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Advance Care Planning: We Can Do It!In my own practice, advance care planning is a part of every history and physical. In the beginning, I found the topic awkward and uncomfortable to bring up with my patients.
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The Pathology of Cutaneous T-Cell LymphomaThe diagnosis of cutaneous T-cell lymphoma (CTCL) requires accurate histopathology, including immunocytochemistry, as well as careful clinical appraisal and analysis for T-cell clonality. This paper reviews the key histologic features of mycosis fungoides (MF) and its variants, and of lymphomatoid papulosis (LyP). Mycosis fungoides is an epidermotropic CTCL that evolves through distinct disease stages of patch, plaque, and tumor, often leading to transformation in the final stages. Disease staging is made clinically, and diagnosis may be difficult during the early stages because several common dermatologic conditions share features with MF. Therefore, clinical appraisal plus the presence of characteristic histopathologic features are needed to ensure accurate diagnosis. Clinical information is particularly important in the diagnosis of LyP, as the disease appears malignant histologically, but has a benign clinical course. Several other T-cell lymphomas were defined in a recent classification of these cutaneous lymphomas, and some key features of these disorders are also briefly reviewed.
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The Heavy Chain Diseases: Clinical and Pathologic FeaturesThis review discusses the clinical presentation; epidemiology; laboratory, radiologic, and pathologic features; and treatment options for each of the heavy chain diseases, emphasising the importance of an accurate pathologic diagnosis and correct interpretation of immunologic studies in their identification.
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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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Cervical Cancer: Issues of Sexuality and FertilityThe importance of quality of lifeduring and after treatment forcervical cancer has been ignoredfor too long. The pervasive attitudethat focuses on cure, withmorbidity an afterthought, is stillparamount in many patients’ and oncologists’minds. However, at the insistenceof patients and families, manyclinicians have recognized and startedto address these issues over thepast 2 decades.
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Bilateral, Multifocal Renal Masses in a 35-Year-Old Man With a History of Tuberous Sclerosis ComplexA 35-year-old man with a known history of tuberous sclerosis complex was referred to the urology clinic by his primary care physician for consultation regarding bilateral, multifocal renal masses.
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Contemporary Management of Prostate Cancer With Lethal PotentialIn this issue of ONCOLOGY, Daviset al provide a succinct overviewof the contemporary managementof high-risk prostate cancer patients.[1] As the authors point out, theintroduction and widespread implementationof prostate-specific antigen(PSA) as a tumor marker hasdriven a remarkable stage migrationin how patients present with prostatecancer, yet a significant number ofmen continue to present with featuresplacing them at high risk for localtreatment failure, development ofprostate cancer metastases, and ultimately,death.
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Commentary (Lipton): Aromatase Inhibitors and Bone LossThe aromatase inhibitors (AIs) anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) are significantly more effective than the selective estrogen-receptor modulator (SERM) tamoxifen in preventing recurrence in estrogen receptor-positive early breast cancer. Aromatase inhibitors are likely to replace SERMs as first-line adjuvant therapy for many patients. However, AIs are associated with significantly more osteoporotic fractures and greater bone mineral loss. As antiresorptive agents, oral and intravenous bisphosphonates such as alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), pamidronate (Aredia), and zoledronic acid (Zometa) have efficacy in preventing postmenopausal osteoporosis, cancer treatment-related bone loss, or skeletal complications of metastatic disease. Clinical practice guidelines recommend baseline and annual follow-up bone density monitoring for all patients initiating AI therapy. Bisphosphonate therapy should be prescribed for patients with osteoporosis (T score < -2.5) and considered on an individual basis for those with osteopenia (T score < -1). Modifiable lifestyle behaviors including adequate calcium and vitamin D intake, weight-bearing exercise, and smoking cessation should be addressed. Adverse events associated with bisphosphonates include gastrointestinal toxicity, renal toxicity, and osteonecrosis of the jaw. These safety concerns should be balanced with the potential of bisphosphonates to minimize or prevent the debilitating effects of AI-associated bone loss in patients with early, hormone receptor-positive breast cancer.
