Showing papers in "Journal of The National Comprehensive Cancer Network in 2007"

NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST)--update of the NCCN clinical practice guidelines.

Abstract: The NCCN Soft Tissue Sarcoma Guidelines include a subsection about treatment recommendations for gastrointestinal stromal tumors (GISTs). The standard of practice rapidly changed after the introduction of effective molecularly targeted therapy (such as imatinib and sunitinib) for GIST. Because of these changes, NCCN organized a multidisciplinary panel composed of experts in the fields of medical oncology, molecular diagnostics, pathology, radiation oncology, and surgery to discuss the optimal approach for the care of patients with GIST at all stages of the disease. The GIST Task Force is composed of NCCN faculty and other key experts from the United States, Europe, and Australia. The Task Force met for the first time in October 2003 and again in December 2006 with the purpose of expanding on the existing NCCN guidelines for gastrointestinal sarcomas and identifying areas of future research to optimize our understanding and treatment of GIST.

The NCCN Guideline for Distress Management: A Case for Making Distress the Sixth Vital Sign

Abstract: Psychosocial care of patients has traditionally been seen as separate from routine medical care and has been criticized as being “soft” and lacking evidence. This traditional perspective continues in many settings, despite the fact that patients and families, when asked, state that emotional care is highly valued. The question of how to integrate psychosocial care into routine cancer care has also been an issue, partly because of the stigma associated with cancer. In 1997, the National Comprehensive Cancer Network (NCCN) established a multidisciplinary panel to examine this problem. 1 Because patient and physician attitudes toward pain can pose similar barriers to care as with distress, the panel used as a model the rating system for assessing pain that resulted in successful improvement of pain management in the United States. The rating system’s success seemed partly based on routinely using a single question to assess a patient’s pain: “How is your pain on a scale of 0 to 10?” The system uses a score of 5 or higher as the indication to reassess pain medications or refer the patient for more expert management. This system is widely used, and patient self-report of subjective symptoms is now accepted as appropriate and reliable. Pain has become the fifth vital sign, after pulse, respiration, blood pressure, and temperature, ensuring that it is evaluated as part of routine care. Drawing on this experience, the NCCN panel recommended a simple question to ask patients about psychosocial concerns. They found that distress was the best umbrella word to represent the range of emotional concerns patients with cancer experience and that it did not carry the stigma of other words sometimes used for emotional symptoms. Several studies have now validated the approach of asking, “How is your distress on a scale of 0 to 10?” and using a score of 4 or above as the trigger for further questions and possible referral to a psychosocial service. 2,3 In 2004, the Canadian Federal Government’s public health agency, Health Canada‐Canadian Strategy for Cancer Control, approved “Emotional Distress as the 6th Vital Sign.” 4 We propose that this system should also be considered in the United States to ensure that psychosocial distress is routinely assessed as part of cancer care and managed according to the NCCN distress management guidelines. This commentary outlines the potential benefits that can accrue for patients, families, and the health care system. Over 2 years beginning in 1997, the NCCN’s multidisciplinary panel de

Implementation of NCCN distress management guidelines by member institutions.

Abstract: Up to half of all adults with cancer experience clinically significant psychological distress and much of this distress goes unrecognized and untreated. As part of an effort to improve the care of cancer patients, the National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines for distress management that include recommendations about the evaluation and treatment of distress. These authors conducted a study to evaluate the implementation of these distress management guidelines by NCCN member institutions. The NCCN member institutions that treat adults were asked in April and May 2005 to describe their distress management practices, and 15 (83%) provided responses. Of these, 8 (53%) conduct routine distress screening for at least some patient groups, with 4 additional institutions (27%) pilot-testing screening strategies. However, only 20% of surveyed member institutions screened all patients as the guidelines recommend. In addition, whether institutions that conduct routine distress screening do so through standardized assessment methods is unclear, because 37.5% of institutions that conduct screening rely only on interviews to identify distressed patients. Findings suggest that most institutions consider screening patients' mental health concerns important and worthwhile, but that greater implementation of guideline recommendations is needed.

