Curr. Oncol., Volume 20, Issue 3 (June 2013) – 23 articles

Radiofrequency ablation (RFA) is a standard treatment for small, unresectable hepatocellular carcinomas (HCCS). However, RFA for larger tumours is less successful, and intravenous lyso-thermosensitive liposomal doxorubicin during RFA is one technique postulated to potentially address that limitation. This drug-plus-device combination therapy was used to completely treat a HCC in a patient who underwent liver transplantation 79 days later. Full article

Spontaneous regression of metastatic melanoma is an exceedingly rare event, with only 76 well-documented cases in the literature since 1866. Here, we present the case of a patient who developed metastatic melanoma despite interferon therapy and who then achieved spontaneous regression shortly after a reaction to tetanus–diphtheria–pertussis vaccination. A common theme among these cases is the development of febrile illness before remission of the malignant disease. A brief overview of proposed mechanisms for these miraculous recoveries is presented, including a highlight on the potential role of the herv-k-mel viral marker, a nona- or decapeptide that appears in most melanomas, with homologies to peptides in pathogenic microorganisms. Full article

With improved average longevity, the issue of polypathology in the cancer population is of growing importance, because it will increasingly affect more people. The present study piloted two self-report surveys aiming to provide preliminary data on the nature of polypathology and supportive care needs (met and unmet) of cancer survivors. Survivors were recruited from outpatient clinics at the Princess Margaret Hospital in Toronto and were asked to complete and give feedback on the surveys. Of a convenience sample of 88 survivors, almost three quarters (73%) reported having polypathology, and 64% had at least 1 unmet need. Results also suggest that those with the highest number of needs were more likely to have polypathology. Our study invites further assessments with self-report surveys of the complex picture that arises when cancer is not the only disease affecting a person. It also highlights the need for innovative supportive services to address patient needs. Full article

Questions: 1. Should surgery be considered for colorectal cancer (crc) patients who have liver metastases plus (a) pulmonary metastases, (b) portal nodal disease, or (c) other extrahepatic metastases (ehms)? 2. What is the role of chemotherapy in the surgical management of crc with liver metastases in (a) patients with resectable disease in the liver, or (b) patients with initially unresectable disease in the liver that is downsized with chemotherapy (“conversion”)? 3. What is the role of liver resection when one or more crc liver metastases have radiographic complete response (rcr) after chemotherapy? Perspectives: Advances in chemotherapy have improved survival in crc patients with liver metastases. The 5-year survival with chemotherapy alone is typically less than 1%, although two recent studies with folfox or folfoxiri (or both) reported rates of 5%–10%. However, liver resection is the treatment that is most effective in achieving long-term survival and offering the possibility of a cure in stage iv crc patients with liver metastases. This guideline deals with the role of chemotherapy with surgery, and the role of surgery when there are liver metastases plus ehms. Because only a proportion of patients with crc metastatic disease are considered for liver resection, and because management of this patient population is complex, multidisciplinary management is required. Methodology: Recommendations in the present guideline were formulated based on a prepublication version of a recent systematic review on this topic. The draft methodology experts, and external review by clinical practitioners. Feedback was incorporated into the final version of the guideline. Practice Guideline: These recommendations apply to patients with liver metastases from crc who have had or will have a complete (R0) resection of the primary cancer and who are being considered for resection of the liver, or liver plus specific and limited ehms, with curative intent. 1(a) Patients with liver and lung metastases should be seen in consultation with a thoracic surgeon. Combined or staged metastasectomy is recommended when, taking into account anatomic and physiologic considerations, the assessment is that all pulmonary metastases can also be completely removed. Furthermore, liver resection may be indicated in patients who have had a prior lung resection, and vice versa. 1(b) Routine liver resection is not recommended in patients with portal nodal disease. This group includes patients with radiologically suspicious portal nodes or malignant portal nodes found preoperatively or intraoperatively. Liver plus nodal resection, together with perioperative systemic therapy, may be an option—after a full discussion with the patient—in cases with limited nodal involvement and with metastases that can be completely resected. 1(c) Routine liver resection is not recommended in patients with nonpulmonary ehms. Liver plus extrahepatic resection, together with perioperative systemic therapy, may be an option—after a full discussion with the patient—for metastases that can be completely resected. 2(a) Perioperative chemotherapy, either before and after resection, or after resection, is recommended in patients with resectable liver metastatic disease. This recommendation extends to patients with ehms that can be completely resected (R0). Risks and potential benefits of perioperative chemotherapy should be discussed for patients with resectable liver metastases. The data on whether patients with previous oxaliplatin-based chemotherapy or a short interval from completion of adjuvant therapy for primary crc might benefit from perioperative chemotherapy are limited. 2(b) Liver resection is recommended in patients with initially unresectable metastatic liver disease who have a sufficient downstaging response to conversion chemotherapy. If complete resection has been achieved, postoperative chemotherapy should be considered. 3. Surgical resection of all lesions, including lesions with rcr, is recommended when technically feasible and when adequate functional liver can be left as a remnant. When a lesion with rcr is present in a portion of the liver that cannot be resected, surgery may still be a reasonable therapeutic strategy if all other visible disease can be resected. Postoperative chemotherapy might be considered in those patients. Close follow-up of the lesion with rcr is warranted to allow localized treatment or further resection for an in situ recurrence. Full article

