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Hodgkin LymphomaThis management guide covers the risk factors, screening, diagnosis, staging, and treatment of Hodgkin lymphoma.
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Changing Treatment Paradigms for Brain Metastases From Melanoma-Part 2: When and How to Use the New Systemic AgentsIn this article, we provide an overview of the currently available systemic agents, including immunotherapeutic agents and targeted tyrosine kinase inhibitors. We also provide a practical management algorithm to guide the practicing oncologist in the use of both of these new therapies and the more traditional local treatments.
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Increased Efficacy Through Moderate Dose Escalation of Chemotherapy: Interim Report From the HD9 Randomized Trial for Advanced Hodgkin’s DiseaseThis report aims to assess the effect of increased drug dose on the efficacy and toxicity of the BEACOPP regimen with
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Pathologic Evaluation of Prostatic Carcinoma: Critical Information for the OncologistAdenocarcinoma of the prostate is now the most common tumor in males. The use of the digital rectal examination, prostate-specific antigen (PSA), and transrectal ultrasound of the prostate with biopsies has improved the detection of prostate cancer and has increased the percentage of patients with organ-confined disease who are treated with radical prostatectomy. It is critical for the practicing urologic and medical oncologist to have accurate and precise pathologic information in order to counsel patients for appropriate therapy. Ideal biopsy and clinical predictive criteria for tumor volume in prostates are not readily available in the literature.
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Adjuvant Chemotherapy of Breast Cancer in the Older PatientAlthough increasing age is the major risk factor for breast cancer incidence and mortality, when adjusted for disease stage, breast cancer mortality is similar among younger vs older patients. Importantly, about 90% of older women with breast cancer present with early-stage disease. The biologic characteristics of breast tumors in older patients suggest they would derive benefit from adjuvant therapy, particularly endocrine therapy, but older women are still frequently undertreated, resulting in poorer survival. Studies suggest that focusing on comorbidity rather than “chronologic age” as a surrogate for life-expectancy is a key aspect of adjuvant decision-making for older patients. Morbidity and mortality from cancer in vulnerable patients with poorer health can be accurately predicted by the Comprehensive Geriatric Assessment (CGA), which evaluates comorbidities, functional status, cognition, social support, psychological state, nutritional status, and polypharmacy. Use of the CGA and newer versions of this tool can lead to interventions that maintain function and improve quality of life in older patients with breast cancer.
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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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A Perspective on Genomic Tests for Breast Cancer: The Need for ProgressIn their review of multi-gene assays of breast cancer, Drs. Gökmen-Polar and Badve highlight the overall similarity of “first-generation” molecular assays that have been developed, using different strategies, to understand the relationship between gene expression within tumor samples and the outcomes of patients with breast cancer.
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Commentary (Goodwin): 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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Anthracycline and Trastuzumab in Breast Cancer TreatmentThis study was designed to evaluate the cardiac safety of the combined treatment of HER2-positive metastaticbreast cancer patients with trastuzumab (Herceptin) plus epirubicin and cyclophosphamide (EC) incomparison with EC alone in HER2-negative metastatic breast cancer patients. Patients included those withmetastatic breast cancer without any prior anti-HER2 treatment, anthracycline therapy, or any other chemotherapyfor metastatic disease. This was a nonrandomized, prospective, dose-escalating, multicenter, openlabel,phase II study in Germany. A control group of 23 patients received EC 90/600 mg/m2 3-weekly for sixcycles (EC90 alone). A total of 26 HER2-positive patients were treated with trastuzumab, or H (2 mg/kg weeklyafter an initial loading dose of 4 mg/kg), and EC 60/600 mg/m2 3-weekly for six cycles (EC60+H); another 25HER2-positive patients received H and EC 90/600 mg/m2 3-weekly for six cycles. Asymptomatic reductions inleft ventricular ejection fraction (LVEF) of more than 10% points were detected in 12 patients (48%) treatedwith EC60 + H and in 14 patients (56%) treated with EC90 + H vs 6 patients (26%) in the EC90 alone cohort.LVEF decreases to < 50% occurred in one patient in the EC60+H cohort and in two patients in the EC90+Hcohort during the H monotherapy. No cardiac event occurred in the cohort with EC90 alone. The overallresponse rates for EC60+H and EC90+H were >60%, vs 26% for EC90 alone. The interim results of this studysuggest the cardiac safety of the combination of H with EC may be greater than that of H with AC (doxorubicin[Adriamycin]/cyclophosphamide); however, studies in larger numbers of patients are warranted. The combinationregimen revealed promising efficacy.
