ONCOLOGY Vol 17 No 8

The incidence of ovarian carcinoma increases with advancing age,peaking during the 7th decade of life and remaining elevated until age80 years. Despite the high prevalence of ovarian cancer in the elderly,the management of these patients is often less aggressive than that oftheir younger counterparts. As a result, many elderly cancer patientsreceive inadequate treatment. However, data do not support the conceptthat age, per se, is a negative prognostic factor. In fact, the majority ofelderly patients are able to tolerate the standard of care for ovariancancer including initial surgical cytoreduction followed by platinumand taxane chemotherapy. Because functional status has not demonstrateda reliable correlation with either tumor stage or comorbidity,each patient’s comorbidities should be assessed independently. Forelderly patients with significant medical comorbidity, the extent ofsurgery and aggressiveness of chemotherapy should be tailored to theextent of disease, symptoms, overall health, and life goals. In addition,enhanced cooperation between geriatricians and oncologists may assistthe pretreatment assessment of elderly patients and improve treatmentguidelines in this population.

Paragangliomas are unusual tumorsof the head and neck butshould be included in the differentialdiagnosis of lateral neck masses.Although malignant paragangliomasare possible, these tumors are usuallybenign. Nevertheless, treatment canlead to great morbidity and possiblemortality. The article by Drs. Hu andPersky addresses a multidisciplinaryapproach to these lesions.

As the population ages over thenext 50 years, the number ofcancer patients is expected todouble from the current 1.3 million to2.6 million, and the majority of thosepatients will be at least 75 years old.[1]Projected increases in life expectancyaccount for this change. For womenliving in industrialized countries, it isestimated that the average life span infuture decades will reach 90 years.[2]Most cancers increase in incidenceand mortality as a population ages,although the causal link between oncogenesisand senescence remainscomplex and elusive. Within the contextof an upsurge in cancer incidence,an analysis of the inequitable treatmentof older patients afflicted withcancer takes on an urgent need.

Hormonal treatment of advanced prostate cancer should be consideredfor patients who have stages C and D1 disease, a high risk of recurrenceafter local therapy, or prostate-specific antigen–measured recurrenceafter local treatment. This approach is dependent on most prostatecancer cells being androgen-dependent, but androgen-independentcells may arise after several years of hormonal therapy. Options forandrogen blockade primarily include orchiectomy, luteinizing hormone–releasing agonists and antagonists, and nonsteroidal antiandrogens.There is some controversy regarding combined androgen blockade,intermittent androgen blockade, and the question of whether earlyandrogen blockade is superior to delayed therapy. Convincing data doexist for the use of adjuvant/neoadjuvant hormonal therapy with external-beam radiation therapy. Although hormonal therapy is an importanttreatment modality for advanced prostate cancer, long-termtreatment carries significant side effects that need to be considered.

With the population aging,cancer in older persons isbecoming an increasinglycommon problem.[1] The benefit ofantineoplastic treatment may be diminishedand the risk enhanced byaging, due to a progressive reductionin life expectancy and in the functionalreserve of multiple organ systems.[2] To establish the most suitablecourse of action in individual cases,the practitioner needs to be able toaddress the following questions: Is thecancer going to compromise the survivalor the quality of life of the patient?Is the patient able to tolerate thepotential risk of cancer treatment?

Paragangliomas most commonly occur in the carotid body, jugulotympanicarea, and vagus nerve but have also been reported in otherareas of the head and neck. These tumors are highly vascular andcharacteristically have early blood vessel and neural involvement,making their treatment particularly challenging. Surgery has traditionallybeen the preferred method of treatment, especially in light of recentadvances in technique. However, compared to radiation therapy, it canresult in a higher incidence of cranial nerve dysfunction. Radiationtherapy has the advantage of avoiding the increased morbidity ofsurgery while offering an equal possibility of cure. Part 2 of this articlediscusses radiation therapy as primary treatment of patients who areineligible for surgery and the elderly and infirm. Results with radiotherapyare comparable to those achieved with surgery. The efficacy ofsalvage therapy with either surgery or radiation is discussed, and atreatment algorithm for these tumors is proposed.

Over the past 2 decades, breast-conservation therapy with lumpectomyand whole-breast radiotherapy has become a standard option for themajority of women with newly diagnosed breast cancer. Long-term localcontrol is achieved in approximately 85% of patients, and the therapy isgenerally well tolerated. There can, however, be long-term effects on thebreast and other nearby tissues that may range from asymptomaticfindings on examination to severe, debilitating problems. Infection, fatnecrosis, and severe musculoskeletal problems such as osteoradionecrosisor soft-tissue necrosis are uncommon, affecting less than 5% ofpatients. However, changes in range of motion, mild-to-moderate musculoskeletalpain, and arm and breast edema are much more common.As more women choose breast-conservation therapy for management oftheir breast cancer, physicians will encounter these problems, as well asin-breast tumor recurrence, with greater frequency. This review willfocus on the incidence, contributing factors, and management of thelate problems of infection, fat necrosis, musculoskeletal complications,and local recurrence following breast-conservation therapy.

