Palliative and Supportive Care

The Food and Drug Administration (FDA) has approved a new every-3-week dosing schedule for Amgen's erythropoiesis-stimulating agent Aranesp (darbepoetin alfa) used in the treatment of chemotherapy-induced anemia in patients with nonmyeloid malignancies. Of the estimated 1.3 million cancer patients who will receive chemotherapy in the United States this year, about 800,000 will develop anemia, one of the most common adverse events associated with the treatment of malignancies.

Telephone calls from an automated voice system that refers patients to a specially prepared guide for help in managing their symptoms proved as effective as calls from nurse educators in helping cancer patients undergoing chemotherapy manage their chemotherapy-related symptoms, according to a randomized trial presented at the American Psychosocial Oncology Society (APOS) Third Annual Conference

FDA Clears Extended Dosing of Darbepoetin for Chemotherapy-Induced Anemia

I was saddened to learn this morning of the death of Dana Reeve from lung cancer. Today was a reminder of what it was like to be a doctor, unable to provide a cure for a young person afflicted with cancer Each loss was a personal one, and served as a reminder of how much we needed to accomplish to prevent those tragic deaths.

A study by Dana-Farber Cancer Institute researchers offers the strongest evidence yet of the effectiveness of rituximab (Rituxan) for chronic graft-vs-host disease (GVHD), a potentially life-threatening complication of donor bone marrow and stem cell transplants.

As inhibitors of the epidermal growth factor receptor (EGFR) become an increasingly common therapeutic option in cancer, appropriate management of their associated toxicities emerges as a critical part of treatment. Cutaneous manifestations, probably linked to the function of the EGFR in epithelial development, are the most common adverse reactions to EGFR inhibition. The key manifestations are follicular eruptions, nail disorders, xerosis, and desquamation. Growing attention continues to be devoted to the analysis of these events, particularly given their potential role as markers of responsiveness to treatment. However, to date, there are few evidence-based guidelines for the appropriate management of these dermatologic events. Multidisciplinary collaboration between oncologists and dermatologists will be required to improve our understanding and optimize the characterization of these skin toxicities, and to design effective management approaches.

Reimbursements for oncology practices have fallen sharply since 2003, and cash flow is becoming a major concern for community cancer clinics.

Medical students and oncology fellows alike benefit from special training in psychological oncology that is integrated into their didactic curriculum in medical school, according to results from a 1-year pilot project.

In a phase III trial, posaconazole (Noxafil Oral Suspension), an investigational broad-spectrum triazole antifungal, significantly reduced the incidence of serious invasive fungal infections (IFIs) and of aspergillosis, and demonstrated a survival benefit, compared with standard azole antifungal treatment in high-risk neutropenic patients undergoing intensive chemotherapy.

ImClone Systems Incorporated and Bristol-Myers Squibb Company recently announced that the US Food and Drug Administration (FDA) has approved cetuximab (Erbitux), an immunoglobulin (Ig)G1 monoclonal antibody, for use in the treatment of squamous cell carcinoma of the head and neck.

In today's regulatory review environment, how do we keep the patient at center stage?

The American Journal of Nursing (AJN) recently released a consensus report based on the outcome of the invitational symposium, "The State of the Science on Nursing Approaches to Managing Late and Long-Term Sequelae of Cancer and Cancer Treatment," which took place in Philadelphia in July 2005. The report, which accompanied the March issue of AJN, offers action strategies and recommendations, from a nursing perspective, for addressing the health needs of the more than 10 million long-term cancer survivors alive today.

Pfizer Inc's Eraxis (anidulafungin) has been approved by the FDA to treat candidemia, the most deadly of the common hospital-acquired bloodstream infections, with a mortality rate of approximately 40%, the company said in a news release.

New data suggest that darbepoetin alfa (Aranesp) improves hemoglobin (Hb) levels among patients undergoing radiation therapy for various types of cancer. Higher hemoglobin levels, in turn, were associated with better measures of quality of life (QOL) and less fatigue. "We all know that anemia occurs in cancer patients undergoing radiotherapy. It might be cancer related or it might be a side effect of the cancer treatment," lead author Dosia Antonadou, MD, said at the 47th Annual Meeting of the American Society for Therapeutic Radiology and Oncology (abstract 136).

