Spotlight on Rituximab in Non-Hodgkin’s Lymphoma and Chronic Lymphocytic Leukemia

Rituximab is an anti-CD20 monoclonal antibody that has demonstrated efficacy in patients with various lymphoid malignancies, including indolent and aggressive forms of B-cell non-Hodgkin’s lymphoma (NHL) and B-cell chronic lymphocytic leukemia (CLL). While the optimal use of the drug in many clinical settings has yet to be clarified, two pivotal trials have established rituximab as a viable treatment option in patients with relapsed or refractory indolent NHL, and as a standard first-line treatment option when combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy in elderly patients with diffuse large B-cell lymphoma (the most common type of aggressive NHL). The former was a noncomparative trial in relapsed indolent NHL (follicular and small lymphocytic subtypes) with clinical responses achieved in about half of patients treated with rituximab 375 mg/m² intravenously once weekly for 4 weeks, which was similar to some of the most encouraging results reported with traditional chemotherapeutic agents. The latter was a randomized comparison of eight cycles of CHOP plus rituximab 375 mg/m² intravenously (one dose per cycle) versus CHOP alone in previously untreated elderly patients (60 to 80 years of age) with diffuse large B-cell lymphoma. In this pivotal trial, 2-year event-free and overall survival were significantly higher with rituximab plus CHOP, and there was no increase in clinically significant adverse effects compared with CHOP alone. Treatment with rituximab is generally well tolerated, particularly in terms of adverse hematological effects and serious or opportunistic infections relative to standard chemotherapy. Infusion-related reactions occur in the majority of patients treated with rituximab; these are usually mild to moderate flu-like symptoms that decrease in frequency with subsequent infusions. In approximately 10% of patients, however, severe infusion-related reactions develop (e.g. bronchospasm, hypotension). These reactions are usually reversible with appropriate interventions and supportive care but there have been rare reports of fatalities. Conclusion: Clinical trials with rituximab indicate that the drug has broad application to B-cell malignancies, although further clarification is needed to determine its optimal use in many of these clinical settings. Importantly, rituximab in combination with CHOP chemotherapy has emerged as a new treatment standard for previously untreated diffuse large B-cell lymphoma, at least in elderly patients. Compared with conventional chemotherapy, rituximab is associated with markedly reduced hematological events such as severe neutropenia, as well as associated infections. Rituximab may be particularly suitable for elderly patients or those with poor performance status, and its tolerability profile facilitates its use in combination with cytotoxic drugs.     

Providers’ Perspectives of Survivorship Care for Young Adult Survivors of Childhood Cancer

We examined healthcare providers’ perceptions of the goals of survivorship care and survivor programs, systems-level barriers and individual patient-level barriers to engaging patients in survivorship care, and potential resources for increasing engagement. In 2012, we recruited 21 healthcare providers of young adult survivors of childhood cancers from a children’s hospital and a cancer center in the Southeastern USA to complete telephone-based semi-structured interviews. The sample was 45.95 years old (SD?=?7.57) on average, 52.4 % female, and 81.0 % MDs. The major goals of survivorship programs identified were medical care management (e.g., addressing late and long-term effects, providing survivorship care plans (SCPs), assisting in transition of care) and holistic care including addressing psychosocial issues and promoting healthy lifestyles. Systems-level barriers to engagement in survivorship care included limited resources (e.g., time), role confusion (e.g., within cancer centers, from treatment team to survivorship care, role of primary care providers), communication challenges within the medical system (e.g., limited tracking of patients, lack of understanding of the role of survivorship clinic), communication challenges with patients (e.g., setting expectations regarding transition to survivorship care), and lack of insurance coverage. Perceived patient-level factors included psychological barriers (e.g., fear, avoidance), resistance to survivorship care, and physical barriers (e.g., distance from survivorship clinics). Resources to address these barriers included increased access to information, technology-based resources, and ensuring valuable services. There are several systems-level and patient-level barriers to survivorship care, thus requiring multilevel interventions to promote engagement in care among young adult survivors of childhood cancer.     

