bluuebunny/crossref_metadata_2025 huggingface dataset:
Advances in Endocrine Treatments for Postmenopausal Women with Metastatic and Early Breast Cancer
Authors: Buzdar Aman U.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Define appropriate candidates for various endocrine therapies. Discuss the choices of therapies for patients with advanced breast cancer. Assess the options for adjuvant endocrine therapy for postmenopausal women.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

For the past 25 years, the estrogen antagonist tamoxifen has been the hormonal treatment of choice for postmenopausal patients with hormone-sensitive metastatic and early breast cancer (EBC). However, tamoxifen is associated with certain tolerability and safety concerns. In addition, the hormonal options after progression are limited, and thus, alternative endocrine treatments have been developed. This review provides a synopsis of the newer alternatives in endocrine therapy of breast cancer: the aromatase inhibitors (AIs) and fulvestrant Faslodex®, the estrogen receptor antagonist that downregulates estrogen and progesterone receptors and has no known agonist activity. The third-generation AIs, anastrozole and letrozole, have been shown to be as effective or more effective than megestrol acetate and tamoxifen as second- and first-line therapies for the treatment of postmenopausal patients with metastatic breast cancer, and exemestane has been approved for second-line use. Fulvestrant has been shown to be as effective as anastrozole as second-line therapy for metastatic breast cancer and has been approved in the U.S. for the treatment of postmenopausal women with hormone-receptor-positive metastatic breast cancer following progression on antiestrogen therapy. Anastrozole is the only AI with published clinical trial data and U.S. Food and Drug Administration approval for adjuvant therapy of postmenopausal women with EBC. The ‘Arimidex,’ Tamoxifen, Alone or in Combination (ATAC) trial, a double-blind, multicenter trial with 9,366 patients, compared tamoxifen with anastrozole, alone and in combination, as adjuvant endocrine treatment for postmenopausal patients with operable, invasive, EBC. The first analysis (at a median follow-up of 33.3 months) showed longer disease-free survival and, in general, better tolerability with anastrozole than with tamoxifen. This pattern was maintained at later analyses with a median follow-up of 47 months for efficacy and 37 months for safety and tolerability. Although longer follow-up is warranted, anastrozole appears to be a well-documented choice of endocrine adjuvant therapy for postmenopausal women with hormone-responsive breast cancer.
Health-Related Quality of Life in Female Long-Term Colorectal Cancer Survivors
Authors: Trentham-Dietz A. , Remington P.L. , Moinpour C.M. , Hampton J.M. , Sapp A.L. , Newcomb P.A.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Appreciate that female long-term colorectal cancer survivors commonly achieve quality of life comparable with that of similarly aged women without a personal history of cancer. Identify age and comorbid conditions, particularly greater body mass, as two strong factors related to quality of life in female long-term colorectal cancer survivors. Recognize that colorectal cancer can be associated with long-term levels of both physical and mental health.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Although the number of women who survive treatment for colorectal cancer is growing, little is known about the quality of life of long-term survivors. The purpose of analyses presented in this paper is to describe the overall health-related quality of life of female long-term colorectal cancer survivors and the factors that may modify their levels of quality of life. A population-based sample of 726 Wisconsin women diagnosed with colorectal cancer from 1990–1991 was recontacted. Of the 443 women alive in 1999, 307 (69%) completed a follow-up questionnaire including the Medical Outcomes Study Short-Form 36 Health Status Survey, which is comprised of 36 items that generate nine domain scale scores and two summary scores: the Physical Component Summary score and the Mental Component Summary score. The mean follow-up was 9 years (range 7–11), and the mean age at follow-up was 72 years (range 43–85). The mean Physical Component Summary score was lower for participants with greater ages, greater numbers of comorbidities, and greater body masses at the time of follow-up. The mean Mental Component Summary score also was lower for participants with greater numbers of comorbidities. Differences associated with degree of comorbidity were observed for all eight domain scales. Female long-term survivors of colorectal cancer appear to report health-related quality of life comparable with that of similarly aged women in the general population. These data suggest that, over the long term, factors attributable to aging, body weight, and chronic medical conditions play more dominant roles in determining physical and mental health than factors related to the initial colorectal cancer diagnosis.
Intensive Concurrent Chemoradiotherapy for Head and Neck Cancer with 5-Fluorouracil- and Hydroxyurea-Based Regimens: Reversing a Pattern of Failure
Authors: Argiris Athanassios , Haraf Daniel J. , Kies Merrill S. , Vokes Everett E.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Discuss the results of multicenter trials with chemoradiotherapy with 5-FU- and hydroxyurea-based regimens for the treatment of locoregionally advanced head and neck cancer. Explain the rationale for the combination treatment of radiation, 5-FU, and hydroxyurea. Recognize the toxicities and potential functional impairment for patients treated with aggressive concurrent chemoradiotherapy. Discuss the experimental role of induction chemotherapy in the management of locoregionally advanced head and neck cancer.