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Docetaxel vs Mitomycin Plus Vinblastine in Anthracycline-Resistant Metastatic Breast CancerThis nonblinded, multicenter, randomized phase III study compares the median time to progression (primary endpoint), response rate, and quality of life, safety, and survival of
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Is Radical Prostatectomy Appropriate for Very-High-Risk Prostate Cancer Patients? No.It is our opinion that surgery is inappropriate for very-high-risk prostate cancer and that a combination of EBRT and ADT should be the preferred treatment modality.
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Subacute Headache in a Patient With Metastatic Gastric CancerA 59-year-old man with metastatic gastric cancer presented to the oncology clinic with a 1-week history of positional headache, nausea, and vomiting. He stated that the headache was located in the frontal region, was 8 on a scale of 10 in intensity.
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ACR Appropriateness Criteria® Ductal Carcinoma in SituManagement of ductal carcinoma in situ (DCIS) commonly involves excision, radiotherapy, and hormonal therapy. Radiotherapy is employed for local control in breast conservation. Evidence is evolving for several radiotherapy techniques exist beyond standard whole-breast irradiation.
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ACR Appropriateness Criteria® Borderline and Unresectable Pancreas CancerThese guidelines review the use of radiation, chemotherapy, and surgery in borderline and unresectable pancreas cancer. Radiation technique, dose, and targets were evaluated, as was the recommended chemotherapy, administered either alone or concurrently with radiation. This report will aid clinicians in determining guidelines for the optimal treatment of borderline and unresectable pancreatic cancer.
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Anthracycline and Trastuzumab in Breast Cancer TreatmentThis study was designed to evaluate the cardiac safety of the combined treatment of HER2-positive metastaticbreast cancer patients with trastuzumab (Herceptin) plus epirubicin and cyclophosphamide (EC) incomparison with EC alone in HER2-negative metastatic breast cancer patients. Patients included those withmetastatic breast cancer without any prior anti-HER2 treatment, anthracycline therapy, or any other chemotherapyfor metastatic disease. This was a nonrandomized, prospective, dose-escalating, multicenter, openlabel,phase II study in Germany. A control group of 23 patients received EC 90/600 mg/m2 3-weekly for sixcycles (EC90 alone). A total of 26 HER2-positive patients were treated with trastuzumab, or H (2 mg/kg weeklyafter an initial loading dose of 4 mg/kg), and EC 60/600 mg/m2 3-weekly for six cycles (EC60+H); another 25HER2-positive patients received H and EC 90/600 mg/m2 3-weekly for six cycles. Asymptomatic reductions inleft ventricular ejection fraction (LVEF) of more than 10% points were detected in 12 patients (48%) treatedwith EC60 + H and in 14 patients (56%) treated with EC90 + H vs 6 patients (26%) in the EC90 alone cohort.LVEF decreases to < 50% occurred in one patient in the EC60+H cohort and in two patients in the EC90+Hcohort during the H monotherapy. No cardiac event occurred in the cohort with EC90 alone. The overallresponse rates for EC60+H and EC90+H were >60%, vs 26% for EC90 alone. The interim results of this studysuggest the cardiac safety of the combination of H with EC may be greater than that of H with AC (doxorubicin[Adriamycin]/cyclophosphamide); however, studies in larger numbers of patients are warranted. The combinationregimen revealed promising efficacy.
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Thalidomide-Induced Cessation of Weight Loss and Improved Sleep in Advanced Cancer Patients With CachexiaThe cachexia of malignancy is considered mediated through excess production of tumor necrosis factor–alpha and other cytokines. Thalidomide (Thalomid), a sedative/hypnotic, has been shown to inhibit tumor necrosis factor–alpha production.
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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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Practical Guide to Opioids and Their Complications in Managing Cancer PainApproximately 60% of cancer patients experience pain, and 25% to 30% have severe pain. With some cancers, opioids will be needed before chemotherapy begins and may be more frequently prescribed than chemotherapy. Given the frequency with which pain management is necessary in cancer patients, all oncologists should be familiar with opioid prescribing principles. This article reviews the World Health Organization recommendations for analgesic therapy in this setting, as well as guidelines for opioid therapy in patients with renal failure or hepatic failure, assessment of pain, dosing strategies in both acute and chronic pain, management of opioid overdose, pain associated with dose-limiting side effects, and pain in the actively dying.
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Integrating Innovative Therapeutic Strategies Into the Management of Renal Cell CarcinomaIn the current critical review we discuss these emerging trends in localized and systemic treatment as well as possible interesting combinations of the two modalities. Finally, we discuss the role of the new systemic agents in non–clear cell RCC.
