The influence of nicotine abuse and diabetes mellitus on the results of primary irradiation in the treatment of carcinoma of the cervix

Factors Influencing the Severity of Acute Radiation-Induced Skin and Mucosal Toxicity in Head and Neck Cancer

Background and purpose

Radiotherapy is a crucial part of cancer therapy armamentarium, but it is associated with skin and mucosal toxicity in a substantial proportion of patients with head and neck cancer. Its extent, however, depends on several patient-related and treatment-related factors. In-depth knowledge of these is prudent for better patient management.

Aim

The aim of this study is to assess the factors influencing the severity of acute radiation-induced skin and mucosal toxicity in patients with head and neck cancer receiving external beam radiotherapy.

Materials and methods

This longitudinal observational study included all patients receiving curative external beam radiotherapy for head and neck cancer aged 18 years or above from January 2018 to December 2018. Patient-related and treatment-related characteristics including age, gender, type, staging and site of cancer, history of smoking and diabetes, surface area exposed, and concurrent chemotherapy were compared in patients experiencing severe and non-severe acute skin and mucosal toxicity using the Radiation Therapy Oncology Group (RTOG) scoring system.

Results

Higher age (p = 0.002), TNM stage IV (p = 0.023), and concurrent administration of chemotherapy (p = 0.002) were statistically associated with severe acute radiation-induced skin and mucosa toxicity, whereas gender, surface area irradiated, history of smoking, and diabetes did not show such an association.

Conclusion

Older patients with TNM stage IV malignancy receiving concurrent chemotherapy are at a high risk of developing skin and mucosal toxicity that might interfere with the treatment protocol and warrant hospitalization, compromising their quality of life.

Treatment-Related Radiation Toxicity Among Cervical Cancer Patients

Objective

The purpose of this study is to identify incidence of and factors associated with severe late toxicity in women treated with radiation for cervical cancer.

Materials and Methods

All patients with cervical cancer treated with radiation as primary or adjuvant therapy from 2005 to 2017 in a single academic institution were included. Records were reviewed for demographic information, Charlson Comorbidity Index, treatment details, toxicities, and outcomes. Patients with and those without severe late gastrointestinal toxicity (SLGIT), severe late genitourinary toxicity (SLGUT), or any SLGIT or SLGUT, defined as any toxicity (AT), were compared. Overall survival and progression-free survival were also compared.

Results

Of 179 patients identified, 21.2% had AT, 17.3% had SLGIT, and 10% had SLGUT. Estimated AT rate at 3 years was 24.2%. The mean duration of follow-up was 37 months (range, 3–146 months). Most patients (84.1%) received 3-dimensional conformal therapy, and 15.9% received intensity-modulated radiation therapy. Factors associated with AT were lower body mass index (24.9 vs 28.3, P = 0.043), white race (63.2% vs 44%, P = 0.035), and active tobacco smoking during treatment (59.5% vs 40.2%, P = 0.036). Any toxicity was not associated with 3-dimensional versus intensity-modulated radiation therapy planning, low-dose versus high-dose–rate brachytherapy or time to complete radiation treatment. Higher total cumulative radiation dose to clinical target volume was associated with SLGIT. Progression-free survival and overall survival were similar among patients with AT compared to those without toxicity.

Conclusions

In patients with cervical cancer, radiation toxicity is correlated with lower body mass index, white race, and smoking. Despite technologic advances in radiotherapy planning and delivery, toxicity remains high and interventions to reduce the burden of treatment are needed.

The association between diabetes/hyperglycemia and the prognosis of cervical cancer patients: A systematic review and meta-analysis

BACKGROUND

The predictive roles of diabetes in the prognosis of many types of cancer have been well studied, but its role in predicting the prognosis of cervical cancer is still controversial. The aim of the study is to evaluate the association between diabetes/hyperglycemia and the prognosis of cervical cancer.

METHODS

We conducted a systematic review for peer-reviewed studies indexed in PubMed, Embase, Web of Science, and Wanfang published before December 2016. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were pooled in the meta-analysis.

RESULTS

This systematic review identified 13 studies with a total of 11,091 cervical cancer patients, of which 11 studies were included in the meta-analysis. The study indicated that diabetes was related to poorer overall survival (HR = 1.59, 95% CI: 1.35-1.87, P < .001) and poorer recurrence-free survival (HR = 1.98, 95% CI: 1.47-2.66, P < .001) in cervical cancer patients. The meta-analysis of adjusted HRs also indicated that diabetes was independently associated with poor overall survival (HR = 1.69, 95% CI: 1.38-2.05, P < .001) and poor recurrence-free survival (HR = 1.98, 95% CI: 1.47-2.66, P < .001) in cervical cancer patients. Sensitivity analysis and subgroup analyses showed similar results. No significant heterogeneity was observed for the included studies.

CONCLUSIONS

The meta-analysis suggests that diabetes is an important predictive factor for cervical cancer prognosis, and it is linked to poorer survival of cervical cancer patients. Diabetes can serve as a useful index in the prognostic evaluation for patients with cervical cancer.

Metabolic toxicities in patients undergoing treatment for nonhematological malignancy: A cross-sectional study

Objectives:

The objective of this study was to evaluate the prevalence of metabolic toxicities in patients with different nonhematological malignancies admitted in oncology ward of a tertiary cancer care center while on treatment.

Methods:

We did this cross-sectional study over a period of 7 months (January–July 2013) for all adult patients (n = 280) who, while undergoing anti-cancer therapy at our center, got admitted to our oncology inpatient ward with metabolic toxicity. Grading of toxicity was done using National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.0.

Results:

A total of 46 events of metabolic toxicities were noted in 31 patients over this period. The most common of them was hyperglycemia (n = 10). The others were hypokalemia (n = 9), hyponatremia (n = 9), hypernatremia (n = 5), hyperkalemia (n = 5), tumor lysis syndrome (n = 4), hypercalcemia (n = 2), and grade ≤2 hypomagnesemia (n = 2). Majority of the patients were asymptomatic (n = 26). However, death occurred in five patients. Treatment interruptions took place in 19 patients. Age ≤40 years (P = 0.03), Eastern Cooperative Oncology Group performance status ≥2 (P = 0.023), history of addiction (P = 0.02), comorbidities (P = 0.037) were associated with increased risk of having metabolic toxicities on univariate analysis. While on multivariate analysis, only age, performance status, and history of addiction retained their statistical significance. Age ≤40 years (P = 0.02), use of more than one modality of treatment (P = 0.013), and hyperglycemia (P = 0.037) were associated with higher risk of death.

Conclusion:

Metabolic toxicities are common phenomena among cancer patients, especially those with young age, comorbidities, and having history of addictions. In young age, they might even be fatal, especially when they are treated with combined modality of treatment.

Smoking, cessation, and cessation counseling in patients with cancer: A population-based analysis

BACKGROUND

Smoking is known to be carcinogenic and an important factor in the outcome of cancer treatment. However, to the authors' knowledge, smoking habits and smoking cessation counseling in patients with cancer have been poorly studied. The authors sought to analyze smoking habits among Americans diagnosed with cancer in a nationally representative dataset.

