"Micrometastases": the pathologist's point of view]

The development of cancer screening has led to the discovery of smaller tumours and less frequent dissemination to lymph nodes and organs that requires special techniques for detection. Numerous papers on micrometastases reflect a considerable amount of work devoted to detection methods, technical problems and the prognostic value of these lesions. Apart from cytological techniques, the pathologist can rely on two methods for the detection of micrometastases: serial slicing of paraffin-embedded blocks and immunohistochemistry. When these methods are combined, the detection rate is similar to that of biological methods and can attain levels as high as 60% for the sentinel node with the added vantage of being able to visualise cells. Despite an impressive body of studies, major disparities are found in detection rates and the prognostic value of micrometastases is not firmly established. In order to facilitate comparisons and analyses, it is essential to adopt a common terminology with precise definitions. The UICC advocates the use of the term micrometastasis which denotes a metastasis smaller than or equal to 2 mm in size. The potential aggressiveness of micrometastases is dependent on other poorly explored parameters such as the number of cells detected in the bone marrow or lymph node and the location of micrometastases. The new pTNM classification takes into account this latter parameter and distinguishes two categories of micrometastases: "isolated tumor cells" located in the lumen of vessels or sinuses and "micrometastasis" which has already invaded an organ. This classification warrants further analysis to determine the prognostic value of these categories. The next challenging problem consists in determining the key biological properties that account for distant dissemination.     

Evaluation of cancer screening from the epidemiologic point of view

In Japan four kinds of cancer screening programs, namely screening programs for stomach cancer, uterine cancer, breast cancer and lung cancer, have been conducted under the Health and Medical Law for the Aged People. Now, however, it is demonstrated that cancer screening is not always effective in reducing cancer mortality. Therefore, new cancer screening programs, including colo-rectal cancer screening, should be evaluated by a well-designed study, like randomized controlled trial, before implementation as a public health policy.     

Breast cancer screening: another point of view.

The breast cancer screening programmes (BCSP) are very controversial at the present time. They are evaluated by different socio-economic sectors, each with its own particular point of view. Large numbers of breast cancer cases are concentrated in the Oncology Services, which are, therefore, sensitive to the changes that these programmes could bring about. All patients attending the medical oncology and radiotherapy services of the Reina Sofia University Hospital, Cordoba from January 1994 until January 2003 were reviewed. Of 1785 patients, 829 went to these services after the start of the BCSP introduced in March 1999 and 956 before it. The variables analysed were age, presentation form, stage and treatment received. In conclusion, the BCSP has produced favourable changes with respect to stage (increasing the percentage of early breast cancer) and therapeutic management (increasing conservative surgery and decreasing the number of adjuvant treatments (radiotherapy and chemotherapy)). These changes are more outstanding in the population group covered by the BCSP.     

DNA topoisomerase inhibitor as chemotherapeutic drug--clinical point of view]

CPT-11 is a semisynthesized derivative of camptothecin that has a potent antitumor activity by inhibiting DNA topoisomerase I. Leukopenia (mainly neutropenia) is DLF (dose limiting factor) and MTD (maximum tolerated dose) is higher than 250 mg/m2 in CPT-11 from the results of clinical phase I study. Now we are going on phase II study of CPT-11. We are seeing the cases responded to the drug in cancer of the lung, ovary, uterus, stomach, colorectum, pancreas, breast, malignant lymphoma etc.     

Esophageal cancer management controversies: Radiation oncology point of view

Esophageal cancer treatment has evolved from single modality to trimodality therapy. There are some controversies of the role, target volumes and dose of radiotherapy (RT) in the literature over decades. The present review focuses primarily on RT as part of the treatment modalities, and highlight on the RT volume and its dose in the management of esophageal cancer. The randomized adjuvant chemoradiation (CRT) trial, intergroup trial (INT 0116) enrolled 559 patients with resected adenocarcinoma of the stomach or gastroesophageal junction. They were randomly assigned to surgery plus postoperative CRT or surgery alone. Analyses show robust treatment benefit of adjuvant CRT in most subsets for postoperative CRT. The Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) used a lower RT dose of 41.4 Gray in 23 fractions with newer chemotherapeutic agents carboplatin and paclitaxel to achieve an excellent result. Target volume of external beam radiation therapy and its coverage have been in debate for years among radiation oncologists. Pre-operative and post-operative target volumes are designed to optimize for disease control. Esophageal brachytherapy is effective in the palliation of dysphagia, but should not be given concomitantly with chemotherapy or external beam RT. The role of brachytherapy in multimodality management requires further investigation. On-going studies of multidisciplinary treatment in locally advanced cancer include: ZTOG1201 trial (a phase II trial of neoadjuvant and adjuvant CRT) and QUINTETT (a phase III trial of neoadjuvant vs adjuvant therapy with quality of life analysis). These trials hopefully will shed more light on the future management of esophageal cancer.     

