AIDS oncology

Kaposi's sarcoma, non-Hodgkin's lymphoma, Hodgkin's disease, and squamous cell carcinoma are among the malignancies seen with increased frequency in patients infected with HIV. The outlook for patients with these malignancies has improved significantly with the utilization of highly active antiretroviral therapy (HAART) and more aggressive cytotoxic therapies. Novel biologic therapies with lesser side effects are currently being evaluated. This article reviews the current knowledge about HIV malignancies, their epidemiology, pathogenesis, clinical manifestations, and treatment.     

Prostatic oncology

Prostate cancer is the most common cancer in men in the United States. Management of prostatic cancer has evolved over the last two decades based on a clearer understanding of the natural history and on improvements in the techniques of radiation therapy, surgery, and hormonal manipulation. Additionally, better methods of prevention and treatment of complications have helped to provide curative therapies for more patients of all ages. Discussion on these topics is followed by a section on special problems in management of elderly patients with prostate cancer.     

Geriatric oncology

The discussion of breast cancer in the older woman implies an outline of unique aspects of cancer and aging. In this analysis, five aspects are highlighted because they pertain to breast cancer control: the diversity of the older population; the age-related increase in cancer susceptibility; the changes in tumor biology that occur with aging; and the implication of these factors for the prevention and treatment of cancer. The comprehensive geriatric assessment accounts for the diversity of the older population in terms of functional reserve and life expectancy and allows an individualized approach to the elderly. The increased susceptibility of the aged to environmental carcinogens has multiple causes and provides theoretical support to cancer prevention to the older individuals. The natural behavior of cancer may change with age due to intrinsic changes in the tumor cells as well as in the tumor host and may lead to both increased and decreased aggressiveness of the neoplasm. In the case of breast cancer, age seems associated with a more indolent tumor. Cancer screening seems effective in older patients with a life-expectancy of 5 or more years. Treatment of cancer with chemotherapy may be associated with increased risk of complications, especially mucositis and neutropenia. The latter may be ameliorated by prophylactic use of growth factors and correction of anemia.     

Cost-effectiveness in oncology

A 1984 report of a British Working Group on Acute Services for Cancer offered guidance to the National Health Service (NHS) on the effective use of resources to achieve maximum benefit for cancer patients. Rees discusses the need to consider the cost effectiveness of these resources. He presents an analysis of the costs of various diagnostic, treatment, and related care modalities in relation to the quality of life achieved, showing that palliative care is considerably more expensive than curative treatment. Rees maintains that these higher costs can be assumed by a compassionate society until they result in an inequitable distribution of resources. He proposes strategies for cost containment based on greater general practitioner and patient involvement, reduction of inpatient care and marginally beneficial follow-up and testing, restriction of the more expensive drugs to curative treatment, and greater use of hospice services.