METHODS

The cancer supplement of the National Health Interview Survey (NHIS) in 2010 was used to obtain information regarding self-reported smoking behavior in a representative sample of the US population. Cancer history, smoking history, quitting behavior, cessation counseling, cessation approaches, and sociodemographic variables were analyzed.

RESULTS

A total of 27,157 individuals were interviewed for the NHIS in 2010, representing 216,052,891 individuals, 7,058,135 of whom had ever smoked and 13,188,875 of whom had been told that they had cancer. Approximately 51.7% of individuals diagnosed with cancer and who were active smokers reported being counseled to quit smoking by a health professional within the previous 12 months. Cancer survivors were no more likely to quit smoking than individuals in the general population. Those diagnosed with a tobacco-related cancer were found to be no more likely to report quitting smoking than those with other types of cancers. Rates of quitting did not appear to vary based on the type of smoking cessation method used (P = .50).

CONCLUSIONS

Patients with cancer, including those diagnosed with a tobacco-related cancer, do not appear to be more likely to quit smoking than the general population. Only approximately one-half of patients with cancer who smoke are counseled to quit. Smoking cessation in patients with cancer is an important area for intervention and investigation.

Severe gastrointestinal complications in the era of image-guided high-dose-rate intracavitary brachytherapy for cervical cancer

PURPOSE

The purposes of this analysis are to report a modern series of severe gastrointestinal toxic effects after definitive chemoradiotherapy in the treatment of locally advanced cervical cancer at our institution and to review the existing literature on factors that contribute to toxic effects and preventive strategies and management.

METHODS

Our institution's cervical cancer cohort was evaluated for patients with late grade 3 to 4 gastrointestinal toxic effects who were retrospectively reviewed for clinical or dosimetric parameters that could have contributed to late toxic effects. A review of the published literature was performed to identify factors associated with late toxic effects, prophylactic agents, and corrective therapy.

FINDINGS

Five of 85 patients were identified as having late grade 3 to 4 gastrointestinal toxic effects with a median follow-up of 13.3 months. Two of 5 patients developed late grade 3 toxic effects, and 3 of 5 developed late grade 4 toxic effects. Three of the 5 patients reviewed ultimately required permanent colostomies. Cumulative median dose (in equivalent dose in 2-Gy fractions) of clinical target volume to the hottest 90% was 107.2 Gy, rectal dose to the hottest 2 cc (D2cc) was 81.7 Gy, sigmoid D2cc was 61.7 Gy, and bladder D2cc was 79.5 Gy. No patient had evidence of disease recurrence in the pelvis. One patient developed oligometastatic disease in the suprarenal gland and was successfully salvaged with adrenalectomy.

IMPLICATIONS

Despite its risk of toxic effects, intracavitary brachytherapy remains a critical component of the treatment of locally advanced cervical cancer. Even with modern radiotherapy planning and delivery techniques, extra attention is warranted to continue to strive for optimal outcomes.

Smokers With Cervix Cancer Have More Uterine Corpus Invasive Disease and an Increased Risk of Recurrence After Treatment With Chemoradiation

Background

Smoking is a risk factor for cervix cancer and causes hypoxemia, which promotes tumor infiltration and potentially impacts on treatment outcome. We performed a retrospective study to determine if smokers had an increased risk of uterine corpus infiltration, which is associated with more advanced disease and/or treatment failure after primary chemoradiation.

Methods

Results from a prospective database of patients treated with primary chemoradiation for locally advanced cervix cancer with a pretreatment MRI were analyzed. Smoking status was assessed by self-report at presentation.

Results

Smoking status was recorded for 346 of the 362 patients with 98 current smokers (28%), 56 ex-smokers (16%), and 192 nonsmokers (55%). Median age was 58 years with ever-smokers having a younger age at diagnosis than nonsmokers. Histologic type, International Federation of Gynecology and Obstetrics stage, tumor volume, and nodal involvement were similar across groups, as were toxicities of treatment. Ever-smokers were more likely to have corpus uterine invasion than nonsmokers. Ever-smokers had more recurrences than nonsmokers, with nonsmokers having a longer median overall survival (50.1 vs 38.7 months, P = 0.004) and relapse-free survival (46.8 vs 28.5 months, P = 0.003). In multifactor analysis, ever-smoking status was a significant predictor of developing corpus invasive disease and of inferior relapse-free and overall survival after treatment.

Conclusions

Smokers have a greater risk for developing corpus invasive cervix cancer. Although nonsmokers have an older age at diagnosis, they live longer and have fewer recurrences after a diagnosis of locally advanced carcinoma of the cervix.

Three distinct urethral fistulae 35 years after pelvic radiation

Introduction:

While the development of fistulae is a well-known complication of radiotherapy, such fistulae can often be challenging to manage.

Case Presentation:

We describe the case of a 37 year old male who developed in succession a urethrocutaneous fistula to the thigh, a rectourethral fistula and a peritoneo-urethral fistula 35 years after radiotherapy for pediatric pelvic rhabdomyosarcoma. These complications were managed successfully after multiple surgical procedures.

Discussion:

We subsequently discuss the different approaches currently employed for the management of radiation induced urinary fistulas and describe the rationale behind our approach towards their surgical management.

Cerebral radiation necrosis: a review of the pathobiology, diagnosis and management considerations

Radiation therapy forms one of the building blocks of the multi-disciplinary management of patients with brain tumors. Improved survival following radiation therapy may come with a cost, including the potential complication of radiation necrosis. Radiation necrosis impacts the quality of life in cancer survivors, and it is essential to detect and effectively treat this entity as early as possible. Significant progress in neuro-radiology and molecular pathology facilitate more straightforward diagnosis and characterization of cerebral radiation necrosis. Several therapeutic interventions, both medical and surgical, may halt the progression of radiation necrosis and diminish or abrogate its clinical manifestations, but there are still no definitive guidelines to follow explicitly that guide treatment of radiation necrosis. We discuss the pathobiology, clinical features, diagnosis, available treatment modalities, and outcomes in the management of patients with intracranial radiation necrosis that follows radiation used to treat brain tumors.

A prospective observational study with dose volume parameters predicting rectosigmoidoscopic findings and late rectosigmoid bleeding in patients with uterine cervical cancer treated by definitive radiotherapy

Purpose

We assessed the value of dose-volumetric parameters predicting rectosigmoid mucosal changes (RMC) and late rectosigmoid complications (LRC).

Methods

Between January 2004 and February 2006, 77 patients with stage IB-IIIB cervical cancer underwent external beam radiotherapy and computed tomography (CT)-based intracavitary irradiation. Total dose to the rectal point and several dose-volumetric parameters for rectosigmoid colon (D_20cc, D_15cc, D_10cc, D_5cc, D_2cc, D_1cc, and D_{0.1cc ,} defined as the minimal doses received by the highest irradiated volumes of 20, 15, 10, 5, 2, 1, and 0.1 cc, respectively), were calculated using the equivalent dose in 2 Gy fractions (α/β = 3, Gy₃). The RMC and LRC were graded by rectosigmoidoscopy and Radiation Therapy Oncology Group criteria every 6 months, respectively.

