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Sexual Health Issues in Men With CancerWhile the cancer patient may be affected by sexual dysfunction throughout the entire course of the disease, sexual health is largely underevaluated and undertreated. Sexual problems should be anticipated and patients should be actively screened as they are unlikely to initiate discussion on sexual issues.
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ESPAC-4: Adjuvant Gemcitabine/Capecitabine in Resected Pancreatic CancerThe ESPAC-4 trial found that adding capecitabine to gemcitabine in patients with resected pancreatic cancer resulted in an improved estimated 5-year survival rate.
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The Evolving Role of Radiation Therapy in DLBCL: From Early-Stage to Refractory DiseaseGavin Jones, MD, and colleagues explore the landscape of radiation therapy in diffuse large B-cell lymphoma.
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Commentary (Quek et al): Management of Patients With Muscle-Invasive and Metastatic Bladder CancerDrs. Henry, MacVicar, and Hussainprovide a timely reviewof the current management ofmuscle-invasive and metastaticurothelial cancer. The emerging roleof neoadjuvant chemotherapy and thepromise of novel, less toxic targetedtherapies are of particular interest inthe treatment of a disease in whichoutcomes remain poor for locally advancedand metastatic involvementdespite an aggressive multimodalityapproach.[1] We wish to briefly commenton three issues raised by theauthors: (1) the role of surgery in themanagement of invasive disease,(2) the indiscriminate use of neoadjuvantchemotherapy for clinically localizeddisease, and (3) the currentstatus of bladder-sparing approaches.
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The Evolution of Liver-Directed Treatments for Hepatic Colorectal MetastasesThis article will review the current practice of hepatic resection for colorectal liver metastases, including the possibility of combined resection of hepatic metastases at the time of resection of the primary cancer.
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Current Status and Optimal Use of RadiosurgeryThe field of stereotactic radiosurgery is rapidly advancing as a result of both improvements in radiosurgical equipment and better physician understanding of the clinical applications of stereotactic radiosurgery. This
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Second-Line Treatment of Small-Cell Lung CancerSmall-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.
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Erlotinib/Gemcitabine for First-Line Treatment of Locally Advanced or Metastatic Adenocarcinoma of the PancreasErlotinib (Tarceva) is a human epidermal growth factor receptor type 1/epidermal growth factor receptor (HER1/EGFR) tyrosine kinase inhibitor initially approved by the US Food and Drug Administration for the treatment of patients with locally advanced or metastatic non–small-cell lung cancer after failure of at least one prior chemotherapy regimen. In this report, we present the pivotal study that led to the approval of erlotinib in combination with gemcitabine (Gemzar) in patients with locally advanced/metastatic chemonaive pancreatic cancer patients. The combination demonstrated a statistically significant increase in overall survival accompanied by an increase in toxicity. Physicians and patients now have a new option for the treatment of locally advanced/metastatic adenocarcinoma of the pancreas.
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Medicare Rule Raises Dilemma in Recurrent Ovarian CancerEpithelial ovarian cancer is the leading cause of death from gynecologic malignancies. In 1996, an estimated 26,000 new cases were diagnosed, and approximately 14,000 women died of this disease in the United States alone.[1] Between 75% and 80% of ovarian cancer patients present with advanced disease at diagnosis, and these patients have a 5-year survival rate of 21%.[2,3]
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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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Camptothecin and Taxane Regimens for Small-Cell Lung CancerFor more than 2 decades, combination chemotherapy has been the standard treatment for patients with small-cell lung cancer. Despite high initial response rates in both extensive- and limited-stage disease, long-term survival
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Antifungal Resistance: The Clinical FrontThe emergence of resistance and changes in the spectrum ofCandida infections have led to an increased interest in susceptibilitytesting of antifungal drugs. Such testing may be particularly useful inpatients with invasive candidiasis who have been previously treated withazole antifungals, those whose infections are not responding to treatment,and those with infections caused by non-albicans species of Candida.The choice of a specific antifungal depends on the clinical statusof the patient, the relative toxicity and efficacy of the drug in the givenpatient population, the infecting species and antifungal susceptibilityof the isolate, and the patient’s prior exposure to antifungal agents.Infectious Diseases Society of America recommendations for the initialmanagement of candidemia and acute disseminated candidiasisinclude an azole, caspofungin, amphotericin B (AmB), or a combinationof fluconazole plus AmB. Caspofungin and voriconazole show goodactivity against most Candida species and may be good alternatives forpatients with Candida glabrata and Candida krusei infections and forthose with relapsing infections.
