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This chapter provides a brief overview of the principles of radiation therapy.The topics to be discussed include the physical aspects of how radiation works(ionization, radiation interactions) and how it is delivered (treatment machines,treatment planning, and brachytherapy). Recent relevant techniques of radiationoncology, such as conformal and stereotactic radiation therapy, also willbe presented. These topics are not covered in great technical detail, and noattempt is made to discuss the radiobiological effects of radiation therapy. It ishoped that a basic understanding of radiation treatment will benefit those practicingin other disciplines of cancer management. This chapter does not addressprinciples of radiobiology, which guide radiation oncologists in determiningissues of treatment time, dose, and fractionation or in combining radiationwith sensitizers, protectors, and chemotherapy or hormones.

In this issue of ONCOLOGY, Dr.Ruckdeschel addresses a subjectthat, fortunately, is not very common,but unfortunately for those inwhom the problem occurs, the outcomesare almost universally poor.The subject is probably one of themost dreaded complications of advancedcancer-malignant spinalcord compression. On a positive note,since Dr. Patchell's plenary sessionpresentation at the 2003 AmericanSociety of Clinical Oncology Annualmeeting,[1] interest in metastatic spinalcord compression has been renewedand there is hope that futurepatients with this problem will farebetter.

Icommend the authors for their excellent review and discussion regarding the integration of hormonal therapy with permanent prostate implants. They address several important issues relating to the sequence and duration of hormonal therapy in combination with externalbeam radiation therapy (EBRT) and its underlying relationships with permanent prostate implants.

Esophageal cancer frequently expresses cyclooxygenase-2 (COX-2)enzyme. In preclinical studies, COX-2 inhibition results in decreasedcell proliferation and potentiation of chemotherapy and radiation. Wereport preliminary results of a phase II study conducted by the HoosierOncology Group in patients with potentially resectable esophageal cancer.All patients received cisplatin at 75 mg/m2 given on days 1 and 29and fluorouracil (5-FU) at 1,000 mg/m2 on days 1 to 4 and 29 to 32with radiation (50.4 Gy beginning on day 1). Celecoxib (Celebrex) wasadministered at 200 mg orally twice daily beginning on day 1 untilsurgery and then at 400 mg orally twice daily until disease progressionor unexpected toxicities, or for a maximum of 5 years. Esophagectomywas performed 4 to 6 weeks after completion of chemoradiation. Theprimary study end point was pathologic complete response (pCR). Secondaryend points included response rate, toxicity, overall survival, andcorrelation between COX-2 expression and pCR. Thirty-one patientswere enrolled from March 2001 to July 2002. Respective grade 3/4 toxicitieswere experienced by 58%/19% of patients, and consisted of granulocytopenia(16%), nausea/vomiting (16%), esophagitis (10%), dehydration(10%), stomatitis (6%), and diarrhea (3%). Seven patients (24%)required initiation of enteral feedings. There have been seven deathsso far, resulting from postoperative complications (2), pulmonary embolism(1), pneumonia (1), and progressive disease (3). Of the 22 patients(71%) who underwent surgery, 5 had pCR (22%). We concludethat the addition of celecoxib to chemoradiation is well tolerated. ThepCR rate of 22% in this study is similar to that reported with the use ofpreoperative chemoradiation in other trials. Further follow-up is necessaryto assess the impact of maintenance therapy with celecoxib onoverall survival.

ATLANTA, Georgia-Children with low-risk Hodgkin’s disease (HD) who have a complete remission after chemotherapy can forego radiation therapy without an increased risk of recurrence, according to a trial presented at the 46th Annual Meeting of the American Society for Therapeutic Radiology and Oncology (abstract 3).

Adjuvant therapy, almost bydefinition, overtreats patients.It is the holy grail of those ofus involved in adjuvant therapy to definethe patients who are going to failso that we can decrease the incidenceof tumor recurrence and avoid givingadditional therapy to patients who havebeen cured by their primary treatment.