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DNA Topoisomerase I-Targeting Drugs as Radiation SensitizersCombination chemoradiation, alone or as an adjuvant to surgery, has been shown to improve treatment outcomes in a number of human malignancies, but may be limited by normal tissue toxicities. A primary challenge in
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Postmastectomy Radiation: Then and NowPostmastectomy radiotherapy has been used since the early part of the 20th century in an effort to decrease local recurrences and potentially improve survival. It clearly reduces the rate of local chest-wall failure following mastectomy, increases relapse-
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Docetaxel/Doxorubicin/Cyclophosphamide in the Treatment of Metastatic Breast CancerPreliminary results from phase I trials suggest that the use of docetaxel (Taxotere) and doxorubicin (Adriamycin) is a well tolerated and highly active combination regimen for
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Focal Therapy: A New Active Surveillance Tool?Focal therapy is an appealing addition to our current AS strategies. As a “lesser evil,” focal therapy is showing promise as a therapy that can provide cancer control, while also avoiding many of the radical treatment–associated morbidities.
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Intermediate- and High-Grade Non-Hodgkin's LymphomasThe non-Hodgkin's lymphomas (NHLs) are a collection of lymphoid malignancies with a diverse pathology and natural history. This diversity is illustrated by the different histologic subtypes and classifications of NHL that have appeared over the years.
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Paraganglioma: A Potentially Challenging TumorThe development of metastatic disease in patients with paraganglioma is an unusual and challenging event. This case report and review describes the specific features of this disease and the multiple therapeutic options.
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MRI for every APBI candidate: An open questionIn this retrospective study by Godinez et al, 30 (38%) of 79 patients had additional foci on MRI. The researchers suggested that MRI should be used prior to APBI to rule out the presence of multifocal or multicentric disease.
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CCR Scores and Beyond: Precision Strategies for Treatment Intensification in Prostate CancerAlvaro Martinez, MD discusses how emerging genomic risk stratification tools such as the clinical cell-cycle risk (CCR) score are transforming personalized prostate cancer treatment by enabling more nuanced assessments of metastasis risk and treatment intensification strategies beyond traditional NCCN risk groupings.
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Commentary (Morales): BCG Immunotherapy for Transitional-Cell Carcinoma in Situ of the BladderVery few people have the level of expertise Dr. Lamm does with the use of bacillus Calmette-Guérin (BCG) for the treatment of superficial bladder cancer. His enthusiasm is based on a large, solid experience with the vaccine. He has pushed the therapeutic effectiveness of BCG to new levels and has reviewed the world literature on the subject frequently and conscientiously. The current review covers most areas of interest in depth. A few key points deserve emphasis, however.
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UFT/Methotrexate/Leucovorin for Breast Cancer Patients in Progression After HDCT/PBPC SupportTwenty-four patients with metastatic breast cancer that had progressed after high-dose chemotherapy with peripheral blood progenitor cell (PBPC) support were given intramuscular methotrexate in combination with oral
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Advantages of Every-3-Week Dosing of Erythropoietic Agents to Manage Chemotherapy-Induced AnemiaPatients receiving chemotherapy for cancer often develop anemia, which can contribute to increased morbidity and reduced quality of life.[1] It is important for clinicians to be aware of current clinical studies in the treatment of chemotherapy-induced anemia. In patients with nonmyeloid malignancies, chemotherapy-induced anemia can be successfully treated using erythropoiesis-stimulating agents (ESAs). The application of these agents has evolved from more frequent to less frequent administration and from weight-based to single, fixed doses. Emerging data show that ESAs can be given safely on the same day as chemotherapy without loss of efficacy,[2] and that these agents may be administered as infrequently as every 3 weeks.[3,4] The every-3-week schedule is convenient and may reduce the burden on patients and their caregivers by reducing the number of visits to the clinic.
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The UFT/Leucovorin/Etoposide Regimen for the Treatment of Advanced Gastric CancerGastric cancer is the most chemosensitive adenocarcinoma among digestive neoplasms. A few years ago, we performed a phase II trial with the FLEP regimen, in which fluorouracil (5-FU) and leucovorin are combined
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Lapatinib Plus Letrozole May Improve EfficacyIn metastatic breast cancer (MBC), lapatinib (Tykerb) + letrozole (Femara) delayed disease progression in HER2+, HR+ patients, according to initial results from a phase III trial (EGF30008) presented by Stephen Johnston, MD (abstract 46).
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Counseling Women at High Risk of Ovarian or Endometrial CancerPatient education and counseling are essential in women at increased risk for ovarian and endometrial cancer. Women must be educated regarding the signs, symptoms, and risks associated with these cancers.
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Diagnostic Evaluation of Hepatocellular Carcinoma in a Cirrhotic LiverHepatocellular carcinoma (HCC) is one of the world’s most common cancers. It is closely associated with cirrhosis, especially that due to viral hepatitis. The incidences of viral hepatitis and HCC are rising steadily in the United
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Multidisciplinary Management of Breast Cancer Brain MetastasesThis review summarizes the most up-to-date approach to the multidisciplinary management of patients with breast cancer brain metastases.
