Palliative effect of chemotherapy: objective tumor response is associated with symptom improvement in patients with metastatic breast cancer

Predicting drug outcome of population via clinical knowledge graph

Optimal treatments depend on numerous factors such as drug chemical properties, disease biology, and patient characteristics to which the treatment is applied. To realize the promise of AI in healthcare, there is a need for designing systems that can capture patient heterogeneity and relevant biomedical knowledge. Here we present PlaNet, a geometric deep learning framework that reasons over population variability, disease biology, and drug chemistry by representing knowledge in the form of a massive clinical knowledge graph that can be enhanced by language models. Our framework is applicable to any sub-population, any drug as well drug combinations, any disease, and to a wide range of pharmacological tasks. We apply the PlaNet framework to reason about outcomes of clinical trials: PlaNet predicts drug efficacy and adverse events, even for experimental drugs and their combinations that have never been seen by the model. Furthermore, PlaNet can estimate the effect of changing population on the trial outcome with direct implications on patient stratification in clinical trials. PlaNet takes fundamental steps towards AI-guided clinical trials design, offering valuable guidance for realizing the vision of precision medicine using AI.

Abducens nerve palsy due to clivus metastasis in a patient with breast carcinoma: A rare case

INTRODUCTION

Breast cancer, comprising 25 % of all diagnosed cancers, predominantly affects women globally. While bone metastasis is common, occurrences at the clivus or skull base are rarely documented. Treatment varies from surgery in early stages to a multifaceted approach for advanced cases, incorporating chemotherapy, radiotherapy, and surgery based on staging and histology.

CLINICAL PRESENTATION

A 40-year-old female presented with a rapidly enlarging lump in her left breast and diplopia on right gaze. Histology was positive for invasive breast cancer (no special type) and Contrast-Enhanced Computed Tomography demonstrated metastatic deposits in multiple vertebrae and bilateral ilium. Further, magnetic resonance imaging of the brain and orbits revealed metastatic deposits in the clivus which extended up-to medial wall of the cavernous sinus, causing compression of the right abducens nerve. Multidisciplinary Tumor Board review recommended chemoradiotherapy.

DISCUSSION

Metastases from breast cancer can occur locally or to distant sites like lymph nodes, bones, lungs, liver, and brain. Unusual symptoms, such as new-onset diplopia, trigger further investigation. Although bone metastases occur in 50-65 % of cases, clivus metastasis is rare. Treatment aims at extending survival, symptom management, and enhancing quality of life through chemotherapy and radiotherapy. Outcomes hinge on metastatic burden and regional therapy responsiveness. Distant metastases substantially reduce the 5-year survival rate from 80 % to approximately 25 %, but cases often improve with regional interventions.

CONCLUSION

Although an extremely rare occurrence, clivus metastasis might be considered in patients with a history of malignancy, in particular, breast malignancy, presenting with new-onset sixth nerve palsy.

Palliative care utilization and racial and ethnic disparities among women with de novo metastatic breast cancer in the United States

PURPOSE

The potential disparities in palliative care delivery for underrepresented minorities with breast cancer are not well known. We sought to determine whether race and ethnicity impact the receipt of palliative care for patients with metastatic breast cancer (MBC).

METHODS

We retrospectively reviewed the National Cancer Database for female patients diagnosed with stage IV breast cancer between 2010 and 2017 who received palliative care following diagnosis of MBC to assess the proportion of patients who received palliative care, including non-curative-intent local-regional or systemic therapy. Multivariable logistic regression analysis was performed to identify variables associated with receiving palliative care.

RESULTS

60,685 patients were diagnosed with de novo MBC. Of these, only 21.4% (n = 12,963) received a palliative care service. Overall, there was a positive trend in palliative care receipt from 18.2% in 2010 to 23.0% in 2017 (P < 0.001), which persisted when stratified by race and ethnicity. Relative to non-Hispanic White women, Asian/Pacific Islander women (aOR 0.80, 95% CI 0.71-0.90, P < 0.001), Hispanic women (adjusted odds ratio [aOR] 0.69, 95% CI 0.63-0.76, P < 0.001), and non-Hispanic Black women (aOR 0.94, 95% CI 0.88-0.99, P = 0.03) were less likely to receive palliative care.