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Combined modality programs that were developed over the past two decades demonstrated that the nonsurgical therapy of locoregionally advanced head and neck cancer is feasible and produces survival outcomes that are at least comparable with surgery. The systemic therapy of head and neck cancer has gained momentum in recent years. Several randomized studies have shown that the concurrent administration of chemotherapy and radiation therapy is superior to radiation therapy alone. In consecutive clinical studies since 1986, we have developed multiagent chemoradiotherapy regimens based on initial observations with the 5-fluorouracil (5-FU), hydroxyurea, and concomitant radiotherapy combination. Three consecutive multicenter phase II trials reported that the combination of 5-FU and hydroxyurea with either cisplatin or paclitaxel along with twice daily radiation therapy administered every other week is a highly effective regimen with local control rates that approach 90% and 3-year survival rates of approximately 60% in patients with stage IV disease. The vast majority of patients in these studies achieved anatomical organ preservation. A reversal of the historical pattern of failure was evident, with distant sites becoming the predominant site of failure in each trial. The paclitaxel-containing regimen was better tolerated than the cisplatin-containing regimen and was advanced to further clinical testing. The incorporation of induction chemotherapy may improve the results of treatment by targeting systemic micrometastatic disease.
Thrombotic Thrombocytopenic Purpura Associated with Bone Marrow Metastasis and Secondary Myelofibrosis in Cancer
Authors: Chang Jae C. , Naqvi Tahir
Published: August 2004

To examine the relationship between cancer and development of thrombotic microangiopathy (TM), the medical records of patients with known TM were examined in one institution from January 1981 to December 2002. Nine out of 93 patients with the established diagnosis of TM had active cancer. All nine of those patients had thrombotic thrombocytopenic purpura (TTP). Among those patients, two patients received chemotherapy prior to the development of TTP. Six of the seven patients who received no chemotherapy had extensive bone marrow metastasis and secondary myelofibrosis. There were two patients each with breast cancer, lung cancer, and stomach cancer. Severe anemia and thrombocytopenia with leukoerythroblastosis were prominent clinical features in all six patients. Four patients had neurological (mental) changes and three developed fever, but none had significant renal dysfunction. Upon establishing the diagnosis of TTP, four patients were treated with exchange plasmapheresis (EP) and two patients were treated with chemotherapy because there were no neurological changes. Three patients achieved complete remission of TTP, one with EP alone and two with chemotherapy. The one patient who achieved remission with EP alone was later treated with chemotherapy and survived for 2 1/2 years. The other three patients treated with EP alone died within 2 months after the diagnosis of TTP. Since TTP occurred in association with bone marrow metastasis and myelofibrosis in six patients among seven chemotherapy-untreated cancer patients, this marrow change was considered to be the possible cause of the development of TTP. It is recommended that all cancer patients with unexplained anemia and thrombocytopenia be evaluated for the coexistence of bone marrow metastasis and TTP.
Venous Thrombosis in Cancer Patients: Insights from the FRONTLINE Survey
Authors: Kakkar Ajay K. , Levine Mark , Pinedo H.M. , Wolff Robert , Wong John
Published: August 2004

Background. Venous thromboembolism (VTE) is a common complication in cancer patients and a significant cause of morbidity and mortality. However, little information is available on oncologists' perceptions of the risk of VTE and its management. The Fundamental Research in Oncology and Thrombosis (FRONTLINE) study is the first comprehensive global survey of thrombosis and cancer. The study was designed to collect data on the perceived risk and patterns of practice with regard to VTE in cancer patients undergoing surgical and medical management of their malignancy and to provide information on international and regional practice patterns, allowing for the design of research studies to answer the concerns of practicing clinicians.

Methods. Literature reviews were performed to provide a current evidence base against which to compare the findings, and a survey was developed under the guidance of an advisory board. A paper-based reply-paid questionnaire was distributed globally between July and November 2001 to clinicians involved in cancer care and was made available on a dedicated website.

