ONCOLOGY Vol 20 No 10

Hana Biosciences recently announced the initiation of a multicenter phase II clinical trial of vincristine sulfate liposomal injection (Marqibo) in patients with relapsed or refractory acute lymphoblastic leukemia (ALL).

Nearly 150,000 people will be diagnosed with colorectal cancer in the United States in 2006. The impact of this diagnosis will be felt by countless family members, coworkers, and friends. Although screening tests for colorectal cancer have been available and encouraged by medical associations such as the American Cancer Society (ACS) and others, public awareness and compliance has been dismal.

The liver is a frequent site of metastatic colorectal disease. Over the past 20 years, improvements in systemic chemotherapy and surgical techniques have improved the survival of patients with hepatic metastases. For 4 decades, fluorouracil and leucovorin were the only drugs available to treat metastatic colorectal cancer, but several new drugs and a variety of novel regimens are now available. Further improvements in results have been seen with the delivery of chemotherapy via the hepatic artery. Surgical resection of liver metastases has been encouraged when possible, and recent advances in surgery such as portal vein embolization, have made liver resection a possibility for more patients. This review considers the timing and sequence of chemotherapy and surgery in this setting, as well as the roles of cryoablation, radiofrequency ablation, and radiation therapy.

MGI Pharma, Inc, recently announced that the US Food and Drug Administration (FDA) has granted decitabine (Dacogen) orphan designation for the indication of acute myeloid leukemia (AML).

Multiple myeloma is now the most common indication for autologous stem cell transplantation (ASCT) in North America, with over 5,000 transplants performed yearly (Center for International Blood and Marrow Transplant Research [CIBMTR] data). While the role of ASCT as initial therapy in multiple myeloma has been established by randomized studies, newer therapies are challenging the traditional paradigm. The availability of novel induction agents and newer risk stratification tools, and the increasing recognition of durability of remissions are changing the treatment paradigm. However, even with arduous therapy designed to produce more complete remissions—for example, tandem autologous transplants—we have seen no plateau in survival curves. A tandem autologous procedure followed by maintenance therapy may be performed in an attempt to sustain remission. Sequential autologous transplants followed by nonmyeloablative allotransplants are pursued with the hope of "curing" multiple myeloma. We examine how the key challenges of increasing the response rates and maintaining responses are being addressed using more effective induction and/or consolidation treatments and the need for maintenance therapies after ASCT. We argue that given the biologic heterogeneity of multiple myeloma, risk-adapted transplant approaches are warranted. While the role of curative-intent, dose-intense toxic therapy is still controversial, conventional myeloablative allogeneic transplants need to be reexamined as an option in high-risk aggressive myeloma, given improvements in supportive care and transplant-related mortality.

The liver is a frequent site of metastatic colorectal disease. Over the past 20 years, improvements in systemic chemotherapy and surgical techniques have improved the survival of patients with hepatic metastases. For 4 decades, fluorouracil and leucovorin were the only drugs available to treat metastatic colorectal cancer, but several new drugs and a variety of novel regimens are now available. Further improvements in results have been seen with the delivery of chemotherapy via the hepatic artery. Surgical resection of liver metastases has been encouraged when possible, and recent advances in surgery such as portal vein embolization, have made liver resection a possibility for more patients. This review considers the timing and sequence of chemotherapy and surgery in this setting, as well as the roles of cryoablation, radiofrequency ablation, and radiation therapy.

Amgen announced interim results from two phase II studies of panitumumab, an investigational fully human monoclonal antibody that targets the epidermal growth factor receptor (EGFR). Results from both studies suggest that the antitumor activity of panitumumab was independent of tumor EGFR expression levels in patients with metastatic colorectal cancer who have failed standard chemotherapy.

The US Food and Drug Administration (FDA) has approved the use of a two-drug combination developed by researchers at Rational Therapeutics Institute (Long Beach, Calif) for the treatment of ovarian cancer.

