Curr. Oncol., Volume 19, Issue 3 (June 2012) – 30 articles

The use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIS) is evolving, as is an understanding of predictive biomarkers for tumour response in non-small-cell lung cancer (NSCLC). In this report, we describe a case of rapidly progressing, borderline-resectable, clinical stage IIIA (micro) papillary adenocarcinoma in a 78-year-old woman who experienced a profound response to neoadjuvant erlotinib without short-term toxicity. On EGFR mutation testing, this patient had an uncommon activating point mutation at L861Q in exon 21. Her response permitted successful surgical resection with negative margins and avoidance of chemoradiation, which she was deemed too frail to tolerate. Our case addresses unique management issues such as preoperative testing for EGFR mutation, utility of histology in predicting EGFR mutations, and use of egfr-tkis pre- and postoperatively for potentially resectable NSCLC. Full article

This case report describes a solitary fibrous tumour presenting as a pedunculated mass arising from an almost completely atretic right middle lobe of lung. The intraoperative findings and pathologic diagnostic criteria used are described. To our knowledge, this is the first case report of a solitary fibrous tumour associated with partial lung atresia. Full article

To reduce local recurrence, adjuvant locoregional radiotherapy is given routinely for post-mastectomy breast patients with 4 or more positive lymph nodes. Most institutions adopt a 3- or 4-field radiotherapy technique, in which the field and shielding placements are informed by bony anatomic landmarks viewed on digitally reconstructed radiographs. Full article

Purpose: We examined the impact of hypofractionated radiation therapy and androgen suppression therapy (AST) on quality of life (QOL) in high-risk prostate cancer patients. Methods: Between March 2005 and March 2007, 60 patients with high-risk prostate cancer were enrolled in a prospective phase ii study. All patients received 68 Gy (2.72 Gy per fraction) to the prostate gland and 45 Gy (1.8 Gy per fraction) to the pelvic lymph nodes in 25 fractions over 5 weeks. Of the 60 patients, 58 received AST. The University of California–Los Angeles Prostate Cancer Index questionnaire was used to prospectively measure qol at baseline (month 0) and at 1, 6, 12, 18, 24, 30, and 36 months after radiation treatment. The generalized estimating equation approach was used to compare the QOL scores at 1, 6, 12, 18, 24, 30, and 36 months with those at baseline. Results: We observed a significant decrease in QOL items related to bowel and sexual function. Several QOL items related to bowel function were significantly adversely affected at both 1 and 6 months, with improvement toward 6 months. Although decreased QOL scores persisted beyond the 6-month mark, they began to re-approach baseline at the 18- to 24-month mark. Most sexual function items were significantly adversely affected at both 1 and 6 months, but the effects were not considered to be a problem by most patients. A complete return to baseline was not observed for either bowel or sexual function. Urinary function items remained largely unaffected, with overall urinary function being the only item adversely affected at 6 months, but not at 1 month. Urinary function returned to baseline and remained unimpaired from 18 months onwards. Conclusions: In our study population, who received hypofractionated radiation delivered using dynamic intensity-modulated radiotherapy with inclusion of the pelvic lymph nodes, and 2–3 years of AST prescription, QOL with respect to bowel and sexual function was significantly affected; QOL with respect to urinary function was largely unaffected. Our results are comparable to those in other published studies. Full article

Objective: The sudden confrontation of a potential health threat such as cancer, even after the diagnosis turns out to be benign, can have enduring adverse psychological consequences, including persistent anxiety, cancer fears, and other manifestations of psychological distress. The present study examines factors that potentially moderate psychological recovery among women who face a breast cancer threat. Design: Participants were adult women had just received a benign outcome from a breast cancer diagnostic procedure that had been conducted because of suspicion of breast cancer (a non-conclusive mammography or ultrasonography result, a referral from their doctor because of pain or family history, detection of a lump, a 6-month follow-up appointment after a breast abnormality from a previous screening or diagnostic procedure, or a fluid leak from one or both breasts). We measured several psychological traits at Time 1 (right after receipt of the “no cancer” feedback) and then each month for the next 3 months. Analyses examined the factors that hindered or facilitated psychological recovery from the cancer threat. Results: Results showed that trait anxiety and family history of cancer hindered recovery and that older age and optimism facilitated recovery and lessened adverse psychological consequences. Self-regulatory strategies such as planful problem-solving, positive reappraisal, and mastery facilitated recovery. Conclusions: Our findings shed light on the factors that are implicated in psychological recovery from a benign breast cancer outcome after a diagnostic procedure (ultrasonography, repeat or initial mammography, stereotactic biopsy, fine-needle aspiration, or ultrasound-guided biopsy). Those factors could be used to identify women who may experience prolonged psychological distress, so as to assist them when they face stressful diagnostic concerns. Full article

