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Principles of Radiation TherapyThis 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 radiation oncology, such as conformal and stereotactic radiation therapy, also will be presented. These topics are not covered in great technical detail. It is hoped that a basic understanding of radiation treatment will benefit those practicing in other disciplines of cancer management. This chapter does not address the principles of radiobiology, which guide radiation oncologists in determining issues of treatment time, dose, and fractionation or in combining radiation with sensitizers, protectors, and chemotherapy or hormones.
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Addressing the Challenge of Managing Radiation Use in Medical Imaging: Paradigm Shifts and Strategic PrioritiesThe rise in utilization of medical imaging-especially computed tomography and nuclear medicine-and the issues of perceived, potential, theoretical, and known risks associated with ionizing radiation exposure from imaging have come to the forefront of public and professional awareness, raising concerns and controversies.
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Issues in the Management of Cancer-Related ThrombocytopeniaThrombocytopenia remains a significant clinical problem for patients with cancer. Management approaches include watchful waiting, platelet transfusions, and the use of pharmacologic agents. Although platelet
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Management of Young Breast Cancer Patients With de Novo Genetic MutationsA 24-year-old woman presents to her primary care provider with a mass in her left breast. Examination confirms a 2.2-cm mass in the upper outer quadrant, with a single mobile axillary node that is firm to palpation.
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Influenza Vaccination in Patients With Cancer: an OverviewInfluenza infection is a potential cause of additional morbidity and mortality in patients who are immunocompromised because of cancer or its treatment. Of particular note, influenza infection may delay or interrupt chemotherapy and necessitate hospitalization. Successful immunization depends on an intact immune system that can produce antibodies in response to antigen exposure. Patients with cancer often have a suppressed immune system, resulting from their disease and/or immunosuppressive therapies, and as a consequence they may have a suboptimal serologic response to influenza vaccination. Since vaccination is the only proven method for preventing influenza infection, the Advisory Committee on Immunization Practices recommends seasonal influenza vaccination for adults without contraindications who have disease- or medication-related immunosuppression. Patients with cancer should be given the trivalent inactivated vaccine. Preliminary data suggest that administering the vaccine between cycles of chemotherapy may yield the best results.
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What Should We Tell Patients About Physical Activity After a Prostate Cancer Diagnosis?There is ample evidence suggesting that physical activity and exercise can be therapeutic tools for patients with prostate cancer. Patients diagnosed with localized disease should be advised to stay physically active; furthermore, patients who are undergoing radiation therapy and/or treatment with ADT appear to benefit from regular aerobic and resistance exercise to alleviate side effects.
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Subcutaneous Rituximab Maintained Efficacy, Was Safe in DLBCL, FLSwitching from intravenous to subcutaneous administration of rituximab for non-Hodgkin diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma (FL) resulted in similar efficacy with no new safety issues.
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Management of Centrally Located Non-Small-Cell CarcinomaTreatment optimization for centrally located lung cancers requires special considerations for determining resectability and patient selection.
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Stereotactic Body Radiation TherapySong and colleagues deliver athorough and fair review of theinitial clinical investigations ofa new paradigm in radiotherapy mostrecently called stereotactic body radiationtherapy (SBRT).[1] Oncology observers may take exception withthe use of the designation “new paradigm.”After all, from a tumor controlpoint of view, skeptics might say,“radiotherapy is radiotherapy.” Recentadvances in radiotherapeutictechnology such as three-dimensionsal(3D) conformal therapy and intensity-modulated radiotherapy (IMRT)have made treatments less toxic, butnot particularly more effective in curingcancer.
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Osimertinib Plus Savolitinib Shows Activity in EGFR-Mutant, MET-Amplified NSCLCCancer Network spoke with Lecia V. Sequist, MD, MPH, about the TATTON study, which tested the combination of osimertinib and savolitinib in previously treated non–small-cell lung cancer patients.
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Cervical CancerThis management guide covers the screening, diagnosis, staging, and treatment of cervical cancers.
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Melanoma’s Radioresistant Reputation ChallengedConventional wisdom would have one believe that melanoma is a highly radioresistant tumor, perhaps even “radiation proof.” This reputation developed as a result of a combination of factors. First, early in vitro studies of melanoma radio-biology suggested that melanoma cells displayed enhanced postradiation survival vs comparison cells.[1] Second, clinical use of radiation therapy for melanoma did not seem to work very well.[2] This combination, a clinical observation supported by laboratory work, seems to have led radiation therapy to be avoided for melanoma treatment.
