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Local Excision for Rectal Cancer: An Uncertain FutureAdenocarcinoma of the rectum remains a significant public health challenge, with 39,000 new cases and 8,500 deaths predicted for 1998. Radical surgery, the current standard therapy, frequently necessitates the formation of
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Current Application and Research Directions for Partial-Breast IrradiationBreast-conservation therapy (BCT), consisting of lumpectomy followed by whole-breast irradiation (WBI), is the standard of care for women with early-stage breast cancer. However, many women who are candidates for BCT either choose mastectomy or lumpectomy alone for myriad reasons. Accelerated partial-breast irradiation (APBI) is a collection of radiotherapy techniques that deliver higher daily doses of radiation to the surgical cavity with margin over a shorter time than WBI, reducing total treatment time from 6-6.5 weeks to 1-2 weeks. Advocates of APBI state that early results of this approach demonstrate excellent local control, minimal acute toxicity, and are associated with more convenience for the patient. Phase III randomized clinical trials are currently underway to assess local control, acute and chronic toxicities, and quality of life associated with APBI compared to WBI. In this review, we hope to clarify the rationale behind APBI and discuss in depth data concerning various partial-breast irradiation techniques that are being used throughout the United States and around the world.
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PSA Screening in Men Newly Diagnosed With Colorectal Cancer: Each According to His Group’s Means?Once a patient has been appropriately educated by an informed healthcare provider about the possible benefits of PSA screening, then patient preference as part of shared decision making regarding PSA screening should be considered in all cases.
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Will Current Clinical Trials Answer the Most Important Questions About Prostate Adenocarcinoma?Despite a heightened focus of the medical and research community on prostate cancer, many important questions about this disease remain unanswered. These include questions about the possible prevention of prostate cancer, as well as the optimal treatment approaches for localized, locally advanced, metastatic, and hormone-refractory disease. A whole host of prospective, well-designed clinical trials are currently in progress that should answer many of these questions. This review briefly explores some of these unresolved issues and describes ongoing trials designed to address them. [ONCOLOGY 11(8):1-11, 1997]
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Cancer and Healthcare Reform: Making the Pieces FitCancer service leaders must create the vision, embrace the change agenda, and drive the roadmap in order to make the strategic and clinical changeover to value.
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Radiotherapy Is NOT Essential to Cure Diffuse Large B-Cell Non-Hodgkin LymphomaDLBCL of any stage remains a systemic disease with early hematogenous spread. Thus, arguments advocating the role of IFRT do not truly address disease biology, and all future efforts to cure patients will require improved systemic therapy.
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Commentary (Byrne): Early Detection and Treatment of Spinal Cord CompressionAs outlined by Dr. Ruckdeschel,the evaluation and management of metastatic spinal metastasesand associated epidural spinalcord compression have been simplifiedby the advent of magnetic resonanceimaging (MRI), which is muchmore sensitive and specific than plainx-rays and radionuclide bone scanning.Furthermore, because most patientscan now undergo MRI ratherthan invasive myelography, thethreshold for diagnosing epiduralmetastatic disease has been lowered.Accordingly, it has become the test ofchoice for evaluating most patientswith suspected spinal metastases.
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Management of Intermediate-Grade LymphomasIntermediate-grade lymphomas are defined by the Working Formulation to include four histologic subgroups: follicular large-cell, diffuse small-cleaved-cell, diffuse mixed small- and large-cell, and diffuse large cell (Groups
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Practice Apoptosis: When Partners RetireKicking off the first in a series of podcasts, a noted healthcare consultant discusses how retirement can fracture a practice.
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A 54-Year-Old Woman With Recurrent Headaches and SeizuresThe patient’s medical history is remarkable only for asthma and mild emphysema. The family history included a grandmother with gastric cancer. The patient had been taking estrogen replacement therapy since menopause 3 years earlier, and she was
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Emerging Data and Future Directions in UCExperts highlight emerging data and novel regimens that have the biggest potential to impact treatment and management of patients with urothelial cancer.
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Sentinel Lymph Node Biopsy in a Young Child With Thick Cutaneous MelanomaHead and neck melanoma is a rare and aggressive childhoodmalignancy. Surgery remains the primary treatment, with lymphaticinvolvement determined by neck dissection. In the adult population,sentinel lymph node biopsy has emerged as a less morbid yet accuratemethod of staging regional lymph nodes. This innovative technique canalso be used in the pediatric population.
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One Institution’s Experience With Implementation of EPIC/Beacon: Lessons LearnedA recent survey of the medical oncologists and oncology nursing staff at UCH showed that 71% of physicians feel Beacon has made patient treatment easier for providers.
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Achieving Meaningful Use of Electronic Health Records for the OncologistIn 2003, the Institute of Medicine (IOM) issued a report outlining key capabilities of an electronic health record.[1]
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Comparative Effectiveness and Comparative CostsKilbridge correctly points out that comparative effectiveness research (CER) does not require cost data. It should also be pointed out, however, that the composition of the quality-adjusted life-year (QALY) gain of one intervention over another-whether the QALY gain is achieved mainly in the dimension of longevity or in the dimension of quality of life-has real consequences in terms of comparative costs of the interventions. Basically, a longevity increase entails additional consumption costs and additional labor earnings, essentially negative costs, during the extended life that should be included in the “cost” of an intervention.[1-3] Because labor earnings tend to be negligible relative to consumption costs toward the end of one’s life, due to sickness or retirement, failure to incorporate consumption costs and labor earnings into the comparative costs of two interventions generates a bias in favor of the intervention with the larger longevity effect.