Lung cancer is the leading cause of cancer mortality in the United States. A significant number of patients present with disease involving mediastinal lymph nodes. As survival after surgery alone for stage III disease is poor, radiation therapy and chemotherapy have been evaluated in the neoadjuvant and adjuvant settings to improve outcomes. The benefit of adjuvant chemotherapy in the subgroup of patients with N2 disease is uncertain. Small randomized trials enrolling patients with stage III disease have shown a benefit of neoadjuvant chemotherapy over surgery alone. Whether neoadjuvant chemotherapy is superior to adjuvant chemotherapy is under investigation. Furthermore, whether neoadjuvant chemoradiotherapy is superior to neoadjuvant chemotherapy is controversial, and few randomized studies comparing these approaches have been reported. Nevertheless, neoadjuvant chemoradiotherapy appears to be associated with higher rates of resection, higher rates of clearance of mediastinal nodal disease, and better local/regional control. The use of postoperative radiation therapy (PORT) has declined since the publication of the 1998 meta-analysis suggested a detriment in survival with this strategy. However, radiation techniques are improving and emerging data support the use of carefully delivered PORT. Finally, it remains unclear whether surgical resection offers an advantage over definitive chemoradiotherapy alone for stage III disease. In summary, locally advanced NSCLC remains a formidable challenge with few cures, and optimal treatment requires the careful use of surgery, chemotherapy, and radiation therapy.

"Although the majority of patients with advanced ovarian cancer will die of the disease, optimism is justified in view of the improved results of surgery followed by cisplatin and carboplatin based chemotherapy."

Multiple myeloma is now the most common indication for autologous stem cell transplantation (ASCT) in North America, with over 5,000 transplants performed yearly (Center for International Blood and Marrow Transplant Research [CIBMTR] data). While the role of ASCT as initial therapy in multiple myeloma has been established by randomized studies, newer therapies are challenging the traditional paradigm. The availability of novel induction agents and newer risk stratification tools, and the increasing recognition of durability of remissions are changing the treatment paradigm. However, even with arduous therapy designed to produce more complete remissions—for example, tandem autologous transplants—we have seen no plateau in survival curves. A tandem autologous procedure followed by maintenance therapy may be performed in an attempt to sustain remission. Sequential autologous transplants followed by nonmyeloablative allotransplants are pursued with the hope of "curing" multiple myeloma. We examine how the key challenges of increasing the response rates and maintaining responses are being addressed using more effective induction and/or consolidation treatments and the need for maintenance therapies after ASCT. We argue that given the biologic heterogeneity of multiple myeloma, risk-adapted transplant approaches are warranted. While the role of curative-intent, dose-intense toxic therapy is still controversial, conventional myeloablative allogeneic transplants need to be reexamined as an option in high-risk aggressive myeloma, given improvements in supportive care and transplant-related mortality.

The 2005 National Health Disparities Report found disparities related to race, ethnicity, and socioeconomic status in the United States health-care system. While varying in magnitude, disparities were observed in almost all aspects of health care including cancer. Disparities were noted across quality and access to health care, levels and types of health care, various health-care settings, and within many subpopulations. In this review, we explore the disparities in cancer care among racial and ethnic minorities. In particular we consider numerous factors that may influence health care for racial and ethnic minority groups including socioeconomic issues, access, cultural beliefs, risk factors, and comorbidities. Although there are extensive confounding factors that vary with each subgroup, trends that may help individual practitioners better understand this complex issue become evident through closer evaluation of available data.

Obesity is a complex, chronic disease that has reached epidemic proportions in the United States. Obesity is now linked with numerous health conditions, including many oncologic diagnoses. Its association with prostate cancer, the most prevalent cancer in men, has also been investigated, with studies suggesting a direct relationship between increasing obesity and prostate cancer mortality. Outcomes data for specific interventions in obese patients with prostate cancer have only recently begun to emerge. Surgery, while feasible even in the very obese, may result in less than optimal cancer control rates. Brachytherapy data are emerging, and are promising. No outcomes data are available for the use of external-beam radiation in obese patients. Long-term data for external-beam radiation, as well as for surgery and brachytherapy, are required to determine the most appropriate treatment for obese patients with prostate cancer. These data, coupled with a more thorough understanding of the biochemical relationship between obesity and prostate cancer, will be necessary to make optimal management decisions for obese patients with prostate cancer in the future.

The field of integrative oncology represents the synthesis of mainstream cancer treatment and rational, databased complementary therapies. These therapies are used not to treat cancer, but to reduce physical and emotional symptoms using noninvasive, nonpharmacologic modalities such as massage and music therapies, acupuncture, meditation, and other mind-body therapies, fitness programs, and the like.

