Showing papers in "CA: A Cancer Journal for Clinicians in 2014"

Cancer statistics, 2014

Abstract: Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data were collected by the National Center for Health Statistics. A total of 1,665,540 new cancer cases and 585,720 cancer deaths are projected to occur in the United States in 2014. During the most recent 5 years for which there are data (2006-2010), delay-adjusted cancer incidence rates declined slightly in men (by 0.6% per year) and were stable in women, while cancer death rates decreased by 1.8% per year in men and by 1.4% per year in women. The combined cancer death rate (deaths per 100,000 population) has been continuously declining for 2 decades, from a peak of 215.1 in 1991 to 171.8 in 2010. This 20% decline translates to the avoidance of approximately 1,340,400 cancer deaths (952,700 among men and 387,700 among women) during this time period. The magnitude of the decline in cancer death rates from 1991 to 2010 varies substantially by age, race, and sex, ranging from no decline among white women aged 80 years and older to a 55% decline among black men aged 40 years to 49 years. Notably, black men experienced the largest drop within every 10-year age group. Further progress can be accelerated by applying existing cancer control knowledge across all segments of the population.

Cancer treatment and survivorship statistics, 2014

Abstract: The number of cancer survivors continues to increase due to the aging and growth of the population and improvements in early detection and treatment. In order for the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborated to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results (SEER) program registries. In addition, current treatment patterns for the most common cancer types are described based on information in the National Cancer Data Base and the SEER and SEER-Medicare linked databases; treatment-related side effects are also briefly described. Nearly 14.5 million Americans with a history of cancer were alive on January 1, 2014; by January 1, 2024, that number will increase to nearly 19 million. The 3 most common prevalent cancers among males are prostate cancer (43%), colorectal cancer (9%), and melanoma (8%), and those among females are cancers of the breast (41%), uterine corpus (8%), and colon and rectum (8%). The age distribution of survivors varies substantially by cancer type. For example, the majority of prostate cancer survivors (62%) are aged 70 years or older, whereas less than one-third (32%) of melanoma survivors are in this older age group. It is important for clinicians to understand the unique medical and psychosocial needs of cancer survivors and to proactively assess and manage these issues. There are a growing number of resources that can assist patients, caregivers, and health care providers in navigating the various phases of cancer survivorship.

Colorectal cancer statistics, 2014

Abstract: Colorectal cancer is the third most common cancer and the third leading cause of cancer death in men and women in the United States. This article provides an overview of colorectal cancer statistics, including the most current data on incidence, survival, and mortality rates and trends. Incidence data were provided by the National Cancer Institute's Surveillance, Epidemiology, and End Results program and the North American Association of Central Cancer Registries. Mortality data were provided by the National Center for Health Statistics. In 2014, an estimated 71,830 men and 65,000 women will be diagnosed with colorectal cancer and 26,270 men and 24,040 women will die of the disease. Greater than one-third of all deaths (29% in men and 43% in women) will occur in individuals aged 80 years and older. There is substantial variation in tumor location by age. For example, 26% of colorectal cancers in women aged younger than 50 years occur in the proximal colon, compared with 56% of cases in women aged 80 years and older. Incidence and death rates are highest in blacks and lowest in Asians/Pacific Islanders; among males during 2006 through 2010, death rates in blacks (29.4 per 100,000 population) were more than double those in Asians/Pacific Islanders (13.1) and 50% higher than those in non-Hispanic whites (19.2). Overall, incidence rates decreased by approximately 3% per year during the past decade (2001-2010). Notably, the largest drops occurred in adults aged 65 and older. For instance, rates for tumors located in the distal colon decreased by more than 5% per year. In contrast, rates increased during this time period among adults younger than 50 years. Colorectal cancer death rates declined by approximately 2% per year during the 1990s and by approximately 3% per year during the past decade. Progress in reducing colorectal cancer death rates can be accelerated by improving access to and use of screening and standard treatment in all populations.

