Les traitements des cancers Précis à l’usage des médecins généralistes

The aim of this article is to help the general practioners in their everyday practice by giving the minimum information necessary to provide care for patients with cancer. This article discusses the various types of cancer therapy (surgery, radiotherapy, chemotherapy, and hormone therapy) and their main expected side effects.     

Fin de vie à domicile dans la dignité et la sérénité : contributions du médecin généraliste

A general practitioner is sometimes with a patient up to the end of their life, when this occurs at home. This is the case of a patient with pancreatic cancer, diagnosed with liver, bone and pulmonary metastases. She wished to die at home, with the support of her children and an old friend. Treatment was greatly facilitated through frank exchanges between all those concerned, and the few healthcare providers involved. The philosophy of life that the patient had shaped over the years, her hopes and her determination turned her death into a necessary passage, accepted with grace. The state of her body was less significant than her social and spiritual well being, which she was keen to preserve until the very last day. She remained lucid up to the very last moment of her life. We are analysing the different elements that facilitated this optimal care, from the perspective of the patient, her family and her treating physician. A discussion on the role of the healthcare providers allows the place of each of them to be determined, when dealing with a death at home. Should this social, philosophical and spiritual dimension of the dying be reserved for healthcare providers specialized in these fields? Can we direct patients towards a spirituality, a philosophy of life that makes death a less harsh reality? We will question the role society has to play in negating death.     

Les médecins généralistes et la détection précoce des cancers de la peau

Introduction

One of the goals of the French Cancer Plan 2009–2013 is to strengthen the role of the general practitioner at each stage of the patient’s care. As part of its mission in informing health professionals on prevention, the French National Cancer Institute, INCa, implements a barometric survey to better assess the knowledge and practices of GPs on the early detection of skin cancer.

Method

This survey was achieved in two steps, in October 2009 and 2011, by phoning a sample of 600 representative GPs, constructed according to the quota method.

Results

A large majority of the GPs believe they have the necessary knowledge on the prevention and early detection of these cancers (81%) and thus feel comfortable answering questions from patients (87%). However a further analysis reveals that they consider their knowledge to be in need of upgrading. They express a strong demand for information and training. In terms of practice, if the examination of the patient’s skin is usual, it is not always fully carried out by the GP. Self-examination for patients identified at risk is not systematically demonstrated (57%). GPs are especially attentive to the color (83%) or the evolution of a nevus (60%), less to other elements of the ABCDE rule. In case of doubt, when noticing a suspicious skin lesion, the GP addresses his patient to the dermatologist (96%). The care management of patients, as established by the French National Health Insurance, was well accepted and did not change the GPs’ practices.

Conclusions

The results of the 2009 survey are comparable with those of 2011. Current actions, carried out in partnership with GPs on this topic, would benefit from a reinforcement of concerted information actions and continuing education.     

La visite médicale à domicile Une spécificité de la médecine générale française

General practitioners’ visits to patients at home, during and after cancer therapy, constitute an essential complement to hospital treatment. Patients faced severe adverse effects after this type of treatment, and care provided by the general practitioner can avoid further hospitalization, which is sometimes unnecessary.     

Impact du génotype sur la tolérance à l’irinotécan et au cisplatine

Irinotecan and cisplatin are two chemotherapeutic agents whose frequent and serious adverse effects — haematological and gastrointestinal toxicity for irinotecan, ototoxicity for cisplatine — show wide and partly genetic-based interindividual variability. Several studies have been undertaken to identify genetic variants responsible of these toxicities in order to predict the risk for patients to suffer from them and to adapt treatment to risk levels. Concerning irinotecan, dosing recommendations are about to emerge from many UDP-glucuronosyl-transferase 1A1 (UGT1A1, main enzyme inactivating the active metabolite of irinotecan SN-38) polymorphism-related studies. The development of such recommendations may be complicated by the recent discovery of the role of other enzymes (from the same UGT1A subfamily) and carriers (particularly ATP-binding cassette (ABC) superfamily) involved in irinotecan’s pharmacokinetics. For cisplatin, identifying candidate genes is still ongoing because of controversies about different studies’ results. Several genes involved in intracellular processes of ototoxicity were discussed, such as the Glutathione S-transferases (GST), megalin, thiopurine methyltransferase (TPMT), catechol O-methyltransferase (COMT) and ABCC3 genes. The last three genes have recently been incorporated in a predictive model of ototoxicity. For both drugs, further studies are still needed to reach a complete individualization of treatment.     