Findings. A total of 3,891 completed responses were available for analysis. Brain and pancreatic tumors were considered to carry a high risk for VTE, and 80% of respondents considered the use of central venous lines to be associated with a high risk of VTE. Marked differences were seen in the use of thromboprophylaxis for surgical and medical cancer patients, with over 50% of surgeons reporting that they initiated thromboprophylaxis routinely, while most medical oncologists reported using thromboprophylaxis in less than 5% of medical patients. Low molecular weight heparin (LMWH) was the most popular method of thromboprophylaxis employed in both surgical and medical patients and was more favored by European than U.S. clinicians. Some 20% of respondents reported using aspirin for prophylaxis, despite there being no reliable evidence for this agent as effective in prevention in this population. For the treatment of VTE, LMWH was again the most common initial treatment, although, for the long-term, oral anticoagulation therapy was widely adopted. Many patients were treated for VTE on an outpatient basis, and secondary prevention of VTE was typically continued for 3 to 6 months after an episode of deep vein thrombosis or for longer in the case of pulmonary embolism.

Interpretation. The results of the FRONTLINE survey demonstrate a need for guidelines to direct clinical practice in line with evidence-based data concerning cancer and VTE. Oncologists need to be educated regarding the true risks of VTE associated with certain cancers and on strategies for prevention and treatment to reduce the morbidity and mortality associated with VTE in all cancer patients. The study has also helped identify areas for future research.
The Molecular Perspective: Histone Deacetylase
Authors: Goodsell David S.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Identify the structure and function of histone deacetylase and its role in cancer treatment.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com
Diagnosis and Management of Central Nervous System Metastases from Breast Cancer
Authors: Chang Eric L. , Lo Simon
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Select appropriate diagnostic tests for brain, spinal, leptomeningeal, and ocular metastases from breast cancer. Select appropriate therapy for brain, spinal, leptomeningeal, and ocular metastases from breast cancer. Discuss the efficacy and toxicities of therapy for brain, spinal, leptomeningeal, and ocular metastases from breast cancer.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

The brain, cranial nerves, leptomeninges, spinal cord, and eye compose the central nervous system (CNS) and are at risk for the development of metastases from breast cancer. Such metastases are diagnosed on the basis of clinical suspicion and substantiated by neuroimaging, resection when indicated, and sampling of cerebrospinal fluid when leptomeningeal metastasis (LM) is suspected. Treatment is aimed at palliation of symptoms and preservation of neurologic function. Historically, conventional radiation therapy has been the mainstay of palliative treatment for brain, cranial nerve, spinal cord, and ocular metastases. However, additional treatment options for brain metastases have been brought about by technological advances in surgery to resect brain metastases, and stereotactic radiosurgery (SRS) to focally irradiate metastases, both of which have been substantiated by data from randomized trials. Ongoing research is aimed at refining criteria to select which patients with brain metastases should undergo surgery and SRS and how these focal therapies should be optimally integrated with whole-brain radiotherapy. Therapy for LM must carefully balance the potential risks and perceived benefits associated with CNS-directed therapies. Despite advances in neuroimaging, surgery, and radiation therapy, novel treatments are needed to improve the effectiveness of treatments for CNS metastases, especially LM, while reducing attendant neurotoxicity.
The Role of ABC Transporters in Clinical Practice
Authors: Leonard Gregory D. , Fojo Tito , Bates Susan E.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Discuss the function of ABC transporters. Outline the levels of expression of MDR in tumors. Determine the role of P-gp inhibitors in clinical practice.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Drug resistance remains one of the primary causes of suboptimal outcomes in cancer therapy. ATP-binding cassette (ABC) transporters are a family of transporter proteins that contribute to drug resistance via ATP-dependent drug efflux pumps. P-glycoprotein (P-gp), encoded by the MDR1 gene, is an ABC transporter normally involved in the excretion of toxins from cells. It also confers resistance to certain chemotherapeutic agents. P-gp is overexpressed at baseline in chemotherapy-resistant tumors, such as colon and kidney cancers, and is upregulated after disease progression following chemotherapy in malignancies such as leukemia and breast cancer. Other transporter proteins mediating drug resistance include those in the multidrug-resistance-associated protein (MRP) family, notably MRP1, and ABCG2. These transporters are also involved in normal physiologic functions. The expressions of MRP family members and ABCG2 have not been well worked out in cancer.

