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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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Weijing Sun, MD, FACP, Reviews Trends in Gastrointestinal Cancer“...we don’t focus on survivorship enough. It’s important to understand the other factors involved in surviving besides just a treatment.”
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Limited-Stage Small-Cell Lung Cancer: Therapeutic OptionsAlmost 40% of patients with newly diagnosed small-cell lung cancer (SCLC) have disease confined to the ipsilateral hemithorax and within a single radiation port, ie, limited-stage disease. The median survival for this group of patients after treatment is approximately 15 months, with one in every four patients surviving 2 years. Current optimal treatment consists of chemotherapy with platinum/etoposide, given concurrently with thoracic radiation. Surgery may represent an option for very early-stage disease, but its added value is uncertain. Prophylactic cranial irradiation (PCI) is used for patients with limited-stage SCLC who have achieved a complete response following initial therapy, as it decreases the risk of brain metastases and provides an overall survival benefit. Newer targeted agents are currently being evaluated in this disease and hold the promise of improving current outcomes seen in patients with early-stage disease.
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Preparing for and selecting an EHRThe government is providing time-sensitive incentives to drive EHR adoption. There's a lot to learn, let's get started.
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Recurrent Pancreatic Adenocarcinoma After Pancreatic ResectionThe University of Colorado Denver School of Medicine faculty hold weekly second opinion conferences focusing on cancer cases that represent most major cancer sites. Patients seen for second opinions are evaluated by an oncologic specialist. Their history, pathology, and radiographs are reviewed during the multidisciplinary conference, and then specific recommendations are made. These cases are usually challenging, and these conferences provide an outstanding educational opportunity for staff, fellows, and residents in training.The second opinion conferences include actual cases from genitourinary, lung, melanoma, breast, neurosurgery, gastrointestinal, and medical oncology. On an occasional basis, ONCOLOGY will publish the more interesting case discussions and the resultant recommendations. We would appreciate your feedback; please contact us at second.opinion@uchsc.edu.
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Palliation of Colorectal Cancer: New Possibilities and ChallengesOver the past decade, new cytotoxic and biologic therapies beyond the old standard-of-care, biomodulated fluorouracil (5-FU), have become available for the treatment of metastatic colorectal cancer (mCRC). The introductions of irinotecan (Camptosar), oxaliplatin (Eloxatin), and bevacizumab (Avastin) have prolonged survival, but the optimal use of these new therapies remains to be determined. Issues remain regarding management of toxicities, treatment of elderly patients or those with poor performance status, and the duration of treatment with front-line therapy. This article reviews recent and ongoing studies of newer therapies in an effort to determine the best use of these drugs in the treatment of mCRC. Current data support the front-line use of bevacizumab added to either 5-FU/leucovorin alone or 5-FU/leucovorin in combination with oxaliplatin (FOLFOX/bevacizumab) or irinotecan (FOLFIRI/bevacizumab). If oxaliplatin is used in first-line therapy, oxaliplatin should be discontinued before the development of severe neurotoxicity and be reintroduced or replaced with irinotecan on disease progression. Definitive conclusions on the sequence and duration of front-line therapy and the most effective strategy to ameliorate toxicity await results of ongoing prospective clinical trials.
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Commentary on Abstracts #613, #1645, #1035, and #1384Thalidomide (Thalomid) has been commercially available in the United States since October 1998. The use of thalidomide in the treatment of malignancies is growing as its potential utility for treating multiple myeloma, renal-cell cancer, and AIDS-
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The Evolution of Liver-Directed Treatments for Hepatic Colorectal MetastasesThis article will review the current practice of hepatic resection for colorectal liver metastases, including the possibility of combined resection of hepatic metastases at the time of resection of the primary cancer.
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Synopsis of Angiogenesis Inhibitors in OncologyAngiogenesis is a dynamic process essential for primary tumor growth and metastases. New insights into the basic understanding of the biologic processes responsible for angiogenesis have led to the characterization of potential therapeutic targets. Several strategies for the development of antiangiogenic therapeutic modalities have been employed, including agents that (1) decrease the activity of specific angiogenic factors, (2) decrease the activity of endothelial survival factors, (3) increase the activity of naturally occurring antiangiogenic agents, or (4) indirectly downregulate angiogenic and survival factor activity.