Phyllodes Tumors of the Breast: Natural History, Diagnosis, and Treatment

Abstract: Phyllodes tumors of the breast are unusual fibroepithelial tumors that exhibit a wide range of clinical behavior. These tumors are categorized as benign, borderline, or malignant based on a combination of histologic features. The prognosis of phyllodes tumors is favorable, with local recurrence occurring in approximately 15% of patients overall and distant recurrence in approximately 5% to 10% overall. Wide excision with a greater than 1 cm margin is definitive primary therapy. Adjuvant systemic therapy is of no proven value. Patients with locally recurrent disease should undergo wide excision of the recurrence with or without subsequent radiotherapy.

Barriers to Clinical Trial Participation as Perceived by Oncologists and Patients

Abstract: Although clinical trial research is required for the development of improved treatment strategies, very few cancer patients participate in these studies. The purpose of this study was to describe psychosocial barriers to clinical trial participation among oncologists and their cancer patients. A survey was distributed to all medical oncologists in Pennsylvania and a subset of their patients. Relevant background information and assessment of practical and psychosocial barriers to clinical trial participation were assessed. Among 137 oncologists and 170 patients who completed the surveys, 84% of patients were aware of clinical trials, and oncologists and patients generally agreed that clinical trials are important to improving cancer treatment. However, oncologists and patients were more likely to consider clinical trials in advanced or refractory disease. When considering 7 potential barriers to clinical trials, random assignment and fear of receiving a placebo were ranked highly by both patients and oncologists. Patients identified fear of side effects as the greatest barrier to clinical trial participation, whereas oncologists ranked this psychosocial barrier as least important to their patients. Overall, the study found that although oncologists and patients are aware of clinical trials and have favorable attitudes toward them, psychosocial barriers exist for patients that may impact participation in clinical trials. Furthermore, important discrepancies exist between the perceptions of oncologists and those of patients regarding what the psychosocial barriers are. We concluded that characterizing oncologist and patient perceived barriers can help improve communication and decision making about clinical trials, such that participation may be optimized.

NCCN Task Force Report: Positron Emission Tomography (PET)/Computed Tomography (CT) Scanning in Cancer

Abstract: The use of positron emission tomography (PET) is increasing rapidly in the United States, with the most common use of PET scanning related to oncology. It is especially useful in the staging and management of lymphoma, lung cancer, and colorectal cancer, according to a panel of expert radiologists, surgeons, radiation oncologists, nuclear medicine physicians, medical oncologists, and general internists convened in November 2006 by the National Comprehensive Cancer Network. The Task Force was charged with reviewing existing data and developing clinical recommendations for the use of PET scans in the evaluation and management of breast cancer, colon cancer, non-small cell lung cancer, and lymphoma. This report summarizes the proceedings of this meeting, including discussions of the background of PET, possible future developments, and the role of PET in oncology.

Photodynamic Therapy for Non-Melanoma Skin Cancer

Abstract: Photodynamic therapy (PDT) involves the administration of a photosensitizing drug and its subsequent activation by light at wavelengths matching the absorption spectrum of the photosensitizer. Because the skin is readily accessible to light-based therapies, PDT with systemic and particularly with topical agents has become important in treating cutaneous disorders. Topical PDT is indicated for treating actinic keratosis, superficial or thin non-melanoma skin cancer, including some cases of nodular basal cell carcinoma, and some cutaneous lymphomas. Advantages of aminolevulinic acid/methyl aminolevulinate PDT include the possibility of simultaneous treatment of multiple tumors and large surface areas, good cosmesis, and minimal morbidity, such as bleeding, scarring, or infection.

Clinical experience with the NCCN distress thermometer in breast cancer patients.

Abstract: A study was conducted to describe our group's experience using the NCCN Distress Thermometer in an outpatient breast cancer clinic. The NCCN Distress Thermometer was administered to patients attending the breast cancer clinic at Huntsman Cancer Institute during a 4-month period. Effects of disease, treatment, and demographic variables on distress level were analyzed. Patients reporting high distress were contacted by a social worker to determine the cause of the distress. Two hundred and eighty-six (286) subjects completed 403 questionnaires, with 96 patients (34%) reporting high levels of distress (5 or greater on a 10-point scale). No relationship was seen between high distress and stage of disease, type of current treatment, time since diagnosis, age, or other demographic factors. Underlying mental health disorders were associated with a higher level of distress. The Distress Thermometer was a useful method to screen, triage, and prioritize patient interventions. In our experience, the tool promoted communication between the patient and the health care team, which enhanced treating psychosocial and physical symptoms. Methods to optimize the use of this screen are proposed.