Background: Evidence-based guidelines are used in health care systems throughout the world to aid in treatment decisions and to ensure quality and consistency in patient care. In breast oncology, guidelines for care are published by several internationally recognized organizations, including those from the United States, Canada, and the United Kingdom. The present study compared clinical breast cancer guidelines from the American Society of Clinical Oncology (asco, United States), Cancer Care Ontario (cco, Canada), and the National Institute for Health and Clinical Excellence (nice, United Kingdom) to determine the quality and consistency of content across international organizations. Methods: We searched for breast cancer guidelines published by asco, cco, and nice. Guidelines on the same theme were identified across organizations and appraised by 4 independent reviewers using the Appraisal of Guidelines for Research and Evaluation (agree) instrument. Content of each guideline was also scored for consistency in overall recommendations across organizations and for consistency in cited evidence. Results: The quality of breast cancer guidelines produced by the targeted organizations was consistently good in the areas of Scope and Purpose, Rigor of Development, and Clarity and Presentation, but variable in the domains of Stakeholder Involvement, Applicability, and Editorial Independence. The content of the guidelines varied slightly in the strength of their recommendations. Conclusions: Our review demonstrated consistency in quality and content for breast cancer practice guidelines published by various organizations. Future guidelines developed by these organizations should focus on how to implement and measure uptake of a guideline. Full article

We present a patient with lymphoepithelioma-like carcinoma (LELC) of the breast whose diagnosis is illustrative of the pathology nuances that must be taken into account to successfully reach correct identification of the disease. We also present an overview of our patient’s proposed treatment in the context of 16 other reported LELC cases. Although LELC cases are rare, a sufficient number have been reported to discern the natural history of this pathologic entity and to undertake a review of those cases and of the application of oncologic first principles in their management. Given the potential for locoregional spread and distant metastases in LELC, adjuvant therapy has a role in the treatment of this entity. Full article

The annual Eastern Canadian Colorectal Cancer Consensus Conference was held in Ottawa, Ontario, October 22–23, 2010. Health care professionals involved in the care of patients with colorectal cancer participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer, such as the use of epidermal growth factor inhibitors in metastatic colon cancer, the benefit of calcium and magnesium with oxaliplatin chemotherapy, the role of microsatellites in treatment decisions for stage ii colon cancer, the staging and treatment of rectal cancer, and the management of colorectal and metastatic pancreatic cancers. Full article

Purpose: Evaluate inter-country variability in the reimbursement of publically funded cancer drugs, and identify factors such as cost containment measures that may contribute to variability. Methods: As of February 28, 2010, licensed indications for 10 cancer drugs (bevacizumab, bortezomib, cetuximab, erlotinib, imatinib, pemetrexed, rituximab, sorafenib, sunitinib, and trastuzumab) were obtained from the drug registries of 6 licensing authorities corresponding to 13 countries or regions: Australia, Canada (Ontario), England, Finland, France, Italy, Germany, Japan, New Zealand, the Netherlands, Scotland, Sweden, and the United States (Medicare Parts B and D). Number of licensed indications reimbursed by public payers and the use of cost containment measures were obtained by survey of health authorities involved in reimbursement and through public documents. Results: The 48 identified licensed indications varied between agencies (range: 36–44 indications). Finland, France, Germany, Sweden, and the United States reimbursed the highest percentage of indications (range: 90%–100%). Canada (54%), Australia (46%), Scotland (40%), England (38%), and New Zealand (25%) reimbursed the least. All 5 countries with the lowest rate of reimbursement incorporated a cost-effectiveness analysis into reimbursement decisions and rejected submissions for reimbursement mainly because of lack of cost effectiveness; in New Zealand, lack of cost effectiveness was the second leading cause of rejection after excessive cost. In 9 countries, risk-sharing agreements were used to contain costs. Indications initially not recommended for reimbursement (9 in Australia, 5 in Canada, and 3 in England, New Zealand, and Scotland) were subsequently approved with risk-sharing agreements or special pricing arrangements. Conclusions: Reimbursement of publically funded cancer drugs varies globally. The cause is multifactorial. Full article

