ONCOLOGY Vol 9 No 11 | Oncology

Commentary (Purdy): Current Techniques in Three-Dimensional CT Simulation and Radiation Treatment Planning

November 01, 1995

Several developments are combining to move radiation oncology into a new era--the 3-dimensional conformal radiation therapy (3-D CRT) era. Modern imaging technologies provide a 3-D view of the cancer patient's anatomy that allows the radiation oncologist to more accurately identify tumor volumes and their relationship with other tissues. The power and reliability of computers continues to increase rapidly while the costs continue to decrease. These advances have spurred the development of CT-simulation/3-D radiation treatment planning systems that are the cornerstones of the 3-D CRT era [1-3].

Current Techniques in Three-Dimensional CT Simulation and Radiation Treatment Planning

November 01, 1995

The 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.

Systemic Treatments for Advanced Cutaneous Melanoma

November 01, 1995

The treatment of advanced cutaneous melanoma remains disappointing. Single-agent cytotoxic drugs usually produce response rates of less than 20%, though newer agents, particularly fotemustine and temozolomide, show some promise, especially in patients with brain metastases.

Applications of QOL Measurements: A Managed Care Perspective

November 01, 1995

The current application of QOL measurements and outcomes in managed care organizations is minimal, but potential applications are significant, since a fundamental goal of managed care is to optimize member/patient

Economic and Quality of Life Outcomes in Oncology: The Regulatory Perspective

November 01, 1995

The federal government's involvement in cost-effectiveness studies, outcomes measures, and practice guideline development is haphazard, with a number of agencies taking part in the process. The Health Care Financing

Costs and Benefits of Nutrition Support in Cancer

November 01, 1995

Patients with advanced cancer or AIDS are frequently bothered by anorexia, decreased food intake, fatigue, weight loss, muscle wasting, and a decline in functional status. Nutritional support may afford these patients a

Commentary (Pazdur): New Anticancer Agents in Clinical Development

November 01, 1995

The article by Eckardt et al reviews numerous anticancer drugs presently undergoing clinical development in the United States. These drugs have an array of biochemical targets. Some agents, such as the camptothecin analogs, represent a novel class of antineoplastic drugs. Other drugs, such as docetaxel (Taxotere), are analogs of currently available drugs (paclitaxel [Taxol]) [1,2]. Still other agents, such as thymidylate synthase (TS) inhibitors (eg, ZD1694 [Tomudex], AG-331, and LY231514) and 5-ethynyluracil, a uracil reductase inhibitor, have been designed prospectively to inhibit specific enzymatic pathways [3-5]. Some agents discussed have preliminary activity in refractory diseases, such as that of irinotecan (CPT-11) in fluorouracil-refractory colon carcinoma and that of docetaxel in cisplatin (Platinol)-refractory non-small-cell lung carcinoma, or show activity in diseases for which standard therapies are less than optimal.

Commentary (Rowinsky): New Anticancer Agents in Clinical Development

November 01, 1995

For nearly two decades, the development of novel cytotoxic agents progressed at a snail's pace. In the 1970s and 1980s--decades of instant gratification in which massive expenditures and manpower were expected to have immediate payoffs, the future of new cytotoxic drug discovery looked dismal.

New Anticancer Agents in Clinical Development

November 01, 1995

A better understanding of the biology and biochemistry of the cancer cell has led to the development of various promising new antineoplastic compounds that are now undergoing phase I, II, and III clinical testing. These drugs include topoisomerase I inhibitors, such as camptothecin and its analogs 9-aminocamptothecin, irinotecan, and topotecan; the paclitaxel analog docetaxel; gemcitabine, an antimetabolite structurally related to cytarabine; and fluorouracil prodrugs and other thymidylate synthase (TS) inhibitors.

Health Resource Utilization in ABMT With and Without G-CSF in Stage III/IV Breast Cancer Patients

November 01, 1995

G-CSF has been available since 1991 for use in patients receiving high-dose chemotherapy/ABMT, and while it has been shown to effectively reduce the risk of febrile neutropenia, its cost effectiveness has been open to question. In this small retrospective study, five indicators of the consumption of health care resources were examined in stage III/IV breast cancer patients who received high-dose chemotherapy with ABMT or peripheral stem cell support. The study covered the time periods before and after the availability of G-CSF. The results showed that patients who received G-CSF had reductions in length of hospital stay of 20% (the purged marrow group) and 17% (nonpurged group), compared with similar groups that did not receive the growth factor; the shortest lengths of stay were seen in the peripheral stem cell group, all of whom received G-CSF. Other findings, including number of days the ANC fell below 500, total days of G-CSF use, and total days of antibiotic use, are presented. [ONCOLOGY 9(Suppl):107-110, 1995]