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Weekly Irinotecan and Concurrent Radiation Therapy for Stage III Unresectable NSCLCIn preclinical studies, the topoisomerase I inhibitor irinotecan (Camptosar, CPT-11) has demonstrated activity as a radiosensitizer, probably due to its ability to inhibit potentially lethal radiation damage repair. We conducted a
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Commentary (Bishop/Wingard)-Patient-Physician Communication in Oncology: What Does the Evidence Show?As noted by Back,[1] the primarygoals of effective patient-physician communicationare to enhance patient understandingof the illness, to improvedecision-making, and to facilitate patientadjustment. These three goalsare sensible and important concernsof the communication dyad. A numberof studies have examined variousaspects of the communication processand the factors that influence communicationoutcomes, and a few evenhave tested interventions to improvephysician communication skills. However,there remains a dearth of studiesthat examine communication effectson the three major goals articulatedabove and that evaluate the effectivenessof communication skill interventionsin influencing patient outcomes.
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Through the Looking Glass: The Evolution of Erythropoiesis-Stimulating Agent UseThe perception and reality of the clinical value of erythropoiesis-stimulating agents (ESAs) in cancer supportive care have undergone a dramatic transformation since their initial use in 1990. The perception of ESA value in patients has evolved from panacea to miscreant over a 2-decade period of laboratory research, clinical trial data, and postmarketing experience. Meanwhile, the real clinical benefits of ESAs have changed very little from those described in the joint American Society of Clinical Oncology/American Society of Hematology guidelines originally published in 2002.[1] Even then, the value of initiation of ESAs was clear only in patients with hemoglobin values < 10 g/dL; quality-of-life measures produced inconsistent and, therefore, clinically inapplicable, results; and ESA use was shown to reduce the proportion of patients requiring red blood cell (RBC) transfusions by approximately 20%. The reality of ESA use that came to light following approval was increased mortality rates in certain populations, higher tumor progression and cancer recurrence rates, and more frequent and severe serious adverse effects including thromboembolism, stroke, and cardiovascular events.
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Book Review:Pediatric Hematology, Second EditionThe second edition of Pediatric Hematolgy, edited by the text's original editors, John S. Lilleyman and Ian M. Hann, as well as a new editor, Victor S. Blanchette, completely updates and expands upon the first edition (published in 1992). The new edition grew from 15 to 40 chapters, with contributions by many of the most well-known investigators and clinicians in pediatric hematology in the world. The textbook will especially be of value to practicing clinicians, house staff, and students.
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Gastric Cancer: Are There New Therapeutic Options?The majority of patients who undergo resection for gastric cancer experience relapse and ultimately die of their disease. Therefore, considerable attention has been paid to neoadjuvant and adjuvant strategies to improve surgical outcomes. Two different approaches have been tested in major clinical trials conducted in the past several years: Postoperative chemoradiotherapy was assessed in a US Southwest Oncology Group/Intergroup study (SWOG 9008/INT 0116), and perioperative chemotherapy was studied in a UK Medical Research Council (MRC) randomized trial (the MRC Adjuvant Gastric Infusional Chemotherapy [MAGIC] trial). These trials demonstrated statistically significant survival benefits in patients with resectable gastric cancer. This review will consider these trials and their implications for clinical practice.
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Gal9/TIM-3 Expression Levels Affects Chemotherapy in Leukemia PatientsA new report suggests targeting the Gal9/TIM3-axis could help boost chances of complete remission in patients with acute myeloid leukemia.
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Preoperative UFT/Leucovorin and Radiation Therapy in Rectal CancerThe use of combined modality regimens has been well established in the treatment of stages II and III rectal cancer. The most common chemotherapy regimens used include continuous-infusion 5-FU delivered with the help of a central venous catheter and the use of portable pumps.
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Emerging Role of EGFR-Targeted Therapies and Radiation in Head and Neck CancerThe treatment of head and neck cancer has been at the forefront ofnovel therapeutic paradigms. The introduction of drugs that interactwith selective biologic pathways in the cancer cell has generated considerableattention recently. A wide variety of new compounds that attemptto target growth-signaling pathways have been introduced intothe clinic. A majority of studies in the clinic have focused on epidermalgrowth factor receptor (EGFR) antagonists, but future studies will likelybuild upon or complement this strategy with agents that target angiogenicor cell-cycle pathways. EGFR activation promotes a multitude ofimportant signaling pathways associated with cancer development andprogression, and importantly, resistance to radiation. Since radiationtherapy plays an integral role in managing head and neck squamouscell cancer (HNSCC), inhibiting the EGFR pathway might improveour efforts at cancer cure. The challenge now is to understand whenthe application of these EGFR inhibitors is relevant to an individualpatient and how or when these drugs should be combined with radiationor chemotherapy. Are there molecular markers available to determinewho will respond to EGFR inhibitors and who should be treatedwith alternative approaches? What are the mechanisms behind intrinsicor acquired resistance to targeted agents, and how do we preventthis problem? We need to formulate integrated laboratory/clinicalresearch programs that address these important issues.
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A Care Model for the Future: the Oncology Medical HomeSurvival for cancer patients in the United States ranks among the highest in the world.[1] Despite the demonstrated success of the US cancer delivery system, government and private payers are forcing changes to the delivery of and payment model for oncology care.