Breast cancer statistics, 2013

Abstract: In this article, the American Cancer Society provides an overview of female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Approximately 232,340 new cases of invasive breast cancer and 39,620 breast cancer deaths are expected to occur among US women in 2013. One in 8 women in the United States will develop breast cancer in her lifetime. Breast cancer incidence rates increased slightly among African American women; decreased among Hispanic women; and were stable among whites, Asian Americans/Pacific Islanders, and American Indians/Alaska Natives from 2006 to 2010. Historically, white women have had the highest breast cancer incidence rates among women aged 40 years and older; however, incidence rates are converging among white and African American women, particularly among women aged 50 years to 59 years. Incidence rates increased for estrogen receptor-positive breast cancers in the youngest white women, Hispanic women aged 60 years to 69 years, and all but the oldest African American women. In contrast, estrogen receptor-negative breast cancers declined among most age and racial/ethnic groups. These divergent trends may reflect etiologic heterogeneity and the differing effects of some factors, such as obesity and parity, on risk by tumor subtype. Since 1990, breast cancer death rates have dropped by 34% and this decrease was evident in all racial/ethnic groups except American Indians/Alaska Natives. Nevertheless, survival disparities persist by race/ethnicity, with African American women having the poorest breast cancer survival of any racial/ethnic group. Continued progress in the control of breast cancer will require sustained and increased efforts to provide high-quality screening, diagnosis, and treatment to all segments of the population.

Childhood and adolescent cancer statistics, 2014

Abstract: In this article, the American Cancer Society provides estimates of the number of new cancer cases and deaths for children and adolescents in the United States and summarizes the most recent and comprehensive data on cancer incidence, mortality, and survival from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries (which are reported in detail for the first time here and include high-quality data from 45 states and the District of Columbia, covering 90% of the US population). In 2014, an estimated 15,780 new cases of cancer will be diagnosed and 1960 deaths from cancer will occur among children and adolescents aged birth to 19 years. The annual incidence rate of cancer in children and adolescents is 186.6 per 1 million children aged birth to 19 years. Approximately 1 in 285 children will be diagnosed with cancer before age 20 years, and approximately 1 in 530 young adults between the ages of 20 and 39 years is a childhood cancer survivor. It is therefore likely that most pediatric and primary care practices will be involved in the diagnosis, treatment, and follow-up of young patients and survivors. In addition to cancer statistics, this article will provide an overview of risk factors, symptoms, treatment, and long-term and late effects for common pediatric cancers.

MicroRNAome genome: a treasure for cancer diagnosis and therapy.

Abstract: The interplay between abnormalities in genes coding for proteins and noncoding microRNAs (miRNAs) has been among the most exciting yet unexpected discoveries in oncology over the last decade. The complexity of this network has redefined cancer research as miRNAs, produced from what was once considered "genomic trash," have shown to be crucial for cancer initiation, progression, and dissemination. Naturally occurring miRNAs are very short transcripts that never produce a protein or amino acid chain, but act by regulating protein expression during cellular processes such as growth, development, and differentiation at the transcriptional, posttranscriptional, and/or translational level. In this review article, miRNAs are presented as ubiquitous players involved in all cancer hallmarks. The authors also describe the most used methods to detect their expression, which have revealed the identity of hundreds of miRNAs dysregulated in cancer cells or tumor microenvironment cells. Furthermore, the role of miRNAs as hormones and as reliable cancer biomarkers and predictors of treatment response is discussed. Along with this, the authors explore current strategies in designing miRNA-targeting therapeutics, as well as the associated challenges that research envisions to overcome. Finally, a new wave in molecular oncology translational research is introduced: the study of long noncoding RNAs.

American Cancer Society prostate cancer survivorship care guidelines

Abstract: Prostate cancer survivors approach 2.8 million in number and represent 1 in 5 of all cancer survivors in the United States. While guidelines exist for timely treatment and surveillance for recurrent disease, there is limited availability of guidelines that facilitate the provision of posttreatment clinical follow-up care to address the myriad of long-term and late effects that survivors may face. Based on recommendations set forth by a National Cancer Survivorship Resource Center expert panel, the American Cancer Society developed clinical follow-up care guidelines to facilitate the provision of posttreatment care by primary care clinicians. These guidelines were developed using a combined approach of evidence synthesis and expert consensus. Existing guidelines for health promotion, surveillance, and screening for second primary cancers were referenced when available. To promote comprehensive follow-up care and optimal health and quality of life for the posttreatment survivor, the guidelines address health promotion, surveillance for prostate cancer recurrence, screening for second primary cancers, long-term and late effects assessment and management, psychosocial issues, and care coordination among the oncology team, primary care clinicians, and nononcology specialists. A key challenge to the development of these guidelines was the limited availability of published evidence for management of prostate cancer survivors after treatment. Much of the evidence relies on studies with small sample sizes and retrospective analyses of facility-specific and population databases.