Background: Surgery is the primary treatment for extremity STS. The combination of radiotherapy with surgery allows for limb salvage by using radiation to biologically “sterilize” microscopic extensions of tumour and to spare neurovascular and osseous structures. Adjuvant chemotherapy in STS—except for rhabdomyosarcoma and Ewing sarcoma—continues to be controversial. Methods: The MEDLINE and EMBASE databases (1975 to June 2011) and the Cochrane Library were searched for pertinent studies. The Web sites of the main guideline organizations and the American Society of Clinical Oncology conference proceedings (2007–2010) were also searched. Results and Conclusions: Thirty-three papers, including four guidelines, one protocol, and one abstract, were eligible for inclusion. The data suggest that patients with clear margins have a better prognosis, but no prospective studies have indicated how wide margins should be. In limb-salvage surgery for extremity STS, the procedure should be planned to achieve a clear margin. However, to preserve functionality, surgery may result in a very close (<1 cm) or even microscopically positive margin. In this circumstance, the use of preoperative or postoperative radiation should be considered. No studies described the optimal number of tissue sections required to assess adequacy of excision nor the appropriate handling of surgical resection specimens. The Sarcoma Disease Site Group made its recommendations based on expert opinion and consensus. Full article

Purpose: The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (CRF) in adults. Methods: The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of CRF. The search included MEDLINE, EMBASE, CINAHL, the Cochrane Library, and other guideline and data sources to December 2009. Results: Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process. Conclusions: Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care. Full article

Introduction: Collecting duct carcinoma (CDC) is a rare, aggressive form of renal carcinoma that presents at an advanced stage and has a poor prognosis. Little is known concerning the optimal management of CDC. We present the results of a systematic review addressing the management of CDC and the McMaster University CDC series. Methods: The MEDLINE, Cochrane Library, and EMBASE databases and conference proceedings were searched to identify studies relating to the management of CDC. Included studies reported on a minimum of 10 subjects receiving a single intervention. Series in which an evaluation of therapeutic effectiveness was not possible were excluded. The McMaster University (Hamilton, Ontario) series of 6 cases of CDC were retrospectively reviewed. Results: We identified 3 studies relevant to the management of CDC that included a total of 72 patients. A gemcitabine–cisplatin or –carboplatin regimen resulted in a 26% objective response rate in 23 patients with metastatic CDC. Two additional studies indicated that 49 patients treated with immunotherapy achieved no response. In the McMaster series, cytoreductive nephrectomy was performed in 4 of 6 patients. In 2 patients, MVAC therapy (methotrexate–vinblastine–doxorubicin–cisplatin) achieved no response. No significant therapeutic complications occurred, but survival was poor (median: 11 months; range: 10–33 months). Conclusions: Our review and clinical experience suggest that the current standard of care for metastatic CDC is a gemcitabine–cisplatin regimen. Full article

