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Management of ductal carcinoma in situ (DCIS) commonly involves excision, radiotherapy, and hormonal therapy. Radiotherapy is employed for local control in breast conservation. Evidence is evolving for several radiotherapy techniques exist beyond standard whole-breast irradiation.

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These guidelines review the use of radiation, chemotherapy, and surgery in borderline and unresectable pancreas cancer. Radiation technique, dose, and targets were evaluated, as was the recommended chemotherapy, administered either alone or concurrently with radiation. This report will aid clinicians in determining guidelines for the optimal treatment of borderline and unresectable pancreatic cancer.

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This study was designed to evaluate the cardiac safety of the combined treatment of HER2-positive metastaticbreast cancer patients with trastuzumab (Herceptin) plus epirubicin and cyclophosphamide (EC) incomparison with EC alone in HER2-negative metastatic breast cancer patients. Patients included those withmetastatic breast cancer without any prior anti-HER2 treatment, anthracycline therapy, or any other chemotherapyfor metastatic disease. This was a nonrandomized, prospective, dose-escalating, multicenter, openlabel,phase II study in Germany. A control group of 23 patients received EC 90/600 mg/m2 3-weekly for sixcycles (EC90 alone). A total of 26 HER2-positive patients were treated with trastuzumab, or H (2 mg/kg weeklyafter an initial loading dose of 4 mg/kg), and EC 60/600 mg/m2 3-weekly for six cycles (EC60+H); another 25HER2-positive patients received H and EC 90/600 mg/m2 3-weekly for six cycles. Asymptomatic reductions inleft ventricular ejection fraction (LVEF) of more than 10% points were detected in 12 patients (48%) treatedwith EC60 + H and in 14 patients (56%) treated with EC90 + H vs 6 patients (26%) in the EC90 alone cohort.LVEF decreases to < 50% occurred in one patient in the EC60+H cohort and in two patients in the EC90+Hcohort during the H monotherapy. No cardiac event occurred in the cohort with EC90 alone. The overallresponse rates for EC60+H and EC90+H were >60%, vs 26% for EC90 alone. The interim results of this studysuggest the cardiac safety of the combination of H with EC may be greater than that of H with AC (doxorubicin[Adriamycin]/cyclophosphamide); however, studies in larger numbers of patients are warranted. The combinationregimen revealed promising efficacy.

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The cachexia of malignancy is considered mediated through excess production of tumor necrosis factor–alpha and other cytokines. Thalidomide (Thalomid), a sedative/hypnotic, has been shown to inhibit tumor necrosis factor–alpha production.

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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.

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Approximately 60% of cancer patients experience pain, and 25% to 30% have severe pain. With some cancers, opioids will be needed before chemotherapy begins and may be more frequently prescribed than chemotherapy. Given the frequency with which pain management is necessary in cancer patients, all oncologists should be familiar with opioid prescribing principles. This article reviews the World Health Organization recommendations for analgesic therapy in this setting, as well as guidelines for opioid therapy in patients with renal failure or hepatic failure, assessment of pain, dosing strategies in both acute and chronic pain, management of opioid overdose, pain associated with dose-limiting side effects, and pain in the actively dying.

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In the current critical review we discuss these emerging trends in localized and systemic treatment as well as possible interesting combinations of the two modalities. Finally, we discuss the role of the new systemic agents in non–clear cell RCC.

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Numerous genomic tests are available for use in colorectal cancer, with a widely variable evidence base for their effectiveness and cost-effectiveness. In this review, we highlight many of these tests, with a focus on their proposed role, the evidence base to support that role, and the associated costs and risks.

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Because treatment for most brain tumors remains inadequate, there has been a sustained interest in using concurrent chemotherapy and radiotherapy to improve local control, prolong overall survival, and reduce

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Ofatumumab (Arzerra) demonstrated clinical benefit was superior to historic outcomes with salvage therapies in this setting, according to lead investigator William G. Wierda, MD, PhD. After about 26 months of median follow-up, progression-free survival and overall survival improved in fludarabine-refractory chronic lymphocytic leukemia and in fludarabine-refractory CLL with bulky lymph nodes.

