Multidimensional geriatric evaluation in elderly cancer patients: a practical approach

Management of cancer in the elderly population is currently perceived as one of the major challenges for clinical research in medical oncology. Multidisciplinary evaluation of the malignant disease and multidimensional assessment of the host represent the key element for correct decision making. Standard methods developed by pioneer geriatric oncologists will be summarized in this review, along with some practical suggestions on when and how they should be employed. Future perspectives concerning some critical issues in multidimensional geriatric assessment will be discussed as well.     

Management of cancer in the older person: a practical approach

The management of cancer in the older aged person is an increasingly common problem. The questions arising from this problem are: Is the patient going to die with cancer or of cancer? Is the patient able to tolerate the stress of antineoplastic therapy? Is the treatment producing more benefits than harm? This article explores a practical, albeit evolving, approach to these questions including a multidimensional assessment of the older person and simple pharmacologic interventions that may ameliorate the toxicity of antineoplastic agents. Age may be construed as a progressive loss of stress tolerance, due to decline in functional reserve of multiple organ systems, high prevalence of comorbid conditions, limited socioeconomic support, reduced cognition, and higher prevalence of depression. Aging is highly individualized: chronologic age may not reflect the functional reserve and life expectancy of an individual. A comprehensive geriatric assessment (CGA) best accounts for the diversities in the geriatric population. The advantages of the CGA include:Recognition of potentially treatable conditions such as depression or malnutrition, that may lessen the tolerance of cancer treatment and be reversed with proper intervention; Assessment of individual functional reserve; Gross estimate of individual life expectancy; and Adoption of a common language to classify older cancer patients. The CGA allows the practitioner to recognize at least three stages of aging:People who are functionally independent and without comorbidity, who are candidates for any form of standard cancer treatment, with the possible exception of bone marrow transplant. People who are frail (dependence in one or more activities of daily living, three or more comorbid conditions, one or more geriatric syndromes), who are a candidate only for palliative treatment; and People in between, who may benefit from some special pharmacological approach, such as reduction in the initial dose of chemotherapy with subsequent does escalations. The pharmacological changes of age include decreased renal excretion of drugs and increased susceptibility to myelosuppression, mucositis, cardiotoxicity and neurotoxicity. Based on these findings, the proposal was made that all persons aged 70 and older, treated with cytotoxic chemotherapy of dose intensity comparable to CHOP, receive prophylactic growth factor treatment, and that the hemoglobin of these patients be maintained >/=12 gm/dl.     

Antibody-dependent and spontaneous lympholysis in urologic cancer patients.

To evaluate cytotoxic function mediated by killer lymphocytes and macrophages in urological cancer patients, we examined antibody-dependent and spontaneous lympholysis of chicken erythrocyte target cells, which is mediated by macrophages. Our results demonstrate a discordance between cytotoxic mechanisms in cancer patients, killer-cell function being impaired whilst macrophage-mediated cytotoxicity was increased.     

Lung cancer patients with previous or simultaneous urologic cancers

Study objectives There have been few reports on clinical characteristics of lung cancer patients with previous or simultaneous urologic cancers. Additionally, it was scarcely reported whether these patients could tolerate standard therapy. To evaluate them, we conducted a retrospective study. Methods The records of patients with lung cancer who had previously or simultaneously urological cancers seen in our division between January 1985 and August 2007 were reviewed. Results During the study period, 1,105 patients with lung cancer were seen at our division. Thirteen (1.2%) had previous or simultaneous urological cancers (11 males). Eleven patients were smokers. The diagnosis of urological cancers preceded the diagnosis of lung cancer in all but three patients, for whom the diagnosis of urologic cancers was made during the workup of primary lung cancer. Histologically, the lung cancers included six squamous cell carcinomas, four adenocarcinomas, and three small cell lung cancers. Four underwent surgical resection. Six were treated with platinum-containing chemotherapy, but none of them developed severe renal toxicity. The median survival following the diagnosis of lung carcinoma for NSCLC patients was 18 months, and for SCLC it was 24 months. The cause of death in the 12 patients who died in the study period was directly related to lung cancer, and recurrence of urological cancers was observed in none of the patients. Conclusions For patients with urological cancers, smoking cessation, a chest radiograph or CT scan at least yearly and swift evaluation of signs or symptoms that are suggestive of lung cancer should be recommended.     

