Ambulatory chemotherapy: pharmaceutical care as a part of oncology service

Cancer patients and the application of pharmaceutical care: 1) Patients with chronic illnesses receive multiple benefits from pharmaceutical care. 2) The pharmaceutical care of the cancer patient must be co-ordinated with the physician. 3) The cancer care-providing pharmacist should acquire psychological competency. 4) The pharmacist sets up and maintains for the patient a drug therapy record and a drug application plan. Cancer patients require our attention and our professional knowledge in many respects.

On the one hand, there is the centralized aseptic preparation of chemotherapy drugs with respective individual requirements, on the other hand there is the monitoring of therapy, pharmacoeconomics, reducing the risk of chemotherapy errors and safe drug handling. All of these require our professional commitment. In order to provide care to cancer patients in community pharmacies, it is essential to establish a structural procedure. Individualized counselling and personal care of the patient is a part of pharmaceutical services.

Development of a constructive and relevant relationship between patient and pharmacist must be cultivated and begins with the issue of the first prescription. Possibly the patient could still frequent his regular pharmacy and use the special pharmacy only for oncology therapy. In the near future, with patient authorization, an exchange of medication-related data between hospital and community pharmacy will also be possible. We consider a possible German concept for oncology out-patients.

Value of diffusion-weighted MRI in diagnosis of uterine cervical cancer: a prospective study evaluating the benefits of DWI compared to conventional MR sequences in a 3T environment

BACKGROUND

Imaging of cervical carcinoma remains challenging as local infiltration of surrounding tissues cannot always be discriminated safely. New imaging techniques, like diffusion-weighted imaging (DWI) have emerged, which could lead to a more sensitive tumor detection.

PURPOSE

To evaluate the benefits of DWI for determination of size, local infiltration, and tumor grading, in patients with primary and recurrent cervical cancer.

MATERIAL AND METHODS

In this prospective, study we enrolled 50 patients with primary (n = 35) and recurrent (n = 15) tumors. All patients underwent 3T magnetic resonance imaging (MRI) including conventional (e.g. T1/T2 ± fs ± contrast) sequences and DWI (b-values of 0, 50, 400, 800 s/mm(2)). All images were analyzed by three readers with different experience levels (1, 3, 6 years), who compared image quality, tumor delineation, dimensions, local infiltration, lymph node involvement, and quantified ADC values compared to the histopathological grading.

RESULTS

Additional use of DWI resulted in significantly better (P < 0.001) tumor delineation for the least experienced reader, but not for experienced readers. Tumor dimensions were assessed almost equally (P > 0.05) in conventional sequences and DWI. Use of DWI led to an increase in sensitivity of infiltrated adjacent tissue (from 86% to 90%) and detection of lymph node metastases (from 47% to 67%). Quantitative assessment of carcinomas showed lower ADC values (P < 0.001) with significant inverse correlations between different grading levels.

CONCLUSION

Our study demonstrates the overall benefits using DWI in 3T MRI resulting in a higher reader confidence, sensitivity of tissue infiltration, and tumor-grading for cervical cancer.

Simultaneous [18F]FDG-PET/MRI: Correlation of Apparent Diffusion Coefficient (ADC) and Standardized Uptake Value (SUV) in Primary and Recurrent Cervical Cancer

Objectives

Previous non–simultaneous PET/MR studies have shown heterogeneous results about the correlation between standardized uptake values (SUVs) and apparent diffusion coefficients (ADCs). The aim of this study was to investigate correlations in patients with primary and recurrent tumors using a simultaneous PET/MRI system which could lead to a better understanding of tumor biology and might play a role in early response assessment.

Methods

We included 31 patients with histologically confirmed primary (n = 14) or recurrent cervical cancer (n = 17) who underwent simultaneous whole-body ¹⁸F-FDG-PET/MRI comprising DWI. Image analysis was performed by a radiologist and a nuclear physician who identified tumor margins and quantified ADC and SUV. Pearson correlations were calculated to investigate the association between ADC and SUV.

Results

92 lesions were detected. We found a significant inverse correlation between SUV_max and ADC_min (r = -0.532, p = 0.05) in primary tumors as well as in primary metastases (r = -0.362, p = 0.05) and between SUV_mean and ADC_min (r = -0.403, p = 0.03). In recurrent local tumors we found correlations for SUV_max and ADC_min (r = -0.747, p = 0.002) and SUV_mean and ADC_min (r = -0.773, p = 0.001). Associations for recurrent metastases were not significant (p>0.05).