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Pain in older cancer patients is a common event, and many times it is undertreated. Barriers to cancer pain management in the elderly include concerns about the use of medications, the atypical manifestations of pain in the elderly, and side effects related to opioid and other analgesic drugs. The care of older cancer patients experiencing pain involves a comprehensive assessment, which includes evaluation for conditions that may exacerbate or be exacerbated by pain, affecting its expression, such as emotional and spiritual distress, disability, and comorbid conditions. It is important to use appropriate tools to evaluate pain and other symptoms that can be related to it. Pain in older cancer patients should be managed in an interdisciplinary environment using pharmacologic and nonpharmacologic interventions whose main goals are decreasing suffering and improving quality of life. In this two-part article, the authors present a review of the management of pain in older cancer patients, emphasizing the roles of adequate assessment and a multidisciplinary team approach.

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The authors provide an excellent overview of the role of pelvic exenteration performed as a curative cancer operation or for palliation. They extend the customary definition of palliation, however, to include exenteration intended for cure when tumor is knowingly left behind or is discovered by pathologic review of the operative specimen. The added definitions are apparently based on observations indicating that these procedures can relieve or reduce symptoms related to the disease or its treatment in some patients, resulting in an improved "quality of life," and that some patients also enjoy an extended survival after exenteration

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We are delighted to reviewthe article by Dr. TonyBack on communicationwith cancer patients. We applaud hiseffort to provide recommendations forenhanced communication with patientsand families based on findings fromthe literature. We agree that using thecancer trajectory to identify key communicationtasks provides a useful heuristicmodel because, by matchingcommunication tasks to "high-stakes"clinical encounters, this approach intuitivelyappeals to practicing clinicians.As clearly described by Dr. Back, thevast majority of recommendations forcommunication among oncologist, patient,and family are not derived fromevidence-based research. This underscoresthe importance of conductingadditional research to use as a basis forguiding clinicians in how to handlethese challenging communication tasks.

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In the following sections, we will first review the radiotherapy techniques that have been investigated. We will then review the progressive advances achieved with the addition of chemotherapeutic strategies to RT in an attempt to achieve better outcomes.

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Because most patients now want to know the truth about their diagnosis and prognosis, the ability to discuss the cancer diagnosis, disease recurrence, or treatment failure, and to solicit patients’ views about resuscitation

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In this review, we critically analyze clinical trials that were specifically designed for the very elderly, and we discuss the challenges encountered by investigators who are conducting studies in this patient population. We conclude by proposing an algorithm to help clinicians determine the optimal therapeutic strategy for treatment of DLBCL in very elderly patients.

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A conventional course of radiation for squamous cell carcinoma in the United States is generally 70 Gy in 7 weeks, with a once-daily dose of 1.8 to 2 Gy. This schedule has a modest success rate in curing head and neck cancer. The

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The 14 reports in this special supplement discuss theuse of the cytoprotectant amifostine in patients withcancer of the head and neck, esophagus, lung, andcervix, as well as those with lymphoma and acutemyelogenous leukemia. Discussions focus on thepotential of this agent to both reduce radiation sideeffects such as xerostomia and permit doseescalation of chemotherapy and/or radiotherapy.Improvements in treatment outcome and quality oflife as a result of cytoprotection are examined.

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Luteinizing hormone-releasing hormone analogs (LHRHa) are often used alone or in combination with tamoxifen to suppress ovarian function in premenopausal women with endocrine-responsive breast cancer. However, aromatase inhitiors (AIs) are now the preferred first-line endocrine treatment for postmenopausal women with breast cancer.

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Over the past 2 decades, two major trends in the treatment of breast cancer-breast-conserving therapy and neoadjuvant (or preoperative) chemotherapy-have converged to stimulate interest in the use of neoadjuvant chemotherapy to facilitate breast conservation in women presenting with large tumors. After being established as the treatment of choice for locally advanced or inoperable breast cancer, theoretical considerations and the desire to extend breast-conserving therapy to more patients with large tumors have resulted in an increase in the use of neoadjuvant chemotherapy in operable patients. Drs. Green and Hortobagyi have provided us with a comprehensive review of the background and the current state of neoadjuvant chemotherapy for breast cancer.

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The development of vascular endothelial growth factor (VEGF) pathway inhibitors and mammalian target of rapamycin (mTOR) inhibitors for the treatment of renal cancer is a real success story.

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At the very start of their clinical training, radiation oncologists tend to embrace technology. The specialty draws a preponderance of technophiles to it, and those few who are not at first passionate about technology quickly become so.