The Emerging Role of Novel Therapies for the Treatment of Relapsed Myeloma

Abstract: Despite advances in the first-line treatment of multiple myeloma, almost all patients eventually relapse, become chemoresistant, and die of the disease. Improved understanding of potential myeloma targets and molecular mechanisms of drug resistance, along with the development and clinical investigation of targeted antitumor agents, have led to new strategies for the treatment of relapsed myeloma. The proteasome inhibitor bortezomib, the immunomodulatory agent thalidomide, and the thalidomide derivative lenalidomide, are all recently approved treatment options for myeloma. Single-agent bortezomib has been shown to provide significantly greater efficacy than high-dose dexamethasone, and bortezomib has also been investigated in combination with other agents commonly used to treat myeloma, including thalidomide and lenalidomide, with high overall and complete response rates. The safety profile of bortezomib has been well characterized, and side effects have been shown to be generally predictable and manageable, including in high-risk and elderly patients and those with renal impairment. Thalidomide has been extensively studied alone and in combination in patients with relapsed myeloma, demonstrating substantial efficacy, and is therefore widely used in this setting. The toxicity profile is dose- and duration-linked, with lower doses appearing to be better tolerated. Lenalidomide plus dexamethasone has been shown to have significantly greater activity than dexamethasone alone in the relapsed setting, with impressive duration of disease control. Other combinations are also under investigation, with promising early results. Some aspects of the toxicity profile appear significantly reduced relative to thalidomide, although myelosuppression is increased. Other novel therapies at earlier stages of development are being studied and may provide further options in the treatment of relapsed myeloma. This review focuses on results from key phase II and III trials of bortezomib, thalidomide, and lenalidomide alone or in combination, and their emerging role in improving outcomes.

Implementing the Fatigue Guidelines at One NCCN Member Institution: Process and Outcomes

Abstract: Fatigue, despite being the most common and distressing symptom in cancer, is often unrelieved because of numerous patient, provider, and system barriers. The overall purpose of this 5-year prospective clinical trial is to translate the NCCN Cancer-Related Fatigue Clinical Practice Guidelines in Oncology and NCCN Adult Cancer Pain Clinical Practice Guidelines in Oncology into practice and develop a translational interventional model that can be replicated across settings. This article focuses on one NCCN member institution's experience related to the first phase of the NCCN Cancer-Related Fatigue Guidelines implementation, describing usual care compared with evidence-based guidelines. Phase 1 of this 3-phased clinical trial compared the usual care of fatigue with that administered according to the NCCN guidelines. Eligibility criteria included age 18 years or older; English-speaking; diagnosed with breast, lung, colon, or prostate cancer; and fatigue and/or pain ratings of 4 or more on a 0 to 10 screening scale. Research nurses screened all available subjects in a cancer center medical oncology clinic to identify those meeting these criteria. Instruments included the Piper Fatigue Scale, a Fatigue Barriers Scale, a Fatigue Knowledge Scale, and a Fatigue Chart Audit Tool. Descriptive and inferential statistics were used in data analysis. At baseline, 45 patients had fatigue only (> or = 4) and 24 had both fatigue and pain (> or = 4). This combined sample (N = 69) was predominantly Caucasian (65%), female (63%), an average of 60 years old, diagnosed with stage 3 or 4 breast cancer, and undergoing treatment (82%). The most common barriers noted were patients' belief that physicians would introduce the subject of fatigue if it was important (patient barrier); lack of fatigue documentation (professional barrier); and lack of supportive care referrals (system barrier). Findings showed several patient, professional, and system barriers that distinguish usual care from that recommended by the NCCN Cancer-Related Fatigue Guidelines. Phase 2, the intervention model, is designed to decrease these barriers and improve patient outcomes over time, and is in progress.

Early detection and biomarkers in pancreatic cancer.