Oncologists’ Perspectives on Consolidation Radiation Treatment after Chemotherapy in Lymphoma: A Survey Study by the Lymphoma Working Committee of the Turkish Oncology Group (TOG)

In this study, we aimed to determine the perspectives of medical and radiation oncologists on consolidation radiotherapy in patients with complete response after chemotherapy in Hodgkin’s and non-Hodgkin’s lymphoma. The survey was designed to identify demographic and occupational features of medical and radiation oncologists and their perspectives on consolidation radiotherapy in their clinical practices, as based on a five-point Likert scale (never, rarely, sometimes, often, and always). The study consisted of 263, out of 935, physicians working in the oncology field as either a medical or a radiation oncologist; the rate of return on the invitations to participate was 28%. The majority of the participants were male radiation oncologists, with a duration of between 5 and 10 years of work as a university hospital official, and the mean age was 38 ± 14 (years). Although the most commonly followed international guidelines were NCCN, among the physicians, the majority of the respondents suggested that the guidelines were unclear regarding recommendations for consolidative radiotherapy. The administered dose for consolidative radiotherapy in patients with lymphoma was indicated as 40 Gy by 49% of all the physicians and the most common cause of hesitancy from consolidative radiation treatment among the physicians was the risk of secondary malignancies as a long-term adverse effect (54%). In conclusion, we suggested that medical oncologists could be most active on the treatment of lymphoma through a continuous training program about lymphomas and current national guidelines.     

4th International Symposium on Leukemia and Lymphoma – Molecular Pharmacology and New Treatment Modalitie

Renal cell carcinomas (RCCs) represent one of the ten leading cancer entities with an increasing incidence especially in the western world. Unfortunately, about 25% of the patients develop metastatic RCC (mRCC) associated with a most unfavorable prognosis. In the recent years, various new agents targeting VEGF or VEGF receptor (VEGFR) or the mTOR pathway have been approved for the treatment of mRCC with significant prolongation of progression-free survival and, in part, of overall survival (OS). Targeting the mTOR kinase is an interesting option for mRCC. Temsirolimus, one of the available mTOR inhibitors, has been approved as a single agent in poor-risk mRCC patients based on the pivotal Phase III trial showing a significant superiority in OS versus IFN-α or temsirolimus + IFN-α, which has been verified by a pivotal Phase III trial. The benefit has been shown for clear cell carcinoma and papillary RCC as well. For poor prognosis patients, temsirolimus improves median survival by 3.6 months. In second-line treatment compared with sorafenib following first-line treatment with sunitinib temsirolimus showed a relative progression-free survival benefit for patients with nonclear cell RCC with temsirolimus. The median OS for the temsirolimus group was 12.27 and 16.64 months for the sorafenib group. In 2007, the US FDA granted approval for temsirolimus for the treatment of advanced RCC.     

Palliative Care in Patients with Leukemia: When and How?

Purpose of Review

Patients with hematologic malignancies get more aggressive treatment and the end-of-life, more ICU deaths, and prolonged hospital stays. In comparison to solid tumors, their access to palliative care and hospice is less.

Recent Findings

Multiple factors seem to play a role including curative goals, different treatment options, stronger relationship between patients and oncologist, symptom burden, and limitations of hospice care.

Summary

Improving the perception of palliative care in these patients, characterizing their needs, and more education can help to increase referrals and access to palliative care. Innovative ways to improve integration between hematology-oncology and palliative care are needed.

