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A Patient With Tumor Lysis SyndromeTumor lysis syndrome (TLS) is a potentially life-threatening metabolic disorder characterized by an elevated uric acid level, elevated serum potassium and phosphorus levels, and a decreased calcium level.
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Hospice and Palliative Care: Program Needs and Academic IssuesWith the renaissance of interest in how best to care for patients with terminal illness comes the need to recognize palliative care and hospice programs as the completion of comprehensive cancer care, not as its antithesis. In
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Recognizing and Managing Side Effects Associated With Novel Targeted Therapies:Nursing management of patients with advanced malignancies presents a formidable challenge. In addition to the discomfort and debilitation these diseases can cause, side effects of traditional treatment modalities such as surgery, chemotherapy, and radiation may lead to severe and sometimes fatal sequelae. New targeted therapies promise an effective treatment with more easily tolerated and managed side effects. Basic understanding of the drugs' mechanism of action contributes to the successful management of the toxicities that can be manifested. Effective patient education results in improved compliance with treatment regimens and potentially improved clinical outcomes. Nursing intervention remains a vital component in the successful use of these novel agents.
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Chemobrain: Is It Time to Initiate Guidelines for Assessment and Management?Cognitive dysfunction during and following treatment for cancer, often referred to as “chemobrain,” is an adverse effect of cancer treatment that may interfere with patients’ ability to resume their precancer lifestyle, with subsequently reduced quality of life.
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Psychological Outcomes Associated With Anemia-Related Fatigue in Cancer PatientsThis article examines the relationships between chemotherapy-induced anemia, fatigue, and psychological distress among anemic cancer patients with solid tumors.
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Gemcitabine/Paclitaxel as First-Line Treatment of Advanced Breast CancerGemcitabine (Gemzar) and paclitaxel exhibit good activity and goodsafety profiles when used alone and together in the treatment of advancedbreast cancer. In a phase II trial, 45 patients with metastaticbreast cancer received gemcitabine at 1,200 mg/m2 on days 1 and 8 andpaclitaxel at 175 mg/m2 on day 1 every 21 days. Twenty-seven patients(60.0%) had prior adjuvant therapy. Objective response was observedin 30 patients (objective response rate 66.7%, 95% confidence interval[CI] = 52%–71%), including complete response in 10 (22.2%) and partialresponse in 20 (44.4%). Median duration of response was 18 months(95% CI = 11–26.7 months), median time to tumor progression for theentire population was 11 months (95% CI = 7.1–18.7 months), medianoverall survival was 19 months (95% CI = 17.3–21.7 months), and the1-year survival rate was 69%. Treatment was well tolerated, with grade3/4 toxicities being infrequent. Grade 3/4 leukopenia, neutropenia, andthrombocytopenia were each observed in six patients (13.3%). No patientwas discontinued from the study due to hematologic ornonhematologic toxicity. Thus, the gemcitabine/paclitaxel combinationshows promising activity and tolerability when used as first-line treatmentin advanced disease. The combination recently has been shownto be superior to paclitaxel alone as first-line treatment in anthracyclinepretreatedadvanced disease according to interim results of a phase IIItrial and it should be further evaluated in comparative trials in breastcancer.
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Self-Care for Oncology Nurses When Dealing With Compassion FatigueNurses need to be able to provide self-care to themselves because compassion fatigue can have negative physical, psychosocial, and spiritual effects.
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Managing Cancer Pain With Non-Opioid ModalitiesJeannine Brant, PhD, APRN-CNS, discussed the importance of using non-opioid modalities to manage cancer patients' pain, during the 2018 ONS Congress.
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Myalgias and Arthralgias Associated With PaclitaxelPaclitaxel-induced myalgias and arthralgias occur in a significantfraction of patients receiving therapy with this taxane, potentiallyimpairing physical function and quality of life. Paclitaxel-inducedmyalgias and arthralgias are related to individual doses; associationswith the cumulative dose and infusion duration are less clear. Identificationof risk factors for myalgias and arthralgias could distinguisha group of patients at greater risk, leading to minimization of myalgiasand arthralgias through the use of preventive therapies. Optimalpharmacologic treatment and possibilities for the prevention of myalgiasand arthralgias associated with paclitaxel are unclear, partially dueto the small number of patients treated with any one medication. Theeffectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) is themost frequently documented pharmacologic intervention, although noclear choice exists for patients who fail to respond to NSAIDs. However,the increasing use of weekly paclitaxel could necessitate daily administrationof NSAIDs for myalgias and arthralgias and leave patients at riskfor adverse effects. This concern may also limit the use of corticosteroidsfor the prevention and treatment of paclitaxel-induced myalgias andarthralgias. Data from case reports suggest that gabapentin (Neurontin),glutamine, and, potentially, antihistamines (eg, fexofenadine [Allegra])could be used to treat and/or prevent myalgias and arthralgias. Giventhe safety profile of these medications, considerable enthusiasm existsfor evaluating their effectiveness in the prevention and treatment ofpaclitaxel myalgias and arthralgias, particularly in the setting ofweekly paclitaxel administration.