Increased drug accumulation and drug resistance reversal with P-gp inhibitors have been well documented in vitro, but only suggested in clinical trials. Limitations in the design of early resistance reversal trials contributed to disappointing results. Despite this, three randomized trials have shown statistically significant benefits with the use of a P-gp inhibitor in combination with chemotherapy. Improved diagnostic techniques aimed at the selection of patients with tumors that express P-gp should result in more successful outcomes. Further optimism is warranted with the advent of potent, nontoxic inhibitors and new treatment strategies, including the combination of new targeted therapies with therapies aimed at the prevention of drug resistance.
Chemoembolization in the Management of Liver Tumors
Authors: Stuart Keith
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Explain the anatomic and biologic rationale for using chemoembolization to treat tumors localized to the liver. Identify appropriate candidates for this treatment based upon tumor biology and patient characteristics. Anticipate and manage the toxicities and complications of chemoembolization. Discuss the variability in results reported in the literature from different centers and in different tumor types.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

The dual vascular supply of the liver affords a unique opportunity to explore intraarterial therapies for hepatic malignancies. Chemoembolization is a well-established technique combining intra-arterial chemotherapy with delivery of embolic agents in order to achieve an antitumor effect due to a high local concentration and prolonged dwell time of the drug, along with select ischemia. Many tumors, such as hepatocellular carcinoma, colorectal cancer, and neuroendocrine tumors, cause symptoms and death by local growth and destruction of the liver. While there are other methods capable of controlling small or isolated hepatic neoplasms, none are suitable for the majority of these patients. Chemoembolization can produce significant results in terms of tumor shrinkage in many of these patients, and there are studies to suggest a survival advantage in hepatocellular carcinoma. Toxicity, however, may be substantial, and patient selection is crucial in order to achieve the optimal benefit of this powerful technique for individual populations.
PET Scans in the Staging of Lymphoma: Current Status
Authors: Friedberg Jonathan W. , Chengazi Vaseem
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Define the role of diagnostic PET in the staging of patients with lymphoma. Discuss the role of PET in the evaluation of residual masses in patients with lymphoma. Explain the limitations of PET scanning and the special situations where PET scanning has been used in the evaluation of patients with lymphoma.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Positron emission tomography (PET) is a novel functional imaging technique that provides several inherent advantages over conventional nuclear scintigraphy. Several studies have suggested a role for PET using the positron emitter fluorine-18 in the diagnosis and follow-up of patients with lymphoma. This review summarizes the existing data evaluating the role of 2-fluoro-2-deoxy-D-glucose (FDG)-PET in both the staging and follow-up of patients with lymphoma. Most studies of PET involve patients with either Hodgkin's disease or diffuse large B-cell non-Hodgkin's lymphoma. PET detects more disease sites above and below the diaphragm on staging of lymphoma than gallium scintigraphy and may have particular utility in the evaluation of the spleen. Moreover, persistently positive PET scans during and after chemotherapy appear to have a high sensitivity for predicting subsequent relapse. A negative PET scan at the end of therapy provides very favorable prognostic information. Persistently positive PET scans at the end of therapy warrant close follow-up or additional diagnostic procedures, since some of those patients may remain in prolonged remission. Clearly, additional studies, including prospective blinded trials and cost-effectiveness analyses, are warranted to determine which subsets of patients with lymphoma ultimately will benefit from this modality.
Pros and Cons of Adjuvant Interferon in the Treatment of Melanoma
Authors: Sabel Michael S. , Sondak Vernon K.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Define the indication for and administration of IFN-α in the adjuvant treatment of melanoma. Explain the rationale both for and against the use of adjuvant interferon. Discuss areas of ongoing research for adjuvant therapy of melanoma.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Should interferon alpha (IFN-α) be considered the standard of care for the adjuvant therapy of high-risk malignant melanoma? For 2003, it was estimated that 51,400 cases of invasive melanoma would be diagnosed. The risk of recurrence after surgery is reported to be approximately 60% for patients with thick primary lesions (T4N0M0, American Joint Committee on Cancer [AJCC] stage IIB) and 75% for patients with regional nodal metastases (T1-4N1M0, AJCC stage III). The observation that melanoma is susceptible to attack by the host's immune system has resulted in the testing of a remarkably broad spectrum of immunotherapies in the adjuvant setting. Many of these approaches failed to demonstrate a significant clinical impact, until the use of adjuvant IFN-α. Conflicting data from several large, randomized clinical trials resulted in a rapid rise and then decline in the use of IFN-α in the adjuvant setting. This roller coaster has left many clinicians still hesitant to strongly recommend it, and the use of adjuvant IFN-α in high-risk melanoma remains controversial. This manuscript reviews the leading arguments for and against its routine use and addresses questions regarding its role in the management of high-risk malignant melanoma.
The Melanoma Epidemic: Res Ipsa Loquitur
Authors: Beddingfield Frederick C.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Describe the factors suggesting the melanoma epidemic is real and not artificial. List the major risk factors for melanoma and preventative measures. Describe the relationships between age and gender and melanoma risk.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Many have debated whether or not we are in the midst of a melanoma epidemic. Some facts are clear and helpful to this debate, while others are less clear. The incidence and mortality of melanoma have increased over the last several decades, but the incidence has risen faster than the mortality. The incidence has risen 3%–7% on average over several decades and even more rapidly among Caucasian men and the elderly. In the U.S., the incidence in men is higher than in women after the age of 40, and the difference between men and women increases from age 40 until the end of life. The incidence in the U.S. has risen most rapidly among in situ and localized lesions, but distant and regional disease have increased as well. Among localized disease, in the U.S. from 1988–1997, all stages increased by comparable amounts. This strongly argues against the idea that the increase in incidence of melanoma is only due to early detection of thin lesions or biologically benign lesions, at least during the time period studied. On the other hand, early detection of thin lesions may well account for lower increases in mortality than incidence and improvements in survival. Survival has increased from approximately 60% in the 1960s to 89% in recent years. Improvements in survival appear to be related to earlier diagnosis, rather than an improvement in survival of a given stage.