Depression is seen in many cancer patients. It is an especially importantissue in palliative care, as depression can be more common inpatients who are at the end of life. Accurate assessment and treatmentcan have a powerful impact on improving a patient's quality of life.This article reviews the definition and the differential diagnosis of depressionin cancer patients. It then focuses on some of the treatmentoptions available, including pharmacotherapy and psychotherapy.

The term “supportive oncology” refers to those aspects of medical careconcerned with the physical, psychosocial, and spiritual issues facedby persons with cancer, their families, their communities, and their healthcareproviders. In this context, supportive oncology describes both those interventionsused to support patients who experience adverse effects caused by antineoplastictherapies and those interventions now considered under the broad rubric of palliativecare. At its core, palliative care is concerned with providing the maximumquality of life to the patient/family unit.

Delirium is highly prevalent in cancer patients with advanced disease.Frequently a preterminal event, the condition is a sign of significantphysiologic disturbance, typically involving multiple medical etiologiesincluding infection, organ failure, adverse medication effects,and in rare situations, paraneoplastic syndromes. Unfortunately, deliriumis frequently underrecognized or misdiagnosed and, therefore,inappropriately treated or untreated in terminally ill patients. The clinicalfeatures of delirium are numerous and encompass a variety of neuropsychiatricsymptoms common to other psychiatric disorders. Threeclinical subtypes of delirium, based on arousal disturbance and psychomotorbehavior, have been described: hyperactive, hypoactive, andmixed. The differential diagnosis for delirium includes depression,mania, psychosis, and dementia. Numerous instruments have been developedto aid the clinician in rapidly screening for the disorder. Standardmanagement requires an investigation of the etiologies, correctionof the contributing factors, and management of symptoms. Symptomaticand supportive therapies, including numerous pharmacologicapproaches, are important, but several aspects of the use of neurolepticsand other agents in the management of delirium in the dying patientremain controversial.

Severe, debilitating fatigue is common in cancer patients. For many,it is the symptom that interferes most with normal routines. Virtuallyevery modality used to treat cancer may cause fatigue, as can complicationsof the disease such as sleep disturbances, infections, malnutrition,hypothyroidism, and anemia. There is a significant overlap betweendepression and fatigue in many patients. Given the high prevalenceof cancer-related fatigue, frequent assessment of patients is essential.The evaluation should include an attempt to identify reversiblecauses of fatigue, and screening for depression. However, many cancerpatients suffer from fatigue even in the absence of any identifiable,reversible cause. For these patients, consideration can be given to suitableexercise programs, educational support and counseling, and energyconservation strategies. A trial of a stimulant medication is alsoreasonable. Given the heterogeneity of patients, individualized approachesare needed. For anemic patients undergoing chemotherapy,erythropoietic agents can increase hemoglobin levels. The impact ofthese drugs on fatigue and quality of life is uncertain. Recent reports ofincreased mortality and thrombotic events in cancer patients treatedwith epoetin require further investigation.

The treatment of breast cancer has progressed substantially overthe past 15 years. Data from randomized adjuvant trials have shownthat the risk of disease recurrence and death is significantly reducedwhen adjuvant chemotherapy and/or hormonal therapy is added to treatment.As new strategies are incorporated, one of the continued controversiesin patient management is whether adjuvant anthracyclinesshould be the preferred treatment for all patients. Data from randomizedand translational clinical trials have become available and arehelping to elucidate the proper role of anthracyclines, as well as their acuteand long-term toxicities. In most situations, an anthracycline is currentlypreferred, but other single and combination chemotherapies arecurrently under evaluation and appear promising for use in the adjuvantsetting. Continued breast cancer research using molecular markers(such as topoisomerase II–alpha and gene clusters) as predictors oftreatment response, could help individualize decisions regardingwhether to incorporate anthracyclines into adjuvant therapy regimens.