Results

Of 77 patients, 27 (35.1%) patients developed RMC ≥ score 3 and 22 (28.6 %) patients developed LRC ≥ grade 2. There was a positive correlation between RMC score and LRC grade (r = 0.728, p < 0.001). In multivariate analyses, D_5cc, among the dose-volumetric parameters, was significant parameter for the risks of RMC ≥ score 3 and LRC ≥ grade 2 (p < 0.05).

Conclusions

D_5cc may be a more reliable estimate than other dose-volumetric parameters for predicting the risk of RMC ≥ score 3 and LRC ≥ grade 2 in CT-based brachytherapy.

Outcome in early cervical cancer following pre-operative low dose rate brachytherapy: a ten-year follow up of 257 patients treated at a single institution

OBJECTIVE

To report the outcome of preoperative low dose rate uterovaginal brachytherapy (LDR-UVBT) followed by radical surgery in the treatment of early cervical carcinoma.

METHODS

257 patients treated at Institut Curie from 1985 to 2008 for cervical carcinoma less than 4cm (FIGO stages Ib1, IIA and IIB) were studied. Patients received preoperative LDR-UVBT followed by hysterectomy Piver II type, with pelvic lymph nodes dissection (PLND). Predictive factors for pathological response to brachytherapy were analyzed with logistic regression, as well as survival rates.

RESULTS

44% of patients had residual tumor, 4.3% of patients had parametrial invasion and 17.9% of patients had lymph node involvement. Predictive factors for an incomplete pathological response were: initial clinical tumor size 20mm (OR 2.1), pN1 (OR 2.77), glandular carcinoma (OR 2.51) and lymphovascular invasion (OR 4.35). 7.4% and 2.7% of patients had respectively grade 2 and grade 3 post-therapeutic late complications. Median follow up was 122 months [1-282]. Five-year actuarial overall survival and disease free survival were respectively 83% CI [78.3-87.5] and 80.9% CI [76.3-85.7]. In multivariate analysis, factors affecting significantly the overall survival and disease free survival rates were: lymph node involvement (RR 4.53 and 8.96 respectively), parametrial involvement (RR 5.69 and 5.62 respectively), smoking (RR 3.07 and 2.63 respectively).

CONCLUSIONS

Preoperative LDR-UVBT results in good disease control with a low complications rate. Its accuracy could be improved by a better selection of patients. Lymph nodes and parametrial evaluation remains a challenging issue that should be achieved with imaging and minimal invasive surgery.

Smoking behaviors among cancer survivors: an observational clinical study

PURPOSE

Smoking is a well-recognized risk factor for several cancers including cancers of the lung, bladder, and head and neck. Studies have shown that smoking can adversely affect the outcomes of different modalities of cancer treatment. This study examines smoking behaviors among cancer survivors to collect information necessary to create successful smoking cessation interventions.

METHODS

For this observational clinical study, questionnaires were sent to 1,000 randomly selected patients diagnosed with cancer between 2003 and 2007 in one cancer center. Data were statistically analyzed to determine the likelihood of a patient quitting smoking after being diagnosed with cancer.

RESULTS

We received 187 responses from the 1,000 surveys sent (18.7%). Of these, 166 were usable for analysis. The mean age of respondents was 64 (± 13) years. Men were more likely than women to be past smokers (55% of men and 32% of women respectively, P = .003). Fifty-two percent of respondents reported having a history of smoking. However, only 20% of patients reported having been active smokers at the time they were diagnosed with cancer. Furthermore, only 44% of these reported having quit smoking after their diagnosis with cancer. Only 62% of all respondents reported that they had been informed of the dangers of smoking by their health care provider during cancer treatment.

CONCLUSION

In our study sample, less than one half (44%) of smoking cancer patients quit smoking after their cancer diagnosis, and only 62% of smoking cancer patients received smoking cessation counseling from their physicians. Intervention programs are needed to help cancer survivors to quit smoking. Prospective clinical trials may help identify the ideal intervention for smoking cessation.

Tobacco smoking and long-lasting symptoms from the bowel and the anal-sphincter region after radiotherapy for prostate cancer

BACKGROUND AND PURPOSE

Tobacco smoking can cause vascular injury, tissue hypoxia and fibrosis as can ionizing radiation. However, we do not know if tobacco smoking increases the risk of long-term side effects after radiotherapy for prostate cancer.

METHODS

We identified 985 men treated with radiotherapy for prostate cancer between 1993 and 2006. In 2008, long-lasting symptoms appearing after radiotherapy for prostate cancer were assessed through a study-specific questionnaire as were smoking habits and demographic factors of all these men. In the questionnaire the prostate-cancer survivors were asked to report symptom occurrence the previous six months.

RESULTS

We obtained information on tobacco smoking from 836 of the 985 prostate-cancer survivors with a median time to follow-up of six years (range 2-14 years). The prevalence ratio of defecation urgency among current smokers compared to never smokers was 1.6 (95% CI 1.2-2.2). Corresponding prevalence ratio for diarrhea was 2.8 (95% CI 1.2-6.5), the sensation of bowel not completely emptied after defecation 2.1 (95% CI 1.3-3.3) and for sudden emptying of all stools into clothing without forewarning 4.7 (95% CI 2.3-9.7).

CONCLUSION

Tobacco smoking among prostate-cancer survivors treated with radiotherapy increases the risk of certain long-lasting symptoms from the bowel and anal-sphincter region.

Radiotherapy versus radiochemotherapy with cisplatin in treatment of cervical cancer

AIM

To compare effects of concomitant radiochemotherapy (RCTh) and radiotherapy (RTh) alone in patients with cervical carcinoma and with 36-months follow-up analysis.

MATERIAL AND METHODS

106 stage IIA-IVA cervical carcinoma women were divided in two groups. RCTh group was treated with teleradiotherapy (50.4 Gy/T), intracavitary brachytherapy (46 Gy), and iv cisplatin (40 mg/m(2)). RTh group was treated with pelvic teletherapy (52-54 Gy/T) and intracavitary brachytherapy (50-55 Gy).

RESULTS

In RCTh group absorbed radiation dose was significantly lower (50.4 vs. 52.7 Gy) and the duration of treatment was significantly shorter (45.1 days vs. 47.8 days). There were no statistical differences in both groups in survival (59% in RCTh group vs. 56% in RTh group), response to treatment (86% vs. 90%), local recurrence (42% vs. 49%) metastasis occurrence (21% vs. 17%), anemia (40% vs. 26%), early postradiation reactions in intestines (77% vs. 65%) and bladder (71% vs. 61%) as well as in incidence of rectovaginal (10% vs. 4%) and vesicovaginal formation of fistulas (6% vs. 4%), respectively. There were significant differences between two groups in: nausea (77% vs. 6%), vomiting (65% vs. 3.7%), leucopenia (69% vs. 26%) and thrombocytopenia (35% vs. 9%), and late postradiation bladder effects (94% vs. 74%). RCTh patients with anemia had lower 36-months survival rates (42% vs. 71%), more frequent local recurrences (77% vs. 31%) and metastasis-free survival rates (61% vs. 90%) than RCTh patients without anemia.

CONCLUSIONS

RCTh gives better treatment results in patients without than in patients with anemia and higher overall survival rates than RTh in patients without anemia. The only clinical prognostic factor for advance cervical carcinoma is the clinical stage of the disease.