CONCLUSIONS

Fewer than 25% of women with MBC received palliative care between 2010 and 2017. While palliative care has significantly increased for all racial/ethnic groups, Hispanic White, Black, and Asian/Pacific Islander women with MBC still receive significantly less palliative care than non-Hispanic White women. Further research is needed to identify the socioeconomic and cultural barriers to palliative care utilization.

Sleep During Oncological Treatment – A Systematic Review and Meta-Analysis of Associations With Treatment Response, Time to Progression and Survival

Introduction

Disrupted sleep and sleep-wake activity are frequently observed in cancer patients undergoing oncological treatment. These disruptions are often associated with aggravated symptom burden and diminished health-related quality of life that in turn may compromise treatment adherence and, thus, effectiveness. In addition, disrupted sleep has been linked to carcinogenic processes, which ultimately could result in worse prognostic outcomes.

Aims

Our aim was to systematically review and conduct a meta-analysis of studies examining the associations between sleep and sleep-wake activity and prognostic outcomes in cancer patients undergoing oncological treatment.

Methods

A comprehensive systematic search of English language papers was undertaken in June 2020 using PubMed, The Cochrane Library, and CINAHL. Two reviewers independently screened 4,879 abstracts. A total of 26 papers were included in the narrative review. Thirteen papers reporting hazard ratios reflecting associations between a dichotomized predictor variable (sleep) and prognostic outcomes were subjected to meta-analysis.

Results

Nineteen of the 26 eligible studies on a total of 7,092 cancer patients reported associations between poorer sleep and poorer response to treatment, shorter time to progression, and/or reduced overall survival, but were highly heterogeneous with respect to the sleep and outcome parameters investigated. Meta-analysis revealed statistically significant associations between poor self-reported sleep and reduced overall survival (HR = 1.33 [95% CI 1.09–1.62], k = 11), and shorter time to progression (HR = 1.40 [95% CI 1.23–1.59], k = 3) and between poor objectively assessed sleep and reduced overall survival (HR = 1.74 [95% CI 1.05–2.88], k = 4).

Conclusion

The current findings indicate that disturbed sleep during treatment may be a relevant behavioral marker of poor cancer prognosis. The limited number of studies, the common use of single item sleep measures, and potential publication bias highlight the need for further high quality and longitudinal studies.

Development and Validation of Prognostic Nomogram for Elderly Breast Cancer: A Large-Cohort Retrospective Study

Purpose

Our research aims to study the bone metastatic patterns and prognostic outcomes in elderly breast cancer (BC) and to develop elder-specific nomograms.

Methods

We downloaded the data of BC patients between 2010 and 2016 from the Surveillance, Epidemiology, and End Results database. The differences in clinical features and prognosis between young (age < 65) and elderly (age ≥ 65) BC patients were compared. The univariate and multivariate Cox analyses were used to determine the overall survival (OS)- and cancer-specific survival (CSS)-related variables and establish two nomograms of BC patients with bone metastasis (BCBM). The receiver operating characteristic (ROC) curve with area under the curve (AUC), calibration curve, decision curve analysis (DCA), and Kaplan–Meier survival curve were selected to evaluate nomograms.

Results

A total of 230,177 BC patients were enrolled in our research, including 142,025 young and 88,152 elderly patients. The prognosis of elderly BCBM patients was significantly worse than young patients. Age, race, breast subtype, tumor size, tumor grade, brain metastasis, liver metastasis, surgery, and chemotherapy were independent prognostic variables for elderly BCBM patients, including OS and CSS. The AUC values at 12, 18, and 24 months were 0.750, 0.751, and 0.739 for OS nomogram and 0.759, 0.762, and 0.752 for CSS nomogram in the training cohort, which were higher than the AUC values of all single independent prognostic variables. The survival curve showed a distinct prognosis between low-, median- and high-risk groups (p < 0.001). Finally, calibration curves and DCA indicated that both nomograms have favorable performance.

Conclusion

Elderly and young patients presented with different bone metastatic frequencies, clinical features, and prognostic outcomes. Two elder-specific nomograms incorporating nine clinical variables were established and validated to be a valuable predictor for elderly BCBM patients.