     

Effects of Radiotherapy on the Risk of Developing Secondary Malignant Neoplasms in Hodgkin’s Lymphoma Survivors

Extended follow-up of Hodgkin lymphoma (HL) survivors indicates that these patients are at high risk of secondary malignant neoplasms (SMNs) contributing to increased morbidity and mortality. This study examined the characteristics of HL survivors who developed SMNs with the aim to report any correlation with radiotherapy (RT) dose. In this retrospective multi-center cohort study of HL patients treated between 1990 and 2011 at three major teaching hospitals in Lebanon, classification was into two groups including those treated with combined modality (RT and chemotherapy-CHT) and those treated with CHT alone. Approval from the University Institutional Review Board (IRB) was obtained. Of the 112 patients evaluated, 52.7% (59) received the combined modality while 47.3% (53) received CHT alone. There were 6 cases of SMNs in the combined modality cohort and 5 cases in the CHT cohort. The mean RT dose in the combined modality cohort was 34.5 Gray (Gy) (SD ± 5.3). A statistically significant increase (1.5 fold) in the risk of developing SMNs was observed among patients who received a dose higher than 41 Gy compared to a dose between 20 to 30 Gy (OR= 1.5; 95% confidence interval= 0.674 to 3.339, p=0.012). The risk of SMNs was not significantly higher among patients who received extended field compared to involved field RT (p=0.964). This study showed that the risk of developing SMNs is higher among patients treated with RT dose greater than 31 Gy, independent of the RT type used.     

Young Adult Cancer Survivors’ Experience with Cancer Treatment and Follow-Up Care and Perceptions of Barriers to Engaging in Recommended Care

We examined correlates of low engagement in the healthcare system, experiences with survivorship care, barriers to follow-up care, and potential resources for promoting follow-up care among young adult survivors of childhood cancers. We conducted a mixed-method study involving surveys of 106 survivors of childhood cancer aged 18–34 recruited from a university-affiliated children’s hospital and an NCI-designated cancer center in the Southeastern USA. Phone-based semistructured interviews were then conducted in a subset of 26. Assessments included health factors, psychosocial factors, healthcare system interaction, and interest in resources to promote engagement in healthcare. Survey participants were on average 22.14?(SD?=?3.16) years old, 50.0 % female, and 77.4 % White. Overall, 46.0 % had attended survivorship clinic, 47.2 % reported receiving a treatment summary, 68.9 % had a primary care provider, and 17.0 % reported no interaction with healthcare in the past 2 years. Correlates of less than annual healthcare provider visits included being older (p?=?0.003), being male (p?<?0.001), lack of insurance (p?=?0.002), and having had chemotherapy (p?=?0.05). Participants reported varied experiences in terms of how health and treatment information was presented, from none or too little to overwhelming or anxiety-provoking amounts. Barriers to engaging in survivorship care included no/limited insurance, time, or transportation; major life changes; anxiety; and difficulty transitioning from pediatrics to adult care. Participants highlighted the need for educational and psychosocial resources, particularly technology-based resources. Multilevel interventions are needed to increase engagement in survivorship care among young adult cancer survivors. Technology-based resources addressing social support and mental well-being are intervention possibilities.     

Impact of a Centralized Database System on Radiation Therapy Quality Assurance Management at a Large Health Care Network: 5 Years’ Experience

PurposeThis study reports the impact of using a centralized database system for major equipment quality assurance (QA) at a large institution.Methods and MaterialsA centralized database system has been implemented for radiation therapy machine QA in our institution at 6 campuses with 11 computed tomographies and 22 linear accelerators (LINACs). The database system was customized to manage monthly and annual computed tomography and LINAC QA. This includes providing the same set of QA procedures across the enterprise, digitally storing all measurement records, and generating trend analyses. Compared with conventional methods (ie, paper forms), the effectiveness of the database system was quantified by changes in the compliance of QA tests and perceptions of staff to the efficiency of data retrieval and analyses. An anonymized questionnaire was provided to physicists enterprise-wide to assess workflow changes.ResultsWith the implementation of the database system, the compliance of QA test completion improved from 80% to >99% for the entire institution. This resonates with the 56% of physicists who found the database system helpful in guiding them through QA, and 25% of physicists found the contrary, and 19% reported no difference (n = 16). Meanwhile, 40% of physicists reported longer times needed to record data using the database system compared with conventional methods, and another 40% suggested otherwise. In addition, 87% and 80% found the database more efficient to analyze and retrieve previous data, respectively. This was also reflected by the shorter time taken to generate year-end QA statistics using the software (5 vs 30 min per LINAC). Overall, 94% of physicists preferred the centralized database system over conventional methods and endorsed continued use of the system.ConclusionsA centralized database system is useful and can improve the effectiveness and efficiency of QA management in a large institution. With consistent data collection and proper data storage using a database, high-quality data can be obtained for failure modes and effects analyses as per TG 100.     