Long-term all-cause mortality in cancer patients with preexisting diabetes mellitus: a systematic review and meta-analysis

CONTEXT

Diabetes mellitus appears to be a risk factor for some cancers, but the effect of preexisting diabetes on all-cause mortality in newly diagnosed cancer patients is less clear.

OBJECTIVE

To perform a systematic review and meta-analysis comparing overall survival in cancer patients with and without preexisting diabetes.

DATA SOURCES

We searched MEDLINE and EMBASE through May 15, 2008, including references of qualifying articles.

STUDY SELECTION

English-language, original investigations in humans with at least 3 months of follow-up were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Of 7858 titles identified in our original search, 48 articles met our criteria.

DATA EXTRACTION

One reviewer performed a full abstraction and other reviewers verified accuracy. We contacted authors and obtained additional information for 3 articles with insufficient reported data.

RESULTS

Studies reporting cumulative survival rates were summarized qualitatively. Studies reporting Cox proportional hazard ratios (HRs) or Poisson relative risks were combined in a meta-analysis. A random-effects model meta-analysis of 23 articles showed that diabetes was associated with an increased mortality HR of 1.41 (95% confidence interval [CI], 1.28-1.55) compared with normoglycemic individuals across all cancer types. Subgroup analyses by type of cancer showed increased risk for cancers of the endometrium (HR, 1.76; 95% CI, 1.34-2.31), breast (HR, 1.61; 95% CI, 1.46-1.78), and colorectum (HR, 1.32; 95% CI, 1.24-1.41).

CONCLUSIONS

Patients diagnosed with cancer who have preexisting diabetes are at increased risk for long-term, all-cause mortality compared with those without diabetes.

Radiation Enterocolitis Requiring Surgery in Patients With Gynecological Malignancies

PURPOSE

To identify the characteristics, risk factors, and clinical outcomes of radiation enterocolitis requiring surgery in patients with gynecologic malignancies.

METHODS AND MATERIALS

The records of 1,349 patients treated with pelvic radiotherapy were retrospectively reviewed. The majority of the patients (88%) were treated with 50 Gy or 50.4 Gy pelvic irradiation in conventional fractionations with anteroposterior fields.

RESULTS

Forty-eight patients (3.6%) developed radiation enterocolitis requiring surgery. Terminal ileum was the most frequent site (50%) and most of the lesions had stenosis or perforation. On univariate analysis, previous abdominopelvic surgery, diabetes mellitus (DM), smoking and primary site had an impact on the complications, and on multivariate analysis, abdominopelvic surgery, DM, and smoking were independent predictors of the complications requiring surgery. After the surgical intervention, the frequency of Grade 2 or more bleeding was significantly lower in patients treated with intestinal resection in addition to decompression than those treated with intestinal decompression alone.

CONCLUSIONS

Severe radiation enterocolitis requiring surgery usually occurred at the terminal ileum and was strongly correlated with previous abdominopelvic surgery, DM, and smoking. Concerning the management, liberal resection of the affected bowel appears to be the preferable therapy.

Vesicovaginal fistula formation in patients with Stage IVA cervical carcinoma

OBJECTIVES

To evaluate the rate of vesicovaginal fistula formation and mortality in women with Stage IVA cervical carcinoma.

METHODS

Data were abstracted from the clinical records of women diagnosed with Stage IVA cervical cancer at the time of examination under anesthesia, cystoscopy, and proctoscopy (EUA/C/P) at a single institution from 1994 to 2004. Demographic and treatment characteristics were compared using either Fisher's exact test or Student's t-test, as appropriate. Survival was calculated using the Kaplan-Meier method.

RESULTS

Twenty-three patients were diagnosed with Stage IVA cervical cancer. All were diagnosed with extension of disease into the bladder; one patient had rectal involvement as well. Concurrent chemotherapy and radiation was used in 60.8%, while 30.4% received radiation alone and 8.7% elected no treatment. Fifty-six percent of the patients were smokers. Eleven patients (47.8%) developed a fistula at a median time of 2.9 months from cancer diagnosis. Fistula formation was significantly increased among smokers as compared to non-smokers (73 vs 27%; p=0.03). Two patients (8.7%) are alive without evidence of disease at a median follow-up of 19 months. The disease-specific survival is 23.1 months. Patients who developed a vesicovaginal fistula had a median survival of 11.2 months after fistula formation.

CONCLUSIONS

High rates of vesicovaginal fistula formation can be expected when treating women with extension of cervical cancer into the bladder, particularly among women who smoke. The routine use of EUA/C/P at the time of initial diagnosis aids in counseling women about the likelihood of this complication. Novel strategies for managing vesicovaginal fistulae after chemoradiation are needed.

Association between cigarette smoking and prognosis in locally advanced cervical carcinoma treated with chemoradiation: a Gynecologic Oncology Group study

OBJECTIVE

To determine if smoking, a known risk factor for a number of cancers including cervical cancer, is associated with poor prognosis in patients with locally advanced cervical carcinoma treated with chemoradiation.

METHODS

Patients with primary, previously untreated, histologically confirmed stage II-B, III-B or IV-A cervical carcinoma participated in a Gynecologic Oncology Group (GOG) phase III study (GOG 165) and were randomly allocated to receive radiation plus either cisplatin or 5-fluorouracil. Smoking behavior was ascertained using an administered questionnaire and by quantifying urine cotinine concentration. Disease progression was defined as a >or=50% increase in the cross product of the existing tumor compared with previous assessments. Patients were followed until death.

RESULTS

Of 328 enrolled patients, 12 were ineligible, one was inevaluable for reported smoking status and 40 others were inevaluable for cotinine-derived smoking status. Among evaluable patients, 133 (42%) were reported smokers and 111 (40%) were cotinine-derived smokers. The kappa for agreement between the groups was 0.872 (P<0.01). Compared with non-smokers, median survival was 15 months shorter for reported smokers and 20 months shorter for cotinine-derived smokers (P<0.01). After adjusting for covariates, a significant increase in the risk of death (but not disease progression) was observed for reported smokers (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: 1.01-2.27; P=0.04) and cotinine-derived smokers (HR: 1.57; 95% CI: 1.03-2.38; P=0.04).

CONCLUSIONS

Smoking predicts worse overall survival in women with locally advanced cervical carcinoma treated with chemoradiation.

Successes and failures of the teachable moment

BACKGROUND

Successful cancer treatment can be significantly compromised by continued tobacco use. Because motivation and interest in smoking cessation increase after cancer diagnosis, a window of opportunity exists during which healthcare providers can intervene and assist in the quitting process.

METHODS

The authors conducted a comprehensive literature review to discuss 1) the benefits of smoking cessation in cancer patients, 2) current knowledge regarding smoking cessation interventions targeted to cancer patients, and 3) treatment models and state-of the-art guidelines for intervention with cancer patients who smoke. The authors present clinical cases to illustrate the challenging nature of smoking cessation treatment for cancer patients.