Prospective Longitudinal Assessment of Health-related Quality of Life in Patients With Brain Metastases Undergoing Radiation Therapy

OBJECTIVE

We conducted a prospective clinical trial of patients receiving radiation (RT) for brain metastases to identify clinical predictors of pre-RT and post-RT health-related quality of life (hrQoL).

MATERIALS AND METHODS

Patients with brain metastases completed overall (European Organisation for Research and Treatment of Cancer QLQ C15-PAL) and brain tumor-specific (QLQ-BN20) hrQoL assessments pre-RT (n=127) and 1 (n=56) and 3 (n=45) months post-RT. Linear and proportional-odds models analyzed patient, disease, and treatment predictors of baseline, 1-, and 3-month hrQoL scores. Generalized estimating equations and repeated measures proportional-odds models assessed predictors of longitudinal hrQoL scores.

RESULTS

Most patients underwent stereotactic radiosurgery (SRS) (69.3%) and had non-small-cell lung (36.0%) metastases. Compared with SRS, receipt of whole brain RT was associated with a higher odds of appetite loss (baseline P=0.04, 1 mo P=0.02) and greater motor dysfunction (baseline P=0.01, 1 mo P=0.003, 3 mo P=0.02). Receipt of systemic therapy was associated with better emotional functioning after RT (1 mo P=0.03, 3 mo P=0.01). Compared with patients with breast cancer, patients with melanoma had higher odds of better global hrQoL (P=0.01) and less pain (P=0.048), while patients with lung cancer reported lower physical function (P=0.048) 3 months post-RT. Nonmarried patients had greater odds of higher global hrQoL (1 mo P=0.01), while male patients had lower odds of reporting more hair loss (baseline P=0.03, 3 mo P=0.045). Patients 60 years and above had lower odds of more drowsiness (P=0.04) and pain (P=0.049) over time.

CONCLUSIONS

Patients receiving SRS versus whole brain RT and systemic therapy reported better posttreatment hrQoL. In addition, melanoma metastases, nonmarried, male, and older patients with reported better hrQoL in various as well as domains after intracranial RT.

Real-World Tumor Response of Palbociclib Plus Letrozole Versus Letrozole for Metastatic Breast Cancer in US Clinical Practice

BACKGROUND

Limited information exists regarding tumor response to palbociclib plus an aromatase inhibitor (AI) versus AI alone in real-world practice.

OBJECTIVE

To evaluate the real-world tumor response of palbociclib plus letrozole (PAL+LET) versus LET alone as first-line treatment for patients with hormone receptor-positive/human epidermal growth factor receptor 2-negative metastatic breast cancer (HR+/HER2‒ MBC) in routine US clinical practice.

PATIENTS AND METHODS

This retrospective analysis included HR+/HER2‒ MBC patients who initiated PAL+LET or LET as first-line treatment between February 2015 and September 2018 in the Flatiron Health Analytics database. Patients were followed until December 2018. Real-world best tumor response (rwBTR) was determined based on physicians' assessment of radiologic evidence for change in burden of disease.

RESULTS

Of the 1383 eligible patients who initiated PAL+LET or LET as first-line therapy in the Flatiron database, 968 patients had ≥ 1 tumor response assessment (662 received PAL+LET and 306 received LET). The rwBTR rate (complete response+partial response) in the first-line setting was 59.8% in the PAL+LET group and 39.2% in the LET group (odds ratio 2.31 (95% CI 1.75‒3.04), P < 0.0001). After 1:1 propensity-score matching, the rwBTR rate was 58.6% in the PAL+LET group versus 39.1% in the LET group (odds ratio 2.21 (95% CI 1.50‒3.25), P < 0.0001).

CONCLUSIONS

This real-world analysis demonstrated that HR+/HER2‒ MBC patients were more likely to respond to PAL+LET compared to LET. These findings further showed the effectiveness of PAL+LET therapy in the real-world setting and support the combination as a standard of care for MBC.

STUDY REGISTRATION

Pfizer; NCT04176354; registered November 25, 2019.