Breast cancer and circadian disruption from electric lighting in the modern world.

Abstract: Breast cancer is the leading cause of cancer death among women worldwide, and there is only a limited explanation of why. Risk is highest in the most industrialized countries but also is rising rapidly in the developing world. Known risk factors account for only a portion of the incidence in the high-risk populations, and there has been considerable speculation and many false leads on other possibly major determinants of risk, such as dietary fat. A hallmark of industrialization is the increasing use of electricity to light the night, both within the home and without. It has only recently become clear that this evolutionarily new and, thereby, unnatural exposure can disrupt human circadian rhythmicity, of which three salient features are melatonin production, sleep, and the circadian clock. A convergence of research in cells, rodents, and humans suggests that the health consequences of circadian disruption may be substantial. An innovative experimental model has shown that light at night markedly increases the growth of human breast cancer xenografts in rats. In humans, the theory that light exposure at night increases breast cancer risk leads to specific predictions that are being tested epidemiologically: evidence has accumulated on risk in shift workers, risk in blind women, and the impact of sleep duration on risk. If electric light at night does explain a portion of the breast cancer burden, then there are practical interventions that can be implemented, including more selective use of light and the adoption of recent advances in lighting technology and application.

Cancer screening in the United States, 2014: A review of current American Cancer Society guidelines and current issues in cancer screening

Abstract: Answer questions and earn CME/CNE Each year the American Cancer Society publishes a summary of its guidelines for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, we summarize current American Cancer Society cancer screening guidelines. In addition, the latest data on the use of cancer screening from the National Health Interview Survey is described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act, including the expansion of the Medicaid program.

Priorities for the primary prevention of breast cancer

Abstract: Despite recent calls to intensify the search for new risk factors for breast cancer, acting on information that we already have could prevent thousands of cases each year. This article reviews breast cancer primary prevention strategies that are applicable to all women, discusses the underutilization of chemoprevention in high-risk women, highlights the additional advances that could be made by including young women in prevention efforts, and comments on how the molecular heterogeneity of breast cancer affects prevention research and strategies.

Implementing and evaluating shared decision making in oncology practice.

Abstract: Engaging individuals with cancer in decision making about their treatments has received increased attention; shared decision making (SDM) has become a hallmark of patient-centered care. Although physicians indicate substantial interest in SDM, implementing SDM in cancer care is often complex; high levels of uncertainty may exist, and health care providers must help patients understand the potential risks versus benefits of different treatment options. However, patients who are more engaged in their health care decision making are more likely to experience confidence in and satisfaction with treatment decisions and increased trust in their providers. To implement SDM in oncology practice, physicians and other health care providers need to understand the components of SDM and the approaches to supporting and facilitating this process as part of cancer care. This review summarizes recent information regarding patient and physician factors that influence SDM for cancer care, outcomes resulting from successful SDM, and strategies for implementing SDM in oncology practice. We present a conceptual model illustrating the components of SDM in cancer care and provide recommendations for facilitating SDM in oncology practice.

Silica: A lung carcinogen

Abstract: Silica has been known to cause silicosis for centuries, and evidence that silica causes lung cancer has accumulated over the last several decades. This article highlights 3 important developments in understanding the health effects of silica and preventing illness and death from silica exposure at work. First, recent epidemiologic studies have provided new information about silica and lung cancer. This includes detailed exposure-response data, thereby enabling the quantitative risk assessment needed for regulation. New studies have also shown that excess lung mortality occurs in silica-exposed workers who do not have silicosis and who do not smoke. Second, the US Occupational Safety and Health Administration has recently proposed a new rule lowering the permissible occupational limit for silica. There are approximately 2 million US workers currently exposed to silica. Risk assessments estimate that lowering occupational exposure limits from the current to the proposed standard will reduce silicosis and lung cancer mortality to approximately one-half of the rates predicted under the current standard. Third, low-dose computed tomography scanning has now been proven to be an effective screening method for lung cancer. For clinicians, asking about occupational history to determine if silica exposure has occurred is recommended. If such exposure has occurred, extra attention might be given to the early detection of silicosis and lung cancer, as well as extra emphasis on quitting smoking.