Breast-conserving therapy maywell be the best-studied therapyin all of medicine, with dataavailable from seven mature prospectiverandomized trials that comparedoutcomes with the “gold standard” ofablative mastectomy, as well as datafrom specific programs across thecountry and globe, reflecting a broadrange of clinical and technical skillsand philosophic and technical variationson the theme of breast-conservingtherapy. However, relatively littlehas been published on the late effectsof this therapy. Frassica et al havedone an excellent job of producing adescriptive catalog of the majority ofpotential late effects in patients whosurvive breast-conserving therapy,complete with suggestions regardingmanagement.

Sequelae that affect quality of lifein women following breastconservationtherapy can begrouped into three categories: (1) thosethat affect cosmesis such as skinchanges, distortion, and asymmetry ofthe breasts; (2) those that cause physicalsymptoms such as local pain, decreasedmobility of the ipsilateralshoulder, and in extreme cases, respiratoryand cardiovascular impairments;and (3) those that require furthertreatment such as breast infection andabscess, arm edema, soft-tissue andbone necrosis, rib fractures, in-breasttumor recurrence, and second malignancieswithin the treated area.

Medicare will grant limited coverage for the use of positronemissiontomography (PET) for certain of its beneficiariessuffering from thyroid cancer, the Centers for Medicare andMedicaid Services (CMS) recently announced. CMS also said that ithad refused a request to provide PET coverage for soft-tissue sarcomabecause imaging techniques currently covered by Medicare providegood diagnostic results.

The adverse effects of cancertreatment can be divided intothree groups: those that aresignificant and life-threatening, thosethat are not life-threatening but resultin lifestyle changes, and those that areof minor severity and limited duration.The potential significant and lifethreateningeffects of radiation in thetreatment of breast cancer includecardiac toxicity and carcinogenesis.Two prospective randomized trials ofbreast-conserving surgery and radiationhave demonstrated no increase inthe risk of non–breast cancer death at20 and 25 years among patients whoreceived radiation compared to thosetreated by mastectomy.[1,2]

For many years, prostate cancerhas been known to be sensitiveto androgens. Indeed, endocrinemanipulations aimed at the reductionof serum testosterone to below oraround the castrate range have beenthe mainstay in the management ofadvanced prostate cancer for the past60 years. Despite widespread testing,the advances with this treatment modalityfor prostate cancer over the pastseveral decades have been modest.Unfortunately, the answers to manyrelevant critical questions still lie inthe future. The limiting factor of hormonaltherapy is that a significant proportionof tumor cells are not affectedby androgen deprivation.

Approximately 70% of patientswith life-threatening diseasestreatable with allogeneic bloodstem cell transplantation do not havematched related donors. The NationalMarrow Donor Program (NMDP) wasestablished in 1986 to provide humanleukocyte antigen (HLA)-matched,volunteer unrelated donors for thesepatients. The NMDP performs thistask by maintaining a registry of morethan 4.9 million volunteer donors ofmarrow and peripheral blood stemcells (PBSC) and 12 cord blood bankscontaining more than 25,000 units ofumbilical cord blood.

Oottamasathien and Crawfordadvance a hypothesis withwhich I heartily agree-androgendeprivation/antagonist (AD/A)strategies should be considered in manymore patients than urologists and oncologiststraditionally teach. However,I think the authors could substantiallysharpen their message. I would like tomake five specific points, and thenoffer a few nitpicking comments.

We have reviewed with interestthe article by Drs. Huand Persky and would liketo congratulate them on an excellentand comprehensive overview of theevaluation and management ofparagangliomas of the head and neck.Their review begins with an excellentlydetailed description of thedisease and staging work-up. Withmodern imaging, most paragangliomasare convincingly diagnosed basedon typical location (carotid bifurcation,nodose ganglia of the vagusnerve, middle ear along tympanic plexus,or near jugular bulb) and characteristicradiographic appearance(hypervascular, intensely enhancingmass). A tissue diagnosis is usuallyunnecessary for such lesions.

Senior officials of the National Cancer Institute are developingstrategies to achieve the goal set forth by NCI director Andrew C.von Eschenbach, MD, of eliminating the suffering and deathcaused by cancer by 2015. The institute expects to unveil the newstrategies during the next 12 months.