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What Is the Optimal Initial Treatment for Chronic Lymphocytic Leukemia?For 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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The Costs of Cancer Care in the United States: Implications for ActionThe total annual cost of cancer care in the United States (including direct and indirect costs) has been estimated at more than $96 billion. Although third-party payers have led the effort to reduce these costs, such high
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Could SBRT Have Role in Metastatic Kidney Cancer?This video examines a pilot trial that tested stereotactic body radiotherapy plus nephrectomy in patients with renal cell carcinoma.
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Commentary (Burke): Melanomas of the Vulva and VaginaDr. Trimble's review of female genital tract melanomas provides a well-organized summary of the published information on these rare cancers. His inclusion of the two recent population-based samples from the United States and Sweden [1,2] is particularly useful because all of the available data on genital tract melanomas comes from long-term retrospective case reviews. The cited incidence rates calculated in the studies represent the first legitimate estimates of the incidence of these uncommon cancers.
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How the Affordable Care Act Has Affected Cancer Care in the United States: Has Value for Cancer Patients Improved?Although data are anecdotal, there is no question that the increased numbers of patients with insurance resulted in cancer patients receiving care they previously could not.
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Erdafitinib in the Treatment of Metastatic Urothelial CarcinomaFrancisco Castro-Alonso, MD, and colleagues describe the effects of the use of erdafitinib in a patient with metastatic urothelial bladder cancer.
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Tagraxofusp in BPDCN: Practical Advice and Future Directions in CareAfter sharing key takeaways on the management of BPDCN, expert hematologist-oncologists highlight unmet needs and forecast evolutions in care.
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The Prostate Cancer Intervention Versus Observation Trial (PIVOT)The Prostate Cancer Intervention Versus Observation Trial (PIVOT) is a randomized trial designed to determine whether radical prostatectomy or expectant management provides superior length and quality of life for men with clinically localized prostate cancer. Conducted at Department of Veterans Affairs and National Cancer Institute medical centers, PIVOT will enroll over 1,000 individuals less than 75 years of age. The primary study end point is all-cause mortality. Secondary outcomes include prostate cancer- and treatment-specific morbidity and mortality, health status, predictors of disease-specific outcomes, and cost-effectiveness. Within the first 3 years of enrollment, over 400 men have been randomized. Early analysis of participants' baseline characteristics indicate that enrollees are representative of men diagnosed with clinically localized prostate cancer throughout the United States. Therefore, results of PIVOT will be generalizable. These results are necessary in order to determine the preferred therapy for clinically localized prostate cancer. [ONCOLOGY 11(8):1133-1143, 1997]
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New Mutation Identified in Primary Myelofibrosis PatientsIn a late-breaking abstract presentation, Thorsten Klampfl, PhD, of the CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences in Vienna, presented data from a whole exome study of primary myelofibrosis patients, identifying a new specific molecular mutation
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Frontline Therapy for Non-Clear Cell RCCThe panel wraps up their discussion with a review of how they would approach treating frontline non-clear cell RCC.
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The Benefits of Achieving Stable Disease in Advanced Lung CancerDr. Kelly has written an excellentarticle demonstrating theclinical significance of achievingstable disease in advanced non–small-cell lung cancer (NSCLC)patients. This hypothesis is supportedby clinical data from two phase IItrials (Iressa Dose Evaluation in AdvancedLung Cancer [IDEAL-1 andIDEAL-2]) of the epidermal growthfactorreceptor (EGFR) inhibitor gefitinib(ZD1839, Iressa) in previouslytreated patients. She appropriatelypoints out that although tumor shrinkageis a conventionally used end pointfor cytotoxic drugs, it may not be appropriatefor the “novel” cytostaticagents. For these agents, stabilizationof disease without obvious tumorshrinkage may result in a clinicalbenefit.
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Genetic Testing: The Bigger PictureSchrader and colleagues provide four compelling examples of the power of genetic testing to impact medical management for probands and their family members.
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Incorporating Collaboration and Personalization of Treatment in Breast Cancer CareThe field of breast oncology is constantly evolving to include trial diversity and multidisciplinary care.
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Head and Neck Cancer: Changing Epidemiology and Public Health ImplicationsCharacterizing the epidemiology of head and neck cancers is challenging and has received limited attention in the medical literature. Traditionally, 80%–90% of head and neck squamous cell carcinomas (HNSCCs) have been attributed to tobacco and alcohol use, but with growing public awareness and tobacco control efforts over the past few decades, there has been a downward trend in smoking prevalence in the US. There is also emerging evidence that human papillomavirus (HPV) is responsible for inconsistencies in HNSCC trends, with oncogenic HPV DNA found in approximately half of oropharyngeal cancers and in a high proportion of oropharyngeal cancers in nonsmokers and nondrinkers. The risk to HNSCC epidemiology is that whatever gains continue to be made in tobacco control may become lost in the increasing numbers of oropharyngeal cancers due to HPV. The purpose of this review is to explore the changing epidemiology of HNSCC, focusing on how it has been shaped by health policy and advocacy interventions and how it will continue to have public health implications in the future, particularly in considering preventive strategies against HPV. Given that the majority of HNSCCs are the result of exposure to preventable public health risks, more focus should be given to this area.
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Long-Term Effects of Chemo on the Cognitive Function of Cancer PatientsIn this podcast we discuss the long-term effects of chemotherapy on the cognitive function of cancer patients and the current status of research in this field.