A new format for use in writing package inserts (PIs) seeks to make prescribing and safety information clearer and more concise for health care professionals and patients. The design will apply to all future drugs FDA approves. All drugs approved within the past 5 years will be converted gradually to the new format. The agency said the new design for package inserts is an effort to better manage the risks of medication use and reduce medical errors.

This case study illustrates some of the off-treatment issues your patients may face and provides some practical solutions to help patients overcome them whether you see them for regular follow-up or just receive an occasional phone call requesting assistance.

Cannabis has been used as a medicine for thousands of years. A body of evidence suggests that this plant, which contains hundreds of active compounds, has potential value for certain patients undergoing cancer treatment. However, largely due to nonscientific political issues, marijuana is still classified as a schedule I drug—an illegal substance having a "high potential for abuse" and "no currently accepted medical use in the United States." This classification, which has been repeatedly challenged, greatly complicates scientific research of this plant's medical potential.

While 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.

Discussing decades of work in developing trastuzumab (Herceptin), and looking to the future based on techniques that led to the understanding of HER2/neu, Dennis J. Slamon, MD, PhD, presented the William L. McGuire Memorial Lecture at the 28th Annual San Antonio Breast Cancer Symposium. Dr. Slamon is director of clinical and translational research at the UCLA Jonsson Comprehensive Cancer Center.

Even an allergic reaction to a chemotherapeutic agent does not always preclude future administration of that drug. In some cases, few other options exist. Michelle J. Ciszewski, RN, BSN, OCN, discussed a desensitization protocol successfully used at her facility during the Oncology Nursing Society 30th Annual Congress (abstract 59).

The FDA has approved Merck & Co.'s Emend (aprepitant) for use with other antiemetic medicines for the prevention of nausea and vomiting associated with initial and repeat courses of moderately emetogenic chemotherapy.

In February 2005, Mark McClellan, MD, PhD, head of the Centers for Medicare & Medicaid Services (CMS), appointed Peter Bach, MD, MAPP, an associate attending physician at Memorial Sloan-Kettering Cancer Center, to serve as senior advisor on health care quality and cancer policy. A pulmonologist and intensivist by training, Dr. Bach has a strong reputation for research on quality cancer care, helping develop guidelines for lung cancer and chronic obstructive pulmonary disease (COPD).

As an oncologist, I am always on the lookout for good patient education material. This book, which is based on the experience of the Stanford Integrative Medicine Clinic Cancer Supportive Care Program, is a good choice for a highly literate, print-oriented patient or family member. The book is divided into five parts: (1) Cancer: Diagnosis, Information, and Treatment, (2) The Role of the Mind, (3) The Care of the Body, (4) Supportive and Social Services for Life and Death Issues, (5) Planning for the Future, and (6) Resources. These five parts are divided into 50 individual chapters covering specific topics, and the chapters are focused, concise, and practical.

Last year, I had the opportunity to spend a week at a cancer institute in equatorial Africa. A colleague of mine, Waafa El-Sadr, MD, heads a Columbia University program establishing health-care units in African nations to treat HIV-infected people with antiretro-viral drugs. Waafa was initiating one such unit at the Ocean Road Cancer Institute (ORCI) in Dar el Salaam, Tanzania. When doctors there expressed a need for a visiting oncologist to update them on issues relevant to HIV-infected patients with cancer, Wafaa thought of me. She felt that my experience treating AIDS patients in the days prior to the elaborate regimens we now have would be particularly instructive in the ORCI setting.

With the aging of the Western population, cancer in the older person is becoming increasingly common. After considering the relatively brief history of geriatric oncology, this article explores the causes and clinical implications of the association between cancer and aging. Age is a risk factor for cancer due to the duration of carcinogenesis, the vulnerability of aging tissues to environmental carcinogens, and other bodily changes that favor the development and the growth of cancer. Age may also influence cancer biology: Some tumors become more aggressive (ovarian cancer) and others, more indolent (breast cancer) with aging. Aging implies a reduced life expectancy and limited tolerance to stress. A comprehensive geriatric assessment (CGA) indicates which patients are more likely to benefit from cytotoxic treatment. Some physiologic changes (including reduced glomerular filtration rate, increased susceptibility to myelotoxicity, mucositis, and cardiac and neurotoxicity) are common in persons aged 65 years and older. The administration of chemotherapy to older cancer patients involves adjustment of the dose to renal function, prophylactic use of myelopoietic growth factors, maintenance of hemoglobin levels around 12 g/dL, and proper drug selection. Age is not a contraindication to cancer treatment: With appropriate caution, older individuals may benefit from cytotoxic chemotherapy to the same extent as the youngest patients.