Background: Guidelines recommend radiotherapy (RT) after breastconserving surgery (BCS) for optimal control of ductal carcinoma in situ (DCIS). The aim of the present study was to characterize the rates of RT consideration and administration, and to identify factors influencing those rates in a cohort of women diagnosed between 1998 and 2005 in Quebec. Methods: Quebec’s medical service claims and discharge abstract database were used. Using consultation for RT as an indicator for RT consideration, odds ratios (ORS) and 95% confidence intervals (CIS) were estimated using a generalized estimating equations regression model. Results: Of 4139 women analyzed (mean age: 58 years), 3435 (83%) received a consultation for RT, and 3057 of them (89%) proceeded with treatment. The rate of RT consideration increased by 7.1% over the study period, with notable differences in the various age groups. Relative to women 50–69 years of age, the ors for being considered for RT were, respectively, 0.89 (95% CI: 0.71 to 1.12), 0.71 (95% CI: 0.55 to 0.92), and 0.20 (95% CI: 0.14 to 0.31) for women younger than 50, 70–79, and 80 years of age and older. Distance to a designated breast care centre lowered the probability of RT consideration, but the presence of comorbidities did not. A surgeon’s volume of BCSS increased the probability of being considered for RT by 7% for every 10 such procedures performed (OR: 1.07; 95% CI: 1.04 to 1.11). Conclusions: Consideration for RT has increased over time. However, older women (despite being in good health) and those living far from a designated breast care centre or having a low-case-volume surgeon were less likely to be considered for RT. Full article

Objective: We set out to review the Rapid Response Radiotherapy Program (rrrp). Methods: We retrospectively reviewed a prospective database of patients referred to the rrrp between August 1, 2008, and June 30, 2012, extracting patient demographics, case dispositions, and wait times in days from referral to consultation and from consultation to treatment. Results: Of 2742 patients referred to the rrrp, 1458 (53%) were men, and 1284 (47%) were women. Median age was 64 years. The most prevalent primary cancer sites were lung (33%), breast (21%), and prostate (17%). The most common reasons for referral were bone metastases (53%) and brain metastases (21%). Palliative radiation therapy was given to 1890 patients. The median wait time from referral to consultation was 3 days. Among treated patients, 60% were treated on the day of their consultation, and 33%, within 1–6 days. Conclusions: The rrrp continues to deliver timely palliative radiation therapy to patients, comparable to earlier reviews. The continued success of the rrrp will remain a model for future rapid-access palliative radiation therapy clinics. Full article

Background: Recruitment to clinical trials remains poor, and patient knowledge of clinical trials is one barrier to recruitment. To identify knowledge deficits, we conducted and compared surveys measuring actual patient knowledge and clinical trialist priorities for patient knowledge. Methods: Consenting patients at a tertiary cancer centre answered a survey that included (i) 2 opinion questions about their own knowledge and willingness to join a trial, and (ii) 22 knowledge questions. Clinical researchers at the centre were asked 13 questions about the importance of various trials factors. Results: Of 126 patients surveyed, 16% had joined a clinical trial, and 42% had a secondary school education or less. The mean correct response rate on the knowledge questions was 58%. Higher rates of correct responses were associated with lower age (p = 0.05), greater education (p = 0.006), prior trial participation (p < 0.001), agreement or strong agreement with perceived understanding of trials (p < 0.001), and willingness to join a clinical trial (p = 0.002). Trialists valued an understanding of the rationale for clinical trials and of randomization, placebo, and patient protection, but those particular topics were poorly understood by patients. Conclusions: Patient knowledge about clinical trials is poor, including knowledge of several concepts ranked important by clinical trialists. The findings suggest that when developing education interventions, emphasis should be placed on the topics most directly related to patient care, and factors such as age and education level should be considered. Full article