Conclusions

Our study demonstrates the feasibility of fast and reliable measurement of SUV and ADC with simultaneous PET/MRI. In patients with cervical cancer we found significant inverse correlations for SUV and ADC which could play a major role for further tumor characterization and therapy decisions.

Lacking hypoxia-mediated downregulation of E-cadherin in cancers of the uterine cervix

Background:

Experimental studies have established a causal connection between tumour hypoxia, hypoxia-associated proteome changes and downregulation of E-cadherin, the final common pathway of epithelial-to-mesenchymal transition (EMT). Our study aimed at elucidating the interrelationship of these processes in cancers of the uterine cervix in vivo.

Methods:

Tumour oxygenation was assessed in 48 squamous cell carcinomas (SCC) of the uterine cervix using polarographic needle electrodes. The expression pattern of E-cadherin was investigated by immunohistochemistry and western blotting, and was compared with that of the hypoxia-inducible proteins glucose transporter (GLUT)-1 and carbonic anhydrase (CA) IX in biopsy specimens of the oxygenation measurement tracks.

Results:

The majority of cervical cancers (52%) were E-cadherin positive, with a complete absence of the antigen in only 10% of the tumours. No correlation was found between the level of E-cadherin expression and the oxygenation status (mean pO₂, median pO₂ and hypoxic fractions). In patients showing partial expression of E-cadherin (38%), staining was not preferentially diminished in GLUT-1- or CA IX-positive areas, and loss of E-cadherin occurred independently of tumour cell scattering.

Conclusion:

Our data provide no evidence in favour of a hypoxia-induced EMT as a mechanistic basis of cervical cancer invasiveness.

[Fatigue in cancer patients]

Fatigue is characterized by persistent tiredness or exhaustion and besides the anorexia-nausea-emesis syndrome one of the most frequent adverse events of cancer treatment. There is a large variety of causes and symptoms. Various non-pharmacologic and pharmacologic interventions can help to ameliorate the symptoms and to improve patient's quality of life. For the effective management of fatigue a systematic approach of the multiprofessional team is required. Last but not least, the pharmacist can contribute to support cancer patients suffering from fatigue.

Cancer permeates locally within ontogenetic compartments: clinical evidence and implications for cancer surgery

The pathophysiologic process of local tumor spread is regarded as an isotropic infiltration of microscopic extensions of the malignant lesion irrespective of tissue boundaries. By contrast, the ontogenetic compartment theory states that malignant solid tumors are locally confined, for a relatively long phase during their natural course, to a permissive compartment derived from a common primordium in embryonic development. Tumor permeation is isotropic within the permissive ontogenetic compartment, but it is suppressed at the compartment borders. The validity of the ontogenetic compartment theory has been shown for cancer of the rectum and of the female lower genital tract. It is hypothesized that ontogenetic compartment resection, the translation of the theory into cancer surgery, holds a great potential to improve oncologic treatment results.

Pattern analysis of regional spread and therapeutic lymph node dissection in cervical cancer based on ontogenetic anatomy

OBJECTIVE

In cervical cancer lymph node dissection is applied for regional tumor staging. Up to now, the use of (chemo)radiation in the nodal positive patient has prevented the exact pattern analysis of regional tumor spread and the evaluation of the therapeutic role of lymph node dissection. New surgical techniques founded on ontogenetic instead of functional anatomy for the treatment of cervical cancer dispensing with adjuvant radiotherapy offer the possibility to accurately determine the topography of regional lymph node metastases which is the prerequisite for optimized diagnostic and therapeutic lymph node dissection.

METHODS

Patients with cervical cancer FIGO stages IB-IIB were treated with total mesometrial resection (TMMR) and lymph node dissection after exposing the ontogenetic visceroparietal compartments of the female pelvis. Resected lymph nodes were allocated to regions topographically defined by the embryonic development of the iliac, lumbar and mesenteric lymph systems prior to histopathological assessment.

RESULTS

71 of 305 treated patients had lymph node metastases. Topographic distribution of these metastases at primary surgery and analysis of pelvic failures showed a spatial pattern related to the ontogenesis of the abdominopelvic lymphatic system. Five-year locoregional tumor control probability was 96% (95% CI: 94-98) for the whole group and 87% (95% CI: 77-97) for nodal positive patients.

CONCLUSIONS

The pattern of regional spread in cervical cancer can be comprehended and predicted from ontogenetic lymphatic compartments. In patients with early cervical cancer lymph node dissection based on ontogenetic anatomy achieves high regional tumor control without adjuvant radiation.