NEW ORLEANS-Palonosetron (Aloxi) prevented chemotherapy-induced nausea and vomiting in older patients better than two other 5-HT3 receptor antagonists-ondansetron

In their article, Drs. Matthew Cooperberg,Sangtae Park, and PeterCarroll summarize four nationalregistries that have studied risk migration,practice patterns, outcomepredictions, and quality-of-life outcomesin prostate cancer. Each of thesefour large registries-the Prostate CancerOutcomes Study (PCOS), the Departmentof Defense Center for ProstateDisease Research (CPDR), the Cancerof the Prostate Strategic Urologic ResearchEndeavor (CaPSURE), and theShared Equal Access Regional CancerHospital (SEARCH)-has a particularstrength that complements theothers. As more patients enroll in theseregistries, researchers will gain greaterinsight into the patterns of care andclinical and health-related quality oflife for diverse cohorts of prostate cancerpatients.

Only a minority of elderly patientswith advanced non–small-cell lung cancer(NSCLC) have been offered palliativechemotherapy, as indicated by clinicalsurveys beginning in the 1980s.Lilenbaum’s thorough review of thetreatment of locally advanced and metastaticNSCLC studies in two specialpopulations (elderly and Eastern CooperativeOncology Group [ECOG]performance status [PS] 2 patients)highlights a new trend seen with theadvent of better-tolerated chemotherapyregimens.

There are two problems with thepaper by Quaranta et al, neitherof which can be overcomewith discussion or sophistry. The firstconcerns the criteria used to determinewhether a report would be includedin this analysis. Specifically,any series with a median follow-up ofonly 3 years was included if it alsomet the other inclusion criteria. Thisis simply inadequate, as there is greatconsensus that studies with 3-year follow-up miss many recurrences. Thesecond problem with the paper is thedefinition of recurrence. The AmericanSociety for Therapeutic Radiologyand Oncology (ASTRO) criteriaused by the authors has proven inferiorto using a cutoff of 0.2 ng/mL forprostate-specific antigen (PSA) nadirfollowing brachytherapy. The inaccuracyin using ASTRO criteria fordetermining cure by brachytherapy isparticularly pronounced in series withshort follow-up such as the 3-yearmedian follow-up criterion used inthis paper.

Guidelines for the management of chemotherapy-induced emesisare necessary to help clinicians match the emetogenicity of antineoplasticagents with the abundance of antiemetic agents now available. Numerousguidelines for antiemetic therapy currently exist, but compliancewith them is inconsistent, in part because optimal antiemetic protectionis not yet possible, even with the best guidelines. For this reason,guidelines must be dynamic and evolve as knowledge increases.Revision of antiemetic guidelines should be prompted by changes ingeneral principles of treatment, not changes in specific details. Recentrecognition of the unique benefits of incorporating selective neurokinin-1 receptor antagonists into regimens for the prevention of nauseaand vomiting caused by highly emetogenic chemotherapy, particularlyin delayed emesis, justifies modification of existing antiemeticguidelines.

Improved understanding of the physiologic and neuropharmacologicmechanisms underlying chemotherapy-induced nausea andvomiting (CINV) has driven significant progress in the treatment ofCINV over the past 2 decades. Recognition of the role of neurotransmittersand their receptors in the process of CINV has been central tothis progress. Initial attention focused on dopamine, then on serotonin,and most recently on substance P, which has yielded a usefulnew class of antiemetic medications known as selective neurokinin-1receptor antagonists. Preclinical studies of these neurokinin-1 receptorantagonists suggested that they would demonstrate broad antiemeticactivity in acute emesis, demonstrate activity against cisplatininduceddelayed emesis, be well tolerated, and contribute to enhancedefficacy when used in combination with other classes of antiemetics.These suggestions appear to have been largely borne out in clinicaltrials. Pharmacogenomics may offer a means to further extend andapply our understanding of CINV by enabling more selective targetingof antiemetic therapies. To date, the application of pharmacogenomicsto CINV has focused on variations in the metabolism of serotoninreceptor antagonists by CYP 450 genotype and variations in the5-HT3 receptor gene itself.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.

The 30 reports in this special supplement to Oncology News International represent highlights of ongoing major clinical trials and new research presented at ASCO 2004 regarding state-of-the-art chemotherapeutic management of gastrointestinal and other cancers. Important developments in capecitabine as adjuvant therapy, novel targeted agents, and new combinations are discussed.