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Neuroblastoma: Biology and TherapyNeuroblastoma is a clinically heterogeneous disease which can have a benign, localized behavior or a rapidly progressive, widely disseminated, lethal character. In recent years, knowledge of tumor biology-genetic changes and other biological markers-has allowed for reliable prediction of patient outcomes. These markers, when combined with clinical staging and histologic findings, determine the relative risk for a given patient and allow therapy to be tailored to that particular level of risk.
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CTLA-4 Antibodies: New Directions, New CombinationsThis review will summarize the preclinical and clinical development of CTLA-4–blocking antibodies, discuss recent insights into the biology of CTLA-4 blockade, review the use of these antibodies in combination with established and novel therapeutic modalities, and comment on ongoing questions regarding their administration.
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Molecular Genetics of Hereditary Ovarian CancerApproximately 10% of all epithelial ovarian carcinoma cases are associated with inheritance of an autosomal-dominant genetic mutation conferring a predisposition to cancer with variable penetrance. Two such manifestations
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Myth Busting: Does Real-World Experience Lead to Better Drug Choices?In the era of evidence-based medicine, clinical guidelines, and personalized medicine, one would think that convincing clinical trial data would influence clinical practice if disseminated in an appropriate manner. However, it has been estimated that only 50% of current medical practice is evidence-based, clearly demonstrating a compelling need to collect and analyze additional data to better inform practice. Current data are usually gathered from a variety of sources, including clinical trials, observational studies, and meta-analyses. Yet according to Jeff Forringer, CEO of IntrinsiQ, data from oncology practices provide real-world outcomes that give better insight into the efficacy of cancer therapeutics.
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Association Between the Rates of Synchronous and Metachronous Metastases: Analysis of SEER DataPatients with cancer are usually staged based on the presence of detectable regional and/or distant disease. However, staging is inexact and cM0 patients may have microscopic metastases (cM0pM1) that later cause relapse and death. Since the clinical tools used to stage patients are fairly similar for different tumors, the ratio of the rates of metachronous to synchronous metastases should be similar for different tumors (hypothesis #1). Improvements in diagnostic tools should have caused the ratio of metachronous-to-synchronous metastases to have decreased over time (hypothesis #2). Finally, the fraction of patients with either metachronous or synchronous metastases should have declined over time due to increased screening and earlier diagnoses (hypothesis #3). To test these hypotheses, Surveillance, Epidemiology, and End Results (SEER) data from 1973-1998 were analyzed for 19 solid tumors. A linear relationship was seen between the rates of metachronous and synchronous metastases, with modestly strong correlation coefficients, consistent with hypothesis #1. Over time, changes in staging methods have not significantly altered the ratio of metachronous/synchronous metastases, contrary to hypothesis #2. Also over time, a decrease in the number of patients with metastases was found, consistent with hypothesis #3. Therefore, the rate of anticipated metachronous metastases can be estimated from the rate of clinically evident metastases at presentation. Changes in screening/staging of disease over time may have reduced the overall fraction of patients with metastases.
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PSA Screening for Colorectal Cancer Patients: Proceeding With CautionIt may be appropriate to offer prostate cancer screening to carefully selected men with a previous history of colorectal cancer. However, the risks and benefits of establishing the diagnosis in this setting need to be considered and discussed with them.
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ICD-10: Getting Sucked in and SurvivingICD-10 is a massive undertaking that expands our current 13,000 codes to 68,000 codes. It will impact nearly all business processes in a physician's practice: verification of eligibility, pre-authorization, clinical documentation, research activities, public health reporting, quality reporting, and claim submission.
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Adult T-cell Leukemia/ Lymphoma: Complexities in Diagnosis and Novel Treatment StrategiesIn this issue of ONCOLOGY, Dr. Tobinai presents a thorough and thoughtful review of the current state of the art of HTLV-related adult T-cell leukemia/lymphoma (ATLL). As described, ATLL is most prevalent in Asia, where it has also been most studied, but is also seen in patients from other HTLV-endemic areas including the Caribbean, South America, and parts of Africa. ATLL is rare in North America and Europe, representing 1% to 2% of T-cell lymphomas compared to 25% in Asia.[1]
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Proposed Algorithm for Managing Ibrutinib-Related Atrial FibrillationAlthough ibrutinib-related atrial fibrillation (IRAF) occurs in up to 11% of patients in clinical trials, these studies have rarely fully characterized bleeding events or risk factors for bleeding when ibrutinib is combined with anticoagulation. Furthermore, guidelines do not provide direction regarding the preferred anti-arrhythmic agent for IRAF.