The 2005 National Health Disparities Report found disparities related to race, ethnicity, and socioeconomic status in the United States health-care system. While varying in magnitude, disparities were observed in almost all aspects of health care including cancer. Disparities were noted across quality and access to health care, levels and types of health care, various health-care settings, and within many subpopulations. In this review, we explore the disparities in cancer care among racial and ethnic minorities. In particular we consider numerous factors that may influence health care for racial and ethnic minority groups including socioeconomic issues, access, cultural beliefs, risk factors, and comorbidities. Although there are extensive confounding factors that vary with each subgroup, trends that may help individual practitioners better understand this complex issue become evident through closer evaluation of available data.

Obesity is a complex, chronic disease that has reached epidemic proportions in the United States. Obesity is now linked with numerous health conditions, including many oncologic diagnoses. Its association with prostate cancer, the most prevalent cancer in men, has also been investigated, with studies suggesting a direct relationship between increasing obesity and prostate cancer mortality. Outcomes data for specific interventions in obese patients with prostate cancer have only recently begun to emerge. Surgery, while feasible even in the very obese, may result in less than optimal cancer control rates. Brachytherapy data are emerging, and are promising. No outcomes data are available for the use of external-beam radiation in obese patients. Long-term data for external-beam radiation, as well as for surgery and brachytherapy, are required to determine the most appropriate treatment for obese patients with prostate cancer. These data, coupled with a more thorough understanding of the biochemical relationship between obesity and prostate cancer, will be necessary to make optimal management decisions for obese patients with prostate cancer in the future.

Genzyme Corporation and Berlex Oncology announced interim results from CAM307, an international confirmatory phase III clinical trial comparing alemtuzumab (Campath) with chlorambucil (Leukeran) in previously untreated patients with progressive B-cell chronic lymphocytic leukemia (B-CLL).

The Maryland-based 20/20 GeneSystems, Inc ("20/20") announced study results showing that its multibiomarker blood test may be able to detect non-small-cell lung cancer (NSCLC) significantly earlier and with better accuracy than computed tomography (CT) scans, the most advanced technique in current use for detecting the disease.

Sanofi-Aventis announced that a meta-analysis performed on seven clinical trials in patients with advanced non-small-cell lung cancer (NSCLC) showed that patients receiving docetaxel (Taxotere) had demonstrated overall survival and less febrile neutropenia than those treated with vinca alkaloid (vinorelbine or vindesine) regimens.

The high prevalence of pain in the cancer population underscores why pain management is integral to comprehensive cancer care. How well pain is controlled can have a profound effect on the cancer experience for both patient and family. The goals of pain assessment are to prevent pain if possible, and to identify pain immediately should it occur. This can be facilitated by standardized screening of all cancer patients for pain, on a routine basis, across care settings. A comprehensive assessment of pain follows if a patient reports pain that is not being adequately managed. Oncology nurses play a huge role in pain assessment and management throughout the course of a patient's disease. A basic understanding of the types of pain seen in the cancer population as well as inferred neurophysiologic pain mechanisms and temporal patterns of pain can help focus the pain assessment. This in turn will lead to targeted pain management strategies

With the trend toward the use of oral rather than intravenous therapies for cancer, nonadherence to treatment has become an increasing concern. Advanced practice nurses are in a good position to assess and monitor adherence to oral endocrine therapies. Research on adherence has been limited; to date there are no specific published guidelines for ensuring adherence to endocrine regimens. However, studies have identified many factors that may lead to nonadherence, including demographic, social, and psychological characteristics of the patient; characteristics of the disease and the treatment regimen; and the nature and quality of the patient/clinician relationship. These factors provide a framework that advanced practice nurses can use to identify potential problems and to work collaboratively with patients.

The close workings of an oncology care team create an overlapping need for knowledge about research, treatment, and the course of patient care. Oncology nurses have long been part of the readership of ONCOLOGY because its articles, while written primarily by and for oncologists, are relevant to their practice as well. Oncology nurses often are the first to address issues of symptom and side-effect management, however. They serve a unique role in communication with patients and their families and are a major point of access to the care system.

Monoclonal antibodies are increasingly becoming a standard part of clinical cancer treatment. Eight monoclonal antibodies are approved by the Food and Drug Administration for the treatment of cancer in the United States. Oncology nurses are expected to be familiar with these agents, their indications, and their adverse effects, to provide appropriate care and symptom management to patients receiving these agents, and to adequately educate patients and families about these treatments and their specific and overlapping side effects. Monoclonal antibody mechanisms of action and indications, infusion guidelines, and symptom management are outlined in this article.