Tobacco use and cessation for cancer survivors: An overview for clinicians

Abstract: Approximately 30% of all cancer deaths in the United States are caused by tobacco use and smoking. Cancers of eighteen sites have been causally linked to smoking, the most common of which are the lung, head and neck, bladder, and esophagus. While quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the recidivism rates are also high. Therefore, screening, treating, and preventing relapse to tobacco use is imperative among patients with and survivors of cancer. To date, research has consistently shown that a combination of pharmacologic and behavioral interventions is needed to achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as a most promising approach. Challenges in health care systems, including the lack of appropriate resources and provider training, have slowed the progress in addition to important clinical considerations relevant to the treatment of tobacco dependence (eg, a high degree of comorbidity with psychiatric disorders and other substance use disorders). However, continued tobacco use has been shown to limit the effectiveness of major cancer treatments and to increase the risk of complications and of developing secondary cancers. The authors recommend that oncology providers screen all patients for tobacco use and refer users to specialized treatment when available. Alternatively, oncology clinicians can provide basic advice on tobacco use cessation and pharmacotherapy and/or referral to outside resources (eg, quitlines). Herein, the authors summarize the current knowledge on tobacco use and its treatment, with a focus on the related available evidence for patients with and survivors of cancer.

Understanding biology to tackle the disease: Multiple myeloma from bench to bedside, and back.

Abstract: Multiple myeloma (MM) is a cancer of antibody-producing plasma cells. The pathognomonic laboratory finding is a monoclonal immunoglobulin or free light chain in the serum and/or urine in association with bone marrow infiltration by malignant plasma cells. MM develops from a premalignant condition, monoclonal gammopathy of undetermined significance (MGUS), often via an intermediate stage termed smoldering multiple myeloma (SMM), which differs from active myeloma by the absence of disease-related end-organ damage. Unlike MGUS and SMM, active MM requires therapy. Over the past 6 decades, major advancements in the care of MM patients have occurred, in particular, the introduction of novel agents (ie, proteasome inhibitors, immunomodulatory agents) and the implementation of hematopoietic stem cell transplantation in suitable candidates. The effectiveness and good tolerability of novel agents allowed for their combined use in induction, consolidation, and maintenance therapy, resulting in deeper and more sustained clinical response and extended progression-free and overall survival. Previously a rapidly lethal cancer with few therapeutic options, MM is the hematologic cancer with the most novel US Food and Drug Administration-approved drugs in the past 15 years. These advances have resulted in more frequent long-term remissions, transforming MM into a chronic illness for many patients.

Obesity and economic environments.

Abstract: This review summarizes current understanding of economic factors during the obesity epidemic and dispels some widely held, but incorrect, beliefs. Rising obesity rates coincided with increases in leisure time (rather than increased work hours), increased fruit and vegetable availability (rather than a decline in healthier foods), and increased exercise uptake. As a share of disposable income, Americans now have the cheapest food available in history, which fueled the obesity epidemic. Weight gain was surprisingly similar across sociodemographic groups or geographic areas, rather than specific to some groups (at every point in time; however, there are clear disparities). It suggests that if one wants to understand the role of the environment in the obesity epidemic, one needs to understand changes over time affecting all groups, not differences between subgroups at a given time. Although economic and technological changes in the environment drove the obesity epidemic, the evidence for effective economic policies to prevent obesity remains limited. Taxes on foods with low nutritional value could nudge behavior toward healthier diets, as could subsidies/discounts for healthier foods. However, even a large price change for healthy foods could close only part of the gap between dietary guidelines and actual food consumption. Political support has been lacking for even moderate price interventions in the United States and this may continue until the role of environmental factors is accepted more widely. As opinion leaders, clinicians play an important role in shaping the understanding of the causes of obesity. CA Cancer J Clin 2014;000:000-000. V C 2014 American Cancer Society.

Palliative radiotherapy at the end of life: A critical review

Abstract: When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life.

Fertility issues in cancer survivorship.

Abstract: Answer questions and earn CME/CNE Breakthroughs in cancer diagnosis and treatment have led to dramatic improvements in survival and the need to focus on survivorship issues. Chemotherapy and radiotherapy can be gonadotoxic, resulting in impaired fertility. Techniques to help cancer survivors reproduce have been improving over the past decade. Discussion of the changes to a patient's reproductive health after cancer treatment is essential to providing comprehensive quality care. The purpose of this review is to aid in pre- and posttreatment counseling, focusing on fertility preservation and other strategies that may mitigate risks to the patient's reproductive, sexual, and overall health. CA Cancer J Clin 2014;64:118–134. © 2013 American Cancer Society.