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Docetaxel Plus Cisplatin: An Active Combination Regimen in Non-Small-Cell Lung CancerDocetaxel (Taxotere) isa semisynthetic taxoid that possesses significant activity as a single
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Neuropathic Cancer Pain: The Role of Adjuvant AnalgesicsNeuropathic pain may be defined as pain related to abnormal somatosensory processing in either the peripheral or central nervous system. This pathophysiologic label is typically applied when the painful symptom is associated
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Molecular Targeting in Cancer Therapy: Can We Fulfill the Promise?Work remains in the development of a clinically useful tumor classification system that includes molecular characterization of tumors, in our understanding of the implications of tumor heterogeneity, and in the development of more relevant and efficient clinical trials. Nonetheless, there is great excitement that a new era in the treatment of cancer is beginning.
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A Young Woman With Distant Recurrent Metastatic Primary Vaginal Carcinoma Salvaged With Radical RadiotherapyPrimary carcinoma of the vagina accounts for 1% to 3% of all gynecologic malignancies, with 70% of cases occurring in women over age 60.[1] Hematogenous dissemination is rare at diagnosis but is more common in patients with advanced, neglected lesions.
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Hematologic Cancers Break Down a ‘Checkpoint’: Targeting the PD-1/PD-L1 AxisWhile the results of the multitude of ongoing PD-1 blockade trials are eagerly awaited, it is clear that research involving the immunotherapy of blood cancers is moving swiftly through this first “checkpoint” at breakneck speed. It is sure to be a fascinating ride.
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The Use of Serum hCG as a Marker of Tumor Progression and of the Response of Metastatic Urothelial Cancer to Systemic ChemotherapyA 55-year-old woman with a history of metastatic melanoma in remission for 8 years presented to the emergency department with gross hematuria. A CT scan, ordered because the patient was in menopause, demonstrated a bladder tumor.
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Contemporary Management of Prostate Cancer With Lethal PotentialScreening for prostate cancer by determining serum prostate-specificantigen (PSA) levels has resulted in a stage migration such thatpatients with high-risk disease are more likely to be candidates for curativelocal therapy. By combining serum PSA, clinical stage, and biopsyinformation-both Gleason score and volume of tumor in the biopsycores-specimen pathologic stage and patient biochemical disease-freesurvival can be estimated. This information can help patients and cliniciansunderstand the severity of disease and the need for multimodaltherapy, often in the context of a clinical trial. While the mainstays oftreatment for local disease control are radical prostatectomy and radiationtherapy, systemic therapy must be considered as well. A randomizedtrial has shown a survival benefit for radical prostatectomy inpatients with positive lymph nodes who undergo immediate adjuvantandrogen deprivation. Clinical trials are needed to clarify whether adjuvantradiation therapy after surgery confers a survival benefit. PSAis a sensitive marker for follow-up after local treatment and has proventhat conventional external-beam irradiation alone is inadequate treatmentfor high-risk disease. Fortunately, the technology of radiationdelivery has been dramatically improved with tools such as three-dimensionalconformal radiation, intensity-modulated radiation therapy,and high-dose-rate brachytherapy. The further contributions of pelvicirradiation and neoadjuvant, concurrent, and adjuvant androgen deprivationtherapy have been defined in clinical trials. Future managementof high-risk prostate cancer may be expanded by clinical trialsevaluating neoadjuvant and/or adjuvant chemotherapy in combinationwith androgen deprivation.
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Chemotherapy Dosing in the Setting of Liver DysfunctionAdvanced cancer in the setting of liver dysfunction poses a dilemmafor physicians, as many cancer chemotherapeutic agents undergo hepaticmetabolism. Most cytotoxic drugs have a narrow therapeutic index,and the administration of chemotherapy to patients with liver impairmentresults in complicated safety issues. We present a concise reviewof cancer chemotherapy dosing in the setting of liver dysfunction.Although caution in treating all patients with hepatic failure is essential,the use of certain agents provokes greater concern than others.Continuous-infusion fluorouracil, capecitabine (Xeloda), mechlorethamine(Mustargen), cyclophosphamide, topotecan (Hycamtin), andoxaliplatin (Eloxatin) appear to be relatively well tolerated. On thecontrary, taxanes, vinca alkaloids, irinotecan (Camptosar), andanthracyclines may cause unacceptable toxicity if administered to patientswith poor hepatic function. For many anticancer agents, the paucityof data prohibits formal dosing recommendations, and most guidelinesremain empiric.
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Tolerability and Side-Effect Profile of rhIL-11Safety data from two randomized phase II and one abbreviated phase III placebo-controlled, double-blind clinical studies in adult patients with nonmyeloid malignancies indicate that recombinant human interleukin-11 (rhIL-11, also known as oprelvekin [Neumega]) has an acceptable toxicity profile as therapy for the mitigation of chemotherapy-induced thrombocytopenia.