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Nursing Challenges of Caring for Patients with HIV-Related MalignanciesThe Moran article presents an excellent summary of the malignancies associated with HIV. The diagnosis of an HIV-related malignancy places additional stress on an already compromised immune system. Neoplasms arising in AIDS patients tend to be aggressive, and because of the immunocompromised state of these patients, they are unable to tolerate the side effects of the various modalities used in treatment.
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Management of Locally Advanced Prostate CancerThe staging and treatment of prostate cancer are complex, particularly in patients with clinical disease that has advanced locally beyond the confines of the gland. Management choices are made more difficult by a paucity of
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Hepatocellular Carcinoma: The Search for Innovative Adjuvant TherapiesThis review summarizes the current data on efficacy and rationale of adjuvant treatment for hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT). The authors review prognostic factors for disease recurrence and adjuvant therapy after OLT, including systemic chemotherapy, intra-arterial chemoembolization, immunosuppressant effects, and sorafenib (Nexavar). Several interesting questions are raised in the article, including: (1) When is the best time to apply systemic chemotherapy?
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Effectiveness of Breast Cancer Screening: What Are the MetricsAs Smith et al[1] discuss, randomized controlled trials (RCTs) have shown that mammography reduces deaths due to breast cancer across ages 40 through 74 years, and within subsets by decade.[2]
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Have We Made Progress in Inflammatory Breast Cancer? Not So FastBreast cancer has long been described as a very heterogeneous disease, and clinicians have struggled with identifying the appropriate treatment program for an individual patient on the basis of multiple variables, including histology, nuclear grade, tumor size, nodal status, hormone receptor status, and a variety of prognostic factors.
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Nutrition During and After Cancer TherapyIn 2008, roughly 1.44 million Americans were diagnosed with cancer,[1] and accordingly were labeled as “cancer survivors.” Fortunately, for roughly 65% of those who were newly diagnosed, this label will expand to encompass issues of long-term survivorship and health maintenance.[2] Extended cancer survivorship is a relatively new concept. In the past, most people who were diagnosed with the disease did not survive it. While longer survival times are a measure of success, the dark side of this victory is that a substantial proportion of these survivors will experience recurrence or second cancers. In addition, many more will go on to develop comorbid conditions such as cardiovascular disease (CVD), diabetes, or osteoporosis, which often kill or debilitate survivors at much higher rates than the cancer itself.[3,4]
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A Patient on Targeted Therapy: CetuximabJeff is a 47-year-old white male who presented to his primary care provider complaining of having had swollen lymph nodes in the right neck for 2 months. He also complained of nasal stuffiness and sore throat. Physical exam found lymphadenopathy in the left cervical triangle less than 2 cm in diameter. He smokes about 2 packs of cigarettes a day and has a 60 pack-year history of smoking. He has been a cabinet-maker for almost 20 years. He has no other significant medical history and is not on any regular medications. He is a social drinker and denies any illicit drug use. He was treated with an antibiotic for 10 days, but on return the lymphadenopathy appeared slightly enlarged. He was sent to an ear, nose, and throat specialist who biopsied the nodal mass. Following an extensive workup, he was diagnosed with stage III (T2, N1, M0) squamous cell carcinoma of the nasopharynx.
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Diagnosis of Invasive Lobular Carcinoma in a Young Woman Presenting With Pleomorphic Lobular Carcinoma in Situ on Core BiopsyA 40-year-old premenopausal woman with a new diagnosis of invasive lobular carcinoma occurring in a background of lobular carcinoma in situ presents to a multidisciplinary second opinion clinic.
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Genetics of Colorectal CancerApproximately 6% of colorectal cancers can be attributed to recognizable heritable germline mutations. Familial adenomatous polyposis is an autosomal dominant syndrome classically presenting with hundreds to thousands of adenomatous colorectal polyps that are caused by mutations in the APC gene.
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Cancer Survivors’ Employment and Insurance Rights: A Primer for OncologistsCurrently, at least 8 million individuals are alive who have survived cancer for 5 or more years.[1] By the year 2000, 1 in 900 individuals between the ages of 16 and 44 years will be survivors of childhood cancer.[2] Given these statistics, the unique
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Survivorship Care: Essential Components and Models of DeliveryWhen caring for patients with a new cancer diagnosis, oncology nurses generally have clear and distinct plans to assist each patient through the phases of diagnosis and treatment. Nurses provide guidance, support, and well-defined patient education regarding the planned treatment, as well as anticipatory guidance regarding management of side effects and emotional responses to diagnosis and treatment.