Les enjeux de la communication médecin-patient et l’importance des caractéristiques psychologiques du médecin

The aim of this paper is to remind that medicine is both an objective and a subjective interpersonal human science. Every scientific and medical progress as regards a disease diagnosis, treatment or prognosis has to be in the service of the patient in the frame of his relationship with his physician. Today, we know that this relationship is underlain by an effective and coherent reciprocal communication that acknowledges the subjectivity of both the patient and the physician, in their cognitive and emotional perception of the physiological problem. From this general point of view, arises the question of the best way to improve communication between physicians and patients suffering from cancer. This is crucial because we know today that an effective and a high-performance communication that implies assessments using both open and open directive questions, listening to and acknowledging patient’s emotional reactions and expectations could have numerous positive effects. For physicians, this communication allows having an effective assessment of patient’s state and breaking the diagnosis more appropriately. Moreover, this communication allows establishing a climate of trust able to promote patient adherence to treatment and to reduce health care professional stress. The question of predicting the acquisition of such effective communication skills by physicians has been the heart of empirical studies. Through the concept of “locus of control” (LOC), this paper shows that physicians are different when they learn communication skills. Results of this paper highlight that physicians’ acknowledgement of their own psychological characteristics could improve communication skills training programs’ effectiveness.     

Traitement à domicile par l’acide zolédronique chez des patients atteints de tumeurs solides : observance et satisfaction du patient et de l’infirmier

PurposeTo explore patient and nurse satisfaction, compliance with best practice, technical feasibility and safety of home infusion of a bisphosphonate.MethodsProspective 1-year survey of home zoledronic acid therapy (4 mg, 15-min intraveinous, every three to four weeks) in patients with bone metastases secondary to a solid malignancy. A physician questionnaire, nurse satisfaction/feasibility questionnaire and patient satisfaction questionnaire were administered.ResultsPhysician participation rate: 56.5% (87/154); 818 patients included; 381 predominantly community nurses; 763/788 case report forms meeting inclusion criteria. Patient characteristics: median age, 68 years (30-95); M/F, 40/60; ECOG-PS 0 or 1, 78.6%; primary tumour site: breast (55.2%), prostate (28.4%), lung (7.2%), other (9.4%). Nurse satisfaction rates: 90.9% (organization of home ZOL therapy); 96.7% (ease of infusion); 97.5% (patient-nurse relationship); 73% (relationship with hospital staff). Patient satisfaction rates: 95.3% overall; 57.6% (quality of the nurse-patient relationship); 68.8% (less travel/waiting); 52.9% (consideration for home environment). Treatment tolerance: 33.63% (discontinuation due to adverse events); 0.6% (osteonecrosis of the jaw); 0.2% fractures. Practitioner compliance with best practice: 76.7% to 83.7% (recommended and/or tolerated dosage), 73% (dental hygiene checks at inclusion; 48 to 56% thereafter); 66% (pre-infusion hydration); often undocumented for calcium/vitamin D supplementation.ConclusionHome zoledronic acid treatment was well tolerated. There was a very high level of both patient and nurse satisfaction with home therapy. However, better compliance with best practice should be encouraged.     

Tumeur à cellules géantes du péroné chez l’enfant: à propos d’un cas

Introduction

Giant cell tumours (GCT) are practically benign and are usually located at the epiphysiometaphyseal level of a young adult’s long bones. Its localisation at a child’s fibula is exceptional.We are presenting a case of a 12-year-old child’s giant cell tumour.

Observation

A 12-year-old girl with a previous history of a road accident at the age of four with an open fracture of her right leg was examined for a tumefaction at the lower extremity. The clinical examination revealed a good general state of health, and no inflammation at the latero-external side of her right leg. A standard X-ray photography showed a bee nest-like osteolysis lesion at the lower fibula metaphyse. A biopsy was performed and it confirmed the diagnosis of a GCT. The treatment consisted in a large ablation of the tumour including part of the healthy zone, followed by an autologous iliac bone graft, stabilized with a Métaizeau pin and a cruropedal plaster. The evolution was favourable after a period of two years.