Micrometastatic cancer cells in lymph nodes, bone marrow, and blood: Clinical significance and biologic implications

Abstract: Cancer metastasis may be regarded as a progressive process from its inception in the primary tumor microenvironment to distant sites by way of the lymphovascular system. Although this type of tumor dissemination often occurs in an orderly fashion via the sentinel lymph node (SLN), acting as a possible gateway to the regional lymph nodes, bone marrow, and peripheral blood and ultimately to distant metastatic sites, this is not a general rule as tumor cells may enter the blood and spread to distant sites, bypassing the SLN. Methods of detecting micrometastatic cancer cells in the SLN, bone marrow, and peripheral blood of patients have been established. Patients with cancer cells in their SLN, bone marrow, or peripheral blood have worse clinical outcomes than patients with no evidence of spread to these compartments. The presence of these cells also has important biologic implications for disease progression and the clinician's understanding of the process of cancer metastasis. Further characterization of these micrometastatic cancer cells at each stage and site of metastasis is needed to design novel selective therapies for a more "personalized" treatment.

Recent developments in the medical and surgical treatment of melanoma.

Abstract: Increasing knowledge of the biology of melanoma has led to significant advances in drug development to fight this disease. Surgery is the primary treatment for localized disease and is an integral part of management in patients with more advanced disease. The last decade has become the era of targeted therapy in melanoma and has revolutionized the treatment of this disease. Since 2011, 4 new agents have been approved for the treatment of patients with metastatic melanoma: ipilimumab, vemurafenib, dabrafenib, and trametinib. Several new agents are currently in phase 3 trials with hopes of even more agents being approved for this once "untreatable" disease. How to integrate surgical options with more effective systemic therapies has become a new challenge for physicians. This review will provide an update on current surgical options, highlight the pathway to the development of the newly approved agents, and further discuss new treatments that are on the horizon.

E-cigarettes and the future of tobacco control.

Abstract: Introduction Electronic cigarettes (or e-cigarettes) are one of today’s most discussed, and controversial, issues in tobacco control, and public health more broadly. However, to best understand e-cigarettes and the effect they may have on the future of tobacco use and control both in the United States and globally, it is important to put them in historical perspective. It has been 50 years since US Surgeon General Luther L. Terry announced that his Advisory Committee on Smoking and Health had, after nearly 2 years of study, concluded that cigarette smoking was a cause of lung and laryngeal cancer. Furthermore, the committee determined that there was suggestive, if not conclusive, evidence that smoking was a cause of several other cancers, as well as such illnesses as emphysema, cardiovascular disease, and chronic bronchitis. A half-century later, these conclusions seem obvious to the public at large and, certainly, any clinician. Yet in 1964, they were considered revolutionary and unsettling, to the extent that the press conference at which Dr. Terry announced his committee’s findings was held on a Saturday morning to avoid a shock to the stock market. To commemorate the 50th anniversary of the publication of that first US Surgeon General’s Report on Smoking and Health, the US Centers for Disease Control and Prevention issued the 32nd Surgeon General’s Report on Smoking and Health in January 2014, entitled The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General, 2014. This report, in addition to noting the enormous number of diseases and illnesses now attributable to cigarette smoking, also summarized the progress in tobacco control since 1964: While cigarette smoking remains the nation’s primary preventable cause of premature death, cigarette smoking has been reduced by more than one-half, with 18% of the US adult population now smoking cigarettes, compared with 43% in 1964; and More than 20 million lives have been lost in the United States since 1964 due to smoking, but nearly 10 million premature deaths have been avoided due to tobacco control measures. In recognizing these successes, the 2014 Report also noted the need to maintain efforts to reduce tobacco use and therefore introduced a new topic for these reports: the potential for developing a plan for a tobacco “endgame,” namely, the elimination of cigarette smoking as a major cause of death and disease in the United States. The idea that the public health community is now in a position to consider how to end cigarette smoking would, of course, have been unthinkable in 1964, but scientific, medical, social, and policy developments in the intervening years have made such an aim an achievable goal. The 2014 Surgeon General’s Report points out that, to reach a smoking “endgame,” tobacco control practitioners will need not only to continue and accelerate interventions that they know to be effective (eg, raising prices on cigarettes; expanding protections from secondhand smoke; making tobacco dependence treatment accessible to all smokers who wish to quit; reducing exposure of youth to smoking imagery in the media, especially movies; conducting strong countermarketing media campaigns) but also to seek out and be open to new approaches to ending the use of combustible (ie, burned) cigarettes, which account for the vast majority of all illnesses caused by tobacco use. Among the newer, additional approaches that the 2014 Report suggests for consideration is whether ending the use of the most harmful tobacco product (ie, combusted tobacco) while decreasing the potential harm from newer, innovative products such as e-cigarettes may be a reasonable goal. This concept of “harm reduction,” an approach to risky behavior that prioritizes minimizing the damage rather than eliminating the behavior, has, of course, been used in other areas of public health (eg, providing clean needles to intravenous drug users rather than attempting the more herculean task of ending drug abuse altogether, or encouraging condom use to prevent the spread of the human immunodeficiency virus and acquired immunodeficiency syndrome rather than trying to promote sexual abstinence).