Abstract: Major advances in cancer control will be greatly aided by early detection for diagnosing and treating cancer in its preinvasive state before metastasis. Unfortunately, for pancreatic ductal adenocarcinoma (PDAC), which is the fourth leading cause of cancer-related death in the United States, effective early detection and screening are currently not available and tumors are typically diagnosed at a late stage, frequently after metastasis. Partly because of low sensitivity/specificity, existing biomarkers such as CA19-9 are not adequate as early detection markers of pancreatic cancer. Thus, a great need exists for new biomarkers for pancreatic cancer. This article focuses on recent developments in the identification of new serum protein biomarkers that are useful in the early detection of PDAC.

Bone Cancer: Clinical practice guidelines in oncology

Abstract: Overview Primary bone cancers are extremely rare neoplasms, likely accounting for fewer than 0.2% of all cancers, although its true incidence is difficult to determine secondary to the rarity of these tumors.1,2 In 2009, an estimated 2570 new cases will be diagnosed in the United States and 1470 people will die of the disease.3 Primary bone cancers show wide clinical heterogeneity and are often curable with proper treatment. Osteosarcoma (35%), chondrosarcoma (30%), and Ewing’s sarcoma (16%) are the 3 most common forms of bone cancer. Malignant fibrous histiocytoma (MFH) and fibrosarcoma of the bone constitute fewer than 1% of all primary bone tumors. Chondrosarcoma is usually found in middle-aged and older adults; osteosarcoma and Ewing’s sarcoma The NCCN

Behavioral interventions in treating anticipatory nausea and vomiting.

Abstract: Anticipatory nausea and vomiting (ANV) is associated with a significant reduction in the quality of life for many chemotherapy patients. The use of 5-hydroxytryptamine type 3 receptor antagonists provides some relief for chemotherapy-induced nausea and vomiting, but does not seem to control ANV. Nonpharmacologic approaches, which include behavioral interventions, may provide the greatest promise in relieving symptoms. Little evidence supports the use of complementary and alternative methods, such as acupuncture and acupressure, in relieving ANV. Behavioral interventions, especially progressive muscle relaxation training and systematic desensitization, should be considered important methods for preventing and treating ANV.

Prevention of emesis from multiple-day and high-dose chemotherapy regimens.

Abstract: The prevention of chemotherapy-induced nausea and vomiting (CINV) has improved significantly with the introduction of the 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists combined with dexamethasone. Most studies have reported on patients undergoing single-day highly or moderately emetogenic chemotherapy. There have been fewer studies and much less success in preventing CINV in patients undergoing multiple-day chemotherapy or high-dose chemotherapy with stem cell transplant. Current practice guidelines suggest the use of a first-generation 5-HT3 receptor antagonist and dexamethasone daily for each day of the multiple-day chemotherapy regimens. This practice seems to control acute CINV, but delayed CINV remains poorly controlled with a complete response (e.g., no emesis, no rescue) of less than 50% in most studies. Three new agents-palonosetron, aprepitant, and olanzapine-have shown high efficacy in preventing acute and delayed CINV in patients undergoing single-day chemotherapy. These agents have high potential for preventing CINV in patients undergoing multiple-day chemotherapy. This article proposes recommendations for their use in clinical trials and in practice.

Molecular targeting of dermatofibrosarcoma protuberans: a new approach to a surgical disease.

Abstract: Dermatofibrosarcoma protuberans (DFSP) is a low-grade malignancy of the skin and subcutaneous tissues that only rarely forms distant metastases. More than 90% of cases are associated with a chromosomal translocation involving the COL1A1 gene on chromosome 17 and the platelet-derived growth factor B gene on chromosome 22. Management of this disease is primarily surgical with excellent rates of local control obtained using either wide local excision or Mohs micrographic surgery. Data have recently shown that inhibiting platelet-derived growth factor receptors (PDGFR) with imatinib can induce high rates of clinical response in patients with unresectable or metastatic DFSP. These data have led to approval of imatinib by the U.S. Food and Drug Administration for treating uresectable DFSP. Although wide surgical excision remains standard care, patients with locally advanced disease not suitable for surgical excision can be treated with the PDGFR-inhibitor imatinib, which sometimes allows residual DFSP to be surgically excised.

Can You Recommend a Doctor for My Brother's Secretary's Sister?

