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Extending Survival After Inoperable Pancreatic Cancer

Extending Survival After Inoperable Pancreatic Cancer

Surgical resection of adenocarcinoma can significantly improve survival, but only 20% of patients are candidates to undergo this treatment. Typically, patients with unresectable pancreatic adenocarcinoma receive palliative, non-curative therapy. Recent research, however, suggests that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients who have been previously deemed unresectable the possibility for curative salvage pancreatectomy. A New Approach for Pancreatic Cancer In the Journal of the American College of Surgeons, my colleagues and I at MD Anderson reported results from a study cohort of 88 high-risk patients who had been informed that their tumors were inoperable after an initial surgical attempt at removal. Of these patients, 66 completed a multidisciplinary treatment protocol with successful tumor removal. Risk for metastatic disease was stratified based on tumor involvement with local blood vessels, biopsy results and the nature of the tumor, and overall health status aside from pancreatic cancer. Patients who met these criteria underwent the MD Anderson protocol, which involved the following: A collaborative interpretation of pancreas-specific CT scans by surgeons and radiologists. Carefully administered preoperative chemotherapy and radiation treatment with multidisciplinary restaging prior to surgery. Use of advanced surgical techniques with planned removal and vascular reconstruction of involved blood vessels near the tumor. Using this protocol, we achieved survival numbers that are comparable to those of patients receiving surgery for clearly operable tumors. On average, patients undergoing the MD Anderson protocol lived about 30 months after tumor removal, which is almost three times longer than the average survival of 11 months for patients who do not undergo tumor resection. Key Considerations: Patient Selection & Imaging Our findings...

New Guidelines for Head & Neck Cancer Reirradiation

Recurrent and second primary head-and-neck squamous cell carcinomas (HNSCC) arising within or close to previously irradiated areas are a significant clinical challenge. Salvage surgical resection is the standard of care, but reirradiation is the only potentially curative treatment when surgery is not an option. Reirradiation is more challenging than initial treatment because of the side effects of prior therapy and concerns about the risks of high cumulative radiation doses to normal structures. Multi-institutional trials and large single institutional experiences have demonstrated that aggressive reirradiation, most often with chemotherapy, is feasible and provides durable locoregional control in some patients. An Expert Consensus on Reirradiation In the August 1, 2011 International Journal of Radiation Oncology * Biology * Physics, the American College of Radiology (ACR) published appropriateness criteria for recurrent head and neck cancer after prior definitive radiation. The ACR expert panel recommended that patient evaluation and reirradiation for HNSCC be performed at a tertiary care center with a head and neck oncology team that is equipped with the resources and experience to manage the complexities and toxicities of retreatment. Evaluation of Patients with Head & Neck Cancer Patient evaluation is important in assuring only appropriate patients are offered reirradiation. Evaluation should include careful restaging imaging, a detailed history and assessment of life expectancy, access to the prior radiotherapy details, and evaluation of: Comorbidities. Performance status. Speech and swallowing function. Sequelae of previous treatment (eg, fibrosis, carotid stenosis, osteoradionecrosis, or other severe toxicity). The ACR recommends that patients with a reasonable performance status who do not have severe soft tissue or bone toxicities from prior therapy and do not have distant...

A New Guide for Using Antiemetics

A significant proportion of all cancer patients experience nausea or vomiting during the course of their treatment. Nausea and vomiting have long been common adverse effects from certain types of cancer therapy and can lead to postponement or refusal of potentially curative treatments in some patients. In addition to reducing quality of life, these side effects often impede patients’ ability to maintain active lifestyles. With the emergence of serotonin receptor antagonists in the early 1990s and, more recently, the NK1 receptor antagonists, there have been steady improvements in the control of nausea and vomiting. In 1999, the American Society of Clinical Oncology (ASCO) published its first guideline on the use of antiemetic therapies to combat nausea and vomiting in cancer patients. In 2006, the guideline was revised based upon substantial developments, including the introduction of the NK1 receptor antagonists. In 2011, ASCO updated its guideline again to integrate new data that have emerged over the past 5 years (Table 1). “Clinicians need to communicate with their patients to optimize results.” “As knowledge about nausea and vomiting has emerged, so too have safe and effective treatments to battle this dreaded complication for patients,” says, Paul J. Hesketh, MD, who served on the steering committee for ASCO’s 2011 guideline. “The new guideline from ASCO emphasizes how the appropriate use of antiemetic therapies can vastly improve a patient’s treatment experience and quality of life by minimizing these side effects. In general, we have more effective and well-tolerated antiemetic agents than ever before. More recently, we’ve learned how to use these agents in more effective ways.” Reclassifying Risk for Vomiting & Nausea An...

The Impact of Complications on Colorectal Cancer Care

Colorectal cancer (CRC) is diagnosed in almost 150,000 patients in the United States each year and is the second leading cause of cancer-related death, accounting for more than 50,000 mortalities annually. The use of adjuvant chemotherapy has been a key quality measure for stage III CRC care because it is associated with a significant survival benefit. Chemotherapy for these patients has been shown to improve survival by as much as 16% after 5 years. However, national data indicate that guideline-recommended care is not provided to many patients. Studies have shown that the rates of adjuvant chemotherapy use for stage III CRC range from only 39% to 71%. Few studies have shed light on the reasons for the underuse of adjuvant chemotherapy in stage III CRC. Some sociodemographic variables (eg, older age, minority ethnicity, and lower socioeconomic status) have been linked to the omission of chemotherapy. However, it’s likely that other clinical predictors— including comorbid diseases, patients opting out of chemotherapy, and the high prevalence of perioperative complications in colorectal surgery—play a role in the receipt of chemotherapy. There may also be physician reluctance to give chemotherapy to patients who are frail or too sick from their surgical recovery. Complications in Colorectal Cancer Surgery In the December 2010 issue of Diseases of the Colon & Rectum, my colleagues and I published a study that examined the extent to which surgical complications are associated with the omission of recommended chemotherapy for CRC patients. We looked at data from 17,108 patients who had surgery for stage III CRC using patients from the Surveillance, Epidemiology, and End Results-Medicare database. Our results showed that at least...
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