Showing papers in "CA: A Cancer Journal for Clinicians in 2009"

Cancer Statistics, 2009

Abstract: Each year, the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute, Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. Incidence and death rates are standardized by age to the 2000 United States standard million population. A total of 1,479,350 new cancer cases and 562,340 deaths from cancer are projected to occur in the United States in 2009. Overall cancer incidence rates decreased in the most recent time period in both men (1.8% per year from 2001 to 2005) and women (0.6% per year from 1998 to 2005), largely because of decreases in the three major cancer sites in men (lung, prostate, and colon and rectum [colorectum]) and in two major cancer sites in women (breast and colorectum). Overall cancer death rates decreased in men by 19.2% between 1990 and 2005, with decreases in lung (37%), prostate (24%), and colorectal (17%) cancer rates accounting for nearly 80% of the total decrease. Among women, overall cancer death rates between 1991 and 2005 decreased by 11.4%, with decreases in breast (37%) and colorectal (24%) cancer rates accounting for 60% of the total decrease. The reduction in the overall cancer death rates has resulted in the avoidance of about 650,000 deaths from cancer over the 15-year period. This report also examines cancer incidence, mortality, and survival by site, sex, race/ethnicity, education, geographic area, and calendar year. Although progress has been made in reducing incidence and mortality rates and improving survival, cancer still accounts for more deaths than heart disease in persons younger than 85 years of age. Further progress can be accelerated by applying existing cancer control knowledge across all segments of the population and by supporting new discoveries in cancer prevention, early detection, and treatment.

Worldwide Variations in Colorectal Cancer

Abstract: Previous studies have documented significant international variations in colorectal cancer rates. However, these studies were limited because they were based on old data or examined only incidence or mortality data. In this article, the colorectal cancer burden and patterns worldwide are described using the most recently updated cancer incidence and mortality data available from the International Agency for Research on Cancer (IARC). The authors provide 5-year (1998-2002), age-standardized colorectal cancer incidence rates for select cancer registries in IARC's Cancer Incidence in Five Continents, and trends in age-standardized death rates by single calendar year for select countries in the World Health Organization mortality database. In addition, available information regarding worldwide colorectal cancer screening initiatives are presented. The highest colorectal cancer incidence rates in 1998-2002 were observed in registries from North America, Oceania, and Europe, including Eastern European countries. These high rates are most likely the result of increases in risk factors associated with "Westernization," such as obesity and physical inactivity. In contrast, the lowest colorectal cancer incidence rates were observed from registries in Asia, Africa, and South America. Colorectal cancer mortality rates have declined in many longstanding as well as newly economically developed countries; however, they continue to increase in some low-resource countries of South America and Eastern Europe. Various screening options for colorectal cancer are available and further international consideration of targeted screening programs and/or recommendations could help alleviate the burden of colorectal cancer worldwide.

Patient adherence and persistence with oral anticancer treatment

Abstract: Given the recent significant increase in the use of oral therapies in cancer management, an understanding of patients' adherence to and persistence with oral therapy is crucial. Nonadherence and early cessation may be substantial barriers to the delivery of valuable therapies, and may impair health. Potential obstacles to adherence and persistence include personal characteristics, treatment features, and system factors. Techniques for measuring adherence and persistence include self-report, pill counts, microelectronic monitoring systems (MEMS), prescription database analysis, and the assessment of serum or urine drug levels. This review article describes available data regarding adherence and persistence among patients with cancer, as well as studies of interventions to improve adherence. All reports of studies of adherence with oral cancer therapy that the authors could find on PubMed or in the reference sections of these PubMed-located articles were included. Adherence and persistence rates ranged from 16% to 100% with different therapies and different methods of measurement. Studies that included educational, behavioral, and multidimensional interventions to improve adherence were also described.

Cancer screening in the United States, 2009: A review of current American Cancer Society guidelines and issues in cancer screening

Abstract: Each year, the American Cancer Society (ACS) publishes a report summarizing its recommendations for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In 2008, the ACS, the American Gastroenterological Association, the American College of Gastroenterology, the Society for Gastrointestinal Endoscopy, and the American College of Radiology issued a joint update of guidelines for colorectal cancer screening in average-risk adults. In this issue, the current ACS guidelines and recent issues are summarized, updates of testing guidelines for early prostate cancer detection and colorectal cancer screening by the United States Preventive Services Task Force are discussed, and the most recent data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System and the National Health Interview Survey pertaining to participation rates in cancer screening are described.

Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment

Abstract: The primary goals of oncologic therapy are the compassionate care of cancer patients, eradication of disease, and palliation of symptoms. Advances in various targeted therapies such as highly conformal and image-guided radiotherapy techniques, sentinel lymph node dissection, and molecularly targeted agents hold the promise of allowing those goals to be reached with fewer treatment-related complications. Unfortunately, certain side effects remain problematic due to the inability to completely avoid injuring normal tissues. Lymphedema, a chronic condition that occurs as a result of the body's inability to drain lymph fluid from the tissues, is a common treatment-related side effect experienced by cancer patients. In this review, many of the important aspects of lymphedema with which clinicians who treat cancer patients should be familiar are outlined, including the anatomy, pathophysiology, diagnosis, and management of this condition. The authors also identify some of the resources available both to cancer patients with lymphedema and to the clinicians who treat them. It is hoped that this review will convey the importance of the early identification and management of this incurable disorder because this is essential to minimizing its complications.

Novel Agents on the Horizon for Cancer Therapy

Abstract: Although cancer remains a devastating diagnosis, several decades of preclinical progress in cancer biology and biotechnology have recently led to successful development of several biological agents that substantially improve survival and quality of life for some patients. There is now a rich pipeline of novel anticancer agents in early phase clinical trials. The specific tumor and stromal aberrancies targeted can be conceptualized as membrane-bound receptor kinases (HGF/c-Met, human epidermal growth factor receptor and insulin growth factor receptor pathways), intracellular signaling kinases (Src, PI3k/Akt/mTOR, and mitogen-activated protein kinase pathways), epigenetic abnormalities (DNA methyltransferase and histyone deacetylase), protein dynamics (heat shock protein 90, ubiquitin-proteasome system), and tumor vasculature and microenvironment (angiogenesis, HIF, endothelium, integrins). Several technologies are available to target these abnormalities. Of these, monoclonal antibodies and small-molecule inhibitors have been the more successful, and often complementary, approaches so far in clinical settings. The success of this target-based cancer drug development approach is discussed with examples of recently approved agents, such as bevacizumab, erlotinib, trastuzumab, sorafenib, and bortezomib. This review also highlights the pipeline of rationally designed drugs in clinical development that have the potential to impact clinical care in the near future.

Review of preoperative magnetic resonance imaging (MRI) in breast cancer: should MRI be performed on all women with newly diagnosed, early stage breast cancer?

Abstract: Randomized controlled trials have shown equivalent survival for women with early stage breast cancer who are treated with breast-conservation therapy (local excision and radiotherapy) or mastectomy. Decades of experience have demonstrated that breast-conservation therapy provides excellent local control based on defined standards of care. Magnetic resonance imaging (MRI) has been introduced in preoperative staging of the affected breast in women with newly diagnosed breast cancer because it detects additional foci of cancer that are occult on conventional imaging. The median incremental (additional) detection for MRI has been estimated as 16% in meta-analysis. In the absence of consensus on the role of preoperative MRI, we review data on its detection capability and its impact on treatment. We outline that the assumptions behind the adoption of MRI, namely that it will improve surgical planning and will lead to a reduction in re-excision surgery and in local recurrences, have not been substantiated by trials. Evidence consistently shows that MRI changes surgical management, usually from breast conservation to more radical surgery; however, there is no evidence that it improves surgical care or prognosis. Emerging data indicate that MRI does not reduce re-excision rates and that it causes false positives in terms of detection and unnecessary surgery; overall there is little high-quality evidence at present to support the routine use of preoperative MRI. Randomized controlled trials are needed to establish the clinical, psychosocial, and long-term effects of MRI and to show a related change in treatment from standard care in women newly affected by breast cancer.

The effect of provider case volume on cancer mortality: systematic review and meta-analysis.