Abstract: How would you respond to a phone call I got yesterday: “Chris, one of my old college professors called me last night. He is a healthy 67-year-old man with newly diagnosed prostate cancer who is not interested in watchful waiting. Which doctors in Richmond would you recommend?” My friend, a family practice doctor and accomplished healthcare consultant, wanted me to help provide a referral based on my knowledge of cancer care in that community. Although I did give him some names and phone numbers, my role as the local family and neighbor cancer referral service always gives me pause. A couple of thoughts always run through my mind: 1. Do I have enough information to be helpful? Since the first referral for prostate cancer often determines the treatment, my response for this patient might significantly affect patient-centered outcomes. In this case, the referral question was posed by a doctor who knew what information to include (low PSA, T1, Gleasons 5—the real details). However, when my brother calls me about his secretary’s sister, it is much less clear. 2. I think I know how good the doctors are in my community but do I really know? I know which doctors have high complication rates, but I have no metrics to evaluate the technical aspects of care. For instance, if the consultant recommends robotic surgery, how much experience does the doctor have with this new technology? What are my favorite doctors’ continence, potency, and local failure rates? Frankly, I don’t have a clue. I know even less about the minute details of radiation, particularly whether the dose distribution of radioactive seed implants varies from one doctor to the next. Attending many guideline panel meetings for NCCN has given me a much greater appreciation for what I don’t know about the fine points of treatment beyond my particular subspecialty. 3. Are my consultants up to date? I know some of the doctors I work with go regularly to conferences and read journals. On the other hand, I don’t think NCCN guidelines have been assimilated by the technical specialties as they have been for medical oncologists. Groups like the American Urological Association have their own guidelines, but their web-based prostate cancer guideline is from 1995 and does not include use of hormones and radiation for locally advanced disease. NCCN guidelines are uniquely multidisciplinary (e.g., the chair is a surgeon) and help coordinate the handoffs between specialties. 4. Should I stay out of these situations altogether and let the system do its work? My guess is that about 85% of the time, the patient has already been guided along the appropriate pathway. Sometimes, though, I have made a difference— hurrying up diagnostic delays, sending patients to doctors with better ideas, and guiding them toward clinical trials. Although I may not have performance data, I know which doctors talk with patients and look them in the eye. I know which ones come to the emergency department at 3 am, and which ones phone it in. I know who goes the extra mile. These are valuable insights to help family and neighbors when they call. Not everyone has access or the willingness to travel to an NCCN institution or the published expert; as a result, we are called all the time to guide patients we don’t know along paths we aren’t sure of. For now, I must use softer criteria; I hope I’ll someday be able to make all my referrals with greater precision. Christopher E. Desch, MD

Managing systemic light-chain amyloidosis.

Abstract: Amyloidosis is a rare disease in which a specific protein is deposited as aggregated interstitial fibrils that can compromise organ function and lead to death. Immunoglobulin (Ig) light-chain amyloidosis (AL), caused by the monoclonal gammopathy of a plasma cell dyscrasia, is the most common type. A hereditary type is also caused by mutant transthyretin and other proteins. Rarely, a patient with amyloid has both a monoclonal gammopathy and a hereditary protein. In AL, circulating monoclonal Ig light chains can be measured with the free light-chain (FLC) assay and provide a target for therapy to eliminate the underlying plasma cell dyscrasia while supporting the patient's organ function. Amyloid deposits can be resorbed and organ function restored if the amyloid-forming precursor FLC is eliminated. For patients with limited organ involvement, intravenous melphalan in doses from 100 to 200 mg/m2 with autologous stem cell support (SCT) is an effective approach and, when followed at 3 months post-SCT with adjuvant thalidomide and dexamethasone for persistent plasma cell disease, has a 1-year hematologic response rate of 77%. Monthly oral melphalan and dexamethasone for 1 year can also be effective therapy for patients too sick for SCT (67% response rate). Hematologic complete responses are usually durable and result in long-term survival and a variable degree of organ recovery. For patients with advanced cardiac involvement, the prognosis remains guarded even with treatment. Drugs effective in multiple myeloma are usually active in AL, depending on side effects. New agents such as bortezomib and lenalidomide have shown promising activity, and novel antibody-based approaches for imaging amyloid and accelerating removal of deposits are being actively investigated.

Multiple myeloma. Clinical practice guidelines in oncology.

Abstract: Although multiple myeloma is sensitive to both chemotherapy and radiation therapy, it remains incurable at present. However, treatment algorithms (based on published data and clinical experience) can be developed to optimize therapy, which include not only therapy for the underlying disease but also supportive therapy to enhance quality of life. Because myeloma is incurable, these guidelines prominently identify the clinical settings appropriate for treatment of patients on clinical research protocols.