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Perioperative Chemotherapy for Colorectal Cancer Liver MetastasesThere is limited data available to guide decision making in the management of colorectal liver metastases. Despite a trend toward increased use of perioperative chemotherapy, others have questioned the role of this approach in patients with solitary lesions and a longer disease-free interval.
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Surgical Management of Neuroendocrine Tumors of the Gastrointestinal TractThis article reviews the surgical management of gastrointestinal neuroendocrine tumors, including the preoperative control of hormonal symptoms, extent of resection required, postoperative outcomes, and differing management strategies as determined by whether the tumor has arisen sporadically or as part of a familial disorder, such as multiple endocrine neoplasia type 1.
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Cardiovascular Toxicity of Newer Chemotherapeutic Agents: The Heart of the MatterStandard heart failure regimens remain the mainstay of therapy for chemotherapy-related cardiac dysfunction until newer randomized trials suggest otherwise, and earlier detection of toxicity through judicious surveillance with biomarkers and noninvasive imaging remains the cornerstone of management for the foreseeable future.
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Combination Immunotherapy: An Emerging Paradigm in Cancer TherapeuticsIn view of the potential for durable responses with immunotherapy, it will be important to identify the most effective and least toxic regimens for individual patients.
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Current Techniques in Three-Dimensional CT Simulation and Radiation Treatment PlanningThe modern CT simulator is capable of interactive three-dimensional (3D) volumetric treatment planning; this allows radiation oncology departments to operate without conventional x-ray simulators. Treatment planning is performed at the time of virtual simulation by contouring the organs or volumes of interest and determining the isocenter.
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Diagnostic DilemmaA 65-year-old man with a history of a "bleeding ulcer" 7 years earlier presents with complaints of progressive dysphagia for solids and liquids over the past 4 months. The patient states that he has had a 40-pound weight loss during this time, but denies any fevers, chills, abdominal pain, melena, or anorexia. He states that recently he cannot go to his favorite restaurant, as whenever he eats he experiences severe coughing fits. He also describes regurgitation of undigested materials soon after eating.
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Controversies in the Management of Intracranial GerminomasDr. Paulino and his coauthors present a thoughtful, comprehensive survey of the literature regarding the evolving management of intracranial germinoma. They review promising areas of clinical research and acknowledge an increasing
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Proton Therapy for Lung Cancer: New Data to ConsiderThe role of radiation therapy (RT) in lung cancer is long established; some of the earliest Radiation Therapy Oncology Group reports dealt with non-small cell lung cancer (NSCLC).[1,2] More recently, the advent of stereotactic body RT (SBRT) techniques has provided significant local control rates after focused treatment of selected small metastases and inoperable early stage lesions.[3,4] Our center has been in the forefront of examining SBRT and its role in central [5] or bilateral [6] lesions, its effect on PET imaging [7] and pulmonary function testing,[8] and subsequent frequency of brachial plexopathy,[9] chest wall toxicity,[10] or pneumonitis.[11] Still, even this highly conformal technique comes with potentially significant dose to adjacent normal tissue. This is in the context of an emerging appreciation for the pulmonary consequences of elevated mean lung dose,[12] or V5 after pneumonectomy.[13] For each lung cancer patient requiring RT, an effective mechanism to deliver dose to the tumor while minimizing dose to uninvolved lung is called for. Enter protons.
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Hematopoietic growth factorsFor years, chemotherapy-associated myelosuppression has represented a major limitation to a patient’s tolerance of anticancer therapy. In addition, the clinical consequences of chemotherapy-induced myelosuppression (such as febrile neutropenia, dose reductions, or lengthy dose delays) may have had significant negative effects on quality of life or even response to treatment.
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Rising PSA After Local Therapy Failure: Immediate vs Deferred TreatmentDr. Moul has done a wonderful job of outlining the scope and magnitude of the “phenomenon” of patients found to have a progressively rising prostate-specific antigen (PSA) level after potentially curative local treatment for prostate cancer. His
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Ovarian Tumors of Low Malignant PotentialThe Trimbles have provided auseful overview of the majorclinical and pathobiologic issuesinvolving ovarian borderlinetumors (also termed atypical proliferativetumors or tumors of low malignantpotential). The borderline category ofovarian tumors comprises a heterogeneousgroup of neoplasms that, whensubdivided according to histologicappearance and the presence of peritoneallesions, form distinctive subgroups,each with characteristicpathologic features and a distinctiveclinical course. Thus, retrospectivereviews of thousands of reported caseshave shown that borderline tumors ofall types that are confined to the ovaries(ie, lack peritoneal “implants”)are associated with virtually 100%survival and an extremely low recurrencerate.[1]
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Human Papillomaviruses: Their Clinical Significance in the Management of Cervical CarcinomaStudies have shown a strong association between certain human papillomaviruses and the development of cervical carcinoma and its precursor lesions. The oncogenic potential of papillomaviruses has been clearly