Issues with implementing a high‐quality lung cancer screening program

Abstract: After a comprehensive review of the evidence, the United States Preventive Services Task Force recently endorsed screening with low-dose computed tomography as an early detection approach that has the potential to significantly reduce deaths due to lung cancer. Prudent implementation of lung cancer screening as a high-quality preventive health service is a complex challenge. The clinical evaluation and management of high-risk cohorts in the absence of symptoms mandates an approach that differs significantly from that of symptom-detected lung cancer. As with other cancer screenings, it is essential to provide to informed at-risk individuals a safe, high-quality, cost-effective, and accessible service. In this review, the components of a successful screening program are discussed as we begin to disseminate lung cancer screening as a national resource to improve outcomes with this lethal cancer. This information about lung cancer screening will assist clinicians with communications about the potential benefits and harms of this service for high-risk individuals considering participation in the screening process.

Patient‐centered, evidence‐based, and cost‐conscious cancer care across the continuum: Translating the Institute of Medicine report into clinical practice

Abstract: In 2013, the Institute of Medicine (IOM) concluded that cancer care in the United States is in crisis Patients and their families are not receiving the information that they need to make informed decisions about their cancer care Many patients do not have access to palliative care and too few are referred to hospice at the appropriate point in their disease trajectory Simultaneously, there is a growing demand for cancer care with increases in new cancer diagnoses and the number of patients surviving cancer Furthermore, there is a workforce shortage to care for this growing and elderly population The IOM's report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, outlined recommendations to improve the quality of cancer care This article provides an overview of the IOM report and highlights the recommendations that are most relevant to practicing clinicians who care for patients with cancer across the continuum The implementation of the recommendations in clinical practice will require better patient-clinician communication, improved care coordination, targeted clinician training, effective dissemination of evidence-based guidelines and strategies for eliminating waste, and continuous quality assessment and improvement efforts

Progress and controversies: Radiation therapy for prostate cancer.

Abstract: Radiation therapy remains a standard treatment option for men with localized prostate cancer. Alone or in combination with androgen-deprivation therapy, it represents a curative treatment and has been shown to prolong survival in selected populations. In this article, the authors review recent advances in prostate radiation-treatment techniques, photon versus proton radiation, modification of treatment fractionation, and brachytherapy-all focusing on disease control and the impact on morbidity. Also discussed are refinements in the risk stratification of men with prostate cancer and how these are better for matching patients to appropriate treatment, particularly around combined androgen-deprivation therapy. Many of these advances have cost and treatment burden implications, which have significant repercussions given the prevalence of prostate cancer. The discussion includes approaches to improve value and future directions for research.

Progress and controversies: Radiation therapy for invasive breast cancer

Abstract: Radiation therapy is a critical component of the multidisciplinary management of invasive breast cancer. In appropriately selected patients, radiation not only improves local control, sparing patients the morbidity and distress of local recurrence, but it also improves survival by preventing seeding and reseeding of distant metastases from persistent reservoirs of locoregional disease. In recent years, considerable progress has been made toward improving our ability to select patients most likely to benefit from radiotherapy and to administer treatment in ways that maximize clinical benefit while minimizing toxicity and burden. This article reviews the role of radiation therapy in invasive breast cancer management, both after breast-conserving surgery and after mastectomy. It focuses particularly on emerging evidence that helps to define the clinical situations in which radiotherapy is indicated, the appropriate targets of treatment, and optimal approaches for minimizing both the toxicity and the burden of treatment, all in the context of the evolving surgical and systemic management of this common disease. It includes a discussion of new approaches in breast cancer radiotherapy, including hypofractionation and intensity modulation, as well as a discussion of promising avenues for future research.