RESULTS

Continued smoking after cancer diagnosis has substantial adverse effects on treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life. Although some encouraging results have been demonstrated with smoking cessation interventions targeted to cancer patients, few empirical studies of such interventions have been conducted. A range of intervention components and state-of-the-art cessation guidelines are available that can be readily applied to cancer patients. Case illustrations highlight the crucial role of healthcare providers in promoting smoking cessation, the harmful impact of nicotine addiction manifested in delayed and failed reconstructive procedures, and unique problems encountered in treating patients who have particular difficulty quitting.

CONCLUSIONS

Despite the importance of stopping smoking for all cancer patients, the diagnosis of cancer is underused as a teachable moment for smoking cessation. More research is needed to empirically test cessation interventions for cancer patients, and attention must be given to complex and unique issues when tailoring cessation treatment to these individuals.

Smoking, the missing drug interaction in clinical trials: ignoring the obvious

Tobacco use is universally recognized as the foremost preventable cause of cancer in the United States and globally and is responsible for 30% of all cancer-related deaths in the United States. Tobacco use, including exposure to secondhand smoke has been implicated as a causal or contributory agent in an ever-expanding list of cancers, including lung, oral cavity and pharynx, pancreas, liver, kidney, ureter, urinary bladder, uterine cervix, and myeloid leukemia. In addition to and independent of the etiologic effects of tobacco carcinogens in numerous cancers, there is a growing literature on the direct and indirect effects of smoking on treatment efficacy (short-term and long-term outcomes), toxicity and morbidity, quality of life (QOL), recurrence, second primary tumors (SPT), and survival time as summarized below. Oncology health professionals have called for increased advocacy for tobacco control. Despite the critical relevance of smoking to cancer outcomes, most oncology clinical trials do not collect data on smoking history and status unless the malignancy is widely acknowledged as smoking related (e.g., lung or head and neck cancer). Usually, these data are collected only at trial registration. Changes in smoking status during treatment or follow-up are monitored in very few trials and are infrequently reported in sample descriptions or included in analysis plans as a potential moderator of outcomes. Based on mounting evidence that tobacco use affects cancer treatment outcomes and survival, we recommend that smoking history and status be systematically collected as core data in all oncology clinical trials: at diagnosis, at trial registration, and throughout treatment and follow-up to long-term survival or death. We feel that the inclusion and analysis of such data in clinical trials will add important information to the interpretation of outcomes and the development of scientific knowledge in this area. Smoking status has been called another "vital sign" because of its relevance to a patient's immediate medical condition. We explain the critical value of knowing the smoking status of every patient with cancer at every visit by providing a brief overview of the following research findings: (a) the effects of tobacco use on cancer treatment and outcome; (b) recent findings on the role of nicotine in malignant processes; (c) some unexpected results concerning tobacco status, treatment, and disease outcome; and (d) identifying key questions that remain to be addressed. We provide a suggested set of items for inclusion in clinical trial data sets that also are useful in clinical practice.

Human papillomavirus type and tobacco use as predictors of survival in early stage cervical carcinoma

OBJECTIVE

Molecular and environmental co-factors are known risk factors for cervical cancer. The aim of this study was to define the prognostic significance of HPV 18 and its phylogenetically related viruses and smoking on survival in patients with early stage cervical cancer.

METHODS

HPV typing was performed on stage IB-IIB cervical tumors. Subjects positive for HPV 18 or 45 were compared to the remainder of the cohort and to women with tumors containing HPV 16, 31, or 52. Tobacco use was ascertained by patient questionnaire.

RESULTS

Tumors of 255 women were evaluated. The presence of HPV 18 or 45 was associated with decreased survival. In a multivariable Cox proportional hazards analysis comparing patients with HPV 18 or 45 containing tumors to the rest of the cohort, the hazard ratio for death from cervical cancer was 2.08 (95% CI, 1.07-4.04). The hazard ratio for death from cervical cancer was 2.41 (95% CI, 1.17-4.96) when the HPV 18 and 45 group was compared to women with HPV 16 or its related viruses, 31 and 52. Smoking was associated with a decreased survival for women with HPV 18 or 45, even after adjusting for other known prognostic factors (P = 0.031).

CONCLUSIONS

In addition to pathologic indicators, molecular and environmental co-factors are important determinates of outcome in early stage cervical cancer. The presence of HPV 18 or 45 is associated with a decreased survival. The adverse effect of HPV 18 and 45 on survival is compounded by tobacco use.

Reduction of carboxyhaemoglobin levels in the venous blood of cigarette smokers following the administration of carbogen

Cigarette smokers have high carboxyhaemoglobin levels which can promote tumour radioresistance. Inhalation of carbogen gas shortens the half-life of carboxyhaemoglobin, increasing tumour radiosensitivity in animal models. Breathing 2.5% carbogen for 30 min results in a greater reduction in venous blood COHb levels than breathing 5% carbogen for 7 min.

The effect of smoking on outcome following external radiation for localized prostate cancer

PURPOSE

We investigated whether a smoking habit affects biochemical and survival outcome after curative external beam radiation therapy (EBRT) for localized prostate cancer.

MATERIALS AND METHODS

The study population comprised 601 men treated with curative EBRT between 1994 and 1997 who had a smoking history available. Pretreatment prognostic factors were examined and high risk was defined as any of prostate specific antigen greater than 20, Gleason greater than 7 or stages T3-4. Biochemical outcome (bNED) was assessed by American Society for Therapeutic Radiology and Oncology, and Houston criteria. Biochemical, clinical, prostate cancer and nonprostate cancer death rates were examined by univariate and multivariate statistics.

RESULTS

Of the men 15% were current smokers, 55% were former smokers and 31% were nonsmokers. Current smokers were younger than former smokers or nonsmokers by a mean of 2.5 years (p <0.001). Current smokers had higher risk cancers than former smokers or nonsmokers (high risk 60%, 40% and 43%, respectively, p = 0.017). Five-year bNED rates for smokers were significantly worse than for former smokers or nonsmokers (55%, 69% and 73%, p = 0.01 and 0.0019, respectively). Median followup was 59 months. Multivariate analysis confirmed smoking as an independent adverse factor for bNED (p = 0.013) even when controlling for prostate specific antigen (p <0.0001), Gleason score (p <0.0001), stage (not significant), radiation dose (not significant) and neoadjuvant hormone use (p = 0.0014). Local and metastatic failure did not differ among the groups. Prostate cancer specific mortality was nonsignificantly worse in smokers but overall mortality was much greater.

CONCLUSIONS

Smokers present with higher risk prostate cancers. Outcomes following EBRT are poorer, even when accounting for differences in known pretreatment factors.

The effect of smoking on tumour oxygenation and treatment outcome in cervical cancer

AIM

Tumour hypoxia is associated with an increased risk of cervical tumour recurrence and death. Because smoking is a modifiable behaviour, it is important to establish the importance of smoking as a prognostic factor. We hypothesized that there is an association between smoking and tumour hypoxia, and that smoking adversely affects radiation response and survival.

METHODS

A smoking history was obtained from 100 of 115 patients with cervical cancer entered into a prospective study of tumour oxygenation. Eighty-seven of these had clinically evident disease and radiation therapy alone was the planned treatment. Patients who smoked within 2 weeks of commencing radiation therapy were considered smokers, and the amount that they smoked was recorded in packs per day. Patients who had never smoked or quit at least 2 weeks prior to radiation therapy were considered non-smokers. Tumour oxygenation was determined using the Eppendorf polarographic oxygen electrode and tumour oxygenation is represented by the hypoxic proportion HP5 (% of pO2 measurements <5 mmHg).