Unilateral Orbital Metastasis as the Unique Symptom in the Onset of Breast Cancer in a Postmenopausal Woman: Case Report and Review of the Literature

The orbit represents an unusual metastases site for patients diagnosed with cancer, however, breast cancer is the main cause of metastases at this level. These orbital metastases were discovered in patients with a history of breast cancer as unique or synchronous lesions. We present a rare case of a unique retroocular metastasis as the first initial symptom of a tubulo-lobular mammary carcinoma in a postmenopausal woman. A 57-year-old patient complains of diplopia, diminishing visual acuity, orbital tenderness, slight exophthalmia and ptosis of the left eyelid, with insidious onset. Clinical examination and subsequent investigations revealed a left breast cancer cT2 cN1 pM1 stage IV. Breast conserving surgery was performed on the left breast. Pathological examination with immunohistochemistry staining established the complete diagnostic: pT2pN3aM1 Stage IV breast cancer, luminal B subtype. After two years from the initial breast cancer diagnosis, the patient was diagnosed by the psychiatrist with a depressive disorder and was treated accordingly. Orbital metastases are usually discovered in known breast cancer patients and they are found in the context of a multi-system end-stage disease. Most reports cite that up to 25% of the total orbital metastases cases are discovered before the diagnosis of the primary tumor, as our case did. MRI is the gold standard for evaluating orbital tumors. The ILC histological subtype metastasizes in the orbitals more frequently than invasive ductal carcinoma. The prognosis of patients with orbital metastases is poor. The median survival after diagnosis of orbital metastases from a breast cancer primary is ranging from 22 to 31 months. Overall survival of our patient was 56 months, longer than the median survival reported in literature. Orbital metastases must be taken into account when patients accuse ophthalmologic symptoms even in the absence of a personal history of cancer. Objective examination of every patient that incriminates these types of symptoms is essential, and breast palpation must be made in every clinical setting. Orbital biopsy is necessary for the confirmation of the diagnosis and for an adequate treatment. Although recommendations for management of orbital metastases are controversial, it appears that multidisciplinary treatment of both metastases and primary cancer improves overall survival.

Quality of life of women living with metastatic breast cancer and receiving palliative care: A systematic review

The quality of life (QoL) of women living with metastatic breast cancer and receiving palliative care needs more attention. We reviewed published studies (1992-2019) examining QoL of women receiving palliative care. The findings were interpreted according to the World Health Organization's (WHO) definition of palliative care. Four themes emerged: (1) the impact of medical treatment on pain relief; (2) the need for psychosocial attention and support; (3) the necessity of an interdisciplinary approach; (4) ambiguous understanding of the term palliative care. A common understanding of the term palliative care and more research is needed to enhance the QoL of women living with metastatic breast cancer.

Tumor Response and Symptom Palliation from RAINBOW, a Phase III Trial of Ramucirumab Plus Paclitaxel in Previously Treated Advanced Gastric Cancer

BACKGROUND

In the intent-to-treat (ITT) population of the RAINBOW study, objective response rate (ORR) was 28% and 16% in the ramucirumab and control arms, respectively. To further characterize tumor response, we present details on timing and extent of tumor shrinkage, as well as associations with symptom palliation.

MATERIALS AND METHODS

Tumor response was assessed with RECIST v1.1, and quality of life (QoL) was assessed with the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (EORTC QLQ-C30) v3.0. Prespecified and post hoc analyses were conducted in the ITT population, patients with measurable disease, or responders, and included best overall response (BOR), ORR, disease control rate (DCR), duration of response, time to response (TtR), change in tumor size, and associations of QoL with tumor shrinkage and BOR.

RESULTS

In both treatment arms, median TtR was 1.5 months. Responses were more durable in the ramucirumab versus control arm (median 4.4 vs. 2.8 months). In patients with measurable disease (78% of ITT), ORR was 36% versus 20%; DCR was 81% versus 61% in the ramucirumab versus control arms. Waterfall plots demonstrated more tumor shrinkage in the ramucirumab versus control arm. Regardless of treatment, tumor response and stable disease were associated with improved or stable QoL, with more tumor shrinkage associated with greater symptom palliation.

CONCLUSION

Treatment with ramucirumab plus paclitaxel yielded the highest ORR reported to date for patients with previously treated advanced gastric or gastroesophageal junction adenocarcinoma. Additional details demonstrate robustness of tumor response results. The extent of tumor shrinkage is directly associated with symptom palliation and should be considered when evaluating patient needs and treatment selection. Clinical trial identification number. NCT01170663.