Adult Non Hodgkin’s Lymphoma Patients: Experience from a Tertiary Care Cancer Centre in North East India

There is paucity of data on non Hodgkin’s lymphoma (NHL) from our population in North-East India. Inthis retrospective study, patients were consecutively followed-up to see the clinic-pathological pattern of NHL,various responses, and pattern of relapses to first line treatment with chemotherapy. All patients in the presentstudy received standard regimen of cyclophosphamde, doxorubicin, vincristine, prednisolone (CHOP) with orwithout rituximab (R-CHOP) as per our institutional protocol as first line therapy. Our study has shown that,in our adult population, the majority of NHL cases present with stage II and stage III disease and extra nodalinvolvement, B-cell lymphomas and diffuse large cell lymphomas being the most common subtypes. Internationalprognostic index was a significant factor for varied responses to treatment. The majority of relapses after completeremission occurred in the first year.     

Oncology Residents’ Perspectives on Communication Skills and Shared Decision Making

Shared decision making (SDM) and effective communication are essential components of cancer care. Residents in oncology-related specialties were surveyed about communication skills and SDM. The response rate was 77% (17/22), and 93% stated that communication skills were very important for their specialty. Most (76%) thought their communication skills were adequate, but areas of difficulty included discussing end-of-life issues, giving hope when the prognosis was bleak and dealing with hostile patients. Only 58% of respondents had heard the term SDM, and 29% were aware of its meaning. More SDM and communication training are required for future oncology physicians.     

The Relationship Between Cancer Survivors’ Socioeconomic Status and Reports of Follow-up Care Discussions with Providers

Socioeconomically disadvantaged cancer survivors are less likely to have adequate follow-up care. In this study, we examined whether socioeconomically disadvantaged survivors are at risk for not having follow-up care discussions with providers, a critical determinant of access to follow-up care and desirable health outcomes. Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, we used a binary logit model with sample weights to examine associations between 1320 cancer survivors’ socioeconomic status (SES) and reports of follow-up care discussions with providers, controlling for clinical and demographic characteristics. The multivariable model indicated survivors with incomes ≤200 % Federal Poverty Level (FPL) had a lower probability of reporting a follow-up care discussion than survivors with incomes >400 % FPL (p?<?0.05). Survivors with less than high school education had a lower probability of reporting a discussion than survivors who had a college education or greater (p?<?0.05). However, even after controlling for income, survivors with financial hardship had a greater probability of reporting a discussion than survivors with no financial hardship (p?<?0.05). Insurance status was not a significant predictor of reporting a discussion (p?>?0.05). Socioeconomically disadvantaged cancer survivors are at risk for not having follow-up care discussions with providers, particularly those who report lower income and education. The development of educational interventions targeting provider communication with socioeconomically disadvantaged cancer survivors, and survivors’ understanding of the benefits of follow-up care discussions, may promote access to these services. Future research assessing mechanisms underlying relationships between survivors’ SES indicators and reports of follow-up care discussions with providers is also warranted.     