RESULTS

There was no significant association between smoking and tumour hypoxia (P=0.3), haemoglobin (P=0.6) nor tumour size (P=0.1). Progression-free survival at 3 years was 56% for non-smokers and 44% for smokers (P=0.23). In both univariate and multivariate analysis, neither smoking status nor amount smoked were significant predictors of progression-free survival or local control.

CONCLUSIONS

There was no significant association between smoking and tumour hypoxia, treatment response or survival in this study of patients with cervix cancer.

Correlation of smoking history and other patient characteristics with major complications of pelvic radiation therapy for cervical cancer

PURPOSE

The purpose of this study was to identify patient-related factors that influence the risk of serious late complications of pelvic radiation therapy.

PATIENTS AND METHODS

The records of 3,489 patients treated with radiation therapy for International Federation of Gynecology and Obstetrics stage I or II carcinoma of the cervix were reviewed for information about patient characteristics, treatment details, and outcomes. Any complication occurring or persisting more than 3 months after treatment that required hospitalization, transfusion, or an operation or caused severe symptoms or the patient's death was considered a major late complication. Complication rates were calculated actuarially. The median duration of follow-up was 85 months, and 99% of patients were followed for at least 3 years or until they died.

RESULTS

Heavy smoking was the strongest independent predictor of overall complications (multivariate hazard ratio, 2.30; 95% confidence interval [CI], 1.84 to 2.87). The most striking influence of smoking was on the incidence of small bowel complications (hazard ratio for smokers of one or more packs per day, 3.25; 95% CI, 2.21 to 4.78). Hispanics had a significantly lower rate of small bowel complications than whites, and blacks had higher rates of bladder and rectal complications than whites. Thin women had an increased risk of gastrointestinal complications, and obese women were more likely to have serious bladder complications.

CONCLUSION

Complications of pelvic radiation therapy are strongly correlated with smoking, race, and other patient characteristics. These factors should be considered before the results of clinical studies are generalized to different cultural and racial groups.

Gynecologic brachytherapy I: Proper incorporation of brachytherapy into the current multimodality management of carcinoma of the cervix

The incidence of carcinoma of the cervix has continuously declined over the past decades because of effective screening. The International Federation of Gynecology and Obstetrics (FIGO) clinical staging, though universally used, is considered inadequate either to determine the type of treatment or to predict treatment outcome. Over the last 10 years, treatment of cervical cancer has become increasingly sophisticated with advances in external beam and brachytherapy in the radiotherapeutic management of this carcinoma. In particular, brachytherapy plays a major role in enhancing both local control and survival. Experience to date suggests that either high-dose-rate (HDR) or low-dose-rate (LDR) brachytherapy, when properly applied, can be effective and give similar rates of local control with minimal complications. This article analyzes the current literature regarding treatment techniques of radiotherapy with special emphasis on brachytherapy integration to optimize radiotherapy treatment outcome.

Effects of tobacco smoke on tumor growth and radiation response of dunning R3327 prostate adenocarcinoma in rats

BACKGROUND

The influence of tobacco smoke has been investigated on the growth rate and histology of prostate cancer, both in untreated tumors and in those subjected to fractionated irradiation.

METHODS

Twenty-five rats were implanted bilaterally with Dunning R3327 tumor fragments at 10 weeks of age. Approximately 3 months later, they were randomly allocated to two groups, one of which was exposed to tobacco smoke for an hour each day, 5 days a week. Three weeks later the groups were further subdivided into two groups which acted as controls or were subjected to 5 daily doses of 6 Gy. The tumors were measured weekly to construct growth curves. At a fixed time, 9 weeks or 20 weeks later, the animals were sacrificed and the tumors were removed for histological evaluation of the tissue composition. Sections from each tumor were scored in a morphometric analysis of the fraction of the area of tumor that was occupied by (epithelial) tumor cells, by stroma, or by luminal spaces. In addition, the density of mast cells was assessed in adjacent sections stained with toluidine blue.

RESULTS

Smoking caused only minor changes in the growth rates of both the control and the irradiated tumors. At the cellular level, smoking caused a small but significant increase in the fraction of tumor cells relative to controls. Irradiation also caused a small but significant decrease in tumor cell fraction compared to controls, even after 20 weeks of regrowth. This difference was reduced in the smoking and irradiation group. The main difference observed was in the mast cell numbers. Smoking caused a 4-fold increase in mast-cell density. Irradiation caused an even greater increase (25-fold). The combination of smoking and irradiation resulted in an intermediate increase (10-fold).

CONCLUSIONS

Long-term smoke exposure can slightly alter the growth rate and morphology of Dunning R3327 rat prostatic adenocarcinoma, but our study does not show a negative effect on the outcome of radiation treatment of this tumor model. We have also demonstrated a highly elevated number of mast cells in the irradiated group, and have shown that smoke exposure significantly depressed the radiation-induced enhancement of the number of mast cells.

Response of hepatoma 9618a and normal liver to host carbogen and carbon monoxide breathing

The effects of hyperoxia (induced by host carbogen [95% oxygen/5% carbon dioxide breathing] and hypoxia (induced by host carbon monoxide [CO at 660 ppm] breathing) were compared by using noninvasive magnetic resonance (MR) methods to gain simultaneous information on blood flow/oxygenation and the bioenergetic status of rat Morris H9618a hepatomas. Both carbogen and CO breathing induced a 1.5- to 2-fold increase in signal intensity in blood oxygenation level dependent (BOLD) MR images. This was due to a decrease in deoxyhemoglobin (deoxyHb), which acts as an endogenous contrast agent, caused either by formation of oxyhemoglobin in the case of carbogen breathing, or carboxyhemoglobin with CO breathing. The results were confirmed by observation of similar changes in deoxyHb in arterial blood samples examined ex vivo after carbogen or CO breathing. There was no change in nucleoside triphosphates (NTP)/P(i) in either tumor or liver after CO breathing, whereas NTP/P(i) increased twofold in the hepatoma (but not in the liver) after carbogen breathing. No changes in tumor intracellular pH were seen after either treatment, whereas extracellular pH became more alkaline after CO breathing and more acid after carbogen breathing, respectively. This tumor type and the liver are unaffected by CO breathing at 660 ppm, which implies an adequate oxygen supply.

Prognostic factors of primary adenocarcinoma of the uterine cervix

OBJECTIVE

To determine which clinicopathological factors influence the prognosis of cervical adenocarcinoma.

METHODS

Three hundred and two cases of primary adenocarcinoma of the uterine cervix, treated between 1977 and 1994, were studied retrospectively. Clinical data and pathological findings with respect to primary therapy were reviewed and evaluated.