Abstract: The authors systematically reviewed the association between provider case volume and mortality in 101 publications involving greater than 1 million patients with esophageal, gastric, hepatic, pancreatic, colon, or rectal cancer, of whom more than 70,000 died. The majority of studies addressed the relation between hospital surgical case volume and short-term perioperative mortality. Few studies addressed surgeon case volume or evaluated long-term survival outcomes. Common methodologic limitations were failure to control for potential confounders, post hoc categorization of provider volume, and unit of analysis errors. A significant volume effect was evident for the majority of gastrointestinal cancers; with each doubling of hospital case volume, the odds of perioperative death decreased by 0.1 to 0.23. The authors calculated that between 10 and 50 patients per year, depending on cancer type, needed to be moved from a "low-volume" hospital to a "high-volume" hospital to prevent 1 additional volume-associated perioperative death. Despite this, approximately one-third of all analyses did not find a significant volume effect on mortality. The heterogeneity of results from individual studies calls into question the validity of case volume as a proxy for care quality, and leads the authors to conclude that more direct quality measures and the validity of their use to inform policy should also be explored.

Advances in understanding and management of myeloproliferative neoplasms.

Abstract: According to the 2008 World Health Organization classification system for hematologic malignancies, the myeloproliferative neoplasms (MPN) include chronic myelogenous leukemia, polycythemia vera, essential thrombocythemia, primary myelofibrosis, mastocytosis, chronic eosinophilic leukemia-not otherwise specified, chronic neutrophilic leukemia, and "MPN, unclassifiable." All of these clinicopathologic entities are characterized by stem cell-derived clonal myeloproliferation, and their phenotypic diversity is ascribed to the occurrence of distinct oncogenic events. In the last 4 years, new JAK2 and MPL mutations have been added to previously described ABL and KIT mutations as molecular markers of disease in MPN. These discoveries have markedly simplified the approach to clinical diagnosis and have also provided molecular targets for the development of small-molecule drugs. In the current article, the authors provide a clinically oriented overview of MPNs in terms of their molecular pathogenesis, classification, diagnosis, and management.

Local Surgical, Ablative, and Radiation Treatment of Metastases

Abstract: Because local therapies directed toward a specific tumor mass are known to be effective for treating early-stage cancers, it should be no surprise that there has been considerable historical experience using local therapies for metastatic disease. In more recent years, increasing interest in the use of local therapy for metastases likely has arisen from improvements in systemic therapy. In the absence of effective systemic therapies, such local treatments were often considered futile given both the difficulty in eliminating all sites of identifiable metastatic disease as well as realities regarding the rapid natural history of uncontrolled tumor dissemination. However, with a higher likelihood of patients surviving longer after effective systemic therapy, even if not cured, the goal of the eradication of residual metastases via potent local therapies can be rationalized. However, this rationalization should be evidence-based so as to avoid harming patients for no established benefit. Although surgical metastectomy remains the most common and first-line standard among local therapies, nonsurgical alternatives, including thermal ablation and stereotactic body radiotherapy, have become increasingly popular because they are generally less invasive than surgery and have demonstrated considerable promise in eradicating macroscopic tumor. Rather than eliminating the need for local therapies, improvements in systemic therapies appear to be increasing the prudent utilization of modern local therapies in patients presenting with more advanced cancer.

Thyroid aspiration cytology: current status

Abstract: In the adult population, thyroid nodules are common and are increasingly detected by ultrasound examination or other scanning techniques Depending on their size and ultrasonographic features, these nodules may require further investigation, including tissue diagnosis Fine-needle aspiration (FNA) has become the predominant method to obtain tissue for microscopic analysis In October 2007, the National Cancer Institute sponsored a conference to review the state of the science for the use of FNA in the management of thyroid nodules This conference reviewed indications for thyroid FNA and pre-FNA requirements, training and credentialing, techniques for thyroid FNA, diagnostic terminology and morphologic criteria, utilization of ancillary studies, and post-FNA testing and treatment options The results of those discussions have been published in both print and electronic versions The aim of the current article was to discuss indications for FNA, diagnostic terminology, and post-FNA options, issues that are important to physicians who are managing patients with thyroid nodules

Cutaneous Manifestations of Internal Malignancy

Abstract: The skin often mirrors changes in the organism it envelops. Many neoplastic diseases that affect internal organs display cutaneous manifestations, which may be the presenting signs and symptoms of the underlying malignancy. These may reflect direct involvement of the skin by the tumor (ie, tumor metastasis) or indirect involvement, in which changes in the skin occur in the absence of malignant cells. This review focuses on the latter conditions, which are often referred to as paraneoplastic dermatoses. Included in the discussion are the cutaneous manifestations of inherited syndromes that are associated with an increased risk of internal malignancy, cutaneous changes in patients with hormone-secreting tumors, and the wide spectrum of proliferative and inflammatory dermatoses that have been associated with internal cancer.

Pharmacogenetics and pharmacogenomics of anticancer agents.