Studies consistently point to a major role for UV light exposure as the most important risk factor for those individuals with a phenotypic susceptibility. Public health efforts aim at primary and secondary prevention strategies. Primary prevention strategies attempt to prevent people from developing melanoma, primarily through avoiding exposure to UV light. There is a particular emphasis on avoidance of UV light exposure in childhood and young adulthood, when it appears the risk is greatest. When strict avoidance cannot be adhered to, sunscreens have been logically recommended. Secondary prevention strategies include screening campaigns and educational campaigns. Many of these strategies appear promising but require further rigorous testing. The melanoma epidemic has arisen for a variety of reasons including: a true increase in melanomas of malignant behavior, a particularly high increase in localized and in situ lesions, and an increase in the number of biopsies performed, which may have resulted in an increased detection of less aggressive lesions. The contribution of possible changes in the diagnostic criteria for melanoma to the increased incidence remains unknown.
Genetics and the Management of Women at High Risk for Breast Cancer
Authors: Mincey Betty A.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Identify appropriate candidates for consideration of genetic testing for mutations in BRCA1 or BRCA2. Explain the importance of appropriate patient counseling prior to proceeding with genetic testing for mutations in BRCA1 or BRCA2, including genetic counseling and education regarding interpretation and implications of test results. Discuss risk management options for BRCA mutation carriers and the available evidence regarding their effectiveness.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

It is estimated that 5%–10% of all breast cancers in women are associated with hereditary susceptibility due to mutations in autosomal dominant genes, such as BRCA1 and BRCA2, p53, pTEN, and STK11/LKB1. Another 15%–20% of female breast cancers occur in women with a family history but without an apparent autosomal dominant inheritance pattern, and are probably due to other genetic factors with environmental influence. Approximately 7%–10% of ovarian cancers occur in women with hereditary susceptibility, primarily secondary to mutations in BRCA1 and BRCA2, with smaller contributions from mutations in mismatch repair genes associated with the hereditary nonpolyposis colorectal cancer and other, as yet undiscovered, genes.
Andropause: Symptom Management for Prostate Cancer Patients Treated With Hormonal Ablation
Authors: Thompson Carrie A. , Shanafelt Tait D. , Loprinzi Charles L.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Explain the side effects of hormonal ablation therapy for prostate cancer. Provide a list of potential non-hormonal therapies for treatment of vasomotor symptoms. Appreciate the impact of hormonal ablation therapy on bone mineral density.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Andropause, or the age-related decline in serum testosterone, has become a popular topic in the medical literature over the past several years. Andropause includes a constellation of symptoms related to lack of androgens, including diminished libido, decreased generalized feeling of well-being, osteoporosis, and a host of other symptoms. The andropause syndrome is very prominent in men undergoing hormonal ablation therapy for prostate cancer. Most significant in this population are the side effects of hot flashes, anemia, gynecomastia, depression, cognitive decline, sarcopenia, a decreased overall quality of life, sexual dysfunction, and osteoporosis with subsequent bone fractures. The concept of andropause in prostate cancer patients is poorly represented in the literature. In this article, we review the current literature on the symptoms, signs, and possible therapies available to men who cannot take replacement testosterone.
The Kenneth B. Schwartz Center at Massachusetts General Hospital Hematology-Oncology Department: Hope for the Homeless
Authors: Penson Richard T. , Fergus Laura A. , Haston Ross J. , Clark John R. , Demotses Andrew , O'Connell James J. , Chabner Bruce A. , Lynch Thomas J.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Explain the personal elements of the barriers to care for homeless patients with cancer. Describe the personal costs and rewards of extraordinary care. Discuss the epidemiology of head and neck cancer and homelessness.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded the Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient and support to caregivers and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum during which caregivers discuss a specific cancer patient, reflect on the important psychological issues faced by patients, their families, and their caregivers, and gain insight and support from their fellow staff members.

