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American Society of Clinical Oncology GI Symposium

New research presented at the Gastrointestinal (GI) Cancers Symposium from the American Society of Clinical Oncology, or ASCO, from January 22-24, 2010 in Orlando addressed key issues on the prevention, screening, and treatment of GI cancers. The features below highlight just some of the studies that emerged from the symposium. Comparing Treatments for True Cardia & Sub-Cardia Cancer The Particulars: Different surgical treatments are available for the treatment of true cardia and sub-cardia cancer. In left thoracoabdominal (LT) approaches, surgeons make a large incision from the left side of the chest to the middle of the abdomen. In abdominal and transhiatal (AT) approaches, the incision is smaller in the upper abdomen. The AT approach does not provide as much space to remove lymph nodes for analysis as the LT approach, but it is less invasive. Data Breakdown: Researchers randomly assigned 167 patients to undergo surgery with AT or LT between 1995 and 2003. After a medium follow-up of 7.7 years, 5-year survival rates were higher in the AT group than the LT group (51% vs 37%). AT recipients experienced significantly less deterioration in respiratory function, body weight, and other symptoms. Take Home Pearl: When surgical treatment is indicated in true cardia or sub-cardia cancer, AT approaches appear to be superior to LT approaches. Predicting Survival in Gastric Cancer The Particulars: Peritoneal cytology is often used to determine the presence of cancer spread in gastric cancer patients that is not visible to the naked eye. It is performed by microscopic examination of cell samples collected during surgery. Data Breakdown: A study was conducted to analyze poor disease-specific survival (DSS) among...

Updated Guidelines for Use of Antiretroviral Therapies in HIV

The Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents issued new guidelines December 1, 2009 for the use of antiretroviral agents in HIV-1-infected adults and adolescents. The revised recommendations update the November 3, 2008 version of the guidelines. “The guidelines serve as a living document and are updated regularly using electronic distribution channels,” says Paul E. Sax, MD, who is on the DHHS panel. In the guidelines, recommendations are based on the best evidence from prospective trials in HIV therapy with defined endpoints. When to Start Antiretroviral Therapy There are several key changes from the November 3, 2008 DHHS guidelines, and one of the most important, in Dr. Sax’s opinion, addresses when to start antiretroviral therapy (ART). “In recent cohort studies, findings support that starting therapy in patients with a higher CD4 cell count is associated with improved outcomes,” he says. “Most of the available evidence recommends starting ART earlier, with specific considerations [Figure 1]. For example, one study suggested that treatment be started before the CD4 cell count falls below 350 cells/mm3 while another found that 500 cells/mm3 should be the threshold. Considering data from observational studies and data from prospective clinical trials, the panel decided that the threshold for starting ART should be increased to between 350 cells/mm3 and 500 cells/mm3.” While there is clearly a movement in the updated DHHS guidelines to begin treatment earlier, Dr. Sax says this strategy does not apply to everyone. “Some patients are clearly not ready to start therapy because they can’t commit to lifelong medication adherence. Providers and patients must work together to...

Improving Survival in Kidney Cancer

When managing kidney cancer, clinicians have traditionally used a one-size-fits-all approach. However, emerging evidence is demonstrating that all kidney cancer patients are not the same. Likewise, not all localized and metastatic kidney cancers are the same. Improving survival rates in kidney cancer is paramount, and several new targeted therapies that have been introduced to the treatment armamentarium have been shown to improve survival. As these therapies continue to emerge as viable treatment options, it’s important to determine the patients who stand to benefit most from them. New Long-Term Data In the November 1, 2008 issue of Cancer, my colleagues and I had a study published in which we assessed nearly 1,500 patients treated for kidney cancer in the last 15 years. Our investigation used an integrated staging system—developed at UCLA—which brought together medical oncologists, urologists, surgeons, clinical trial experts, and scientists for collaboration. A key finding of our study was that patients with localized kidney cancer could have low-, intermediate-, or high-risk cancers, and some may have better outcomes than others depending on the aggressiveness of the disease. Patients with low-risk, localized cancer had a 5-year survival rate of 97% and a 10-year survival rate of 92%. Those at intermediate-risk had 5- and 10-year survival rates of 81% and 61%, respectively. High-risk patients had 5- and 10-year survival rates of 62% and 41%, respectively. In the past, these groups of patients may have been treated in similar manners, but it’s clear that they should be treated individually according to their risk levels. In patients with metastatic kidney cancer, our study showed that those with low-risk disease should receive aggressive...

