ONCOLOGY Vol 17 No 4

With the increasing successof both autologous and allogeneicmarrow transplantationin achieving cure of inheritedand acquired disorders, the numberof people who have become longtermsurvivors has steadily increasedworldwide. Concomitant with thisincrease has been greater attention tothe long-term health needs of theserecipients. Many studies have outlinedthe problems experienced bylong-term survivors and have betterinformed physicians about the medicalproblems that may require interventionand consultation.[1]

As increasing numbers of stemcell transplant recipients becomelong-term survivors, interestin understanding their longtermimmune status also assumesgreater urgency. One important strategyfor protecting patients againstcertain infections is the use of vaccinations.Just a few years ago, therewere no published recommendationsregarding this issue. Since then, boththe European Group for Blood andMarrow Transplantation (EBMT)and the Centers for Disease Controland Prevention (CDC) have publishedrecommendations. Drs. Goldberg,Cicogna, Rowley, and Pecoracritically review the CDC recommendationsin a nicely written articleand provide important backgroundinformation.

Two cancer-related issues-evidence-based cancer screening andpain control in advanced cancer-are among 20 priority areasthat an Institute of Medicine (IOM) committee has urged publicand private organizations to focus on as a way of transforming healthcare in the United States. Goals regarding screening, especially forcolorectal and cervical cancer, the report said, are "to increase thenumber of people who receive screenings and to provide timely followup."Regarding pain control in patients with advanced cancer, thecommittee urged efforts to "emphasize cooperation in protocols acrosscare settings, advance planning for changes in settings, as well asheightened pain, and public education regarding the merits of opioidmedications in this area."

Areport focused on women [andsmoking] is greatly neededNo longer are the first signsof an epidemic of tobacco-related diseasesamong women being seen, aswas the case when the [first such reportfrom the US Surgeon General in1980] was written. Since 1980, hundredsof additional studies have expandedwhat is known about the healtheffects of smoking among women, andthis report summarizes that knowledge.Today the nation is in the midst of afull-blown epidemic. Lung cancer,once rare among women, is now theleading cause of female cancer deathin this country, accounting for 25% ofall cancer deaths among women.

In the current issue of ONCOLOGYDrs. Bendell and Ryan have provideda valuable review of analcancer. They describe the dramaticeffect of multimodality therapy onthe quality of life and survival ofanal cancer patients. Currently, themajority of patients enjoy long-termsurvival without requiring major surgeryor a stoma. At Memorial Sloan-Kettering Cancer Center, we basetreatment recommendations on stageat presentation and the presence ofcomorbid disease.

Confronted with essentially stagnant budgets in coming years, theNational Cancer Institute (NCI) is initiating an unprecedentedeffort to solicit the views of the cancer community about settingits future research priorities. NCI wants greater input from its own staff andadvisory groups, cancer researchers and clinicians, advocates, and othergroups that fund cancer research as it decides where to focus its futureefforts, according to a briefing document provided to the National CancerAdvisory Board (NCAB) subcommittee on budget and planning.

Drs. Novello and Le Chevalierhave reviewed the subject ofchemotherapy for non–smallcelllung cancer (NSCLC) in greatdetail, organized under numerous subheadings.I will systematically commenton each section of this excellentoverview, which deals with most ofthe published or recently presenteddata on the subjects discussed. Insome cases, trials of multimodalitytherapies, and not just chemotherapy,are included in the review.

The prognosis of patients with advanced non–small-cell lung cancer(NSCLC) remains poor. Systemic chemotherapy prolongs survivalin this group of patients and palliates symptoms compared to bestsupportive care alone but more effective therapeutic strategies areneeded. Novel agents that selectively target biological pathways oftumor growth offer hope of improving response and survival ratesbeyond what has been achieved with standard cytotoxic chemotherapy.Part 2 of this two-part article addresses the role of chemotherapy inlocally advanced and advanced NSCLC, including the use of novelagents, considerations in elderly patients, and studies of second-linetreatment.

