, and whether the goal of therapy is maximization of CR and PFS or palliation of symptoms with minimal toxicity.
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Lung Cancer Management in 2010Exciting advances in understanding the biology of lung cancer have occurred over the last few years.
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Endoscopic Ultrasound in the Diagnosis and Staging of Pancreatic CancerPatients with signs and symptoms suggestive of a pancreatic neoplasm typically undergo initial imaging with transabdominal ultrasound or computed tomography. This evaluation often reveals the presence of a pancreatic mass or fullness.
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Smaller Incisions for Smaller CancersSmaller early-stage tumors may lend themselves to less radical lung parenchymal sparing resections or no surgery at all.
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Commentary (Mastrangelo/Berd): Systemic Treatments for Advanced Cutaneous MelanomaAnderson and colleagues present a comprehensive and factually accurate overview of systemic treatment for advanced melanoma. They correctly identify dacarbazine as the only single agent officially sanctioned for the treatment of metastatic melanoma. They further opine that "dacarbazine alone remains the standard of care for initial chemotherapy treatment of metastatic melanoma." With overall response rates of 10% to 20%, a complete response rate of less than 4%, and no evidence that treatment with dacarbazine improves survival over best palliative care, one questions whether or not dacarbazine would merit approval if reevaluated today.
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Michael J. Morris, MD, on Future Directions of PSMA Imaging in Prostate CancerResults of phase 3 CONDOR study could have a far-reaching impact on patients with prostate cancer.
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The Economics of Prostate Cancer ScreeningThe introduction of prostate-specific antigen (PSA) testing for use in the early detection of prostate cancer has led to controversy regarding the appropriateness of prostate cancer screening and any subsequent treatment. Much
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Current Status of Adjuvant Therapy for Colorectal CancerAdjuvant therapy with chemotherapy and/or radiation therapy inaddition to surgery improves outcome for patients with high-risk carcinomasof the colon or rectum. For colon cancer, fluorouracil (5-FU)combined with leucovorin is a current standard of care that improveslong-term survival. A recent European trial (MOSAIC) has documentedsignificant improvement in 3-year disease-free survival when oxaliplatin(Eloxatin) was added to infusional 5-FU and leucovorin in the FOLFOXregimen. Two US cooperative group trials will evaluate the addition ofantiangiogenesis therapy with bevacizumab (Avastin) to chemotherapy.A third trial will evaluate FOLFOX, irinotecan (Camptosar) combinedwith infusional 5-FU and leucovorin (FOLFIRI), and the sequentialuse of FOLFOX followed by FOLFIRI. In rectal cancer, postoperative5-FU–based chemotherapy combined with irradiation can improve bothlocal tumor control and survival. The German Rectal Cancer Grouphas recently reported that preoperative combined-modality therapy isless toxic and more effective in preventing local tumor relapse comparedto similar treatment given postoperatively. A coordinated pair ofcooperative group clinical trials will evaluate oral capecitabine (Xeloda)as a radiation enhancer in the preoperative setting, and the FOLFOXand FOLFIRI regimens compared to 5-FU and leucovorin followingsurgery. Predictive and prognostic molecular markers will be studiedin these new adjuvant therapy clinical trials for both colon and rectalcancer with the goal of developing future regimens tailored to individualpatients. There has been a recent and dramatic increase in thepace of drug development for colorectal cancer which holds promise tofurther improve curative therapy as part of a multidisciplinary approachin the surgical adjuvant setting.