Conclusion

The GCTcase we are presenting is fairly exceptional because of its location and the age of the patient. The diagnosis was suspected with the standard radiology and will be confirmed by histology, and the treatment consists of a large ablation with an autograft fill.     

Étude prospective monocentrique de la toxicité et de l’efficacité du trastuzumab concomitant à la radiothérapie

PurposeProspective monocentric study of the toxicities related to concurrent administration of trastuzumab to breast radiotherapy.Patients and methodsOne hundred and seventy-three patients were treated between June 2003 and March 2009 by concurrent trastuzumab with normofractionated radiotherapy. Trastuzumab was delivered every 3 weeks (8 mg/kg in the first infusion then 6 mg/kg) during a median time of 12 months (2–62). Left ventricular ejection fraction was assessed by echocardiography or cardiac scintigraphy at baseline, before and after radiotherapy, every 3 months for 1 year and annually. A left ventricular ejection fraction strictly lower than 55% was considered as altered. All toxicities were evaluated using Common Terminology Criteria for Adverse Effects version 3.0.ResultsMedian follow-up was 52 months (17–88). Median age was 52 years (25–83). One hundred and thirty-four patients (77.5%) received radiotherapy to the internal mammary chain. Acute grade 1, 2 and 3 epithelitis was described in 132 (76.3%), 32 (18.5%) and six patients (3.4%), respectively. At 23 months, grade 1 and 2 fibrosis was observed in 31 and eight patients, respectively (18.8 and 4.6%). Left ventricular ejection fraction remained normal for 159 patients (91.9%) before radiotherapy. Among them, 18 (11.3%) experienced a left ventricular ejection fraction alteration, eight (5.0%) at the completion of radiotherapy. Congestive heart failure occurred in one patient (0.6%).ConclusionsToxicities related to the association of trastuzumab to breast radiotherapy were mild. Further follow-up is warranted.     

Aspects cliniques et pronostiques des cancers du sein triple négatifs à l’unité de sénologie du CHU Le-Dantec de Dakar

Objectives

To determine the epidemiological and clinical characteristics, prognosis, and therapeutic modalities of triple negative breast cancer.

Patients and methods

It is a retrospective observational study of all cases of breast cancer with hormone receptors and HER-2 negative followed between April 2009 and March 2012. The following were studied: the sociodemographic characteristics of patients, the diagnostic features of triple negative breast cancer, and therapeutic modalities and outcome of followed cases. Data were entered and analyzed using SPSS software, version 19.0.

Results

Twenty-two patients were included. The rate was 33.8% of all breast cancers and 5.7% of breast pathologies recorded during the study period. The average age of patients was 45.4 years. The majority (63.6%) had less than 50 years. A proportion of 59.1% were premenopausal. The mean gravidity was 4 and mean parity 3.6. The mean delay for consultation was 11.1 months. The discovery of a breast mass was the reason for consultation in almost all cases (95.5%). Cancer was locally advanced in 86.3% of cases. Axillary lymph node involvement was present in 68.1% of patients. In 27.3% of cases, there were already secondary locations at the time of diagnosis. Infiltrating ductal carcinoma accounted for 86.4% of histological types. We found 68.2% of grade 3 tumors. In 59% of patients, the initial treatment was neoadjuvant chemotherapy. A clinical response was obtained in 61% of cases. Surgery in all cases was a mastectomy according to Patey-modified technique followed by axillary dissection. Three patients received radiotherapy. The mean time to recurrence was 16.9 months. This recurrence was observed in 27% of cases. The median overall survival was 25 months (from 21.1 to 28.8, CI 95%), and the median survival for metastatic patients was 16.5 months. The survival rate at 5 years was 41%.

Conclusion

This series shows a high frequency of triple negative breast cancer. These tumors are very aggressive with a very poor prognosis. In view of these results, collaboration with research teams in developed countries is needed to better identify triple negative breast cancer in Africa to improve prognosis.     