A homeless man with head and neck cancer presents to the emergency room: a sad and familiar story. But this story is redeemed by his 35-year friendship with a priest, a man whose unconditional love and support became critical to the patient's care and treatment. The patient had lived for 30 years in homeless shelters, had problems with alcohol abuse, and was notoriously noncompliant with medical caregivers. He could not speak due to his disease, was illiterate with limited intellectual capacity, and had neither a job nor a family. Despite huge and apparently insurmountable problems for the patient, the oncology team was able to carve out a package of care, successfully communicate, and mobilize a support network to allow successful completion of chemoradiation therapy. The team developed a strong commitment to his care and an affectionate bond, which very positively affected all of those involved. We discuss issues of access to cancer care, and the special problems presented by homeless patients.
The Molecular Perspective: Epidermal Growth Factor
Authors: Goodsell David S.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Describe the structure and function of epidermal growth factor and its role in cancer development and treatment.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com
Goals and Objectives in the Management of Metastatic Breast Cancer
Authors: Chung Cathie T. , Carlson Robert W.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Describe the natural history of untreated breast cancer. Identify the characteristics of women with metastatic breast cancer who may have especially favorable prognoses. Balance physician and patient perspectives in the selection of treatments for metastatic breast cancer.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Patients with metastatic breast cancer consist of a heterogeneous group of patients whose prognoses and clinical courses can vary depending on host factors, such as comorbidity and age, and on tumor factors, such as hormone-receptor status, grade, and anatomical site of disease. Although the median survival time for patients with metastatic breast cancer is 2–4 years, subsets of patients with either indolent or limited metastatic disease may have prolonged survival times. Further, expectations of treatment, both in terms of efficacy and of toxicity, vary greatly based upon the specific treatment, patient characteristics, and tumor characteristics. Thus, the goals of treatment for patients with metastatic breast cancer are influenced by estimates of prognoses as well as a balance between physician and patient preferences regarding efficacy and toxicity considerations. Traditionally, objective measures of response and survival have been the targeted end points in clinical trial design and in physician selection of therapy for metastatic breast cancer. More recently, issues of quality of life have surfaced as important end points, especially from the perspective of the patient. The decision-making process in selecting the optimal treatment for patients with metastatic breast cancer is, therefore, a multidimensional process involving subjective as well as objective goals of treatment. Ultimately, the benefits of treatment must justify the risks and toxicities of the treatment, and the impact of treatment should be measured in relation to specified goals. Both physician and patient perspectives are important in establishing the objectives of treatment, and this process is optimally an interactive and ongoing process throughout the course of disease.
Update on Locally Advanced Breast Cancer
Authors: Giordano Sharon H.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Discuss the heterogeneity of locally advanced breast cancer. Explain the rationale for the multidisciplinary coordination of care for patients with locally advanced breast cancer. Identify the current standard of care for the treatment of locally advanced breast cancer.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Locally advanced breast cancer remains a clinical challenge as the majority of patients with this diagnosis develop distant metastases despite appropriate therapy. Patients with locally advanced disease encompass a wide range of clinical scenarios including advanced primary tumors (stage T4), advanced nodal disease (fixed axillary nodes or involvement of ipsilateral supraclavicular, infraclavicular, or internal mammary nodes), and inflammatory carcinomas. The prognoses of women with locally advanced breast tumors are also heterogeneous and depend on tumor size, extent of lymph node involvement, and the presence or absence of inflammatory carcinoma. Women with locally advanced disease require multimodal therapy, and coordinated treatment planning among the medical oncologist, surgical oncologist, and radiation oncologist is necessary to optimize patient care. In this article, the epidemiology, evaluation, prognostic factors, and treatment for locally advanced breast cancer are discussed. Inflammatory cancer is also reviewed, but is considered separately due to its distinct biology and clinical behavior.
Activation of Tyrosine Kinases in Cancer
Authors: Vlahovic Gordana , Crawford Jeffrey
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Identify the advantages of small molecule inhibitors. Explain the significant role that tyrosine kinase plays in signal transduction. Describe the tyrosine kinase inhibitors clinical data.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Receptor and nonreceptor tyrosine kinases (TKs) have emerged as clinically useful drug target molecules for treating certain types of cancer. Epidermal growth factor receptor (EGFR)-TK is a transmembrane receptor TK that is overexpressed or aberrantly activated in the most common solid tumors, including non-small cell lung cancer and cancers of the breast, prostate, and colon. Activation of the EGFR-TK enzyme results in autophosphorylation, which drives signal transduction pathways leading to tumor growth and malignant progression. Randomized clinical trials of the EGFR-TK inhibitor gefitinib have demonstrated clinical benefits in patients with advanced non-small cell lung cancer whose disease had previously progressed on platinum- and docetaxel-based chemotherapy regimens. Bcr-Abl is a constitutively activated nonreceptor TK enzyme found in the cytoplasm of Philadelphia chromosome-positive leukemia cells. STI571 (imatinib mesylate) inhibits the Bcr-Abl TK, blocks the growth of these leukemia cells, and induces apoptosis. STI571 also inhibits other TKs, including the receptor TK c-kit, which is expressed in gastrointestinal stromal tumors. As TK inhibitors become available for clinical use, new challenges include predicting which patients are most likely to respond to these targeted TK inhibitors. Additional clinical trials are needed to develop the full potential of receptor and nonreceptor TK inhibitors for cancer treatment.
Cancer Survival and Incidence from the Surveillance, Epidemiology, and End Results (SEER) Program
Authors: Gloeckler Ries Lynn A. , Reichman Marsha E. , Lewis Denise Riedel , Hankey Benjamin F. , Edwards Brenda K.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Describe the role and significance of the NCI Surveillance and End Results (SEER) Program. Discuss the evolving changes in cancer mortality statistics in the U.S. Explain some of the important definitions of population science as they relate to cancer.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