Abstract: Large interindividual variation is observed in both the response and toxicity associated with anticancer therapy. The etiology of this variation is multifactorial, but is due in part to host genetic variations. Pharmacogenetic and pharmacogenomic studies have successfully identified genetic variants that contribute to this variation in susceptibility to chemotherapy. This review provides an overview of the progress made in the field of pharmacogenetics and pharmacogenomics using a five-stage architecture, which includes 1) determining the role of genetics in drug response; 2) screening and identifying genetic markers; 3) validating genetic markers; 4) clinical utility assessment; and 5) pharmacoeconomic impact. Examples are provided to illustrate the identification, validation, utility, and challenges of these pharmacogenetic and pharmacogenomic markers, with the focus on the current application of this knowledge in cancer therapy. With the advance of technology, it becomes feasible to evaluate the human genome in a relatively inexpensive and efficient manner; however, extensive pharmacogenetic research and education are urgently needed to improve the translation of pharmacogenetic concepts from bench to bedside.

Patient Decision Aids for Prostate Cancer Treatment: A Systematic Review of the Literature†‡§

Abstract: Treatment decision-making can be difficult and complex for patients with low-risk prostate cancer. To the authors' knowledge, there is no consensus regarding an optimal treatment strategy and the choice of therapy involves tradeoffs between differing harms and benefits that are sensitive to patient values. In such situations, patients are often asked to participate actively in the decision-making process, and high-quality decisions require a well-informed patient whose values and preferences have been taken into consideration. Prior studies have indicated that patients have poor knowledge and unrealistic expectations regarding treatment, and physician judgments concerning patient preferences are often inaccurate. Decision aids (DAs) have been developed to help inform patients with low-risk prostate cancer about treatment options and assist in the decision-making process; however, little is currently known regarding the effects of such programs in this population. Thirteen studies of DAs for patients with prostate cancer were reviewed and it was found that the use of DAs can improve knowledge, encourage more active patient involvement in decision-making, and decrease levels of anxiety and distress. The effect of DAs on treatment choice was less clear, although fewer patients chose surgery compared with historical controls, particularly in Europe. Further studies are needed to determine how best to implement DAs into practice, and whether they improve the consistency between patient preferences and treatment choice.

Tobacco control in the United States--recent progress and opportunities.

Abstract: Effective tobacco control efforts have resulted in substantial declines in tobacco use and tobacco-related cancer deaths in the United States. Nearly 40% of reductions in male lung cancer deaths between 1991 and 2003 can be attributed to smoking declines in the last half century. Nevertheless, tobacco use still remains the single, largest preventable cause of disease and premature death in the United States. Each year, smoking and exposure to secondhand smoke result in nearly half a million premature deaths of which nearly one-third are due to cancer. In a previous report, we described youth and adult smoking prevalence and patterns and discussed policy measures that had proven effective in comprehensive tobacco control. In this report, we update trends in youth and adult smoking prevalence. We find that while adult smoking prevalence has declined overall, socioeconomic gradients in smoking still persist within race and ethnic subgroups. In addition, we describe the diffusion of tobacco-control strategies at the national, state, and community level. Although recent developments, such as the Food and Drug Administration's (FDA) regulation of tobacco products, hold promise for tobacco control, there continues to be a need for broader dissemination of sustainably funded comprehensive national and state tobacco-control programs.

New Molecular Classifications of Breast Cancer

Abstract: Traditionally, pathologic determinations of tumor size, lymph node status, endocrine receptor status, and human epidermal growth factor receptor 2 (HER2) status have driven prognostic predictions and adjuvant therapy recommendations for patients with early stage breast cancer. However, these prognostic and predictive factors are relatively crude measures, resulting in many patients being overtreated or undertreated. As a result of gene expression assays, there is growing recognition that breast cancer is a molecularly heterogeneous disease. Evidence from gene expression microarrays suggests the presence of multiple molecular subtypes of breast cancer. The recent commercial availability of gene expression profiling techniques that predict risk of disease recurrence as well as potential chemotherapy benefit have shown promise in refining clinical decision making. These techniques will be reviewed in this article.

Screening for prostate cancer

Abstract: Prostate cancer screening is a fait acomplis in the United States at this time. Regardless of whether it is justifiable from a scientific standpoint, it is occurring. The evidence for this statement can be found in the incidence rates of prostate cancer before and after the advent of prostate-specific antigen (PSA) screening. Figure 1 graphically demonstrates this phenomenon. PSA became widely available in 1987–1988, and screening for prostate cancer increased dramatically shortly thereafter.

