ONCOLOGY Vol 17 No 2

Advanced cancer is associated with symptomsthat negatively affect the quality of life of patientsand their families. One significant effect is thechange cancer evokes in the nociceptive system. Thepatient's pain threshold may change to the pointwhere stimuli not previously considered painful (eg,touching, coughing, and walking) are now perceivedas painful, and painful stimuli evoke an exaggeratedperception of pain. About 75% of patients withadvanced cancer experience moderate to severe pain.

For several decades, the nutritional deterioration ofpatients diagnosed with cancer has been recognized,and attempts have been made to prevent orreverse it. However, with all the advancements intechnology and medicine, it is somewhat surprisingto find that little has altered in the approach or themanagement of cancer patients suffering from acompromised nutritional status or altered metabolismdue to either the treatment or the disease process.

Aseven-state pilot project will study the best way to help oldersmokers kick their nicotine habit. The program, financed by theCenters for Medicare & Medicaid Services (CMS), will testcounseling in person and by phone, a prescription smoking cessationdrug, nicotine patches, and education materials. The 1-year MedicareStop Smoking Program will be conducted in Alabama, Florida, Missouri,Nebraska, Ohio, Oklahoma, and Wyoming, which were selectedusing a formula that included the prevalence of older smokers. Additionalinformation on the program is available at 1-866-652-3446.

Small-cell lung cancer is an aggressive tumor associated with highrates of regional or distant metastases at diagnosis. Although highlychemosensitive to agents given in the first-line setting (eg, etoposideand cisplatin), most patients relapse and have a poor prognosis.Treatment options for relapsed patients include radiotherapy forlimited-stage disease and chemotherapy or combined modalities foradvanced-stage disease. In clinical practice, however, some oncologistsmaintain that chemotherapy provides an insufficient survivalbenefit to justify the sometimes debilitating toxicity associated with themore active regimens in particular. Other potential barriers to furthertreatment include patient comorbidities, performance status, site(s) ofprogression, progression-free interval, and previous treatments. However,numerous clinical trials demonstrate that some patients benefitfrom treatment, achieving prolonged survival, symptom palliation,improved quality of life, and the opportunity, albeit rare, for durableremission. Additionally, several novel chemotherapeutics are availablethat alone or in combination help patients lead an improvedquality of life. Finally, alternative routes and schedules-oral formulations,weekly administration, and prolonged treatment vacations-have been developed to deliver chemotherapy to patients with poorperformance status or multiple comorbidities. This article reviews theadvantages and disadvantages of treating recurrent small-cell lungcancer and summarizes the utility of several active agents.

Dr. Nabhan and his coauthorshave written a comprehensivereview of the use of monoclonalantibodies in the treatment ofchronic lymphocytic leukemia (CLL).They have highlighted importantclinical trials with newer antibodies,including apolizumab (Hu1D10,Remitogen) and IDEC-152 (anti-CD23). The authors concisely describethe use of rituximab (Rituxan)and alemtuzumab (Campath) as singleagents and in combination therapy.Both antibodies have efficacy inthe treatment of CLL, but both havelimitations when used as singleagents.

In this review, Dr. Garrison andher colleagues present a generaloverview of the development ofmyalgias and arthralgias associatedwith taxane chemotherapy. As notedby the authors, these side effects oftreatment can be quite distressing,although clearly not life-threatening.Fortunately, only a minority of patientsexperience such severe symptomsthat consideration needs to begiven to discontinuing treatment orsubstantially altering the planned taxanedose and schedule.

As Dr. Raghavan has emphasizedin his excellent overviewof the current therapyfor testis cancer, it is critical that thesuccess of therapy for this diseasenot be compromised by a desire toavoid the complications of therapy.We would wholeheartedly agree withhis assertion that modifications intherapy must be introduced with athoughtful and structured approachto minimize the risk to efficacy.

Dr. Derek Raghavan, a recognizedexpert in the managementof testicular cancer, isto be congratulated for a clear andconcise overview of the contemporarymanagement of testicular cancer.As a urologist with almost 20years’ experience in the treatment oftesticular cancer, I fully agree withthe concept of not modifying or delayingthe use of proven treatmentprotocols.I can remember as an internand junior resident seeing youngcontemporaries die a horrible deathfrom testicular cancer. Any clinician40 years of age or older can relate tothis scenario, and it probably had thesame impact on them as it did onme-we don’t ever want to “gothere” again.