Analysis of multiple primary cancers in patients with urologic cancer

Background The study of the clinical features of multiple primary cancers (MPC) may provide insight into the pathogenesis of specific cancers, as well as the issue of treatment-related induction of second tumors. Methods Between 1972 and 1995, 94 of 765 patients with urologic cancer treated at our hospital had MPC. We retrospectively analyzed the clinical features of these patients, and compared them with those of the 671 patients with single primary cancers (SPC). Results The frequency of MPC among all 765 patients was 12.3%. The average age at diagnosis of urologic cancer in the male patients was significantly higher in the MPC group than in the SPC group. In the MPC group, the organs most commonly involved were the bladder and prostate (urologic cancers), and the stomach and lung (nonurologic cancers). Adenocarcinoma was the most common tumor in the MPC group. The interval between the first and second cancer diagnoses was significantly longer in female patients with MPC than in male patients. No significant difference between the MPC and SPC groups was observed in the distribution of ABO blood groups or in the frequency of history of tobacco or alcohol use. Four MPC patients had second cancers considered to have been induced by the treatment for the first cancer. The prognoses were significantly poorer for the patients with MPC. The rate of death due to urologic cancer was much lower in the patients with MPC than in those with SPC. Conclusions We found that more than 10% of the 765 patients with urologic cancer whose cases we reviewed had another primary cancer. Because the number of cases of MPC is increasing, it is important to be aware of the possibility of the development of MPC and to therefore carefully follow up cancer patients.     

Psychosocial care for cancer patients: A new holistic psychosomatic approach in acute care and rehabilitation

The Tumor Biology Center is an innovative model institution for cancer treatment and research which includes basic and applied research institutions and two different types of clinics: an acute care hospital (80 beds) and a rehabilitation hospital (120 beds). The department for psycho-oncology is an integrated part of the two hospitals and consists of a multidisciplinary team of psychologists, a social worker, a music therapist, an art therapist and an occupational therapist. The psychosocial care program uses different kinds of group therapy, as well as counselling and psychotherapy with the patients and their spouses. The psychosocial treatment approach is patient-oriented and aimed at the improvement of the patients coping skills and the psychological management of cancer-referred symptoms such as pain, anxiety or side effects of chemotherapy. The programs are described with regard to the psychosomatic treatment approach of the whole center and the peculiarities of the two different settings (acute care and rehabilitation).     

Primary cutaneous B-cell lymphomas: a practical approach

PCBCL are a heterogeneous group of B-cell lymphomas that originate in the skin, with the absence of extracutaneous disease at diagnosis. Overall, these cutaneous lymphomas have an excellent prognosis. Recurrences are common but dissemination is rare. The EORTC classification allows a more uniform diagnosis and treatment of patients with PCBCL. Careful clinical and pathologic correlation is critical in confirming a diagnosis of PCBCL, before deciding on therapy. Several therapeutic options that are aimed at cure, are available. In most instances, chemotherapy should not be the first line of treatment.     

Imaging of hepatocellular carcinoma: a practical approach.

Imaging of hepatocellular carcinoma (HCC) is complicated because the tumor has a varied radiologic appearance and frequently coexists with cirrhotic regenerative and dysplastic nodules. In cirrhotic patients, any dominant solid nodule that is not clearly a hemangioma should be considered a HCC until proven otherwise, especially if the lesion is hypervascular, of high T2 signal intensity, or demonstrates venous invasion. Biopsy of HCC in cirrhosis is risky and surveillance is often preferable. The doubling time of HCC is 1 to 12 months, and a nodule that is stable over 4 months is very unlikely to be a HCC. However, stable nodules cannot be dismissed, since livers containing dysplastic nodules are at high risk to develop HCC. In noncirrhotic patients, any solid mass that is not clearly a hemangioma or focal nodular hyperplasia is potentially a HCC, and biopsy may be required. Venous invasion by tumor should be distinguished from bland thrombus. Imaging detection of nodal metastases is limited by the frequent finding of benign reactive lymphadenopathy in cirrhosis. Resection is the preferred treatment for HCC, but is contraindicated in the presence of tumors in both lobes, major venous invasion, invasion of adjacent organs other than the gallbladder, tumor rupture, nodal metastases, or distant metastases.     