Adult Cancer Survivorship: Evolution, Research, and Planning Care

Abstract: Increases in the number of adult cancer survivors and other issues have forced the oncology community to examine, evaluate, and alter the cancer care paradigm Pediatric oncologists are grappling with the task of transitioning a growing population of adult survivors of childhood cancer to adult medicine, while oncologists caring for adult cancer survivors are seeking models of follow-up care that are acceptable to patients and providers Workforce and access-to-care issues suggest that primary care providers will see more cancer survivors in their practices across time, although it is unclear how prepared they are for this task Translational research is needed to develop evidence-based clinical care and survivorship care plans A broad picture of the evolving field of adult cancer survivorship is presented The recent focus on young adult survivors of childhood cancer, an overview of translational research needed to inform the physical and psychosocial care of cancer survivors, and the roles of primary and specialty care providers managing this population is examined Finally, an overview of evolving treatment summary and care plan initiatives is presented

Current Status of Palliative Care—Clinical Implementation, Education, and Research†‡

Abstract: Palliative and end-of-life care is changing in the United States. This dynamic field is improving care for patients with serious and life-threatening cancer through creation of national guidelines for quality care, multidisciplinary educational offerings, research endeavors, and resources made available to clinicians. Barriers to implementing quality palliative care across cancer populations include a rapidly expanding population of older adults who will need cancer care and a decrease in the workforce available to give care. Methods of integrating current palliative care knowledge into care of patients include multidisciplinary national education and research endeavors, and clinician resources. Acceptance of palliative care as a recognized medical specialty provides a valuable resource for improvement of care. Although compilation of evidence for the importance of palliative care specialities is in its initial stages, national research grants have provided support to build the knowledge necessary for appropriate palliative care. Opportunities are available to clinicians for understanding and applying appropriate palliative and end-of-life care to patients with serious and life-threatening cancers.

Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice

Abstract: Patients with advanced cancer face difficult decisions regarding their treatment, and many will need to make difficult choices about end-of-life care because although cancer-directed therapies are increasingly available, few provide a cure. High-quality cancer care includes access to palliative care throughout the cancer care continuum, and increasing evidence suggests that timely enrollment in hospice can increase quality of life for patients dying from cancer. Therefore, clinicians must learn to recognize patients who are hospice-eligible and to develop prognostication and communication skills that enable honest provider-patient dialogue about end-of-life options. In this article, the authors review available tools for prognostication in advanced cancer and present a method for discussing prognosis by using the SPIKES acronym. In addition, by using patient-identified goals and service needs, the authors recommend a method for making a hospice referral after disclosure of poor prognosis.

Treating tobacco dependence in a medical setting.

Abstract: The US Public Health Service Guideline for Treating Tobacco Use and Dependence 2008 Update emphasizes tobacco use as a chronic medical disorder; highlights both behavioral counseling and the use of 1 or more of the 7 approved medications; and points out the utility, efficacy, and reach of telephone quitlines. The treatment of users of smokeless tobacco continues to be less than optimal. Although providing evidence-based treatment for tobacco- dependent patients is a challenge for busy physicians, a team approach including trained and certified tobacco treatment specialists (TTS) provides an efficient treatment model. TTS represent a new and growing part of the health care team and hold great potential for expanding the collective tobacco treatment expertise in the medical setting. The effective treatment of tobacco dependence frequently requires tailoring, and often intensifying, interventions (both counseling and pharmacotherapy) to meet the needs of the individual patient.

Prostate cancer: current evidence weighs against population screening.