Background: After an initial diagnosis of breast cancer, the risk of contralateral breast cancer is approximately 0.5% per year. Annual mammography is recommended to identify local recurrences and contralateral new primaries. Because the sensitivity of mammography tends to be lower in younger women, we conducted a retrospective review of the method of detection and pathologic stage of metachronous contralateral primary breast cancers according to age at diagnosis in a cohort of breast cancer patients. Methods: The Henrietta Banting Database contains information on cases of breast cancer diagnosed at Women’s College Hospital from 1987 to 2004. From among 1992 women in the database, 71 patients were identified who were initially diagnosed before age 60 and who subsequently developed a contralateral breast cancer. Medical records were obtained for 53 of the 71 patients. Results: Of the 53 contralateral cancers, 33 (62%) were detected by mammography, including 4 in 16 patients (25%) diagnosed before age 50 and 29 in 37 patients (78%) diagnosed at age 50 or older (p ≤ 0.001). Conclusions: Mammography has poor sensitivity for the surveillance of contralateral breast cancer in early-onset breast cancer patients. Other imaging modalities should be evaluated in this setting. Full article

Despite the success of standard treatments in chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL), patients are often unable to tolerate aggressive regimens, and they require effective alternatives. Bendamustine is a bifunctional alkylator with unique properties that significantly distinguish it from other agents in its class. In untreated CLL, bendamustine has demonstrated rates of response and progression-free survival (PFS) that are superior to those with chlorambucil, with an acceptable toxicity profile. In the relapsed setting, combination treatment with bendamustine–rituximab (BR) has demonstrated promising activity in high-risk patients such as those refractory to fludarabine or alkylating agents. In untreated patients with indolent NHL and mantle cell lymphoma, BR has demonstrated a PFS significantly longer than that achieved with R-CHOP (rituximab–cyclophosphamide–doxorubicin–vincristine–prednisone), with significantly reduced toxicity. In the relapsed setting, BR has demonstrated rates of response and PFS superior to those with fludarabine–rituximab, with comparable toxicity. In the United States and Europe, bendamustine has been approved for the treatment of CLL and indolent NHL; its approval in Canada is pending and eagerly awaited. Once available, bendamustine will benefit many Canadian patients with NHL and CLL. Full article

Purpose: In 2006, the American Society of Clinical Oncology established guidelines on fertility preservation in cancer patients, but recent data suggest that the guidelines are not widely followed. To identify the frequency of fertility discussions and the characteristics that influence the rate of discussion, we performed a retrospective chart review for patients less than 40 years of age with newly diagnosed colorectal cancer (crc). Methods: Charts of patients aged 18–40 years with newly diagnosed crc presenting to the Juravinski Cancer Centre from 2000 to 2009 were reviewed for documentation of discussions regarding fertility risks with treatment and reproductive options available. The influences of sex, age, year of diagnosis, stage of cancer, and type of treatment on the frequency of discussions were explored. Results: The review located 59 patients (mean age: 35 years) who met the criteria for inclusion. A fertility discussion was documented in 20 of those patients [33.9%; 95% confidence interval (ci): 22.1% to 47.4%]. In the multivariate analysis, the odds of fertility being addressed was higher for patients receiving radiation [odds ratio (or): 9.31; 95% ci: 2.49 to 34.77, p < 0.001) and lower by age (or: 0.86; 95% ci: 0.74 to 0.99; p = 0.040). Of patients less than 35 years of age undergoing radiation treatment, 85% had a documented fertility discussion. We observed no significant difference in the frequency of discussions after 2006, when the American Society of Clinical Oncology guidelines were published (31.4% for 2000–2006 vs. 37.5% for 2007–2009, p = 0.63). Conclusions: Discussions about fertility risks associated with crc treatment occur infrequently among young adults with newly diagnosed crc. However, discussions occur more frequently in younger patients and in those undergoing radiation. Further investigations assessing barriers and physician attitudes to fertility risk discussion and reproductive options are planned. Full article