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Commentary (Ellis): The Horizon of Antiangiogenic Therapy for Colorectal CancerIn this issue of ONCOLOGY, Olszewski,Grossbard, and Kozuchprovide an excellent overview ofthe role of antiangiogenic therapy inthe treatment of patients with metastaticcolorectal cancer. The authorshave brought several important issuesto the forefront that warrant furtherdiscussion, and these issues will beaddressed in this commentary.
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Irinotecan in Lymphoma, Leukemia, and Breast, Pancreatic, Ovarian, and Small-Cell Lung CancersIrinotecan (CPT-11 [Camptosar]) has a broad range of antitumor activity. Extensive preclinical and early clinical work has demonstrated its activity against many tumor types--head and neck, esophagus, stomach, pancreas,
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Recent Advances in Preventing Chemotherapy-Induced Nausea and VomitingThis article will address changes in CINV guidelines over the past 5 years and provide updates on recently approved agents and agents that are expected to be approved, based on published phase III trials. It will also explore other factors affecting optimal CINV control, including the role of patient-related risk factors and the role of physician adherence to antiemetic guidelines in reducing the residual risk of CINV.
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Exercise in Regulation of Inflammation-Immune Axis Function in Cancer Initiation and ProgressionThis article provides an overview of the current state of knowledge pertaining to exercise modulation of the inflammation-immune axis in cancer. The current evidence suggests that exercise may be a promising adjunctive strategy that can favorably alter numerous components of the immune system, which, in turn, may modulate tumorigenesis.
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Endometrial Cancer: Recent Developments in Evaluation and TreatmentEndometrial carcinoma is the most common gynecologic malignancy in the United States. Most cases are diagnosed at an early stage. However, the outcome for women diagnosed with advanced-stage disease remains poor. The etiology of most endometrial carcinomas stems from the effects of excess estrogen, whether this comes from exogenous or endogenous sources. Differences in epidemiology and presentation suggest the existence of two forms of endometrial cancer: those related to and those unrelated to hormonal stimulation. Most women with endometrial cancer present with abnormal uterine bleeding; endometrial sampling is essential to exclude endometrial carcinoma in such patients. Endometrial cancer is surgically staged, and staging usually includes a hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy also should be performed in selective cases to better assess disease spread and to evaluate the need for adjuvant therapy. Adjuvant treatment may include the use of radiation, progestins, or cytotoxic chemotherapeutic agents. Several clinical trials are underway to compare these treatment modalities, as well as to determine the optimal combination of active chemotherapeutic agents, such as doxorubicin, platinum agents, and paclitaxel (Taxol). [ONCOLOGY 13(12):1665-1675, 1999]
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Use of Transcription Factors as Agents and Targets for Drug DevelopmentCells respond to external signals by either activating or inhibiting key regulatory proteins of gene expression called transcription factors (TFs). Abnormal expression of these factors plays a critical role in many human
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Dr. Emens Discusses Overall Survival in HER2+ Breast CancerDr. Leisha Emens of the University of Pittsburgh Medical Center's Hillman Cancer Center discusses the overall survival in the KATE2 study.
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COUNTERPOINT: The Role of Stem Cell Transplantation in Mantle Cell LymphomaManagement strategies for patients with mantle cell lymphoma continue to demonstrate pendulum-like swings between those appropriate for low-grade lymphoma, and those appropriate for very aggressive lymphoma.
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Evaluating the Role of Serine Protease Inhibition in the Management of Tumor MicrometastasesConservation of blood is apriority during surgery, owingto shortages of donor bloodand risks associated with transfusionof blood products.[9,10] However,blood transfusions have been linkedto a number of negative postoperativesequelae, including poorer prognosisafter cardiac and cancer surgery.[11-21] In this context, recognition thatallogeneic transfusion-associatedimmunomodulation can increasemorbidity in allogeneically transfusedpatients has become a major concernin transfusion medicine.[9,22,23]
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Hematopoietic Stem Cell Transplantation for Non-Hodgkin’s LymphomaHigh-dose myeloablative therapy with autologous or allogeneicstem cell rescue is an effective treatment strategy for non-Hodgkin’slymphoma (NHL), but NHL is much less likely to stay in remission afteran autologous transplant than after an allogeneic transplant. Thebenefit of undergoing an autologous transplant earlier in the course ofthe disease, especially for patients who present with intermediate orhigh scores on the International Prognostic Index of risk factors, is stillunclear. The addition of immunotherapy, biologic modifiers, andantibody therapy such as rituximab (Rituxan) or radiolabeled antibodyto the autologous transplant are approaches undergoing evaluation.Historically, there has been a high regimen-related mortality rateassociated with myeloablative allogeneic transplant that has made thisapproach a less appealing option for therapy. The use of nonmyeloablativeallogeneic transplants as treatment for NHL is less well studiedand remains to be defined.