Hyperthermia for cancer: a practical perspective

A causal relationship between hyperpyrexia and tumor regression was first suggested in 1866, when Busch reported the cure of a histologically diagnosed sarcoma in a middle-aged woman, following a bout of erysipelas. Over the years, interest in the effect of heat on cancer has remained alive, but this interest has increased dramatically in recent years. The literature on this subject is broadly reviewed and the clinical results discussed. It is apparent from clinical studies thus far that it is a relatively simple undertaking to treat superficial neoplasms with hyperthermia. However, the major challenges in clinical thermotherapy pertain to patients with deeply situated tumors. The lack of safe and reliable methods of monitoring temperature in deep tissues is a major impediment to a thorough understanding of thermal dosimetry in clinical hyperthermia, and routine thermal dosimetry in clinical hyperthermia will have to await the development of reliable noninvasive thermometry. As responses have been reported with modest levels of hyperthermia, the need for thermometry is somewhat lessened, given that invasive monitoring is imperfect and somewhat risky when used in deeply seated tumours. The eventual place of thermotherapy in the treatment of malignant tumours in man is as yet unclear and must be rigourously and thoroughly assessed in well-designed, prospective, randomized patient trials.     

Sexual dysfunction in cancer patients.

As a result of the convergence of increased numbers of cancer survivors, heightened awareness of quality of life issues and improved methods of treatment with sex therapy, the problem of sexual dysfunction after cancer treatment is receiving increased attention. In this article, the recent literature is reviewed by tumor site, including breast, bladder, colorectal, gynecologic, testicular, prostate, and other malignancies. Limitations and advances in the available literature are discussed, and recommendations for future research and clinical work are made.     

Treatment of venous thrombosis in cancer patients: practical aspects

The risk of venous thromboembolism (VTE) is increased in association with malignancy, and has a potential to produce significant morbidity and mortality. Treatment of such patients with anticoagulants is associated with both benefit and a high rate of complications. In the early phase, the treatment is usually achieved with low molecular weight heparin (LMWH), which has a number of advantages over unfractionated heparin (UFH): once or twice daily administration, no necessary laboratory monitoring, lesser risk of bleeding and no drugs interactions. Nevertheless, the UFH is the anticoagulant of choice when a rapid anticoagulant effect or stop of anticoagulant effect is required, in the treatment of massive pulmonary embolism or severe renal insufficiency. Prolonged anticoagulation with LMWH (over 3 or 6 months) appears to be beneficial on survival for such patients. The subject of anticoagulation in patients with primary or secondary brain tumours is controversial. The long-term anticoagulation mainly use LMWH or vitamin K antagonist. The last ones are more difficult to use because of an unpredictable response with higher rate of recurrence and bleeding. The optimal duration of treatment is not known but the patients should be treated for at least 6 months, even at least 12 months after a second episode of venous thromboembolism. On the primary prevention in high-risk surgical oncology, the LMWH are at least as effective and safer as UFH when the optimal dose was administered. For the medical patients, the use of prophylactic anticoagulant treatment is less clear except the patients who are bedridden for prolonged periods of time. For the secondary prevention, the LMWH seems to be more effective over vitamin K antagonists. For these patients, the anticoagulant therapy is recommended indefinitely or until cancer is resolved.     

i Sexual function in breast cancer patients: a prospective study from Iran

Background

Sexual function in patients with breast cancer especially in younger patients is an important issue from clinical and psychosocial perspectives. This study aimed to assess sexual function among Iranian breast cancer patients.

Methods

This was a prospective study of sexual function in breast cancer patients attending the Cancer Institute of Iran. Sexual function was assessed using the Female Sexual Function Index (FSFI) at two points in time: baseline (pre-treatment) and after completion of cancer treatment at follow-up visits (post-treatment). Pre- and post-treatment data were compared. In addition logistic regression analysis was performed to find out factors that contributing to post-treatment sexual dysfunction.

Results

In all 277 breast cancer patients were approached. Of these, 231 patients (83%) were sexually active and data for 216 patients (93.5% of sexually active patients) were available at pre-and post-treatment. Overall pre- and post-treatment sexual dysfunction was found to be 52% and 84%, respectively indicating a significant deterioration in sexual function among breast cancer patients. The results obtained from multiple logistic regression analysis indicated that younger age [OR = 0.95, 95% CI = 0.93-0.98; P = 0.04], receiving endocrine therapy [OR = 3.34, 95% CI = 1.37-7.91; P = 0.007] and poor sexual function at pre-treatment [OR = 12.3, 95% CI = 3.93-39.0; P < 0.0001] were the most significant contributing factors to post-treatment sexual disorders.