Impact of Quality of Life Outcomes on Clinical Practice

November 01, 1995

This paper reviews the current status of translation of quality of life outcomes from research to clinical practice. A major barrier in this process is the lack of mature results from quality of life studies in phase III randomized controlled trials. As more trials are completed, we can expect the diffusion of those results into clinical practice and decision making. Further, as quality of life measurement tools are used more widely and become more user-friendly, we can anticipate their adoption in the routine clinical assessment of patients in the oncologist's practice. [ONCOLOGY 9(Suppl):61-65, 1995]

The Costs of Cancer Care in the United States: Implications for Action

November 01, 1995

The total annual cost of cancer care in the United States (including direct and indirect costs) has been estimated at more than $96 billion. Although third-party payers have led the effort to reduce these costs, such high

Economic Impact of Antiemesis

November 01, 1995

Control of chemotherapy-induced nausea and vomiting is a major concern for patients receiving cancer therapy and a major quality of life issue. However, the fact that antiemetic control improves quality (but not duration) of

The Cost of Managing Lung Cancer in Canada

November 01, 1995

The POpulation HEalth Model (POHEM) lung cancer microsimulation model has provided a useful framework for calculating the cost of managing individual cases of lung cancer in Canada by stage, cell type, and treatment modality, as well as the total economic burden of managing all cases of lung cancer diagnosed in Canada. These data allow an estimation of the overall cost effectiveness of lung cancer therapy. The model also provides a framework for evaluating the cost effectiveness of new therapeutic strategies, such as combined modality therapy for stage III disease or new chemotherapy drugs for stage IV disease. By expressing the cost of lung cancer treatment as cost of life-years gained, such analyses allows useful comparisons of the cost effectiveness of these treatments with those of other costly but accepted medical therapies. [ONCOLOGY 9(Suppl):147-153, 1995]

Economic and Quality of Life Outcomes: Managed Care Perspectives

November 01, 1995

A variety of economic factors have created a growing demand for health care reform and the rapid expansion of managed care plans. Absence of a clear, commonly accepted definition of managed care constitutes one of the

Measurement of Utilities and Quality-Adjusted Survival

November 01, 1995

Quality-adjusted survival as a measure of the effectiveness of medical interventions captures the tradeoffs between length and quality of life that are often involved in choosing between alternative treatment strategies.

Outcome Issues in Ovarian Cancer

November 01, 1995

Ovarian cancer is the leading cause of death from a gynecologic malignancy in the United States. Most patients present with advanced disease and are treated with a combination of surgery and chemotherapy. Recently,

Measuring Quality of Life: 1995 Update

November 01, 1995

Often, new treatments for cancer are evaluated solely on the basis of increased survival, depriving us of valuable information about other benefits and drawbacks of these treatments. It is important to raise the question of the

Issues in the Economic Analysis of Therapies for Cancer Pain

November 01, 1995

Economic analysis of cancer pain management is hampered by the lack of systematic outcomes research. There is some consensus on the broad structures that should be in place to provide optimal care, but the relative costs and

A Cost Analysis of Hematopoietic Colony-Stimulating Factors

November 01, 1995

The administration of hematopoietic colony-stimulating factors (CSFs) to reduce the severity and duration of neutropenia associated with systemic chemotherapy has become widespread, although the appropriate use of

Commentary (Loeffler/Shrieve): An Overview of Radiotherapy Trials for the Treatment of Brain Metastases

November 01, 1995

Each year more than 100,000 cancer patients in the United States develop brain metastases [1]. Of these, the majority will have either multiple lesions or uncontrolled primary or metastatic disease [2-4]. The treatment and care of patients with brain metastases remains a serious health-care problem. The article by Berk is a comprehensive review of completed or ongoing clinical trials worldwide evaluating the role of radiotherapy in the treatment of patients with brain metastases.

An Overview of Radiotherapy Trials for the Treatment of Brain Metastases

November 01, 1995

A review of the English literature was undertaken to (1) determine the efficacy of radiation therapy for the treatment of brain metastases, (2) identify prognostic factors, and (3) ascertain whether there is an effect of treatment technique on outcome. Critical analysis of relevant randomized trials indicated that radiation therapy can effectively palliate the symptoms of brain metastases.

Including Oncology Outcomes of Care in the Computer-Based Patient Record

November 01, 1995

Changes in the health care system have caused a shift in research to outcomes of care, effectiveness, efficiencies, clinical practice guidelines, and costs. The greater use of computer systems, including decision support systems, quality assurance systems, effectiveness systems, cost containment systems, and networks, will be required to integrate administrative and patient care data for use in determining outcomes and resource management. This article describes developments to look forward to in the decade ahead, including the integration of outcomes data and clinical practice guidelines as content into computer-based patient records; the development of review criteria from clinical practice guidelines to be used in translating guidelines into critical paths; and feedback systems to monitor performance measures and benchmarks of care, and ultimately cost out cancer care. [ONCOLOGY 9(Suppl):161-167, 1995]

Current Issues in Oncology Reimbursement

November 01, 1995

The reimbursement policies of Medicare, Medicaid, and private insurers can have a major impact on the ability of oncologists to deliver care to their patients. This article explores current issues of particular interest to

Economic Outcomes Associated With Hematopoietic Growth Factors

November 01, 1995

The myeloid growth factors G-CSF and GM-CSF have had an impact on the supportive care of cancer patients as well as on the strategies utilized in chemotherapy dose intensification. Therapy with these factors has not been

Historical and Methodological Perspectives on Cancer Outcomes Research

November 01, 1995

Outcomes research is the study of the net effects of the health care process on the health and well-being of individuals and populations. It encompasses a wide breadth of issues, including measurement of patient preferences and health status, broadly referred to as quality of life. Evaluation of health-related quality of life in research studies has been facilitated by the development of a number of measurement tools. In addition to general health tools, cancer-related tools are available, some of which include cancer site-specific or symptom-specific measures. Preference assessment, from the perspective of the patient or general population, is necessary to incorporate quality of life into economic analyses. Various techniques are available to assign preference values to outcomes; metrics such as quality-adjusted life-years (QALYs) are then used to combine quality and quantity of life into a usable value for economic analyses. In the future, quality of life and economic measurements should be incorporated into phase III trials, effectiveness trials, and observational studies. [ONCOLOGY 9(Suppl):23-32, 1995]

Economic and Quality of Life Outcomes in Oncology

November 01, 1995

This publication is the fourth in a series of quality of life symposia proceedings. The title of our first symposium, which took place in 1989, was "Quality of Life in Current Oncology Practice and Research." In the foreword to the first proceedings, we

The Role of Oncology Clinical Practice Guidelines in the Managed Care Era

November 01, 1995

The development of clinical practice guidelines in oncology presents unique problems and challenges due to the heterogeneity of disease presentations and the complexity of therapeutic decisions. Guidelines should incorporate

Commentary (Cumberlin): An Overview of Radiotherapy Trials for the Treatment of Brain Metastases

November 01, 1995

The author gives a comprehensive review of the literature on the treatment of brain metastasis by radiation therapy. His emphasis is on randomized trials, the most extensive and comprehensive of which are those conducted by the Radiation Therapy Oncology Group (RTOG). This commentary will provide some amplification of the data presented in the review.

Cost Effectiveness and Other Assessments of Adjuvant Therapies for Early Breast Cancer

November 01, 1995

The 1992 metaanalysis of adjuvant therapies after surgery in early breast cancer summarizes the most extensively studied of all cancer treatments via randomized controlled trials. This study found overall benefits with use of adjuvant therapies, and their expanded use outside the clinical trial setting was assumed to be effective and implied to be cost effective. Thus, the primary remaining questions are which form of adjuvant therapy to use and how to identify which patients are unlikely to benefit. In British Columbia, the effectiveness of adjuvant therapy outside the clinical trial setting was reassuringly similar to the metaanalysis efficacy. Our decision analysis model of hypothetical cohorts of women with early breast cancer confirmed that the efficacy of adjuvant treatment is the primary determinate of its incremental cost effectiveness. Future cost-effectiveness and quality of life assessments should move from hypothetical cohorts assessed via models to prospective data collected within clinical trials or integrated health delivery system. [ONCOLOGY 9(Suppl):129-134, 1995]

Economic Analysis During Phase III Clinical Trials: Who, What,When, Where, and Why?

November 01, 1995

With the recent surge in interest in health care reform and the growth of managed care organizations, the cost of care has become a major determinant of the types and intensity of therapy that patients receive. If data on the

An Overview Cost-Utility Analysis of Prostate Cancer Screening

November 01, 1995

The value of prostate cancer screening remains controversial because of the high prevalence of the disease and the fact that many tumors detected through screening are not destined to lead to morbidity or mortality, rendering

Commentary (Mastrangelo/Berd): Systemic Treatments for Advanced Cutaneous Melanoma

November 01, 1995

Anderson and colleagues present a comprehensive and factually accurate overview of systemic treatment for advanced melanoma. They correctly identify dacarbazine as the only single agent officially sanctioned for the treatment of metastatic melanoma. They further opine that "dacarbazine alone remains the standard of care for initial chemotherapy treatment of metastatic melanoma." With overall response rates of 10% to 20%, a complete response rate of less than 4%, and no evidence that treatment with dacarbazine improves survival over best palliative care, one questions whether or not dacarbazine would merit approval if reevaluated today.

Commentary (Herman/Wharam): Current Techniques in Three-Dimensional CT Simulation and Radiation Treatment Planning

November 01, 1995

Stephenson and Wiley demonstrate that three-dimensional (3D) CT-based simulation is an improvement in the simulation process. The growing importance of CT in radiation oncology treatment planning has been discussed previously [1] and is further emphasized in this article. The advantages of geometric optimization in three dimensions for radiation therapy treatment planning also are described. These results are applicable to both 3D and two-dimensional (2D) dose planning, because the treatment team can visualize and delineate structures on axial or reconstructed CT planes in greater detail than is possible with conventional simulation projected radiographs.