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The Challenge of Selecting Adjuvant Breast Cancer Chemotherapy for Older PatientsDr. Hy Muss is a well recognized expert in the treatment of elderly women with breast cancer, and his article “Adjuvant Chemotherapy of Breast Cancer in the Older Woman” is an extremely important addition to the limited existing literature on this topic. As he points out, nearly half of all breast cancer diagnoses occur in women over 65 years of age. As the total number of women in that demographic increases with the aging of our population, medical oncologists will be faced with a growing number of elderly breast cancer patients, for whom evidence-based recommendations on treatment are needed. As any medical oncologist who sits face-to-face with these older women knows, it is not acceptable to simply tell the patient that there are inadequate data to guide recommendations for adjuvant chemotherapy in her age group, though this is what the EBCTCG (Early Breast Cancer Trialists Collaborative Group) overview has concluded.
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Management of Metastatic Colorectal CancerThe management of colorectal cancer is a complex endeavor that requires treatment individualization founded on molecular characterization of the tumor, an in-depth understanding of the patient, and an appreciation of the interaction between the two.
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Optimization of Genetic Testing for mCRPCJason M. Hafron, MD, CMO, and Oliver Sartor, MD, share their approach for the optimal management of mCRPC through genetic testing.
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Accelerated Partial-Breast Irradiation: The Current State of Our KnowledgeAccelerated partial-breast irradiation is a shorter, alternative radiation technique for select patients with favorable early-stage breast cancer. We review here the different modalities of delivery and discuss the possible benefits and harms associated with these treatments.
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Multidisciplinary Management of Pediatric Soft-Tissue SarcomaThe management of pediatric soft-tissue sarcomas has improved drastically through the use of multimodal therapy. These tumors include rhabdomyosarcomas and nonrhabdomyosarcomas. Both are staged using
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Castration-Refractory Prostate Cancer: New Therapies, New QuestionsResistance to androgen deprivation is an ominous milestone in the natural history of metastatic prostate cancer:this disease state, now referred to as castration-refractory prostate cancer (CRPC), is historically associated with a median survival of less than two years. Until recently, only docetaxel (in combination with prednisone or estramustine) demonstrated a benefit in overall survival vs comparator therapy with mitoxantrone plus prednisone.[1,2] However, in the past year, compelling data in support of several promising new treatments for CRPC have been reported. The new data offer evidence-based treatment options, but also raise many questions for patient management and future clinical research.
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Honing Therapy for Rectal CancerEpidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) are often overexpressed in colorectal cancer and are associated with inferior outcomes. Based on successful randomized phase III trials, anti-EGFR and anti-VEGF therapeutics have entered clinical practice. Cetuximab (Erbitux), an EGFR-specific antibody, is currently approved in the United States in combination with irinotecan (Camptosar) for patients with metastatic colorectal cancer refractory to irinotecan or as a single agent for patients unable to tolerate irinotecan-based therapy. In retrospective analyses, patients with EGFR-expressing rectal cancer undergoing neoadjuvant radiation therapy had a significantly inferior disease-free survival and lower rates of achieving pathologic complete response. Based on the positive data in metastatic colorectal cancer and synergy with radiation therapy seen in preclinical models, there is a strong rationale to combine cetuximab with neoadjuvant radiation therapy and chemotherapy in rectal cancer. Bevacizumab (Avastin), a VEGF-specific antibody, was the first antiangiogenic agent to be approved in the United States for use in combination with standard chemotherapy in the first- and second-line of treatment in metastatic colorectal cancer. VEGF-targeted therapy may lead to indirect killing of cancer cells by damaging tumor blood vessels, and may increase the radiosensitivity of tumor-associated endothelial cells. VEGF blockade can also "normalize" tumor vasculature, thereby leading to greater tumor oxygenation and drug penetration. This review will address completed and ongoing trials that have established and continue to clarify the effects of these agents in rectal cancer.
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Improving Outcomes in Advanced DLBCL: Systemic Approaches and RadiotherapyIn this review, we will first briefly summarize prior attempts to improve outcomes in advanced DLBCL using systemic therapy approaches, and then we will highlight the potential role of RT in advanced DLBCL.