Despite nearly a decade of paclitaxel’scommercial availability,the best strategy formanaging several paclitaxel-relatedtoxicities including myalgia/arthralgiaremains to be elucidated. Mostavailable data in the treatment of myalgia/arthralgia have been anecdotal,reported in the form of case studiesor within the toxicity results of publishedpaclitaxel-containing clinicaltrials. Garrison et al have provided awell-written review summarizingwhat is currently known about theincidence and management of thisquality-of-life–impacting toxicity.

In this issue of ONCOLOGY, Dr.John Eckhardt provides an excellentreview of the challenge oftherapy for patients with small-celllung cancer (SCLC) who relapse afterfirst-line therapy. Dr. Eckhardt outlinesthe prognostic factors influencingresponse to second-line treatment,survival, and treatment-related toxicity.These prognostic factors includethe response to first-line therapy, theprogression-free interval, and performancestatus. The influence of the chemotherapyregimen and the durationof treatment on symptom palliationand quality of life are also discussed.Dr. Eckhardt provides an excellentsummary of the activity of multipleagents in the second-line setting.

The Department of Health and Human Services (HHS) has createda unified advisory committee on human immunodeficiency virus(HIV) and sexually transmitted diseases (STD) by merging twoexisting groups. The new committee brings together the AdvisoryCommittee for HIV Prevention at the Centers for Disease Control andPrevention (CDC) and the AIDS Advisory Committee at the HealthResources and Services Administration (HRSA). The two groups havemet jointly on several occasions during the last 2 years, and all currentmembers of the two bodies will serve on the new CDC/HRSA AdvisoryCommittee on HIV and STD Prevention and Treatment.

A6-year prostate cancer research plan released by the NationalInstitutes of Health (NIH) contains a detailed outline of theNational Cancer Institute’s (NCI) future strategy for dealingwith the disease, which includes a shift in the standard treatment modelfrom seek-and-destroy to target-and-control.

In a recent study, Wolfe and others interviewed 103parents of children who had died from cancer.[1]Approximately 80% of these children suffered anorexia,or loss of appetite. Over 35% of parents identifiedanorexia as a cause of distress for their child whena physician failed to recognize it. Wolfe and othersconcluded,"greater attention to symptomcontrol.…might ease…suffering." In adults, the syndromeof cancer anorexia/weight loss is no lesspervasive, and no less distressing. Anorexia is one ofthe most deleterious symptoms, surpassed only bypain and fatigue.[2] The majority of adults withadvanced cancer suffer from it toward the end of life.Among all cancer patients-regardless of age orcancer type-"greater attention to [the anorexia/weightloss syndrome]…might ease…suffering."

Specialty nutrition for patients with cancer is anexciting area in research. It is well known thatpatients with cancer experience many nutritionalproblems during the course of their disease-in particularanorexia and weight loss.[1,2] Specialty nutritioncan impact nutritional status directly by improvingweight and lean body mass, or indirectly by improvingcommon symptoms often associated with cancerand cancer therapies.

Drs. Nabhan, Dyer, and Rosenprovide an excellent and comprehensivereview of the therapeuticrole of rituximab (Rituxan)and alemtuzumab (Campath) inchronic lymphocytic leukemia (CLL).We take this opportunity to offer ourcomments concerning these two monoclonalantibodies in CLL.

Small-cell lung cancer (SCLC)poses one of the greatest managementchallenges in clinicaloncology, as the mortality rate approaches95% within 2 years afterpresentation for patients with extensivedisease, despite widespread useof combination chemotherapy.[1]Given a disease that is largely managedby the community physician andfor which recent definitive clinicaltrials are relatively scarce,[2] it isincumbent upon the clinician to becognizant of the critical factors innostudies suggesting that three-drugcombinations are indicated.

Neurotoxicity is a well-describedside-effect of paclitaxeltherapy, often characterizedas a peripheral sensory neuropathy.Neuropathy is a dose-dependenteffect, occurring with cumulative cyclesand higher doses. Occasionally,this may be dose-limiting for patientswho are benefiting from treatment, aswell as problematic for subsequenttherapies. Another well-recognizedthough less-described neurotoxic effectof paclitaxel is myopathy. Myopathy,consisting of myalgias andarthralgias, can be at least as commonwith standard paclitaxel regimens andequally troubling for patients. In thisissue of ONCOLOGY, Garrison andcolleagues review paclitaxel-associatedmyopathy and offer suggestionsfor patient management.

During 1973–1999, both the incidenceof and death rates forcervical cancer decreased byapproximately 50% in the UnitedStates. For 2002, approximately13,000 new cases of invasive cervicalcancer are expected, and approximately4,100 women will die of the disease.Although invasive cervical cancer canbe prevented by regular screening, theprevalence of Pap testing remains relativelylow among minority populationssuch as Hispanic women.