Background: The generally poor prognosis and poor quality of life for lung cancer patients have highlighted the need for a conceptual model of integrative practice. Although the philosophy of integrative oncology is well described, conceptual models that could guide the implementation and scientific evaluation of integrative practice are lacking. Purpose: The present paper describes a conceptual model of integrative practice in which the philosophical underpinnings derive mainly from integrative oncology, with important contributions from Traditional Chinese Medicine (tcm) and the discipline of nursing. The conceptual model is described in terms of its purpose, values, concepts, dynamic components, scientific evidence, clinical approach, and theoretical underpinnings. The model argues that these components delineate the initial scope and orientation of integrative practice. They serve as the needed context for evaluating and interpreting the effectiveness of clinical interventions in enhancing patient outcomes in lung cancer at various phases of the illness. Furthermore, the development of relevant and effective integrative clinical interventions requires new research methods based on whole-systems research. An initial focus would be the identification of interrelationship patterns among variables that influence clinical interventions and their targeted patient outcomes. Full article

This paper unpacks the slippery slope argument as it pertains to assisted death. The assisted-death regimes of the Netherlands, Belgium, Luxembourg, Switzerland, and the states of Washington and Oregon are discussed and examined with respect to the slippery slope analytical rubric. In addition to providing a preliminary explanation of how the slippery slope argument has been academically defined and constructed, the paper examines assisted-death models from the perspective of considering what might exist at the top and at the bottom of the slippery slope. It also explores the nature and scope of safeguards implemented to avoid slippage, and shows that what lies at the top and bottom of the slippery slope may be different from jurisdiction to jurisdiction. After identifying some of the recent concerns that have arisen within each of the jurisdictions (concerns that might be viewed by some as evidence of slide), the paper concludes by making note of certain critical issues in the current assisted-death debate that merit deeper examination. Full article

A large and convincing body of evidence demonstrates the benefits of exercise for cancer survivors during and after treatment. Based on that literature, more cancer survivors should be offered exercise support and programming. Unfortunately, exercise programs remain an exception rather than the norm in cancer care. Not surprisingly, common barriers to the implementation of exercise programs in oncology include limited resources, expertise, and awareness of benefits on the part of patients and clinicians. To improve the accessibility and cost-effectiveness of cancer exercise programs, one proposed strategy is to combine the resources of hospital and community-based programs with home-based exercise instruction. The present paper highlights current literature regarding exercise programming for cancer survivors, describes the development of an exercise program for cancer patients in Toronto, Canada, and offers experiential insights into the integration of exercise into oncologic care. Full article

Objective: To review the empirical claims made in: Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. Curr Oncol 2011;18:e38–45. Design: We collected all of the empirical claims made by Jose Pereira in “Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls.” We then collected all reference sources provided for those claims. We compared the claims with the sources (where sources were provided) and evaluated the level of support, if any, the sources provide for the claims. We also reviewed other available literature to assess the veracity of the empirical claims made in the paper. We then wrote the present paper using examples from the review. Results: Pereira makes a number of factual statements without providing any sources. Pereira also makes a number of factual statements with sources, where the sources do not, in fact, provide support for the statements he made. Pereira also makes a number of false statements about the law and practice in jurisdictions that have legalized euthanasia or assisted suicide. Conclusions: Pereira’s conclusions are not supported by the evidence he provided. His paper should not be given any credence in the public policy debate about the legal status of assisted suicide and euthanasia in Canada and around the world. Full article

