Should adjuvant radiotherapy to the supraclavicular fossa be routinely given in patients with breast conservative treatment?

BACKGROUND: To analyze the overall outcome, supraclavicular fossa (SCF) recurrence rate, and pattern of failure in breast cancer patients treated with conservative surgery and adjuvant radiotherapy excluding SCF treatment. METHODS: A total of 143 patients were enrolled in the study. Ninety-two percent of patients were stages I and II, and 8% were stage III. The median age was 44 years, and 31% of patients were /= 4, and 0.8% in patients with N < 4. The 5-year SCF-recurrence-free survival in patients with N >/= 4 and N < 4 was 80% and 99%, respectively (P < 0.001). N >/= 4 was the only independent predictor for locoregional control (P = 0.045), disease-free survival (P = 0.001), and overall survival (P = 0.008) in multivariate analysis. CONCLUSIONS: Women with N >/= 4 have a significantly higher risk of SCF recurrence and poorer survival. The SCF might be safely spared in patients with N < 4, but should be routinely included in the radiotherapy design for those with N >/= 4.     

Should all adjuvant breast cancer patients receive a bisphosphonate?

This commentary discusses the report by Trevor Powles and colleagues on their double-blind, placebo-controlled randomised trial of 2 years' adjuvant oral clodronate. Although the reported survival benefit in the clodronate-treated group confirms the results of one prior study as well as the generally held view that bisphosphonates could be advantageous, the reviewer does not feel that the data support the universal use of this additional adjuvant therapy.     

Should adjuvant chemotherapy become standard treatment for patients with stage II colon cancer? For the proposal

Adjuvant chemotherapy is regarded as standard treatment for patients with stage III colon cancer; however, use of chemotherapy after surgery in patients with stage II disease remains controversial because of a lack of level I evidence. In 2005, the Minimum Clinical Recommendations, issued by the European Society for Medical Oncology (ESMO), did not advocate use of chemotherapy in stage II disease, but did state that chemotherapy "may be considered in selected node-negative patients". Similarly, in 2004, treatment recommendations from the American Society of Clinical Oncology (ASCO) for stage II colon cancer proposed that there might be some "patients with stage II disease that could be considered for adjuvant therapy, including patients with inadequately sampled nodes, T4 lesions, perforation, or poorly differentiated histology". Consequently, use of adjuvant chemotherapy in patients with stage II colon cancer is not universal. In this Debate, Alberto Sobrero from Genoa, Italy, and Claus-Henning K?hne from Oldenburg, Germany, present the arguments for and against the use of this type of treatment.     

Should adjuvant chemotherapy become standard treatment in all patients with resected non-small-cell lung cancer?

Surgery remains the main curative treatment for patients with early-stage non-small-cell lung cancer (NSCLC); however, because many patients probably have undetectable micrometastasis even at diagnosis, adjuvant treatment is usually needed. The results for radiotherapy have mostly been disappointing, and a strong emphasis has, therefore, been placed on chemotherapy as the preferred modality. Adjuvant chemotherapy, and in particular, platinum-based regimens, have been assessed in several studies, but the results have been conflicting. Most trials have included patients with a wide range of disease stages and have shown, at most, only moderate improvements in survival. Thus, although clearly indicated in some patients, whether adjuvant chemotherapy should be used in all patients with resected disease is highly controversial. In this debate, Thierry Le Chevalier and colleagues and Giorgio Scagliotti present opposing arguments for whether this approach should be considered standard.     

Should women under 50 be screened for breast cancer?

Despite some controversy in recent years, the majority of experts agree on the evidence for effectiveness of breast screening by mammography for women aged 50 years and above, but for those under 50 years, the picture is much less clear. However, the issue remains of importance both to policy makers and to individual women; although the incidence of breast cancer is lower at younger ages, the life years lost due to cancers diagnosed below 50 years amount to a third of all those lost due to the disease.     

Can some patients avoid adjuvant chemotherapy for early-stage breast cancer?

Adjuvant chemotherapy reduces the risk of relapse and mortality for women with early-stage breast cancer. However, many women diagnosed with early-stage breast cancer experience the toxic effects associated with adjuvant chemotherapy without any meaningful benefit. There are a variety of clinicopathological factors--including hormone receptor expression, histology, and proliferation markers such as Ki-67--that can be used to try to identify patients who can safely avoid adjuvant chemotherapy. In addition, novel molecular tools, including the intrinsic molecular subtypes, prognostic multigene assays, and levels of urokinase-type plasminogen activator, provide further prognostic and predictive information to the standard clinicopathological factors thereby improving the accuracy of risk-of-relapse estimation and of the likelihood of response to cytotoxic chemotherapy.     

Should high-dose interleukin-2 still be the preferred treatment for patients with metastatic renal cell cancer?

Interleukin-2 (IL-2) was the preferred treatment for medically fit patients with advanced kidney cancer, but recently, several targeted therapies have been approved for metastatic renal cell carcinoma. We wished to determine the long-term survival rate for patients with kidney cancer treated with IL-2 and whether the use of intense inpatient IL-2 has declined since the introduction of targeted therapies. Patients who received IL-2 were identified from clinical trial enrollment, pharmacy logs, and financial billing records. Survival was determined from the earliest date of IL-2 therapy. There were 79 patients hospitalized for high-dose infusional IL-2 between March 1989 and March 2009. Median age was 58 years, and 27% were older than 65 years at the time of treatment. At the time of this analysis, 72 patients had deceased. Median survival was 9.9 months, but 5-year survival was 19.4%. The average number of patients with IL-2 increased from 2.2 per year during 1989-1992 to 5.6 during 1993-2001 after FDA approval, but dropped to 2.0 during 2002-2009. High-dose IL-2 is associated with a 5-year survival rate that is higher than objective response rates, suggesting a delayed immunotherapy benefit for some patients. The use of intensive IL-2 has declined dramatically in recent years, but unless a long-term survival benefit can be shown for these new targeted products, we feel that inpatient IL-2 remains the preferred initial treatment.