With the aging of the Western population, cancer in the older person is becoming increasingly common. After considering the relatively brief history of geriatric oncology, this article explores the causes and clinical implications of the association between cancer and aging. Age is a risk factor for cancer due to the duration of carcinogenesis, the vulnerability of aging tissues to environmental carcinogens, and other bodily changes that favor the development and the growth of cancer. Age may also influence cancer biology: Some tumors become more aggressive (ovarian cancer) and others, more indolent (breast cancer) with aging. Aging implies a reduced life expectancy and limited tolerance to stress. A comprehensive geriatric assessment (CGA) indicates which patients are more likely to benefit from cytotoxic treatment. Some physiologic changes (including reduced glomerular filtration rate, increased susceptibility to myelotoxicity, mucositis, and cardiac and neurotoxicity) are common in persons aged 65 years and older. The administration of chemotherapy to older cancer patients involves adjustment of the dose to renal function, prophylactic use of myelopoietic growth factors, maintenance of hemoglobin levels around 12 g/dL, and proper drug selection. Age is not a contraindication to cancer treatment: With appropriate caution, older individuals may benefit from cytotoxic chemotherapy to the same extent as the youngest patients.

With the aging of the Western population, cancer in the older person is becoming increasingly common. After considering the relatively brief history of geriatric oncology, this article explores the causes and clinical implications of the association between cancer and aging. Age is a risk factor for cancer due to the duration of carcinogenesis, the vulnerability of aging tissues to environmental carcinogens, and other bodily changes that favor the development and the growth of cancer. Age may also influence cancer biology: Some tumors become more aggressive (ovarian cancer) and others, more indolent (breast cancer) with aging. Aging implies a reduced life expectancy and limited tolerance to stress. A comprehensive geriatric assessment (CGA) indicates which patients are more likely to benefit from cytotoxic treatment. Some physiologic changes (including reduced glomerular filtration rate, increased susceptibility to myelotoxicity, mucositis, and cardiac and neurotoxicity) are common in persons aged 65 years and older. The administration of chemotherapy to older cancer patients involves adjustment of the dose to renal function, prophylactic use of myelopoietic growth factors, maintenance of hemoglobin levels around 12 g/dL, and proper drug selection. Age is not a contraindication to cancer treatment: With appropriate caution, older individuals may benefit from cytotoxic chemotherapy to the same extent as the youngest patients.

The myriad changes that oncology physicians have experienced in the last 20 years are certainly applicable to oncology nurses, in particular, the technology explosion and its effects on diagnosis, treatment, and survivorship; the emergence of cancer as a disease of the elderly; challenges posed by shortages of health care workers; and the fact that almost all cancer patients today are treated as outpatients. Recent therapeutic innovations and management approaches have been keenly felt by oncology nurses, who typically play a major role in patient education.

This case study illustrates some of the nonmedical issues your cancer patients often encounter, particularly when they are unable to return to work as a result of their disease or its treatment. Questions about disability benefits are something you may have to face on a regular basis. For patients, pursuing disability benefits is often a rocky road that is difficult to navigate even without the added burden of dealing with a cancer diagnosis. This case study portrays how you can help your patients deal with such issues and what resources are available to them.

Xerostomia is a permanent and devastating sequela of head and neckirradiation, and its consequences are numerous. Pharmaceutical therapyattempts to preserve or salvage salivary gland function through systemicadministration of various protective compounds, most commonlyamifostine (Ethyol) or pilocarpine. When these agents are ineffective orthe side effects too bothersome, patients often resort to palliative care, forexample, with tap water, saline, bicarbonate solutions, mouthwashes, orsaliva substitutes. A promising surgical option is the Seikaly-Jha procedure,a method of preserving a single submandibular gland by surgicallytransferring it to the submental space before radiotherapy. Improved radiationtechniques, including intensity-modulated radiotherapy andtomotherapy, allow more selective delivery of radiation to defined targetsin the head and neck, preserving normal tissue and the salivary glands.Acupuncture may be another option for patients with xerostomia. All ofthese therapies need to be further studied to establish the most effectiveprotocol to present to patients before radiotherapy has begun.