Breast or chest-wall pain (bcp) is prevalent in 20%–50% of breast cancer survivors, and it affects quality of life (qol). To determine the feasibility and potential efficacy of an exercise program to improve patient qol and bcp, such a program was offered to breast cancer patients suffering from bcp. The study enrolled 10 breast cancer patients with moderate-to-severe bcp at 3–6 months after completion of all adjuvant treatments. These patients participated in a 12-week comprehensive health improvement program (chip). Intensity was adjusted to reach 65%–85% of the patient’s maximal heart rate. Before the chip and at 1 and 6 months after completion of the chip, qol and pain were measured using questionnaires [European Organisation for Research and Treatment of Cancer Quality of Life core and breast cancer modules (qlq-C30, -BR23) and the McGill Pain Questionnaire short form] completed by the patients. Results were compared with those from case-matched control subjects from another study at McGill University. After the chip, patients reported significant and clinically important improvements in qol and symptoms. At 1 and 6 months post-chip, patients in the study felt, on average, better in overall qol than did historical control subjects. Our study suggests that patients who experience chronic bcp may benefit from an exercise program. A randomized controlled trial is warranted. Full article

In the November 2010 issue of Current Oncology, an editorial by Dr. David Benatar appeared, titled “Should there be a legal right to die?” In his editorial, Dr. Benatar concluded that “it is an indecent imposition on people—an unconscionable violation of their liberty—to force them to endure a life that they have reasonably judged to be unacceptable [...] Full article

Purpose: Colorectal cancer (crc) screening is particularly valuable in Newfoundland and Labrador (NL), where a substantial proportion of crc cases have a hereditary link. We examined the perceptions of gastroenterologists and general surgeons with respect to screening practices for patients with hereditary crc. Methods: We surveyed all gastroenterologists and general surgeons in NL to determine demographic and professional practice characteristics and screening knowledge, practices, and attitudes for four groups of patients with hereditary crc. Results: Of the 43 eligible physicians, 36 (83.7%) responded. Most of the physicians surveyed knew the correct age to start screening, preferred screening by colonoscopy, had a systematic means in their own practice of prioritizing patients for screening, and felt that family doctors or patients (or both) should be responsible for monitoring screening compliance. Most physicians reported that patients with hereditary nonpolyposis crc and familial adenomatous polyposis waited 3 months for screening; patients with a family history of crc or adenomatous polyp waited 6 months or longer. Although respondents agreed on the need for a province-wide crc registry [4.36 on a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree)], they disagreed that wait times were reasonable (2.81) and that other health professionals should perform colonoscopies (2.86). They were equivocal about the need for centralized bookings (3.25) and about whether genetic testing is useful for prioritizing patients (3.25). Conclusions: Gastroenterologists and general surgeons in NL were knowledgeable about screening, but had varying opinions about individual roles in screening, wait times, and the means for prioritizing and providing screening for patients with hereditary crc. Full article

Certain jurisdictions in Canada legally require that physicians report unfit drivers. Physician attitudes and patterns of practice have yet to be evaluated in Canada for patients with brain tumours. We conducted a survey of 97 radiation oncologists, eliciting demographics, knowledge of reporting laws, and attitudes on reporting guidelines for unfit drivers. Eight scenarios with varying disability levels were presented to determine the likelihood of a patient being reported as unfit to drive. Statistical comparisons were made using the Fisher exact test. Of physicians approached, 99% responded, and 97 physicians participated. Most respondents (87%) felt that laws in their province governing the reporting of medically unfit drivers were unclear. Of the responding physicians, 23 (24%) were unable to correctly identify whether their province had mandatory reporting legislation. Physicians from provinces without mandatory reporting legislation were significantly less likely to consider reporting patients to provincial authorities (p = 0.001), and for all clinical scenarios, the likelihood of reporting significantly depended on the physician’s provincial legal obligations. The presence of provincial legislation is of primary importance in determining whether physicians will report brain tumour patients to drivers’ licensing authorities. In Canada, clear guidelines have to be developed to help in the assessment of whether brain tumour patients should drive. Full article

Among the most prevalent cancers, only five— breast cancer, 3rd most prevalent; melanoma, 7th; thyroid, 8th; oral cancers, 13th; testis, 23rd (1)—are easily detectable by external palpation of accessible organs (breasts, thyroid, mouth, skin, and testes) and do not require some form of corporeal invasion for assessment. [...] Full article