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This management guide covers the symptoms, screening, diagnosis, and treatment of small-cell lung cancer (SCLC), mesothelioma, and thymoma from a surgical, medical, and radiation oncology approach.

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The stated aim of Seo’s article isto focus on the diagnosis andmanagement of infections thatcan occur in patients with lung cancer.Most of the studies of infections in cancer patients over the past 4 decadeshave dealt predominantly withopportunistic infections in immunocompromisedindividuals who havelymphoproliferative malignancies.Less attention has been given to infectionsassociated with solid tumors,so a comprehensive review of theproblem in patients with lung canceris greatly needed.

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Sphincter-preserving operations represent an important model for integrating the goals of surgery for rectal cancers. These goals--the achievement of cure and local control and the preservation of autonomic visceral

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Plasmacytoma is a rare B-lymphocyte neoplastic disorder that usually presents as the generalized disease multiple myeloma. Less than 5% of the cases present as a solitary mass of monoclonal plasma cells in the bone or soft tissue. Although solitary extramedullary plasmacytoma (SEP) may arise in any organ, it rarely involves the urinary bladder. A 67-year-old male without a history of multiple myeloma presented with urinary frequency and nocturia; he was later diagnosed with SEP of the bladder. The patient was initially treated with a course of radiation therapy without symptomatic improvement; therefore a chemotherapy regimen consisting of lenalidomide and dexamethasone was subsequently given for six cycles. SEP usually carries a better prognosis and higher cure rate than solitary plasmacytoma of bone, as SEP is radiation sensitive. The role of adjuvant chemotherapy in the treatment of SEP that is resistant to radiation therapy is not clear, since most of the recommendations have been derived from the experience of head and neck SEP. The literature also lacks recommendations for choice of a chemotherapy regimen and surveillance of isolated bladder plasmacytoma. Here we present the first case of a radiation-resistant solitary plasmacytoma of the bladder that was successfully treated with lenalidomide and dexamethasone with successful clinical remission.

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In the United States and Europe, the combination of oral UFT plus leucovorin has been reported to produce objective responses and survival rates similar to those achieved with standard intravenous 5-fluorouracil plus leucovorin in patients with metastatic colorectal cancer, with reduced toxicity.

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In less than a decade, docetaxel (Taxotere) has progressed from initial studies in anthracycline-refractory metastatic breast cancer to several large, phase III randomized trials evaluating its efficacy as adjuvant, neoadjuvant, and first-line therapy for metastatic breast cancer, non-small-cell lung cancer (NSCLC), and ovarian cancer. In other tumor types, including prostate, head and neck, gastric, and bladder cancer, ongoing phase III trials are comparing docetaxel-containing regimens to previously established regimens. For the seven tumor types reviewed in this supplement, phase III study information for docetaxel or docetaxel-based combinations are presented. Impressive results have been consistently demonstrated in the trials reported to date.

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The majority of ovarian cancer patients present with advanced-stagedisease, for which the goal of surgery is not only to document the extentof disease but also to perform surgical cytoreduction or tumordebulking. Cytoreductive surgery for ovarian cancer is generally performedat the time of diagnosis, when it is referred to as primarycytoreduction. It is also performed during primary chemotherapy (intervalcytoreduction) and after disease recurrence (secondarycytoreduction). Over the past 3 decades, numerous retrospective analyseshave established the role of primary cytoreduction in the managementof advanced-stage ovarian cancer. However, recent studies havereported that certain patients benefit from a neoadjuvant chemotherapeuticapproach, in which chemotherapy is given to those with presumedadvanced ovarian cancer prior to cytoreductive surgery. Althoughseveral theoretical advantages of this approach over primarycytoreduction have been reported, significant concerns remain. Therole of neoadjuvant chemotherapy is being investigated in a randomizedstudy currently being conducted by the European Organizationfor the Research and Treatment of Cancer (EORTC) and the NationalCancer Institute of Canada. The benefit of interval cytoreduction wasinvestigated in two randomized prospective trials conducted by theEORTC and the Gynecologic Oncology Group (GOG). Final resultswere somewhat conflicting, but both studies supported an extensiveattempt at surgical cytoreduction during primary therapy. In the managementof recurrent disease, the majority of retrospective studies demonstratea benefit to secondary cytoreduction. The GOG is currentlyattempting to better define the role of secondary cytoreduction in aprospective, randomized trial.