Prévention et lutte contre le cancer dans la région africaine de l’OMS : un appel à l’action

Cancer is an increasingly significant public health problem worldwide. The majority of new cancer cases and cancer related morbidity and mortality are now occurring in developing countries, especially in Africa. This paper outlines the situation in the WHO African region and describes the priority interventions needed to address the problem. It advocates for the allocation of increased national and international resources for a more equitable access to optimal cancer prevention, diagnosis, care and management. The WHO is committed to supporting capacity-building in Member states with respect to cancer prevention and control and to sharing good practice with respect to integrated approaches to the prevention, treatment and monitoring of cancer and other non-communicable diseases. An impassioned plea for resource mobilization, collaboration and partnership will result in improved cancer prevention and control in Sub-Saharan Africa.     

Déterminants moléculaires et génétiques d’efficacité et de toxicité du 5-fluoro-uracile

At the present time, 5-FU remains the standard molecule in the treatment of a large number of solid tumours and is the first choice when it comes to gastrointestinal cancers. A large number of markers, indicators of response and safety, have been described for this molecule and its oral form, capecitabine. Although the number of markers with clinically validated relevance remains low, combining both genetic and molecular research at the patient’s bedside with these markers will provide personalised oncological medicine and aims to improve the efficacy/safety balance for these medicinal products. To this end, and at a time where multicentre studies presenting strong evidence are available, 5-Fluorouracil and other fluoropyrimidines should be seen as the molecules of choice, fully benefiting from the progress being made in the area of biomarker-based medicine.     

Iatrogénie médicamenteuse nosocomiale et gestion des risques d’erreur médicamenteuse: à propos de l’analyse des notifications du réseau REEM

Résumé: La pathologie iatrogène médicamenteuse nosocomiale est un problème de santé publique où la responsabilité de létablissement hospitalier est de plus en plus fréquemment engagée. Elle résulte pour une grande part des erreurs médicamenteuses impliquant des dysfonctionnements non intentionnels dans lorganisation du circuit du médicament. À partir de 458 notifications spontanées derreurs médicamenteuses potentielles et avérées du réseau REEM (Réseau épidémiologique de lerreur médicamenteuse) et utilisant le référentiel de classification NCC MERP, larticle montre comment tirer les leçons dune analyse systémique des erreurs médicamenteuses survenant en milieu hospitalier, en tenant compte de leurs causes, de leurs conséquences en termes de préjudice pour le patient, des facteurs de risque de survenue et de gravité. Les résultats montrent que 47,4 % des erreurs ont atteint le patient (erreurs avérées), parmi lesquelles 23,5 % lui ont provoqué un préjudice dont 2,8 % la mise en jeu du pronostic vital ou le décès. Ces taux varient selon le mode dorganisation du circuit du médicament. Les circonstances de survenue, les types derreurs, les causes inhérentes au médicament et à lordonnance sont analysés, ainsi que les médicaments impliqués. Les principales classes thérapeutiques à risque derreur sont les antinéoplasiques, les digitaliques et les antibiotiques. Les causes inhérentes aux facteurs humains ainsi que les facteurs contributifs à lerreur sont analysés en tenant compte notamment du taux derreur avérée et du taux de préjudice induit et subi par le patient. Une analyse systémique est proposée comme outil de connaissance et de formation pédagogique des professionnels de santé pour lévaluation et le suivi du niveau de sécurisation du circuit du médicament ainsi que lélaboration de propositions dactions en gestion de risque pour améliorer la sécurité du patient dans les établissements de santé.     

Face à la loi Claeys-Leonetti : l’ambivalence des patients et des soignants

Patient ambivalence and the uncertainty of carers are calling out for a meeting. The end of life bill, Advance Directives (living wills) and more broadly, the legal texts regarding the information to give to a patient and the potential of appointing a trusted person have merit: 1) in affirming the importance of end of life; 2) in giving significance to respecting the wishes of the patient; 3) in helping the trusted person; 4) in not hiding the possibility of making the decision to terminate treatment and its importance and indeed the consequences; 5) in offering assistance in making a joint decision. But all the legislative text should not take away from the fact that patient ambivalence and the uncertainties of clinical practices remains the norm within a serious disease context. The aim of good care should not be to remove the ambivalence, but progressively check that it is continuing to support the patient. The care provider cannot therefore be relieved of their worries and concerns by taking the word of the patient, covered by the bill and directly responding to all their questions concerning it. The bill, irrespective of what it is called, its ambition and its details, cannot replace the thoughts and words of doctors and care providers. The bill will never say how to find the right words. In response to the discussions and the suffering of patients, doctors and care providers must keep their freedom to speak, listen and care.