New approach to cancer therapy based on a molecularly defined cancer classification

Abstract: Translational and clinical cancer research, as well as clinical trials and treatment of cancer, are essentially structured based on the organ in which tumors originate. However, the recent explosion of knowledge about the molecular characteristics of tumors is opening a new way to tackle cancer. This article proposes a different approach to the classification of cancer with important implications for treatment and for basic, translational, and clinical research. The authors postulate that cancers from diverse organs of origin with similar molecular traits should be managed together. The common molecular features observed in different tumors determine clinical actions in a better way than organ-based classification. Thus, comparisons between tumors residing in different locations but with shared molecular characteristics will improve the therapeutic approach and the understanding of the biology of cancer.

The First Surgeon General's Report on Smoking and Health: The 50th Anniversary

Abstract: group of experts began more than 18 months earlier to assess the science related to tobacco use and its effect on humans. The group came to the conclusion that cigarette smoking causes lung cancer and laryngeal cancer. The report also noted that there was suggestive evidence, if not definitive proof, of a causative role of smoking in other illnesses such as emphysema, cardiovascular disease, and various types of cancer. The conclusions reached by this report are arguably the most important and far-reaching in the history of public health and are, perhaps, the classic example of science driving public policy. It gave extraordinary momentum to the tobacco control movement and caused public opinion and behavior to change considerably, even though a large part of the population was not initially predisposed to accept the message. At the time, cigarette smoking was a significant part of America’s culture and the tobacco industry was a significant part of the US economy. In surveys, 52% of American men and 35% of American women were active cigarette smokers. The United States grew, manufactured, and exported more tobacco than any other country. In 1960, tobacco contributed $15 billion in wages to some 660,000 American workers. 2,3 Given the numerous medical controversies today, it is of value to explore why this process was so successful and why so many were willing to accept this pronouncement as truth. The findings of the 1964 Surgeon General’s report were not the first pronouncement that tobacco use was harmful. In the 7 years prior, there had been at least 2 previous statements from the previous Surgeon General and several announcements from expert consensus panels in the United States and abroad. The process used to establish and run the group set a precedent for dealing with and interpreting controversial medical and scientific issues. A group of learned individuals was brought together to review the science as a type of grand jury. A critical criterion for committee membership was being capable of reaching beyond one’s own discipline to learn about and consider complex data. The process also set a standard for choosing scholarly individuals who have no financial or emotional conflicts of interest to consider a highly charged controversial issue. They would review more than 7000 papers and intensively study more than 27 case-control and cohort studies and 7 broader cohort studies in order to reach their then-momentous conclusions.

Efforts to control prescription drug abuse: Why clinicians should be concerned and take action as essential advocates for rational policy