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Costs and Effectiveness of Genomic Testing in the Management of Colorectal CancerNumerous genomic tests are available for use in colorectal cancer, with a widely variable evidence base for their effectiveness and cost-effectiveness. In this review, we highlight many of these tests, with a focus on their proposed role, the evidence base to support that role, and the associated costs and risks.
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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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Ofatumumab generates high response rates in refractory CLLOfatumumab (Arzerra) demonstrated clinical benefit was superior to historic outcomes with salvage therapies in this setting, according to lead investigator William G. Wierda, MD, PhD. After about 26 months of median follow-up, progression-free survival and overall survival improved in fludarabine-refractory chronic lymphocytic leukemia and in fludarabine-refractory CLL with bulky lymph nodes.
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Considerations for Treating Pain in the Older Cancer PatientPain in older cancer patients is a common event, and many times it is undertreated. Barriers to cancer pain management in the elderly include concerns about the use of medications, the atypical manifestations of pain in the elderly, and side effects related to opioid and other analgesic drugs. The care of older cancer patients experiencing pain involves a comprehensive assessment, which includes evaluation for conditions that may exacerbate or be exacerbated by pain, affecting its expression, such as emotional and spiritual distress, disability, and comorbid conditions. It is important to use appropriate tools to evaluate pain and other symptoms that can be related to it. Pain in older cancer patients should be managed in an interdisciplinary environment using pharmacologic and nonpharmacologic interventions whose main goals are decreasing suffering and improving quality of life. In this two-part article, the authors present a review of the management of pain in older cancer patients, emphasizing the roles of adequate assessment and a multidisciplinary team approach.
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Palliative Pelvic Exenteration: Patient Selection and ResultsThe authors provide an excellent overview of the role of pelvic exenteration performed as a curative cancer operation or for palliation. They extend the customary definition of palliation, however, to include exenteration intended for cure when tumor is knowingly left behind or is discovered by pathologic review of the operative specimen. The added definitions are apparently based on observations indicating that these procedures can relieve or reduce symptoms related to the disease or its treatment in some patients, resulting in an improved "quality of life," and that some patients also enjoy an extended survival after exenteration
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Commentary (Baile/Parker)-Patient-Physician Communication in Oncology: What Does the Evidence Show?We are delighted to reviewthe article by Dr. TonyBack on communicationwith cancer patients. We applaud hiseffort to provide recommendations forenhanced communication with patientsand families based on findings fromthe literature. We agree that using thecancer trajectory to identify key communicationtasks provides a useful heuristicmodel because, by matchingcommunication tasks to "high-stakes"clinical encounters, this approach intuitivelyappeals to practicing clinicians.As clearly described by Dr. Back, thevast majority of recommendations forcommunication among oncologist, patient,and family are not derived fromevidence-based research. This underscoresthe importance of conductingadditional research to use as a basis forguiding clinicians in how to handlethese challenging communication tasks.
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Management of Locally Advanced or Unresectable Head and Neck CancerIn the following sections, we will first review the radiotherapy techniques that have been investigated. We will then review the progressive advances achieved with the addition of chemotherapeutic strategies to RT in an attempt to achieve better outcomes.
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Discussing Disease Progression and End-of-Life DecisionsBecause most patients now want to know the truth about their diagnosis and prognosis, the ability to discuss the cancer diagnosis, disease recurrence, or treatment failure, and to solicit patients’ views about resuscitation
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Diffuse Large B-Cell Non-Hodgkin Lymphoma in the Very Elderly: Challenges and SolutionsIn this review, we critically analyze clinical trials that were specifically designed for the very elderly, and we discuss the challenges encountered by investigators who are conducting studies in this patient population. We conclude by proposing an algorithm to help clinicians determine the optimal therapeutic strategy for treatment of DLBCL in very elderly patients.
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Altered Fractionation for Head and Neck CancerA conventional course of radiation for squamous cell carcinoma in the United States is generally 70 Gy in 7 weeks, with a once-daily dose of 1.8 to 2 Gy. This schedule has a modest success rate in curing head and neck cancer. The
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Dose-Escalated IMRT Plus Chemo Studied in Locally Advanced Cervical CancerThe 14 reports in this special supplement discuss theuse of the cytoprotectant amifostine in patients withcancer of the head and neck, esophagus, lung, andcervix, as well as those with lymphoma and acutemyelogenous leukemia. Discussions focus on thepotential of this agent to both reduce radiation sideeffects such as xerostomia and permit doseescalation of chemotherapy and/or radiotherapy.Improvements in treatment outcome and quality oflife as a result of cytoprotection are examined.