An overview of data on cancer at all sites combined and on selected, frequently occurring cancers is presented. Descriptive cancer statistics include average annual Surveillance, Epidemiology, and End Results (SEER) Program incidence, U.S. mortality and median age at diagnosis, and death for the period 1996–2000. Changes during the time period 1992–2000 are summarized by the annual percent change in SEER incidence and U.S. mortality data for this period. Five-year relative survival for selected cancers is examined by stage at diagnosis, based on data from 1990–1999. In addition, 5-year conditional survival for patients already surviving for 1–3 years after diagnosis is discussed as well as relative survival for other time periods. These measures may be more meaningful for clinical management and prognosis than 5-year relative survival from time of diagnosis.

The likelihood of developing cancer during one's lifetime is 1 in 2 for males and 1 in 3 for females, based on 1998–2000 data. It is estimated that approximately 9.6 million people in the U.S. who have had a diagnosis of cancer are alive. Five-year relative survival varies greatly by cancer site and stage at diagnosis, and tends to increase with time since diagnosis. The median age at cancer diagnosis is 68 for men and 65 for women. The 5-year relative survival rate for persons diagnosed with cancer is 62.7%, with variation by cancer site and stage at diagnosis. For patients diagnosed with cancers of the prostate, female breast, corpus uteri, and urinary bladder, the relative survival rate at 8 years is over 75%.
An Update on Hepatic Arterial Infusion Chemotherapy for Colorectal Cancer
Authors: Cohen Adam D. , Kemeny Nancy E.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Explain the rationale for using HAI chemotherapy in patients with isolated liver metastases from colorectal cancer. Summarize the data from randomized clinical trials using HAI chemotherapy in patients with both unresectable and resectable metastases. Describe current approaches combining HAI chemotherapy with newer systemic chemotherapeutic or biologic agents.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Hepatic metastases are a frequent complication of colorectal cancer (CRC), affecting over half of all CRC patients. Resection of isolated metastases can result in long-term survival, but the majority of patients relapse, and most have unresectable disease. Hepatic arterial infusion (HAI) chemotherapy delivers high concentrations of cytotoxic agents directly to liver metastases with minimal systemic toxicities. Advances in surgical techniques, development of fully implantable pumps, and modification of drug regimens have decreased complications and improved patient tolerability. Randomized trials comparing HAI with systemic chemotherapy have demonstrated superior response rates and times to hepatic progression for unresectable disease, and have shown better times to progression and overall survival rates in the adjuvant setting following hepatic resection. HAI chemotherapy has unique toxicities, including chemical hepatitis and biliary sclerosis, which can be mitigated by the addition of dexamethasone to therapy. In an attempt to prevent extrahepatic progression, combinations of HAI with systemic chemotherapy, including newer agents such as irinotecan and oxaliplatin, are currently being investigated, with promising early results.
Chronic Pain Following Treatment for Cancer: The Role of Opioids
Authors: Ballantyne Jane C.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Explain the principles of chronic pain management in cancer patients. Discuss the principles of opioid use in patients with chronic pain. Recognize and prevent substance-related disorders in cancer patients treated with opioids.