Abstract: Introduction Faced with mounting evidence of a public health crisis so serious that the US Centers for Disease Control and Prevention (CDC) has termed it an “epidemic” of prescription painkiller abuse, resulting in an epidemic of prescription drug overdoses, federal and state government agencies have taken up the mantle in full force to implement a variety of far-reaching policy initiatives intended to address these related public health crises. Characteristic of most governmental efforts to rein in drug abuse over the past century or longer, many of these policy changes have focused almost exclusively on reducing the supply of medications available for abuse. Over the past decade, this has involved a particular emphasis on prescription opioid analgesics. From a policy standpoint, efforts to address the “supply side” of the drug abuse supply-and-demand equation are much easier to conceive and carry out than those focusing on primary prevention and access to appropriate substance abuse treatment on the “demand side.” Some have questioned the effectiveness of this heavy supply-side focus, but it nonetheless remains the staple of policy makers, regardless of whether the drugs in question are licit or illicit. For health care professionals and the patients with pain for whom they care, supply-side solutions pose a major concern. The CDC suggests that increased pain treatment involving more frequent prescribing of opioid analgesics is responsible for the abuse and overdose epidemics. Clinicians certainly need to be cognizant of the potential for their opioid prescriptions to be misused, abused, and diverted, and they support taking reasonable steps to prevent such outcomes, not to mention the overdoses that can result. Concerned clinicians want to participate in a system that takes appropriate steps to prevent drug abuse and diversion, but they also need a system that allows them to provide optimal pain care for individuals with pain. Implementing a system that achieves both aims is challenging, especially in the current environment that focuses heavily on misuse, abuse, addiction, and overdose rather than on pain and suffering. Thus, the flip side of the connection between prescribing and misuse/abuse/diversion, as noted by the CDC, also should concern clinicians and their patients: the possibility that a restricted supply (in an effort to control prescription drug abuse) may reduce the availability of medications needed by patients who use them therapeutically to control their pain and maintain their quality of life. If supply limitations are severe enough, it is possible that many of the gains in controlling pain and relieving suffering over the past 2 decades could be reversed, which is a devastating consequence by any measure. Management of cancer-related pain has, for many years, understandably been a driving force behind policies focused on improving clinical access to prescription opioid analgesics, spurred largely by studies documenting a high prevalence of untreated pain, particularly among patients with metastatic disease. Over time, the resulting prescribing practices for these medications were extended to treat other types of chronic and disabling noncancer pain, causing opioid analgesic prescribing to increase dramatically overall. Now, however, the quality care gains made in pain treatment that have helped preserve the functional status and quality of life for many individuals with pain, whether or not the pain is related to cancer, may be in jeopardy. That is a steep and unacceptable price to pay in the name of taking a strong national stand against prescription drug abuse.

Bevacizumab in neoadjuvant chemotherapy increases the pathological complete response rate in patients with triple-negative breast cancer.

Abstract: A recent study demonstrated increased pathological complete response (pCR) rates when bevacizumab is added to the neoadjuvant chemotherapy regimen in patients with triple-negative breast cancer (TNBC) (Ann Oncol. 2013;24:2978-2984). This research is part of the multicenter GeparQuinto study, conducted by investigators from the German Breast Group. TNBC is defined as breast cancer that is negative for estrogen and progesterone receptors, as well as human epidermal growth factor receptor 2 (HER2). Better ways to treat TNBC are needed because it confers a high risk of recurrence and mortality.

Evolution of "The Guideline Advantage": Lessons learned from the front lines of outpatient performance measurement.

Abstract: Heart disease, cancer, stroke, and diabetes mellitus collectively account for >1.37 million US deaths each year.1 Compounding the tragedy is the knowledge that many of those deaths could be avoided through better application of clinical guidelines related to primary and secondary prevention or disease management. The combined control of blood pressure, lipids, and glucose has been shown to substantially reduce mortality and cardiovascular events.2,3 Screening for colon, cervical, breast, and lung cancer has been proven to reduce age-adjusted mortality from these diseases.4 In recognition of the common risk factors across these disease areas, the chief executive officers of the American Cancer Society, American Diabetes Association, and American Heart Association formed the Preventive Health Partnership in 2004. The 3 organizations have been working closely ever since to increase public awareness about healthy lifestyles, support policies that increase funding for and access to prevention programs and research, and increase the focus on prevention among healthcare providers. The American Cancer Society, American Diabetes Asso ciation, and American Heart Association have long developed scientific statements and evidence-based guidelines that promote public health services and clinical interventions of known efficacy for improving patient outcomes. Thus, maximizing adherence to quality-of-care guidelines is a high priority for each organization, because this will save lives and improve quality of life. This common purpose has served as a focal point for much of the collaborative work undertaken by the 3 organizations, including The Guideline Advantage (TGA). Launched in 2011, TGA is a jointly operated program designed to promote consistent use of evidence-based practice guidelines through existing healthcare technology in the outpatient setting. The ultimate goal of this undertaking is to improve patient care through quality improvement programs that provide feedback to clinicians and their practices on performance across various quality measures. The data gathered …

False elevations of carcinoembryonic antigen levels are common in patients under surveillance for colorectal cancer recurrence

Abstract: The National Comprehensive Cancer Network guidelines recommend that CEA levels be routinely monitored every 3 to 6 months after the treatment of CRC with curative intent. A CEA level greater than 5 ng/mL will usually trigger a workup to look for possible disease recurrence. Although it has been established that false-positive CEA elevations occur, the study authors believed these elevations had not been well characterized within the context of currently available high-quality imaging, and set out to establish the frequency and range of false-positive CEA levels in patients previously treated for nonmetastatic CRC.