Toward the settlement and development of home care

Ever since Sendai Ohshin Clinic inaugurated the operations in 1996, the clinic has been involved in the home care of 850 people in total. At present, the clinic provides care to 200 people at their homes including 38 people with serious diseases under artificial respiration and 40 people with terminal cancer. 513 people who were under care by the clinic died at home, and it is now quite natural that people live at home to the last breath. I noticed various issued through the provision of home care in Sendai and want to present the desirable direction of medical care using a couple of key words.     

Breast cancer and pregnancy: decision making and the point of view of the mother

For the treatment of breast cancer, modifications of decision making related to pregnancy could be assessed through three questions. Why a decision had been chosen? In that case, the hypothesis is that decisions are based on the expected utility. The theory assumes weighting and computation of complete possibilities with their associated probabilities and values. However values exhibits a wide inter-individual variation range. Therefore the predictability of choice based on this model is indeed very low. Furthermore it is likely that the willingness of pregnancy after breast cancer contains besides classic constituents of appeals of motherhood, a specific meaning of recovery both of health and femininity. The second question: who is in charge of the decision? And under the paradigm of autonomy, women' decision is, merely by itself, the right decision. The last question is how? For some situations for which foreseeing is quiet complex, the value of the process in itself is increased and could help the end-oriented or self-determined decision. Casuistic analysis could therefore improve women' decisions. The issue is not only about decision but also related to patient-physician relationship, about an issue that is not only a biomedical problem.     

A physician's point of view

What follows are the perceptions of two individuals-a patient and a highly respected medical oncologist who did not participate in the care of this patient but read the patient's essay. We encourage readers to share their thoughts about these essays in correspondence. Barrie E. Cassileth, Ph.D. Department of Integrative Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York A. Bernard Ackerman, M.D. Ackerman Academy of Dermatopathology, New York, New York Copyright 2000 American Cancer Society.     

Cancer of the breast and pregnancy: the point of view of the breast cancer specialist

Breast cancer is the most common cancer in pregnant women occurring in about 1 in 3,000 pregnancies; the engorgement of the breasts in this period may hinder detection of masses and delays in diagnosis are common; this delay, the young age can explain that overall survival of pregnant women is generally worse than in nonpregnant women. In early stage cancer surgery is recommended as the primary treatment; radiation must be avoided during this period but chemotherapy, if considered necessary, specially in late stage disease, may be given after the first trimester without risk of fetal malformation; termination of pregnancy has not been shown to have any beneficial effect but may be considered if maternal treatments are limited by continuation of pregnancy. In contrast, pregnancy in patients with a prior history of breast cancer does not appear compromise the survival of women and no deleterious effects have not been demonstrated in the fetus: if a risk of relapse exists for the breast carcinoma, it's recommended that patients wait two or three years after diagnosis before attempting to conceive.     

Mechanism of cancer metastasis and its inhibition--a point of view from clinical aspects

Metastasis is one of the most distinct but complicated biological phenomena in cancer. It is hard to decide the most important prospect which must be performed at the present as well as in future studies on cancer metastasis. However, the final goal of the studies on metastasis can be simply concluded as that metastasis should be prevented before dissemination. In this review, we discussed several points to do research in metastasis.     

Cardiac prevention: the oncologic point of view

Between the different anticancer treatments, radiation therapy, chemotherapies and some target therapies could have cardiac toxicity. This toxicity could be a clinical cardiac insufficiency reducing the global benefit of these treatments. Between the different anticancer drugs the more cardiotoxic and frequently used are anthracyclines. The combination of anthracyclines with other agents like trastuzumab or paclitaxel could improve the treatment results, but with an increasing risk of cardiac toxicity. Different strategies have been developed and evaluated concerning the prevention of cardiac toxicity induced by anthracyclines. They are: using of potentially less cardiotoxic anthracyclines but with no direct comparison in adjuvant trials; modification of anthracycline infusion not so used because of technical problems; developing therapeutic strategies who could offer the opportunity to optimize the combination of different treatment with no increasing of cardiac toxicity. Use of a cardioprotecting agent before anthracycline infusion (as dexrazoxane is) is possible. However, the indication is not well defined despite existence of efficacy results.     

The changing needs of patients with cancer at home. A longitudinal view.

Changes in the daily living needs of 629 patients with advanced cancer were investigated (1) during and (2) 3 to 6 months after a course of outpatient chemotherapy and/or radiation treatment. The analytic sample consisted of patients completing both baseline and follow-up interviews (n = 434). At both times, the point prevalence of need and unmet need for assistance with personal care, instrumental activities, transportation, and home health tasks was calculated. In addition, the prevalence of new need and unmet need at follow-up was determined as were the rates of resolution of baseline need. The prevalence of need for assistance with personal care increased from 7% at baseline to 16% at follow-up; the dynamic of need acquisition and resolution resulted in relatively constant prevalence rates in other task areas. Acquisition of need at follow-up was associated primarily with disease and treatment-related characteristics. Approximately one third of patients reporting need for assistance during at least one interview did not have enough help. New unmet need at follow-up was associated most strongly with patients' mobility and the ability of their informal support system to provide care. The apparently rapid fluctuation in patients' experience of need and unmet need suggests the necessity for ongoing appraisal of patients' physical condition and social situation.