GLUT-1 staining of squamous cell carcinomas of the uterine cervix identifies a novel element of invasion

Perturbation of the normal tissue architecture in solid malignant tumors is perceived to be the consequence of actively migrating cancer cells which invade the adjacent normal host tissue. The opposite, invasion of cancer cell clusters by a vascularized stroma, has not been considered. The latter process should, however, be expected to occur since the hypoxic cores of tumor cell aggregates, under the control of HIF-1, are known to secrete cytokines (e.g., bFGF, VEGF) which attract fibroblasts and induce blood vessel formation. In this study, the expression of glucose transporter (GLUT)-1, a major HIF-1 target gene, was examined in 51 squamous cell carcinomas of the uterine cervix by immunohistochemistry to identify the localization of hypoxic tumor cell areas. The relationship of the expression pattern of GLUT-1 with the localization and morphology of the tumor stroma was analyzed. We identified three recurrent histological signs which represent strong evidence in favor of an invasion of solid tumor masses by actively migrating stromal cells. According to our findings, the histological structure of squamous cell carcinomas of the uterine cervix may in part result from the interplay between the inherent tendency of neoplastic epithelial cells to expand in the form of coherent aggregates and the fragmentation of these aggregates by invading, finger- or wedge-like stromal protrusions which carry new blood vessels, driven by gradients of hypoxia-induced pro-angiogenic, pro-migratory and growth-promoting molecules emanating from the hypoxic core.

Pessimism predicts anxiety, depression and quality of life in female cancer patients

OBJECTIVE

The aim of this study was to investigate the predictive value of optimism/pessimism for anxiety, depression and health-related quality of life in female cancer patients, quantified with and without controlling the corresponding base level.

METHODS

A total of 97 women with breast cancer and other gynaecological cancer completed the Life Orientation Test, the Hospital Anxiety and Depression Scale and the Health Survey SF-8 at three time points: during their stay in the hospital (T1), 2 weeks later (T2) and 3 months later (T3).

RESULTS

The degree of self-assessed pessimism at T1 was significantly associated with anxiety, depression and health-related quality of life at T3. After controlling for the base levels of anxiety, depression and health-related quality of life, only the predictive value of pessimism remained significant and substantial.

CONCLUSIONS

Especially, women with a high level of pessimism are at risk for higher levels of anxiety and depression in addition to lowered health-related quality of life in the course of the disease. The results indicate that it seems to be more important not to be pessimistic than to be optimistic.

[Oncological pelvic surgery from a gynecological perspective]

The established gynecological cancer operations are based on functional anatomy derived from the mature organism and on a model of radial progressive tumor permeation. Surgical treatment aims to resect the tumor with a metrically defined radial margin of tissue microscopically free of neoplastic or dysplastic disease. However, despite adequate surgical performance local tumor relapses still occur. In the presence of histopathological risk factors adjuvant radiation is therefore recommended which increases treatment-related morbidity. The Leipzig School of Radical Pelvic Surgery has developed new gynecological cancer operations from a different perspective on anatomy and local tumor spread. Tissue mapping is deduced by following the organism's development from the stage of tissue deposition to maturity (ontogenetic anatomy) to define permissive compartments for cancer permeation. The variants of mesometrial resection (TMMR, PMMR) and vulva field resection (VFR) achieve very high (>95%) local control rates in stages I and II cancer of the lower and middle female genital tract without adjuvant radiation. Laterally extended endopelvic resection (LEER) provides sustained tumor control even in locally advanced and recurrent disease as well as cancer of the distal vagina.

Anxiety and depression in cancer patients compared with the general population

The objective of this study was to compare the prevalence of anxiety and depression in cancer patients with the prevalence found in the general population, using the Hospital Anxiety and Depression Scale (HADS). Participants were 1529 cancer patients treated between 2002 and 2004 in Germany and 2037 persons from the German general population. In the cancer patients, the risk of psychiatric distress was nearly twice that of the general population. While for older age groups (61 years and above) there were only small differences between cancer patients and the general population, the differences in both scales were high for young persons. There were differences between the HADS mean scores of the patients with different tumour localisations, with high values for brain cancer and low scores for prostate cancer. The influence of the tumour stage on anxiety and depression was weak. However, depression scores of patients with a survival time less than 1 year were elevated. The results show that large sample sizes are necessary to evaluate the psychological situation of cancer patients, and that age and gender differences must be taken into account when several samples are compared.