Abstract: Prostate–specific antigen (PSA) measurement, obtained from a simple blood sample, has been widely proposed as a screening tool for prostate cancer, which is currently the leading cancer diagnosis in men in several developing countries.1 In many parts of the world, the PSA test is now widely used, and is frequently used indiscriminately. For example, in a cohort of greater than half a million men aged 70 years assembled from 104 US Veterans Administration hospitals during 2002 and 2003, 56% of elderly men had a PSA test (64% of men ages 70–74 years and 36% of men aged 85 years).2 PSA screening has remained a controversial topic, and findings from 2 large randomized trials have been eagerly awaited. The PSA test was first approved by the US Food and Drug Administration in 1986 for monitoring progression in patients with prostate cancer. It was later approved for the detection of disease in symptomatic men and has not been approved for screening asymptomatic men.3 In 1991, Catalona et al4 published results from a large series of men in whom PSA was measured and concluded that the screening program was able to identify patients at a high risk for prostate cancer. For the purposes of evaluating PSA as a screening tool, the absence of a parallel control group was a major handicap; the study simply involved testing levels of PSA in a large series of consecutive male patients. It demonstrated that PSA could be used to help diagnose early stage prostate cancer. It did not address the question of whether PSA screening reduces the prostate cancer mortality rate or saves lives. Findings from prospective randomized clinical studies were/are desperately needed. To our knowledge, to date 4 randomized trials have investigated the efficacy of prostate cancer screening, mainly using the PSA test. The Quebec study5,6 was proclaimed as the first randomized trial to demonstrate the efficacy of screening for prostate cancer. Labrie et al5 presented the data in the plenary session at the annual meeting of the American Society of Clinical Oncology in Los Angeles, California, in 1998. They reported death rates of 48.7 per 100,000 in unscreened men and 15 per 100,000 in screened men, with a claimed odds ratio of 3.25 in favor of screening. This analysis was widely criticized as flawed. It excluded men assigned to the screening group who were invited to screening and did not participate. Reanalysis with a more appropriate intention–to–screen method found a 16% excess of deaths in the group invited to screening compared with those in the control group. The reanalysis strongly suggested that the original findings were significantly affected by selection bias.7 In other words, men who were invited to screening may have opted to accept the invitation because they were more healthy than men who refused the invitation. To exclude this latter group biases the data and the findings.8 The second randomized trial to be published came from Sandblom et al in Sweden9 and reported a 47% higher rate of diagnosis in screened men than in controls. The intention–to–screen analysis of the data calculated the relative risk of death from prostate cancer to be 1.04 (ie, a [statistically nonsignificant] 4% increase in the risk of death from prostate cancer

American Cancer Society Perspectives on Environmental Factors and Cancer

Abstract: Cancer prevention is central to the mission of the American Cancer Society (ACS). The ACS's prevention activities take many forms, but are primarily focused on modifiable risk factors that have been demonstrated to have the largest impact on cancer risk in the general population (with particular emphasis on tobacco use because of its large impact on cancer), and well-proven policy and program interventions. The ACS addresses nutrition, physical inactivity and obesity, alcohol consumption, excessive sun exposure, prevention of certain chronic infections, and selected other environmental factors through a variety of venues, including consensus guidelines (eg, nutrition and physical activity, human papillomavirus vaccination) and developing educational materials for health care providers and the general public. In contrast to the broad definition of environmental factors used by the ACS and most other public health agencies, some members of the general public associate the term "environmental" only with toxic air and water pollutants and other, predominantly manmade, hazards that people encounter, often involuntarily, in their daily life. This article will provide an overview of the ACS's approach to the prevention of cancer associated with such toxic pollutants in the context of its mission and priorities with respect to cancer prevention.

Recruitment to breast cancer clinical trials: what makes a difference?

Abstract: Only 5.4% to 8.5% of patients being treated for breast cancer enroll in clinical trials, according to a Canadian study published in the Journal of Clinical Oncology (2008;26:44584465). Researchers in Canada undertook the study to determine what characteristics of cancer care protocols and environments stand in the way of enrolling patients in clinical trials of breast cancer treatments. Their findings indicate that the lack of an available clinical trial is the biggest roadblock for patients. The researchers also determined that recruitment could be enhanced if longer intervals between diagnosis and/or surgery and trial enrollment were permitted.

Taking action to ease suffering: Advancing cancer pain control as a health care priority