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Opioids are the most effective analgesics for severe pain and the mainstay of acute and terminal cancer pain treatments. In those settings, opioids are used over a limited time period so that opioid tolerance, if it develops, is relatively easy to overcome, and other problems of opioid use, including substance abuse, are unlikely to be problematic. As cancer treatments improve and increasing numbers of cancer patients experience long remissions, chronic pain due to cancer, or to cancer treatment, becomes a clinical problem that oncologists will encounter. Chronic pain differs from acute and terminal pain in several fundamental respects. In the case of chronic pain, functional restoration is a predominant goal of treatment. Because it is often due to neuronal damage, the pain may be particularly sensitive to nonopioid medications, and opioids can be reserved for refractory pain. If opioids are chosen, tolerance, dependence, and addiction can interfere, and safeguards designed to minimize these must be built into the treatment plan. This article reviews the principles of chronic opioid therapy for non-cancer pain and how these principles may be adapted for patients with chronic pain due to cancer.
Small-Molecule Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors
Authors: Janmaat Maarten L. , Giaccone Giuseppe
Published: August 2004

The growth and proliferation of cells are usually tightly regulated processes that are activated by stimuli from their environment. Epidermal growth factor (EGF)-related peptides represent a class of molecules that can trigger cell proliferation, among several cellular processes, such as differentiation, migration, and survival. Binding of EGF-like peptides to the EGF receptor (EGFR) at the cell surface leads to a cascade of intracellular reactions that transduce signals to the nucleus, resulting in particular gene expression patterns. However, in many tumor cells, the regulation of EGFR activity is lost, due to increased or aberrant expression of the receptor or its ligands, and this contributes to many processes important for tumor growth, including cell proliferation, survival, angiogenesis, invasion, and metastasis. Many strategies have been developed that specifically target the EGFR and inhibit its activity. Of these, small-molecule tyrosine kinase inhibitors represent one of the most promising classes of anticancer agents. Here, we describe the status of small-molecule EGFR tyrosine kinase inhibitors in preclinical and clinical development.
Breaking Bad News: A Patient's Perspective
Authors: Dias Lauren , Chabner Bruce A. , Lynch Thomas J. , Penson Richard T.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Explain the importance of compassionate care and clear communication in oncology. Recognize the advantages and limitations of good communication. Communicate better with patients and families who face life-threatening illness.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery that provides hope to the patient, support to caregivers, and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members.

Clinicians in the field of oncology are unavoidably forced to break bad news. The Schwartz Center Rounds focuses on issues of communication between patients and their caregivers, one of the most difficult aspects of which is breaking bad news. The invited patient, a woman who had been living with a low-grade cancer for many years, spoke about her experiences both as a person living with cancer and as the daughter of a patient diagnosed with cancer. Her father's suicide, precipitated by being told his diagnosis, puts the horror of receiving bad news into stark relief. She provides a fascinating account of how she proactively adjusted to her diagnosis, and fought for optimal quality of life. This article discusses issues of support, abandonment, and how hope is conveyed, and reviews the literature that informs good clinical practice in breaking bad news.
The Molecular Perspective: Protein Farnesyltransferase
Authors: Goodsell David S.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:Describe the structure and function of protein farnesyltransferase and its role in cancer treatment.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com
The Molecular Perspective: DNA Polymerase
Authors: Goodsell David S.
Published: August 2004

Learning Objectives

After completing this course, the reader will be able to:

Describe the structure and function of DNA polymerase and its role in cancer.

Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com