Drs. Novello and Le Chevalierhave written a comprehensivereview on the role of chemotherapyin the treatment of non–smallcelllung cancer (NSCLC). Theirreview spans chemotherapy’s controversialuse in early-stage disease toits mainstream use in late-stage disease.The authors highlight the controversiesin the treatment andresearch of all stages of NSCLC anddiscuss ongoing research in combiningchemotherapy with the new molecularlytargeted agents.

Drs. Novello and Le Chevalierhave produced a comprehensivesummary of a large numberof trials of chemotherapy for allstages of non–small-cell lung cancer(NSCLC). This is a broad subjectarea, constantly changing and rifewith controversy; selecting the keytrials with international relevance isno small feat. Nonetheless, the reviewhighlights many salient issuesin the treatment of lung cancer.

Anal cancer accounts for 1.5% of digestive system malignancies inthe United States. In the past 30 years, substantial progress has beenmade in understanding the pathophysiology and treatment of thedisease. Anal cancer was once believed to be caused by chronic localinflammation of the perianal area, and treatment was abdominoperinealresection. From epidemiologic and clinical studies, we nowknow that the development of anal cancer is associated with humanpapillomavirus infection and that the disease has a pathophysiologysimilar to that of cervical cancer. Less invasive treatments have alsobeen developed, and the majority of patients with anal cancer can nowbe cured with preservation of the anal sphincter using concurrentexternal-beam radiation therapy and fluorouracil (5-FU)/mitomycin(Mutamycin) chemotherapy. Current areas under investigation includethe incorporation of platinum agents into the chemotherapyregimen and the use of cytologic screening studies for high-riskpopulations.

Blood and marrow transplantation, a curative treatment for avariety of serious diseases, induces a period of sustained immunosuppressionpredisposing recipients to opportunistic infections. Both forthe protection of the individual transplant recipient and as a matter ofpublic health policy, the US Centers for Disease Control and Prevention(CDC) has developed guidelines for the use of vaccination in theprevention of infectious disease following transplantation. This reviewexamines the primary clinical research supporting vaccinationpolicies in this target population. Widely accepted recommendationsfor transplant recipients based on scientific data are sparse, as fewlarge studies have been conducted in this population. Anecdotalreports, expert advice, summaries, and limited series involving lessthan 50 patients using surrogate end points form the basis of thescientific literature, with the result being a wide variation in practice.Although based largely on inadequate scientific data, the CDC recommendationsoffer a pragmatic approach to the prevention of opportunisticdisease in hematopoietic transplant recipients and serve as auseful starting point for standardization of practice while defining thedirection of future studies in transplant recipients and other immunocompromisedhosts.

The article by Drs. Bendell andRyan reviews the associationbetween anal cancer and humanpapillomavirus (HPV) infectionand discusses current managementstrategies for patients with squamouscell carcinoma of the anal canal. Theauthors should be complimented ona thorough review of the literature,which supports that association andthe use of chemoradiation as the goldstandard for treatment of this groupof patients.

Drs. Kochhar and coauthors areto be congratulated for providingconcrete examples ofopioid dosing errors that contributeto inadequate management of cancerpain. As the authors note, controllingcancer pain is far more complicatedthan the World Health Organization’sthree-step ladder of nonsteroidal antiinflammatorydrug (NSAID)/aspirin,codeine, and morphine would suggest.

Iread with pleasure this articlefrom the staff of the Harry R.Horvitz Center for Palliative Medicine,an institution with expertiseand experience to draw upon. Allmultidisciplinary cancer centersshould have an expertise in palliativemedicine if not a formalized program,as one of the most important jobs ofoncologists is to relieve pain and sufferingfor patients and their families.When pain is effectively addressed,the patient’s aggregate quality of lifeis optimized and time spent with familyand friends is more enjoyable.

Many individuals with advanced malignancy continue to sufferfrom pain and, consequently, impaired quality of life. The clinicalscenarios in advanced cancer pain are complex, and successful managementmay require a more sophisticated and individualized approachthan suggested by the World Health Organization guidelines.In patients referred to the Harry R. Horvitz Center for PalliativeMedicine in Cleveland, numerous commonly occurring errors inopioid use have been noted. This article describes these errors andoffers strategies with which to improve outcomes for patients sufferingwith cancer pain.