RESULTS

The 5-year survival rates for stages I, II, and III/IV were 75.9, 62.9, and 25.1%, respectively. International Federation of Gynecology and Obstetrics stage (P < 0. 0001), cell type (P = 0.0176), tumor grade (P = 0.023), lymph node status (P = 0.018), and bulky tumor (P = 0.007) were found to be independent factors using the stepwise Cox proportional hazards model. Old age (P = 0.0581), presence of hypertension (P = 0.46), diabetes mellitus (P = 0.18), obesity (P = 0.15), and oral contraceptive use (P = 0.42) were not found to adversely influence survival rates for cervical adenocarcinoma after adjusting for other covariates. Adenosquamous adenocarcinoma had a better prognosis than endocervical columnar cell adenocarcinoma in stages I and II (P = 0. 0235). Also, in cervical adenocarcinoma's early stages, multivariate modeling revealed that chances of survival were significantly better for patients treated by radical surgery than for patients treated by radiation therapy (P < 0.001).

CONCLUSIONS

Survival rates for cervical adenocarcinoma were significantly influenced by stage, histologic subtype, tumor grade, the presence of a positive lymph node, and tumor size. Although a randomized prospective study is needed, our data imply that radical surgery may be considered a better primary modality of treatment than radiation therapy for the early stages of cervical adenocarcinoma. Further, the presence of hypertension, diabetes mellitus, or obesity may not adversely influence survival rates.

Prognostic factors for acute and late skin reactions in radiotherapy patients

PURPOSE

Patients treated with identical radiotherapy schedules show a substantial variation in the degree of acute and late normal tissue reactions. To identify any possible contributing factors to this phenomenon, we have analyzed the treatments of 402 breast cancer patients.

METHODS AND MATERIALS

The patients received adjuvant postoperative radiotherapy between 1972 and 1985 and have been followed up since then. Multivariate analyses were performed with peak reflectance erythema and peak acute reaction score as endpoints for the acute reactions, and with progression rate of telangiectasia as well as telangiectasia score as endpoints for the late reactions. Twenty patient- and treatment-related factors were tested such as age, menopausal status, hemoglobin level, serum calcium, smoking habits, hypothyroidism, diabetes, hypertension, blood pressure, cardiovascular and autoimmune disease, the influence of hormone therapy and chemotherapy, pretreatment reflectance value, acute skin reactions, radiation quality, individual dose, bilateral fields, and the total effect (TE) for the dose schedule applied.

RESULTS

The TE was a strong prognostic factor for all endpoints. In addition to TE, blood pressure was prognostic for the peak erythema measured by reflectance spectrophotometry, and the pretreatment reflectance value was prognostic for the acute score. The only independent prognostic factors found for the progression of skin telangiectasia and telangiectasia score except for TE were the individual dose and the acute skin reactions.

CONCLUSIONS

These factors explained at most about 30% of the variance describing the total patient-to-patient variability for each endpoint. The remaining variability is still unexplained but may be related to individual differences in cellular radiosensitivity, partly determined by genetic variations and partly by unknown epigenetic factors.

Chronic lymphocytic leukemia and the central nervous system: a clinical and pathological study

Chronic lymphocytic leukemia is the most common human leukemia but infrequently causes neurologic symptoms. We have reviewed all previously reported cases of chronic lymphocytic leukemia in the CNS along with three new cases; one patient was diagnosed antemortem and treated with immediate improvement and 4-year survival. In addition, we reviewed all autopsy cases since 1972 and available lumbar puncture data on patients with chronic lymphocytic leukemia admitted to the Massachusetts General Hospital. Invasion of the CNS by chronic lymphocytic leukemia often leads to confusional state, meningitis with cranial nerve abnormalities, optic neuropathy, or cerebellar dysfunction. Lumbar puncture shows a lymphocytosis consisting of monoclonal B cells, but CSF cytology studies are of limited value in establishing the diagnosis. Long-term survival may be related to the stage of chronic lymphocytic leukemia at the time of CNS disease and may be associated with intrathecal chemotherapy. A mild, asymptomatic infiltration of the brain, frequently noted in late-stage chronic lymphocytic leukemia in autopsy series, may explain the CSF lymphocytosis in some patients with late-stage chronic lymphocytic leukemia.

Age, substance abuse, and survival of patients with cervical carcinoma

BACKGROUND

The poor survival of young patients with cervical cancer in a low income, disadvantaged community stimulated an investigation of pathologic and behavioral risk factors.

METHODS

The records of 1173 patients with cervical cancer diagnosed in 1967-1988 were evaluated with respect to age, stage, histology, and presenting symptoms. Histopathologic risk factors were evaluated in 196 patients with Stage IB disease treated by initial hysterectomy. Substance abuse behaviors were evaluated for 332 symptomatic patients with Stages IB-III disease diagnosed from 1976 to 1988.

RESULTS

There were no significant age-related differences in survival for patients without squamous cell carcinoma or those with Stage IA and asymptomatic Stage IB squamous cell carcinoma. Women age 70 years and older had a poorer survival rate than did younger women with Stages IB-III disease. Symptomatic patients with squamous cell carcinoma younger than age 50 years had a poorer survival than did patients age 50-69 years with Stages IB/IIA, IIB, and III disease. For patients with symptomatic Stage IB tumors, poor prognostic histopathologic factors were distributed equally among women younger than age 50 and those aged 50-69 years. Substance abuse was significantly more prevalent among younger patients, and patients who smoked or abused alcohol or drugs had significantly poorer survival than did nonsubstance abusers. However, in a multivariate analysis of age, stage, and substance abuse, young age remained a significantly poor prognostic factor.

CONCLUSIONS

Substance abuse may contribute to poor outcome of young patients with symptomatic squamous cell carcinoma but does not explain adequately their poor survival.

Effect of carbon monoxide breathing on hypoxia and radiation response in the SCCVII tumor in vivo

PURPOSE

To study the influence of a clinically relevant concentration of carbon monoxide (CO) on tumor oxygenation and response to irradiation.

METHODS AND MATERIALS

The murine tumor model was the SCCVII squamous cell carcinoma transplanted to the feet of C3H/Km mice.

RESULTS

Sixty minutes of breathing CO at 200 ppm resulted in a carboxyhemoglobin level of 15%. This resulted in a reduction in p50 (the oxygen partial pressure at which hemoglobin is 50% saturated) to 78% of the control value, and a decrease in tumor blood perfusion to 73% of the control value. The combined effect of a decrease in effective hemoglobin and blood perfusion resulted in a reduction in tumor oxygen supply to 62% of the control value. In agreement with this, intratumoral pO2 measurements showed a significant increase in tumor hypoxia, such that the percentage of measurements with low pO2 (< or = 5 mmHg) increased from 33% to 62%. The fraction of clonogenic hypoxic cells, measured radiobiologically by paired cell survival curves, similarly increased from 0.2% to 3.8%. Radiation sensitivity, evaluated from in vivo-in vitro excision assay, was significantly decreased by CO breathing with both single dose and fractionated irradiation. The observed enhancement ratios for radiation given in 1, 4, 8, and 12 fractions were 0.71, 0.77, 0.83, and 0.71, respectively.

CONCLUSION

The present SCCVII tumor data confirm the general experimental observation that CO breathing significantly increases tumor hypoxia and reduces the effectiveness of ionizing irradiation.