Abstract: “We don’t beat the Reaper by living longer. We beat the Reaper by living well.” Professor Randy Pausch made this declaration in his May 2008 address to graduates at Carnegie Mellon University just months before his death last September. His cancer battle and his personal priorities, as he described in his Carnegie “Last Lecture,” resonated with the public in a remarkable way and captured the heart and soul of what most patients believe and want. There is no doubt that persons diagnosed with cancer want to be cured or, at least, achieve a long remission from disease. But setting aside prognosis, most patients and their loved ones also want to be able to live well with their cancer—whether that life lasts weeks, months, or years. They also want to have comfort, dignity, and relief from pain as they face the end of life. Pain remains one of the most feared and burdensome symptoms for cancer patients and survivors. Nearly all cancer pain can be relieved, yet the prevalence of pain and its undertreatment has remained consistently high and largely unchanged for more than 4 decades.1 Still more troubling, significant pain treatment and access disparities in medically underserved and socioeconomically disadvantaged populations continue to be documented.2–5 Many effective pain medicines and nondrug therapies are available to bring pain relief to cancer patients so that they can complete scheduled treatments, continue to work, and enjoy the company of family and friends.6,7 But significant pain assessment and management deficiencies are consistently reported in the clinical settings where cancer patients are seen.8–10 Open communication with health-care professionals about pain, the medications for it, and other methods available to treat it is essential to relieve symptoms and improve quality of life. Opioid analgesics, generally recognized as a mainstay of treatment for moderate to severe cancer pain, pose particular policy challenges for practitioners. These controlled substances tend to trigger a dueling policy debate among physicians, who must consider the interface between providing pain relief and curbing diversion and misuse.11,12 Health care professionals are increasingly being recruited to fight on both fronts, but they are armed with very little clear and practical prescribing guidance from the Drug Enforcement Administration (DEA) or state medical boards.13 Adding to the challenge, the growing misuse of prescription pain medications appears to be receiving more frequent attention, including in the popular press. USA Today, and several other media outlets, covered the White House Director of National Drug Control Policy’s release of the DEA’s National Prescription Drug Threat Assessment this May and reported that unintentional deaths involving prescription opioids increased 114% from 2001 to 2005 (8,500 deaths nationwide), with pain relievers identified as the most widely abused and diverted, particularly among teens. According to this DEA report, 1 in 5 new drug abusers indicated that they began their illicit drug use with potent opioids such as oxycodone, hydrocodone, and methadone.14 The Food and Drug Administration (FDA) also has had its scope expanded and chose to carve out a role in drug control through its ongoing Risk Evaluation and Mitigation Strategy deliberations for cer-

Developing a Quality Screening Colonoscopy Referral System in Primary Care Practice: A Report from the National Colorectal Cancer Roundtable

Abstract: The use of colonoscopy in colorectal cancer (CRC) screening has increased substantially in recent years. Media messages and changes in insurance reimbursement, as well as new screening guidelines from the American Cancer Society and the US Preventive Services Task Force, have contributed to this increase. Primary care providers (PCPs) are frequently responsible for making the recommendation and referral for screening. The process of successfully referring a patient for screening colonoscopy can be cumbersome and requires a coordinated effort between the PCP and the endoscopist. In recognition of the potential complexity of this process, the National Colorectal Cancer Roundtable has issued a report to describe the components of a quality screening colonoscopy referral system in primary care practice. The elements of a quality program include an optimal scheduling and referral system, the appropriate patient preparation information, consistent reporting and follow-up systems, and a detailed approach to dealing with special situations.

It is time to include cancer and other noncommunicable diseases in the millennium development goals.

Abstract: John R. Seffrin, PhD, Chief Executive Officer, American Cancer Society, Atlanta, GA; David Hill, PhD, President, International Union Against Cancer (UICC), Geneva, Switzerland; Werner Burkart, PhD, Deputy Director General, International Atomic Energy Authority, Vienna, Austria; Ian Magrath, MB, BS, FRCP, FRCPath, President, International Network for Cancer Treatment and Research (INCTR), Brussels, Belgium; Rajendra A Badwe, MD, MBBS, Director, Tata Memorial Centre, Mumbai, India; Twalib Ngoma, MD, President, African Organisation for Research and Training in Cancer (AORTIC), Ocean Road Cancer Institute, Dar-Es-Salaam, Tanzania; Alejandro Mohar, MD, Director General, Mexican National Cancer Institute, Mexico City, Mexico; Nathan Grey, MPH, National Vice President, International Affairs, American Cancer Society, Atlanta, GA

Lymph node evaluation as a colon cancer quality measure

Abstract: “What steps will help with recruitment? It’s a complex area,” said Dr. Comis. He explained that according to surveys conducted by the Coalition, a large percentage of patients believe that they could be randomized to receive only placebo treatment. “We’re always trying to dispel this myth about placebos,” he said, explaining that this is a major difference between cancer clinical trials and other clinical trials. “If there is a standard of care for a particular type of cancer, we’d never use a placebo in lieu of that standard of care,” he said, adding that a placebo might be used in addition to standard-of-care treatment.