Background: Our retrospective study in breast cancer patients evaluated whether integrating subtype and pathologic complete response (pCR) information into axillary lymph node restaging after neoadjuvant chemotherapy (NAC) adds significance to its prognostic values. Methods: Patients included in the analysis had stage II or III disease, with post-NAC axillary lymph node dissection (ALND), without sentinel lymph node biopsy before completion of NAC, with definitive subtyping data and subtype-oriented adjuvant treatments. The ypN grading system was used to restage axillary lymph node status, and ypN0 was adjusted by pCR in both breast and axilla into ypN0(pCR) and ypN0(non-pCR). Univariate and multivariate survival analyses were performed. Results: Among the 301 patients analyzed, 145 had tumours that were hormone receptor–positive (HR+) and negative for the human epidermal growth factor receptor (HER2–), 101 had tumours that were positive for HER2 (HER2+), and 55 had tumours that were triple-negative. The rate of pCR in both breast and axilla was 11.7%, 43.6%, and 25.5% respectively for the 3 subtypes. Compared with the non-pCR patients, the pCR patients had better disease-free survival (DFS) and overall survival (OS): p = 0.002 for DFS and p = 0.011 for OS. In non-pCR patients, DFS and OS were similar in the ypN0(non-pCR) and ypN1 subgroups, and in the ypN2 and ypN3 subgroups. We therefore grouped the ypN grading results into ypN0(pCR) (n = 75), ypN0– 1(non-pCR) (n = 175), and ypN2–3 (n = 51). In those groups, the 3-year DFS was 98%, 91%, and 56%, and the 3-year OS was 100%, 91%, and 82% respectively. The differences in DFS and OS between those three subgroups were significant (all p < 0.05 in paired comparisons). Multivariate Cox regression showed that subtype and ypN staging adjusted by pCR were the only two independent factors predicting DFS. Conclusions: Axillary lymph node status after NAC, adjusted for pCR in breast and axilla, predicts differential DFS in patients without prior sentinel lymph node biopsy. Full article

Background: Primary prophylaxis with granulocyte colony–stimulating factors (PP-G-CSF) is recommended in patients undergoing chemotherapy carrying a febrile neutropenia (FN) risk of 20% or more. In the present study, we examined clinical practice patterns and the impact of PP-G-CSF on FN incidence in women with early-stage breast cancer (EBC) treated with modern adjuvant chemotherapy (ACT). Methods: This single-centre retrospective cohort study of women with EBC, who were identified from the pharmacy database and who received at least 1 cycle of modern ACT from January 2009 to December 2011, was conducted at the Cancer Centre of Southeastern Ontario. Data on patient demographics, pathology, stage distribution, chemotherapy, PP-G-CSF use, dose reductions, chemotherapy delays, treatment discontinuation, relative dose intensity, and FN events were collected. Chi-square tests, t-tests, univariate and multivariate logistic regression analyses, and nonparametric Mann–Whitney U-tests were used for data analysis. Results: Of the 239 women eligible for analysis, 145 (61%) received PP-G-CSF, and 50 (21%) developed at least 1 episode of FN. Use of PP-G-CSF was associated with a significantly lower rate of FN (14% vs. 31%, p = 0.002) and trends to fewer dose delays (17% vs. 27%, p = 0.060) and dose reductions (19% vs. 25%, p = 0.28). Among women receiving PP-G-CSF, higher fn rates were associated with an age of 65 years or older, taxane-based chemotherapy, and prophylaxis with filgrastim. Conclusions: Clinical practice patterns at our institution showed that more than 50% of EBC patients treated with modern ACT received PP-G-CSF, which led to fewer FN episodes and increased delivery of planned ACT. The observed high FN risk despite PP-G-CSF was linked to older age, taxane-based chemotherapy, and filgrastim. Full article

Introduction: In rectal cancer, decisions about the use of adjuvant and neoadjuvant treatment rely on clinical information from a variety of sources. Currently, the quality and accuracy of the aggregate of this clinical information is unclear. The objectives of the present study were to evaluate the completeness and quality of clinical information available to oncologists managing rectal cancer. Methods: All patients diagnosed with rectal cancer in Nova Scotia between 2001 and 2005 were identified through the provincial cancer registry. The registry was linked to other administrative databases to obtain demographic, diagnostic, and treatment data. Patients undergoing radiation oncology consultation were identified, and a standardized review of the cancer centre chart was performed on a random sample, stratified by year. Results: For the 222 patients reviewed, the relevant endoscopy report was present in 113 cases (51%). The level of the tumour was documented in 75% of those reports, and colonoscopy completeness, in 81%. The relevant operative report was available in 192 cases (87%). Tumour level was described in 59% of those reports, and local extension, in 73%. Elements of total mesorectal excision were partially described in 97%. In pathology reports (10% of which were synoptic), we observed significant variability in the presence of important elements. Reporting of those elements was significantly better in the synoptic pathology reports. Conclusions: Clinical information related to adjuvant and neoadjuvant therapy decision-making in rectal cancer is often not available or incomplete. A synoptic reporting system in endoscopy, surgery, and pathology could potentially be a beneficial tool in rectal cancer care. Full article