Chemotherapy-induced febrile neutropenia (FN) predisposes patients to life-threatening infections and typically requires hospitalization. The goal was to investigate whether a risk assessment tool aligned with national guidelines could help identify patients at risk of FN and reduce FN-related hospitalizations. Beginning in October 2004, oncology nurses applied the new risk assessment tool to all patients initiating chemotherapy or a new regimen. Patients at risk for FN received prophylactic colony-stimulating factor. Charts for 189 patients receiving chemotherapy in fiscal year 2005 (FY05) were compared with charts of 155 patients receiving chemotherapy in FY04, before the tool was implemented. The incidence of FN-related hospitalization declined by 78%, from 9.7% in FY04 to 2.1% in FY05 (P = .003). Total hospital days decreased from 117 to 24. Routine systematic evaluation by oncology nurses improves recognition of patients at risk of FN and substantially reduces FN-related hospitalization.

Wall Chart Featuring Skin-Related Toxicities of Targeted Therapies

Pain is a very individual experience so it is important for you to help doctors and nurses know if you are in pain. Please be sure to describe your pain and rate it on the 0 = no pain to 10 = worst pain scale.

Dr. Ann Berger does an excellent job of writing to the chronic pain sufferer in her book Healing Pain. Health-care providers and family caregivers will also find it an excellent resource and can benefit greatly from reading this work. Throughout the book the author maintains a true sense of hope for the individual experiencing significant pain. Her ability to communicate this sense of hope will be rather contagious for the health-care provider who may have become less than enamored with our ability to accomplish pain management in individuals with complex pain syndromes.

The liver is a frequent site of metastatic colorectal disease. Over the past 20 years, improvements in systemic chemotherapy and surgical techniques have improved the survival of patients with hepatic metastases. For 4 decades, fluorouracil and leucovorin were the only drugs available to treat metastatic colorectal cancer, but several new drugs and a variety of novel regimens are now available. Further improvements in results have been seen with the delivery of chemotherapy via the hepatic artery. Surgical resection of liver metastases has been encouraged when possible, and recent advances in surgery such as portal vein embolization, have made liver resection a possibility for more patients. This review considers the timing and sequence of chemotherapy and surgery in this setting, as well as the roles of cryoablation, radiofrequency ablation, and radiation therapy.

Multiple myeloma is now the most common indication for autologous stem cell transplantation (ASCT) in North America, with over 5,000 transplants performed yearly (Center for International Blood and Marrow Transplant Research [CIBMTR] data). While the role of ASCT as initial therapy in multiple myeloma has been established by randomized studies, newer therapies are challenging the traditional paradigm. The availability of novel induction agents and newer risk stratification tools, and the increasing recognition of durability of remissions are changing the treatment paradigm. However, even with arduous therapy designed to produce more complete remissions—for example, tandem autologous transplants—we have seen no plateau in survival curves. A tandem autologous procedure followed by maintenance therapy may be performed in an attempt to sustain remission. Sequential autologous transplants followed by nonmyeloablative allotransplants are pursued with the hope of "curing" multiple myeloma. We examine how the key challenges of increasing the response rates and maintaining responses are being addressed using more effective induction and/or consolidation treatments and the need for maintenance therapies after ASCT. We argue that given the biologic heterogeneity of multiple myeloma, risk-adapted transplant approaches are warranted. While the role of curative-intent, dose-intense toxic therapy is still controversial, conventional myeloablative allogeneic transplants need to be reexamined as an option in high-risk aggressive myeloma, given improvements in supportive care and transplant-related mortality.

Obesity is a complex, chronic disease that has reached epidemic proportions in the United States. Obesity is now linked with numerous health conditions, including many oncologic diagnoses. Its association with prostate cancer, the most prevalent cancer in men, has also been investigated, with studies suggesting a direct relationship between increasing obesity and prostate cancer mortality. Outcomes data for specific interventions in obese patients with prostate cancer have only recently begun to emerge. Surgery, while feasible even in the very obese, may result in less than optimal cancer control rates. Brachytherapy data are emerging, and are promising. No outcomes data are available for the use of external-beam radiation in obese patients. Long-term data for external-beam radiation, as well as for surgery and brachytherapy, are required to determine the most appropriate treatment for obese patients with prostate cancer. These data, coupled with a more thorough understanding of the biochemical relationship between obesity and prostate cancer, will be necessary to make optimal management decisions for obese patients with prostate cancer in the future.