The management of germ cell tumors has advanced dramatically,with cure rates approaching 90% to 95%. Treatment of stage I/Aseminomas generally includes orchiectomy and adjuvant radiotherapy.Treatment of stage I/A nonseminomatous germ cell tumors involvesorchiectomy followed by retroperitoneal lymph node dissection oractive surveillance. One of the major advances has been the introductionof cisplatin-based chemotherapy for metastatic disease and thedevelopment of a system of risk attribution. The logical managementof any patient with curable disease is to provide curative therapy andthen follow the patient in a structured manner, to diagnose and treatany complications in a timely manner.

Despite many therapeutic options for chronic lymphocytic leukemia(CLL), the disease remains incurable. Since monoclonal antibodiesand recombinant toxins that bind surface antigens expressed on themalignant lymphocytes have been developed, targeted therapy hasbecome a vital option in treating CLL. Rituximab (Rituxan), a chimerichuman-mouse anti-CD20 antibody, and alemtuzumab (Campath), ahumanized anti-CD52 monoclonal antibody, have both shown activityin CLL-as single agents and in combination with conventionalchemotherapy. The possibility of combining antibodies has beenexplored as well, with some efficacy. In this review, we discuss theclinical data on the activity of commercially available antibodies inCLL, both as monotherapy and in combination with other agents.

Paclitaxel-induced myalgias and arthralgias occur in a significantfraction of patients receiving therapy with this taxane, potentiallyimpairing physical function and quality of life. Paclitaxel-inducedmyalgias and arthralgias are related to individual doses; associationswith the cumulative dose and infusion duration are less clear. Identificationof risk factors for myalgias and arthralgias could distinguisha group of patients at greater risk, leading to minimization of myalgiasand arthralgias through the use of preventive therapies. Optimalpharmacologic treatment and possibilities for the prevention of myalgiasand arthralgias associated with paclitaxel are unclear, partially dueto the small number of patients treated with any one medication. Theeffectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) is themost frequently documented pharmacologic intervention, although noclear choice exists for patients who fail to respond to NSAIDs. However,the increasing use of weekly paclitaxel could necessitate daily administrationof NSAIDs for myalgias and arthralgias and leave patients at riskfor adverse effects. This concern may also limit the use of corticosteroidsfor the prevention and treatment of paclitaxel-induced myalgias andarthralgias. Data from case reports suggest that gabapentin (Neurontin),glutamine, and, potentially, antihistamines (eg, fexofenadine [Allegra])could be used to treat and/or prevent myalgias and arthralgias. Giventhe safety profile of these medications, considerable enthusiasm existsfor evaluating their effectiveness in the prevention and treatment ofpaclitaxel myalgias and arthralgias, particularly in the setting ofweekly paclitaxel administration.

Approximately 30,300 people will be diagnosedwith pancreatic cancer in the UnitedStates this year. The 99% mortality rate is thehighest of any cancer, and most patients die within 1year of diagnosis.[1] There are only two drugs approvedas a first-line indication for pancreatic cancerpatients, and treatment options are very limited.These patients have poor prognoses and few options,and must make decisions in short time frames.

Nurses seeking to meet the palliative care nutritionalneeds of their patients are increasinglychallenged to work with ongoing, evolving situations,as patients live longer and longer. In the complexcase described below, which illustrates some ofthese challenges, it was useful to have in place,accessible, standardized assessment tools that allowedfor continued nutritional follow-up acrosspractice settings, targeting interventions that best fitwith the patient's goals.

Traditionally, dietitians have relied on objectiveparameters (such as anthropometric, biochemical,and immunologic measures) to assess nutritionalstatus. The usefulness of these parameters has beenquestioned in view of the many non-nutritional factorsaffecting the results. Hence, subjective assessmentof nutritional status has been used to overcomethese difficulties.

Dr. Raghavan is to be commendedfor a concise andcomprehensive overview ofthe management of germ cell tumors.As he suggests, given the demographicsof this relatively uncommon diseaseand the high cure rate that canbe achieved with proper treatmentand follow-up, it behooves us to maintainthese excellent results, even whilestriving to reduce the toxicity of treatment.We will highlight a few additionalpoints to complement thissuperb review.

Palliative care, previously viewed by many as anend-of-life movement, is now recognized as anapproach whose principles should infuse the care ofall patients with a chronic illness throughout the fullcourse of that illness. For example, the World HealthOrganization (WHO) has redefined palliative care asfollows: