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Emmanoulides, Miles, and Mitsuyasu have written an excellent review summarizing our current understanding of the pathogenesis of AIDS-related Kaposi's sarcoma (AIDS/KS). The authors cover what is currently well established and also provide their viewpoint on future developments in AIDS/KS. My commentary will highlight some of the major questions related to this complex disease.

Although there is general agreement that screening women over age 50 years with mammography reduces mortality from breast cancer, there has been controversy over the effectiveness of mammography in women 40 to 49 years old. Until 1993, the most widely accepted recommendation for screening mammography included baseline mammography between ages 35 and 40, mammography every 1 to 2 years between ages 40 and 50, and annual mammograms after age 50.

Drs. Coleman and Stevenson have done a superb job in covering diverse aspects of biology relevant to clinical radiotherapy. They note that recent advances in understanding DNA repair may lead to practical applications in radiotherapy. For example, a dual benefit of unraveling DNA repair mechanisms may be to identify which tumors are the most likely to respond to therapeutic radiation and which patients are most likely to develop radiation-induced tumors. The authors point out that gene induction observed in vitro following large radiation doses may not necessarily be relevant to doses employed clinically. Coleman and Stevenson highlight the importance of defining the sequence of genes induced by radiation in clinically relevant doses.

The occurrence of Kaposi's sarcoma (KS) in patients with HIV infection is more than 7,000 times higher than in the non-HIV infected population. The reason for this association is unclear but may involve decreased immune surveillance as a result of the profound cellular immune deficiency caused by HIV, a sexually transmitted KS-inducing virus, whose KS-transforming capabilities may be enhanced by HIV, or a direct or indirect effect of HIV itself in susceptible individuals.

Improved understanding of the underlying biologic mechanisms that pertain to radiation oncology is providing an explanation for the cellular and tissue responses to ionizing radiation and is leading to the potential for novel

SEATTLE--In a retrospective study of 39 children (aged 4 to 12 years) given patient-controlled analgesia (PCA) for pain associated with bone marrow transplantation (BMT), researchers found that 95% of children successfully mastered PCA to control their pain.

SEATTLE--In the 1970s, Hawaii led the way in state efforts at controlling health-care costs while expanding coverage; in the 1980s, physicians and insurers in California forged ahead with managed care; and in the 1990s, Oregon has led the way in prioritizing health services to provide greater access to care.

The issues, cases, decisions and situations discussed by Severin indicate that, fortunately in one area and unfortunately in another, the more things change, the more they stay the same. Furthermore, his article raises an important medicolegal policy issue.

Oral morphine remains the drug of choice for most patients with severe cancer pain, and the sustained-release form (MS-Contin, Roxanol SR), has certain advantages, Ronald Blum, MD, said at a conference sponsored by Cancer Care, Inc.

BETHESDA, Md--The Oncologic Drugs Advisory Committee (ODAC) has recommended that Sclerosol (sterile aerosol talc) be approved for use in relieving fluid around the lungs (malignant pleural effusion) of patients with cancer. The sponsor for Sclerosol, Bryan Corporation (Woburn, Mass), presented nine controlled trials (six articles and three abstracts), with an average of 12 patients each, in support of the talc.

The experimental anticancer drug topotecan shows continued promise as a potent anticancer drug, according to new research.

BETHESDA, Md--Cable television, not computers, may be the best way to reach the poor with information about cancer research, Harold P. Freeman, MD, said at a meeting of the National Cancer Advisory Board (NCAB) that focused on issues of minority recruitment into clinical trials.

When it comes to reimbursement for cancer treatments, the brave new world of managed care may seem like the La Brea Tar Pits. Through its Ombudsman program, the Candlelighters Childhood Cancer Foundation has made it a top priority to help families of childhood cancer patients navigate this treacherous terrain. At the Foundation's 25th anniversary conference, Grace Powers Monaco, jd, mentor to Gib Smith who directs the Candelighters Ombudsman Program and Director of the Medical Care Ombudsman Program of the Medical Care Management Corporation, described some sure-fire methods for prying money out of recalcitrant insurance companies.

SEATTLE--Fludarabine (Fludara) has demonstrated impressive results in previously untreated patients with active chronic lymphocytic leukemia (CLL) when compared with chlorambucil (Leukeran), Kanti Rai, MD, said at the American Society of Hematology (ASH) annual meeting.

CHICAGO--The American Cancer Society has presented its Humanitarian Award to C. Stratton Hill, Jr., MD, of the University of Texas M.D. Anderson Cancer Center. The award is given for dedication to thea improvement of cancer control and genuine accomplishment in human welfare.

In the past few years, this country has seen a major change in the financing of health care. According to a recent survey by Foster Higgins, an international employee-benefits consulting agency, at the end of 1994, 63% of all privately insured Americans were enrolled in a managed care plan.

MARINA DEL REY, Calif--Comparing the technical services portion of an oncology practice to a car that has been driven 25,000 miles, Dean H. Gesme, Jr., MD, managing partner of Iowa Cancer Care, P.L.C., said that he and his partners decided to spin off that part of their Cedar Rapids practice while it still had a high market value.

Patients reported with inflammatory atypia on Pap smears demonstrated a significantly improved rate of reversion to normal cytology following treatment with MetroGel-Vaginal (metronidazole 0.75% vaginal gel), according to a study presented at the District IV Junior Fellow meeting of the American College of Obstetricians and Gynecologists by Dr. Michael D. Randell, an obstetrician and gynecologist in Atlanta, Georgia.

The latest addition to the Contemporary Neurology series, devoted to the neurologic complications of cancer, is authored solely by Dr. Posner. Although this book has been written for both the student and trained professional, who can quickly adapt to the definitive nature of the tables, diagrams, and clinical approaches, it is likely to be most appealing to the neuro-oncologic specialist.

BUFFALO, NY--Renewed interest in cryosurgery may soon translate into a viable therapeutic option for patients with primary and secondary liver cancers.

Dr. Severin's article is a valuable asset for the practitioner--legal or medical--or academician concerned with the burgeoning of civil lawsuits over failure to comply with new approaches to the management and control of cancer. The article identifies two types of such suits and explores the history of medical malpractice litigation relating to cancer care. The focus is the physician who either misses or fails to make a timely diagnosis of hereditable cancer.

NEW YORK--Attaching iodine-131 to the anti-CD20(B1) antibody (radioimmunotherapy or RAIT) may provide durable remissions in relapsed non-Hodgkin's lymphomas (NHL), Oliver Press, MD, PhD, said at a symposium sponsored by the New York City-based Cancer Research Institute.

In order to keep its $90 million per year cancer research budget highly focused and not duplicative of government-sponsored efforts, the American Cancer Society (ACS) has announced a major restructuring of its research and professional training programs. The changes call for a new focus on beginning scientists and targeted research projects and an increased commitment to epidemiologic research, psychosocial, behavioral and health- care policy research, and cancer prevention--areas not currently being emphasized by other cancer research funding agencies.

SEATTLE--With advanced molecular genetic techniques now available to researchers for the identification and study of genes involved in cancer, the question arises: Is the study of chromosomal translocations, additions, and deletions still a worthwhile pursuit?

MIAMI BEACH--Sphincter-preserving surgical techniques can be safely and effectively combined with high-dose preoperative radiation for tumors in the most distal segments of the rectum, Mohammed Mohiuddin, MD, said at the American Society for Therapeutic Radiology and Oncology (ASTRO) meeting.

NORWOOD, Mass--A new implantable pump with an inexhaustible power supply and a constant flow feature may allow lower morphine doses in patients with cancer pain.

Cancer cachexia may be an immunologic phenomenon related to increased cytokine production that occurs in response to the tumor itself or to the stress of surgery, John M. Daly, MD, said at the Society of Surgical Oncology's Annual Cancer Symposium. As such, the routine administration of preoperative total parenteral nutrition (TPN) may not be a useful strategy for all types of cancer.

The National Coalition for Cancer Survivorship (NCCS) recently surveyed health providers, government officials, professional and advocacy organizations, scientists, and others regarding a critical issue facing this nation's 8 million cancer survivors: quality cancer care. The responses were illuminating as they portrayed a system in flux. The United States is moving away from a health care system where fee for service insurance plans predominate to one where market-based alternatives are quickly gaining favor among employers, consumers, and other purchasers of health care coverage. What this fundamental transition will mean for survivors and individuals with other serious or life-threatening diseases and the people who care for them is an open question with important public policy implications

Multiple endocrine neoplasia type 2 (MEN-2) is known to be associated with missense mutations in the RET proto-oncogene, and specific RET mutations have been detected in families. This disease can be deadly since more than half of patients who harbor the genetic susceptibility present with metastatic medullary thyroid carcinoma. About 50% of patients affected with MEN-2 will develop pheochromocytoma (often bilateral), and 10% to 20% will develop functioning parathyroid adenomas.

Drs. Lerman and Croyle provide a quite thorough review of an area in need of continuing research-ie, patients' behavioral and emotional responses to genetic testing for cancer susceptibility. The authors present current information on what we do and don't know about the psychological characteristics of individuals likely to undergo testing, possible adverse reactions, issues specific to the genetic counseling process, family coping and adaptation, and possible ways of managing psychological sequelae of genetic testing. Admirably, the authors note that much of their discussion should be considered speculative until more empirical data specific to genetic testing is available. Given this "state of the science," I will raise some additional questions based on some of the statements made by Drs. Lerman and Croyle.