Population-Level Trends in Posttreatment Cancer Survivors’ Concerns and Associated Receipt of Care: Results from the 2006 and 2010 LIVESTRONG Surveys

There is a need to better understand the posttreatment concerns of the nearly 14 million survivors of cancer alive in the United States today and their receipt of care. Using data from 2,910 posttreatment survivors of cancer from the 2006 or 2010 LIVESTRONG Surveys, the authors examined physical, emotional, and practical concerns, receipt of care, and trends in these outcomes at the population level. Results: 89% of respondents reported at least one physical concern (67% received associated posttreatment care), 90% reported at least one emotional concern (47% received care), and 45% reported at least one practical concern (36% received care). Female survivors, younger survivors, those who received more intensive treatment, and survivors without health insurance often reported a higher burden of posttreatment concerns though were less likely to have received posttreatment care. These results reinforce the importance of posttreatment survivorship and underscore the need for continued progress in meeting the needs of this population. Efforts to increase the availability of survivorship care are extremely important to improve the chances of people affected by cancer living as well as possible in the posttreatment period.     

Wilms Tumor 1 Expression at Diagnosis Correlates With Genetic Abnormalities and Polymorphism But Is Not Independently Prognostic in Acute Myelogenous Leukemia: A Hokkaido Leukemia Net Study

Background

The prognostic effect of Wilms tumor 1 (WT1) expression at the diagnosis of acute myelogenous leukemia (AML) has been controversial. The aim of the present study was to determine the correlations of WT1 expression at the diagnosis of AML with established prognostic alterations.

Parents’ and Health-Care Providers’ Perspectives on Side-Effects of Childhood Cancer Treatment in Indonesia

Background: Efficacy of childhood cancer treatment in low-income countries may be impacted by parents’and health-care providers’ perspectives on chemotherapy-related side-effects. This study explores prevalence andseverity of side-effects in childhood cancer, and compares health beliefs about side-effects between parents andhealth-care providers, and between nurses and doctors in Indonesia. Materials and Methods: Semi-structuredquestionnaires were filled in by 40 parents and 207 health-care providers in an academic hospital. Results:Parents exporessed a desire to receive more information about side-effects (98%) and worried about this aspectof treatment (90%), although side-effects were less severe than expected (66%). The most frequent was behavioralteration (98%) and the most severe was hair loss. Only 26% of parents consulted doctors about side-effects.More parents, compared to health-care providers, believed that medicines work better when side-effects are moresevere (p<0.001), and accepted severe side-effects (p=0.021). More health-care providers, compared to parents,believed that chemotherapy can be stopped or the dosage altered when there are side-effects (p=0.011). Morenurses, compared to doctors, stated that side-effects were unbearable (p=0.004) and made them doubt efficacyof treatment (p<0.001). Conclusions: Behavior alteration is the most frequent and hair loss the most severeside-effect. Apparent discrepancies in health beliefs about side-effects exist between parents and health-careproviders. A sustainable parental education program about side-effects is recommended. Health-care providersneed to update and improve their knowledge and communication skills in order to give appropriate information.Suchmeasures may improve outcome of childhood cancer treatment in low-income countries, where adherenceto therapy is a major issue.     

Surviving Childhood Leukemia in a Latin Culture: An Explorative Study Based on Young Adults’ Written Narratives

This study investigated memories of childhood leukemia conveyed by survivors belonging to a Latin culture, exploring whether benefit findings was spontaneously reported, as by non-Latin survivors. Three hundred patients previously treated for leukemia were contacted by post/e-mail and asked to write freely about their illness experience. The 106 letters received were analyzed for narrative structure and content, according to a grounded theory approach. Participants expressed most of the themes conveyed by childhood cancer survivors in non-Latin countries, and benefit finding was spontaneously reported. To the latter, the usefulness of creating and maintaining personal narratives on cancer experience, sustained by health care professionals, is discussed.     

“You’re too young for this”: Adolescent and Young Adults’ Perspectives on Cancer Survivorship

Adolescent and young adult cancer survivors face unique challenges not systematically addressed by cancer clinicians. Four focus groups and two individual interviews were conducted with 19 survivors to profile experiences and identify key concerns for future interventions. The resultant themes reflect cancer care continuum challenges (such as delays in diagnosis, problems with adherence), psychosocial concerns (such as infertility and reproductive concerns, changing social relationships, financial burden), and the paradox of being diagnosed with cancer as a young adult. Future intervention development for adolescent and young adult survivors should involve patient voices at each stage of the research process.