The relationship between carbon monoxide breathing, tumour oxygenation and local tumour control in the C3H mammary carcinoma in vivo

The effect of acute carbon monoxide (CO) breathing on blood oxygenation and tumour hypoxia was related to the radiation response of the C3H/Tif mammary carcinoma. Blood gas analysis showed that CO breathing caused a time- and dose-dependent formation of carboxyhaemoglobin (HbCO), a significant left shift of the oxygen dissociation curve and a reduction in tumour blood perfusion. These factors all contributed to a marked drop in tumour oxygen supply. In agreement with this, tumour hypoxia was found to be significantly increased: Microelectrode PO2 measurements showed a clear relationship between CO concentration and the proportion of low PO2 measurements (< or = 5 mmHg). The fraction of clonogenic hypoxic cells increased from 8% in air-breathing animals to 13%, 18% and 54% with 75,220 and 660 p.p.m. CO respectively. The tumour hypoxia resulted in significant radiation modification. The local tumour control after single-dose and fractionated irradiation gave TCD50 enhancement ratios (relative to air-breathing controls) of 0.90, 0.85 and 0.89 for single dose and five or ten fractions given in 5 days (P < 0.005 for all values). For 15 fractions in 5 days with 6- 6- and 12 h intervals, the TCD50 was similar in CO- and air-breathing mice, presumably as a consequence of insufficient reoxygenation during the short inter-fraction intervals. It is concluded that elevated HbCO levels to increased tumour hypoxia and that the induced hypoxia has a significant impact on the local tumour control also after fractionated irradiation.

Prognostic significance of selected lifestyle factors in urinary bladder cancer

To examine the prognostic significance of lifestyle factors in urinary bladder cancer, we conducted a follow-up study of 258 incident bladder cancer patients, who were originally recruited in a case-control study in metropolitan Nagoya. Information on individual survivals was obtained from the computer data-file of the tumor registry of the Nagoya Bladder Cancer Research Group. Univariate analyses revealed significant associations of 5-year survivorship with educational attainment, marital status, drinking habits and consumption of green tea in males, and age at first consultation, histological type and grade of tumor, stage and distant metastasis in both sexes. After adjustment for age, stage, histology (histological type and grade) and distant metastasis by means of a proportional hazards model, drinking of alcoholic beverages was significantly associated with the prognosis of bladder cancer in males. Its adjusted hazard ratio was 0.46 (95% confidence interval: 0.26-0.79), favoring patients who had taken alcoholic beverages. In detailed analysis, ex-drinkers and all levels of current drinkers demonstrated hazard ratios smaller than unity, although no clear dose-response relationship was detected. No prognostic significance was found for such lifestyle factors as smoking habit, uses of artificial sweeteners and hairdye, and consumption of coffee, black tea, matcha (powdered green tea) and cola.

Prognostic factors in advanced stage squamous cell cancer of the cervix

BACKGROUND

This study was undertaken to review prognostic factors for advanced squamous cell cancer of the cervix.

METHODS

A clinicopathologic review of patients diagnosed with advanced stage squamous cell cancer of the cervix was performed at the University of Michigan Medical Center, Ann Arbor, Michigan, from 1970-1985.

RESULTS

All patients had squamous cell disease and were divided according to the following stages: Stage IIIa (4), Stage IIIb (113), Stage IVa (32), and Stage IVb (26). The cumulative 5-year survival was as follows: Stage IIIa (50%), Stage IIIb (37%), Stage IVa (14%), and Stage IVb (4%). Prognostic features for Stage IIIb disease showed that the intravenous pyelogram status significantly predicted cumulative 5-year survival (P = 0.00001). When the intravenous pyelogram was normal, 47% survived. When ureteral obstruction was present without renal failure, 29% survived, and when renal failure occurred, all patients were dead of disease by 16 months. The lymph node status significantly influenced cumulative 5-year survival (P = 0.004). When lymph nodes were negative, 47% survived. When three or fewer were positive, 44% survived. When more than three were positive, 11% survived. When pelvic lymph nodes were positive and paraaortic node status was determined, 25% survived when paraaortic lymph nodes were negative, while 8% survived when these were positive (P = 0.06). Factors that did not influence 5-year survival included one or both sidewall involvement (P = 0.77), tumor grade (P = 0.23), diabetes (P = 0.92), hypertension (P = 0.85), and obesity (P = 0.47). The diagnosis of Stage IVa disease was made by the presence of fistula at initial presentation (n = 8), cystoscopy (n = 21), and sigmoidoscopy (n = 1). One patient developed a treatment-related vesicovaginal fistula when bladder involvement was diagnosed by cystoscopy. All 18 patients who presented with renal failure (Stage IIIb, 9; Stage IVa, 9) were analyzed as a group, and only 1 patient survived. The median survival in 15 patients who underwent nephrostomy was 8 months, range 1-36 months. Ten of 15 patients (66%) were dead of disease within 1 year. Three patients refused renal bypass, and these three patients died at 1, 2, and 3 months, respectively.

CONCLUSIONS

Advanced stage disease represents a significant challenge, and when ureteral obstruction or renal failure is present, the prognosis is markedly decreased.

Larger axillary metastases in obese women and smokers with breast cancer--an influence by host factors on early tumor behavior

To better define the influence by host factors on very early breast cancer behavior, we retrospectively analyzed nodal status, diameter of the largest axillary metastasis (M), diameter of the primary tumor (P), the M/P ratio, tumor estrogen receptor status, age, obesity, and smoking habits in 176 women with node-positive breast cancer. Both M/P ratios and M were larger in the 72 obese women and in the 40 nonobese smokers than in the 64 nonobese nonsmokers after control for other factors. Step-wise regression analysis demonstrated independent associations between M/P ratios and obesity (p = 0.0002), larger primary tumors (p < 0.0001), more positive nodes (p < 0.0001), and smoking (p = 0.0268), as well as between M and obesity (p = 0.0201), larger primary tumors (p = 0.0093), and more positive nodes (p = 0.0001). Among the 104 nonobese women, smoking was associated both with larger M (p = 0.0257) and larger M/P (p = 0.0055). Our observations suggest more rapid growth by metastases in obese women and smokers with breast cancer, as well as earlier metastasis from their primary tumors.

Smoking and smoking cessation in cancer patients

Persons with malignant disease have been a neglected population for research in smoking cessation. Besides the well-established role of cigarette smoking in the development of several types of cancers, there are numerous adverse health consequences of continued smoking for the diagnosed cancer patient. These include: increased risk of further neoplasms, poorer survival, and complications of surgery, radiation and chemotherapy; risk of non-neoplastic smoking-related diseases; and additional impairment of appetite and nutrition. Smoking prevalence at diagnosis is highest among patients with smoking-related cancers. Prospective studies of a variety of cancer patient populations are needed to assess patterns of continued smoking and cessation. Systematic quit smoking programs should be integrated into cancer treatment regimens. Currently, two trials testing interventions delivered by medical providers are in progress. Important research issues concerning intervention in cancer patient smoking behavior include: identification of relevant target groups; definition of intervention style and content; delineation of dimensions of treatment; and documentation of beneficial effects. The growing number of long-term cancer survivors and the complications from other smoking-related diseases dictate that the smoking cessation needs of this population be addressed.