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Metabolic Syndrome After Hormone-Modifying Therapy: Risks Associated With Antineoplastic TherapyThe incidence of metabolic syndrome is rapidly increasing. Metabolic syndrome is associated with elevated morbidity and mortality secondary to cardiovascular disease, insulin resistance, and hepatic dysfunction. A body of evidence has already implicated metabolic syndrome as a cancer risk factor; emerging evidence now suggests that cancer survivors themselves may be at risk for developing metabolic syndrome as a result of their anti-cancer therapy. Treatment of both breast cancer and prostate cancer often involves hormone-modifying agents that have been linked to features of metabolic syndrome. Androgen suppression in men with prostate cancer is associated with dyslipidemia, increasing risk of cardiovascular disease, and insulin resistance. Anti-estrogen therapy in women with breast cancer can affect lipid profiles, cardiovascular risk, and liver function. Similar findings have been noted in men with testicular cancer treated with chemotherapy. In addition, several emerging therapies, including mammalian target of rapamycin (mTOR) inhibitors and targeted kinase inhibitors, are increasingly associated with some features of metabolic syndrome. As the number of cancer survivors continues to grow, consideration of these factors and of the risk of metabolic syndrome will become increasingly important when choosing between therapy options and managing long-term follow-up.
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Current and Emerging Treatments for Brain MetastasesConventional methods for treating brain metastasis, such as surgery, WBRT, and SRS, each compete with and complement one another. A plethora of recent studies have helped define and expand the utility of these tools.
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Management of a Patient With Borderline Resectable Pancreatic CancerIn this case report, we discuss the presentation, workup, and therapeutic management of a 40-year-old man who presented with borderline resectable, periampullary pancreatic cancer and underwent a margin-negative resection following neoadjuvant chemoradiotherapy.
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Imaging Tumoral Hypoxia: Oxygen Concentrations and BeyondThe role of hypoxia as a key determinant of outcome for human cancers has encouraged efforts to noninvasively detect and localize regions of poor oxygenation in tumors. In this review, we will summarize existing and developing techniques for imaging tumoral hypoxia. A brief review of the biology of tumor oxygenation and its effect on tumor cells will be provided initially. We will then describe existing methods for measurement of tissue oxygenation status. An overview of emerging molecular imaging techniques based on radiolabeled hypoxic markers such as misonidazole or hypoxia-related genes and proteins will then be given, and the usefulness of these approaches toward targeting hypoxia directly will be assessed. Finally, we will evaluate the clinical potential of oxygen- and molecular-specific techniques for imaging hypoxia, and discuss how these methods will individually and collectively advance oncology.
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The Moving Target of Cancer Care CostsPatients aged 65 years and older represent 12% of the US population yet account for approximately 56% of cancer cases and 69% of all cancer mortalities. The overall cost of cancer in 2005 was $209.9 billion—$74 billion for direct medical costs and $118.4 billion for indirect mortality costs. This paper considers the direct, indirect, and out-of-pocket expenditures incurred by cancer patients ‚â • 50 years of age. Several major empirical studies on supportive care for older patients and cancer-related costs were reviewed. Insurance coverage, hematologic malignancies, squamous cell carcinoma of the head and neck, and cancers of the breast, prostate, colorectum, and lung were evaluated. Major sources of direct medical expenditures covered by third-party insurers for patients aged 65 years and older include extended length of hospital stay, home health assistance following hospital discharge, adjuvant prescription medications, lower-risk treatment (for prostate cancer), and advent of new pharmaceuticals (for colorectal cancer). The mean total direct medical cost for breast cancer is $35,164, and the cumulative cost for prostate cancer is $42,570. Emerging targeted cancer drug costs range from $20,000 to $50,000 annually per patient. Additional clinical trials and cost-effective treatments are needed for older patients to ameliorate the disproportionate economic burden among older individuals with cancer. Additional research about cancer costs may also lead to reforms in cancer care reimbursement, and therefore provide access to affordable health care for older patients.
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Genomic Subtypes in Choosing Adjuvant Therapy for Breast CancerAdditional insight into the biology of ER-positive breast cancers, particularly the higher risk luminal B cancers, could aid in identifying potential targets and new, effective therapies. And though the majority of triple-negative breast cancers are the “basal-like” subtype, significant proportions are in other subtypes.