Conference Highlights: CROI 2010

The Conference on Retroviruses and Opportunistic Infections, or CROI, held its 2010 annual conference from February 16 to 19 in San Francisco. The features below highlight some of the news emerging from the meeting. For more information on these items and other research that was presented, go to http://retroconference.org/2010. Hormonal Contraception in Women With HIV The Particulars: There has been a significant unmet need for contraception among HIV-positive women. Reports from the World Health Organization currently conclude that most forms of contraception are safe for HIV-positive women. Use of hormonal contraception has doubled over the past decade, but had still reached only 19.2% in 2005-2006. Data Breakdown: A population-based study of 625 women in Uganda who had more than 10 years of follow-up and yearly information on contraceptive use was conducted. Hormonal contraception was associated with a median of 4.45 years longer until AIDS or death compared with no contraception. However, hormonal contraception appeared to offer no more benefit with regard to risk of AIDS and death than other forms of contraception. Take Home Pearls: Hormonal contraception appears to carry no harm for women with HIV. Users of the pill and other forms of hormonal contraception appear to be protected against progression to AIDS or death. Increasing the Identification of HIV The Particulars: Identifying patients with HIV earlier, when they have higher CD4 counts, is important because these individuals are more likely to respond to therapy. Washington, DC has one of the highest rates of HIV in the United States, with an estimated prevalence of 3%. Data Breakdown: Washington, DC’s Department of Health launched an initiative in 2006 with...

Extending Survival for HIV-Infected Patients

Over the past few decades, advances in antiretroviral therapy (ART) have enabled many HIV-infected patients to live longer lives. Despite these successes, substantial avoidable losses in life expectancy of HIV-infected persons persist in the United States. The factors that exert a significant impact on survival include: • Late diagnosis. • Late initiation of care. • Premature discontinuation of therapy. • Background behavioral risk factors, such as alcohol, substance abuse, and smoking, which are prevalent in individuals with HIV. Assessing Survival Losses In the November 15, 2009 issue of Clinical Infectious Diseases, my colleagues and I published a study in which we estimated survival losses related to HIV disease in the U.S. This included 1) behavioral risk factors in the absence of HIV, 2) HIV disease per se, and 3) late initiation and/or early discontinuation of life saving ART. For individuals who were not infected with HIV and had risk profiles similar to those who were infected, we found that the projected life expectancy, starting at age 33, was 34.6 years, compared with 42.9 years for the general U.S. population. These findings suggested that about 8 fewer years, or a 19% reduction, in life expectancy is due to substance abuse and other high-risk behaviors even in the absence of HIV. These losses underscore the critical importance of interventions which focus on reducing substance abuse and other high-risk behaviors. Patients infected with HIV lost an additional 11.9 years of life if they received HIV care that was concordant with guidelines (representing an additional 28% reduction). The estimated life expectancy for HIV-infected patients who initiated ART very late—when CD4 cell counts reached...

The 2009 American Heart Association Scientific Sessions

The American Heart Association held its 2009 Scientific Sessions from November 14 to 18 in Orlando. The features below highlight some of the news emerging from the meeting. For more information on these items and other research that was presented, go to www.americanheart.org. Migraine Headaches Increase Stroke Risk The Particulars: Identifying people at highest risk of ischemic stroke is crucial to preventing disabling strokes. Many articles about the relationship between migraine and ischemic stroke have been published, but this relationship has not been well characterized. Data Breakdown: Researchers pooled results from 21 studies involving 622,381 men and women, assessing migraine and subsequent risk for ischemic stroke. Study participants were between the ages of 18 and 70, and none had suffered a stroke prior to enrollment. The risk of ischemic stroke for those with migraines was 2.3 times that of those without migraine. For those who experienced aura, the risk of ischemic stroke was 2.5 times higher. In women who experienced aura, the risk of ischemic stroke was 2.9 times as high as those without migraine with aura. Take Home Pearls: Migraine headaches appear to be associated with more than a two-fold higher risk of ischemic stroke. Physicians should consider addressing stroke risk factors in patients with a history or signs of light aura associated with severe migraine headaches. Benefits of Mechanical Thrombectomy in Primary PCI The Particulars: Previous studies have shown that myocardial perfusion after primary PCI is a strong predictor of mortality, independent from infarct-related coronary artery reopening. The EXPIRA (Thrombectomy With Export Catheter in Infarct-Related Artery During Primary Percutaneous Coronary Intervention) trial randomized 175 STEMI patients to...
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