Diet and breast cancer risk reduction.

Abstract: The association between diet and breast cancer risk has been investigated extensively and has led to some recommendations for prevention. Research suggests that maintaining a healthy weight may reduce the risk for breast cancer after menopause. Additionally, alcohol increases the risk for breast cancer even at moderate levels of intake, and women who drink alcohol also should take sufficient folate, which can mitigate this excess risk. Interesting questions for future research include the role of soy products, red meat, energy balance, and vitamin D, with particular attention to timing of exposure in early life. Breast cancer is a heterogeneous disease, and dietary factors may differentially affect certain breast cancer subtypes; future studies should therefore attempt to characterize associations according to tumor characteristics.

Depression and pancreatic cancer.

Abstract: Although pancreatic carcinoma and depression have been linked for years, the prevalence and relationship of these often coexisting diseases are still poorly understood. A clinical gestalt asserts that many patients present with depression before pancreatic carcinoma is diagnosed. Published studies reviewing this issue have found that many patients with pancreatic cancer are depressed. If the definition of depression is broadened to include mild depression in addition to major depression, these numbers increase. This article reviews the literature linking pancreatic carcinoma and depression.

Are All 5-HT3 Receptor Antagonists the Same?

Abstract: The 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists have become the cornerstone for preventing and treating chemotherapy-induced nausea and vomiting. Four 5-HT3 antagonists are commercially available in the United States, and numerous reports have been published comparing 2 or more agents. The studies ranged from randomized, double-blinded to open-label or retrospective trials; included chemotherapy-naive and -non-naive patients; and covered a range of doses and routes of administration with and without concomitant steroids, for preventing and treating nausea and vomiting after highly and moderately high emetogenic chemotherapy. With few exceptions, the studies uniformly show an equivalent efficacy rate and side effect profile among the various agents at equivalent doses. This article reviews the pharmacology of the class for insight into minor differences among the agents that could possibly influence drug selection for certain patients, and considers data on the absorption, half-life, metabolism, and receptor activity. Clinical trials support the claim of various guidelines that the 5-HT3 receptor antagonists are therapeutically similar in safety and efficacy, particularly because the current best practice for preventing nausea and vomiting after highly and moderately high emetogenic chemotherapy is a combination of a 5-HT3 antagonist, steroids, and aprepitant.

Interventional therapies for cancer pain management: important adjuvants to systemic analgesics.

Abstract: Optimized use of systemic analgesics fails to adequately control pain in some patients with cancer. Commonly used analgesics, including opioids, nonopioids (acetaminophen and non-steroidal anti-inflammatory drugs), and adjuvant analgesics (anticonvulsants and antidepressants), have limited analgesic efficacy, and their use is often associated with adverse effects. Without adequate pain control, patients with cancer not only experience the anguish of poorly controlled pain but also have greatly diminished quality of life and may even have reduced life expectancy. Interventional pain therapies are a diverse set of procedural techniques for controlling pain that may be useful when systemic analgesics fail to provide adequate control of cancer pain or when the adverse effects of systemic analgesics cannot be managed reasonably. Commonly used interventional therapies for cancer pain include neurolytic neural blockade, spinal administration of analgesics, and vertebroplasty. Compared with systemic analgesics, which generally have broad indications for control of pain, individual interventional therapies generally have specific, narrow indications. When appropriately selected and implemented, interventional pain therapies are important components of broad, multimodal cancer pain management that significantly increases the proportion of patients able to experience adequate pain control.

Role of Lymph Node Dissection in Primary Surgery for Thyroid Cancer

Abstract: The preoperative evaluation of the clinically N0 neck and the operative management of cervical lymph nodes in patients with papillary and medullary thyroid cancer remains controversial. The appreciation that even patients with low-risk disease have a significant risk for recurrence has generated interest in a more comprehensive preoperative evaluation of the neck and has renewed debate on the extent of lymphadenectomy at the time of thyroidectomy. The authors recommend using preoperative ultrasound before thyroidectomy for all patients with thyroid cancer and before any subsequent surgeries for recurrent disease to identify the extent of lymph node metastases and thereby facilitate complete surgical removal of all gross disease in the neck. The optimal surgical procedure for removing cervical lymphadenopathy is compartment-oriented neck dissection based on the findings from preoperative ultrasound.