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Risk of Breast and Ovarian Cancer in Women With Strong Family HistoriesAssessing the risk of breast and ovarian cancer starts with obtaining a complete and accurate family history. This can reveal evidence of inherited cancer risk. The highest risk of cancer is associated with germ-line abnormalities
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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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COUNTERPOINT: Standard vs Investigational Agents as Upfront Treatment for High-Risk AMLAs we learn more about the biology of AML, it appears that 7+3 only rarely clears residual leukemic clones in patients with higher-risk disease. New therapies are needed that can target and eradicate resistant subclones early in the disease course.
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Practical Management of Chemotherapy-Induced Nausea and VomitingApproximately 70% to 80% of all patients who receive chemotherapyexperience nausea and vomiting, which can disrupt their lives in numerousways. Chemotherapy-induced nausea and vomiting (CINV) hastraditionally been classified according to three patterns: acute, delayed,and anticipatory. Additional classifications include refractory and breakthroughnausea and vomiting. The mechanisms by which chemotherapycauses nausea and vomiting are complex, but the most common isthought to be activation of the chemoreceptor trigger zone. An appreciationof the risk factors for developing CINV is important when matchingantiemetic treatment to risk. The emetogenicity of the chemotherapyregimen-generally categorized as high, moderate, low, or minimal-greatly affects a patient’s risk for developing CINV. In addition to establishedand emerging pharmacologic approaches to managing CINV,many complementary and integrated modalities may be options.Progress in CINV management must include a better understanding ofits etiology and a focus on prevention. This review will consider theetiology, assessment, and treatment of patients with CINV.
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Results may be biasedThe [Godinez study] referral pattern for MRI represents a bias in this study population toward young women and women with ambiguous findings on routine imaging, who are not necessarily the same patients referred for APBI, said Dr. Woodward, assistant professor of radiation oncology at M.D. Anderson Cancer Center.
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Coming to Grips With Hand-Foot SyndromeHand-foot syndrome is a localized cutaneous side effect associatedwith the administration of several chemotherapeutic agents, includingthe oral fluoropyrimidine capecitabine (Xeloda). It is never life-threateningbut can develop into a painful and debilitating condition thatinterferes with patients' normal daily activities and quality of life. Severalsymptomatic/prophylactic treatments have been used to alleviatehand-foot syndrome, but as yet there is insufficient prospective clinicalevidence to support their use. The only proven method of managinghand-foot syndrome is treatment modification (interruption and/or dosereduction), and this strategy is recommended for patients receivingcapecitabine. Retrospective analysis of safety data from two largephase III trials investigating capecitabine as first-line therapy in patientswith colorectal cancer confirms that this strategy is effective inthe management of hand-foot syndrome and does not impair the efficacyof capecitabine. This finding is supported by studies evaluatingcapecitabine in metastatic breast cancer. Notably, the incidence andmanagement of hand-foot syndrome are similar when capecitabine isadministered in the metastatic and adjuvant settings, as monotherapy,or in combination with docetaxel (Taxotere). It is important that patientslearn to recognize the symptoms of hand-foot syndrome, so thatprompt symptomatic treatment and treatment modification strategiescan be implemented.
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Differentiated Thyroid Carcinoma: Risk Group Assignment and Management ControversiesIn this review, we provide a framework for clinical decision-making in the treatment of differentiated thyroid cancer. The clinical discussion and treatment recommendations are relevant to an adult population (more than 16
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Metastatic Malignant Melanoma From an Unknown Primary Presenting as a Large Axillary MassThe patient is an otherwise healthy male transferred from an outside hospital with a newly diagnosed melanoma from an unknown primary presenting as a large, left axillary mass.
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Gynecologic Malignancies in Older WomenThe aging of the population is a social phenomenon that will present a challenge to clinical practice in the 21st century. Women constitute a majority of the elderly population as they outlive males by 5 to 7 years. Ovarian,
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Unexpected N2 Lymph Node Involvement Found During Surgery for Early-Stage NSCLCDuring investigation of an episode of self-limiting abdominal pain, a 63-year-old Caucasian female never-smoker was found to have an asymptomatic right lower lobe pulmonary mass. A positron-emission tomography/computed tomography (PET/CT) scan revealed the right lower lobe mass to be 25 × 32 mm with a standardized uptake value (SUV) of 10.2, without evidence of hilar or mediastinal lymphadenopathy or of distant metastases.