Conclusion

A significant number of breast cancer patients experience deterioration in sexual function over time. The findings from this study indicated that younger age, receiving endocrine therapy, and poor sexual function at diagnosis were the most significant predicting factors for sexual disorders following treatment.     

Nutritional workshops for cancer patients: a pilot approach]

The authors describe an original experience with 3 years of a nutritional workshop for cancer patients. This intervention combine an information about nutritional aspects of cancer with psychosocial support, to buffer psychological and nutritional consequences of cancer. The workshop, leaded by two specialized teams, one in medical oncology, the other in public health, is proposed to patients during and after a specific treatment. In one day, it provided information about nutrition and cancer, diet education and psychosocial support with supportive-expressive group. At this day, the evaluation of this intervention is only subjective. Fifty-six patients participated in at least one workshop, with majority of women (91%). Nineteen workshops were leaded with average participant number of 7 per workshop the third year. The authors believe that nutritional workshops are of great help for cancer patients, by enhancing social reinsertion, giving opportunity of emotional expression and humanizing the treatment. Our experience show it is possible to propose psychosocial intervention in institution in the context of Mediterranean country. We are leading currently a study that will permit a more systematic evaluation of the effects of this intervention.     

Ultrasound-based combination therapy: potential in urologic cancer

Immune-sensitive urologic malignancies include prostate, kidney and bladder cancers. To date, most immunotherapeutic treatments have been applied to advanced metastatic disease. Limited efficacy in this setting is likely due to an excessive disease burden, which overwhelms the capacity of the immune system. Immunotherapy has not been widely utilized in a low-disease-burden state - a setting in which the immune system may be best suited to effectively mount a clinically meaningful response. The emergence of high-intensity focused ultrasound, and more recently, low-intensity focused ultrasound technologies, have demonstrated not only immune-stimulatory effects but also an interesting capacity to alter tissue architecture and cell membrane properties, which may be exploited to increase tumoral uptake of drugs and vaccines. In this article, we review the literature supporting the novel use of ultrasound combination therapy with adjunctive agents in the treatment of urologic malignancy.     

Sentinel node biopsy as a practical alternative to axillary lymph node dissection in breast cancer patients: An approach to its validity

Background:Sentinel node biopsy (SNB) has been proposed as analternative to axillary lymph-node dissection (ALND) in breast cancer. Beforeimplementing SNB in our practice, we wished to test its validity by comparingit to the standard ALND, both in our hands and with other reported series. Patients and methods:One hundred thirty-two patients wereincluded prospectively. SNB and immediate ALND were performed. For SNB, atechnetium-colloid was used to produce preoperative lymphoscintigraphy andintraoperative gamma-probe search for the SN. Serial sectioning andimmunostains were used on the SN. A comprehensive review of the literature wasdone in order to run a meta-analysis of diagnostic tests using a summaryreceiver operating characteristic curve (SROC) to calculate the pooledparameters of sensitivity and associated 95% confidence interval(95% CI), including our own data. Results:Our technical success rate was 96%. Localsensitivity was 96%, with a 95% CI from85%–99%. Seven patients were upstaged by the SNB. Aliterature search identified 18 studies published from 1996–1999.Estimates of sensitivity ranged from 83%–100%. The pooleddata meta-analysis gave a global sensitivity of 91%, with a 95%CI from 89%–93%. The area under the global SROC curve was0.9967. Conclusions:The minimally invasive SNB was shown to be apractical alternative to ALND. We propose to use local as well as globalsensitivity and associated 95% CI to test the validity of SNB in theclinical setting. Due to limitations of ALND as the golden standard, SNB canin fact be considered a more accurate method for nodal staging.     

Optimizing the care of lung cancer patients: a multidisciplinary approach

Lung cancer poses an immense problem for our society, both in terms of health and the economic costs of caring for affected patients. This introductory overview highlights the issues that are addressed in this Clinics devoted to non-small cell lung cancer.