Counterpoint: robot-assisted laparoscopic prostatectomy: perhaps the surgical gold standard for prostate cancer care.

Abstract: Robot-assisted laparoscopic prostatectomy (RALP) has gained immense popularity. This article examines the most critical outcome measures in prostate cancer surgery and shows the reasons why this technique is gaining in popularity. Operative time, length of stay, blood loss, transfusions, postoperative pain, continence, potency, and cancer control all favor or tend toward improvement and benefit in RALP compared with traditional radical retropubic prostatectomy. In addition, as even greater experience and technological improvements are incorporated, further outcome improvements will be appreciated. RALP is now an accepted treatment option for prostate cancer and may soon be the most desirable treatment of prostate cancer patients.

Summary and Comparison of Myeloid Growth Factor Guidelines in Patients Receiving Cancer Chemotherapy

Abstract: Chemotherapy-induced neutropenia and its complications are major dose-limiting toxicities of cancer chemotherapy. The myeloid growth factors have been shown to reduce the risk of neutropenic events across malignancies, regimens, and associated risk categories often enabling the delivery of greater chemotherapy dose intensity. Three different practice guidelines for the myeloid growth factors have recently been published by major professional organizations. A comprehensive review and comparison of the guidelines using a priori structured content criteria and a previously validated quality appraisal tool are reported. Consistency in the final recommendations from these guidelines is observed for primary prophylaxis with the colony-stimulating factors (CSFs) when the risk of febrile neutropenia is in the range of 20% or greater. There is also consistency in the recommendation that patients receiving regimens associated with lower risk should have CSF use guided by individual risk assessment. Critical quality appraisal indicates that the scope and purpose, stakeholder involvement, and applicability of the guidelines differ little. There is more emphasis on comprehensive literature reviews in the ASCO and EORTC guidelines while the NCCN guidelines are more current based on systematic annual updates. The clarity of presentation also favors the NCCN guidelines with recommendations generally presented as both text and algorithmic diagram. All three new or updated guidelines recommend prophylactic use of the myeloid growth factors in patients at greater than a 20% risk of febrile neutropenia and in those with important factors increasing individual risk of neutropenic complications.

The role of radiation treatment in the contemporary management of bone tumors.

Abstract: Radiotherapy is integral in the multidisciplinary approach to patients with musculoskeletal neoplasms. Multiple studies have established a role for radiotherapy as a definitive local treatment of unresectable lesions or when surgery might yield unacceptable functional outcomes, such as in Ewing's tumor or base of skull chondrosarcoma. Radiotherapy is also used as an adjuvant treatment after surgery with close or positive margins. In the metastatic setting, external beam radiotherapy and bone-seeking intravenous radioisotopes are used on a case-by-case basis for palliation. As radiotherapy and its delivery techniques have evolved, so has its role in treating tumors such as Ewing's sarcoma, chordoma and chondrosarcoma, osteosarcoma, primary lymphoma of bone, malignant fibrous histiocytoma of bone, and vascular tumors. Radiation can also be successfully used to treat unresectable or recurrent benign tumors, such as giant cell tumor and aneurysmal bone cyst. This article reviews the indications for radiotherapy for various bone tumors and summarizes some of the important data supporting its use.

The STAR trial: evidence for raloxifene as a breast cancer risk reduction agent for postmenopausal women.

Abstract: The 1998 approval of tamoxifen for breast cancer risk reduction opened the era of breast cancer chemoprevention. Women at increased risk for breast cancer now had an option other than healthy lifestyle and prophylactic surgery to reduce risk. However, women and their physicians were reluctant to use tamoxifen because of associated risks. Several trials investigating raloxifene suggested it may reduce breast cancer risk without having an apparent effect on the endometrium. The Study of Tamoxifen and Raloxifene (STAR) for the Prevention of Breast Cancer trial opened in 1999 to directly compare raloxifene to tamoxifen for breast cancer risk reduction. Since the unblinding of the STAR trial in 2006, raloxifene has emerged as an option for reducing breast cancer risk for postmenopausal women at increased risk for the disease.