Purpose: Cancer patients face substantial care-related out-of-pocket (oop) costs that may influence treatment decisions, attitudes, and use of drug- or appointment-related cost-saving strategies. We examined the relationship between oop costs and care-related responses by patients. Methods: We surveyed 170 prostate and 131 breast cancer patients presenting at clinics or support groups, or listed on the cancer registry in Newfoundland and Labrador. Results: In the 3-month period before the survey, 18.8% of prostate and 25.2% of breast cancer patients had oop costs greater than $500. Those oop costs consumed more than 7.5% of quarterly household income for 15.9% of prostate and 19.1% of breast cancer patients. Few patients (8.8% prostate, 15.3% breast) ever adopted any drug- or appointment-related cost-saving strategy. Few patients (7.2% prostate, 9.6% breast) said oop costs influenced treatment decisions, told their physicians about their oop costs (27.0% prostate, 21.1% breast), or were aware of available financial assistance programs (27.3% prostate, 36.9% breast). Compared with patients having low or moderate oop costs (22.9% prostate, 16.7% breast, and 25.7% prostate, 58.3% breast respectively), a larger proportion of prostate (56.0%) and breast (58.3%) cancer patients with high oop costs said that those costs created stress. Among prostate cancer patients, a larger proportion of those having high oop costs (compared with low or moderate costs) used drug-related (22.2% vs. 3.3% and 9.6% respectively) and appointment-related (11.1% vs. 1.1% and 3.8% respectively) cost-saving strategies, said oop costs created an unusual amount of stress (48.0% vs. 18.4% and 10.4%), and had difficulty paying those costs (29.2% vs. 6.2% and 10.4%). Conclusions: For a small group of breast and prostate cancer patients, oop costs are high, but rarely lead to the use of care-related cost-saving strategies or influence care decisions. Full article

Background: Most lung cancer patients experience multiple symptoms related either to the disease or its treatment. The commonly reported symptoms are pain, depression, anxiety, nausea, and poor well-being. The aim of the present study was to evaluate the effect of acupuncture as a potential treatment modality in symptomatic lung cancer patients. Methods: This prospective observational study enrolled 33 lung cancer patients from the Peter Brojde Lung Cancer Centre between August 2010 and May 2012. All patients received 45-minute sessions of acupuncture, 1–2 times weekly for a minimum of 4 sessions. Symptom severity was assessed using the Edmonton Symptom Assessment System (esas) before and after completion of acupuncture. Results: The study cohort included 30 patients with non-small- cell lung cancer and 3 with small-cell lung cancer. Mean age was 62 years (range: 36–88 years); 17 of the patients were women. Most of the patients had advanced-stage cancer (73%) and good performance status (Eastern Cooperative Oncology Group 0–1: 88%). Of these patients, 67% received anticancer treatment (chemotherapy or radiotherapy, or both) with acupuncture. Of the remaining 10 patients, 8 received acupuncture after a complete surgical resection of their tumour, and because of their advanced age, 2 received acupuncture and best supportive care. The median number of acupuncture sessions was 7 (interquartile range: 4–13 sessions). Statistically significant improvements in pain, appetite, nausea, nervousness, and well-being were observed. A clinically important improvement (2 points on the esas) was reported by 61% of patients for pain and by 33% for well-being. A significant positive correlation between improved well-being and the number of acupuncture sessions was observed. This correlation remained significant even after controlling for treatment and narcotic use. Receiver operating characteristic analysis demonstrated that a minimum of 6 acupuncture sessions are required for a 70% chance of a clinically important improvement in well-being. Conclusions: The present study is the first to demonstrate that acupuncture may be an effective approach for improving symptoms—in particular, pain and well–being—in lung cancer patients. Acupuncture is a safe and minimally invasive procedure, and it is potentially useful even in patients undergoing anticancer treatment. Full article