IMPLICATIONS FOR PRACTICE

Ramucirumab plus paclitaxel is a recognized standard of care as it improves survival for patients with advanced gastric or gastroesophageal junction adenocarcinoma who have been previously treated with recommended first-line therapy. These additional data on tumor response demonstrate a positive association between tumor shrinkage and symptom palliation in a patient population that is often symptomatic. These observations included patients with nonmeasurable disease, a group of patients often underrepresented in clinical trials. This knowledge can inform treatment decisions, which align individual patient characteristics and needs with demonstrated benefits.

Health-related quality of life in the randomized phase 3 study of ramucirumab plus docetaxel versus placebo plus docetaxel in platinum-refractory advanced urothelial carcinoma (RANGE)

BACKGROUND

To evaluate patient-reported outcomes with ramucirumab plus docetaxel, a regimen which improved progression-free survival in platinum-refractory advanced urothelial carcinoma (aUC).

METHODS

RANGE-a randomized, double-blinded, phase 3 trial in patients with platinum-refractory aUC. Ramucirumab (10 mg/kg) plus docetaxel (75 mg/m2) or placebo plus docetaxel were administered every 21 days until disease progression or unacceptable toxicity. Patients received maximum 10 cycles of docetaxel. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and EuroQoL five-dimensions (EQ-5D-5L) were administered at baseline, start of each cycle, and 30-day follow-up visit. A ≥ 10-point change in QLQ-C30 scores was considered meaningful. Rates of improved/stable scores were compared between treatment arms using Fisher's exact test. Time to deterioration (TtD) was estimated and compared using Kaplan-Meier estimation and log-rank test.

RESULTS

Of the 530 patients, ~ 97% patients in each arm provided baseline QLQ-C30 data. On-treatment compliance was ≥ 88% for first 8 cycles. Mean baseline QLQ-C30 scores were similar between arms, with global quality of life (QoL), fatigue, pain, and insomnia having greatest impairment. Postbaseline rates of improved/stable QLQ-C30 scores were similar between treatment arms except for greater improvement in pain score with ramucirumab. TtD of QLQ-C30 scales favored ramucirumab arm. Baseline EQ-5D-5L index and visual analogue scale scores were similar between arms, followed by relatively stable on-treatment scores. EQ-5D-5L scores worsened at post-discontinuation follow-up visit.

CONCLUSIONS

Ramucirumab plus docetaxel did not negatively impact QoL compared with docetaxel alone in platinum-refractory aUC. Improved TtD and tumor associated rates of pain favored ramucirumab treatment.

CLINICAL TRAIL REGISTRATION

NCT02426125. https://clinicaltrials.gov/ct2/show/NCT02426125 . Date of registration: April 24th 2015.

Systematic Review of the Prevalence, Predictors, and Treatment of Insomnia in Palliative Care

Introduction:

The primary function of palliative care is to improve quality of life. The recognition and treatment of symptoms causing suffering is central to the achievement of this goal. Insomnia reduces quality of life of patients under palliative care. Knowledge about prevalence, associated factors, and treatment of insomnia in palliative care is scarce.

Methodology:

Literature review about the prevalence, predictors, and treatment options of insomnia in palliative care patients. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in identified articles and selected reviews. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

Results:

A total of 65 studies were included in the review. Most studies had acceptable /good quality. The prevalence of insomnia in the included studies ranged from 2.1% to 100%, with a median overall prevalence of 49.5%. Sociodemographic factors such as age; clinical characteristics such as functional status, disease stage, pain, and use of specific drugs, including opioids; psychological factors such as anxiety/depression; and spiritual factors such as feelings of well-being were identified as predictors. The treatment options identified were biological (pharmacological and nonpharmacological), psychological (visualization, relaxation), and spiritual (prayer).

Conclusions:

The systematic review showed that the prevalence of insomnia is high, with at least one in 3 patients affected in most studies. Insomnia’s risk factors and treatment in palliative care are both associated to physical, psychological, social, and spiritual factors, reflecting its true holistic nature.

An update on the currently available and future chemotherapy for treating bone metastases in breast cancer patients

INTRODUCTION

Bone metastases in breast cancer patients are a common clinical problem. Many factors influence the treatment decision, including tumor characteristics, previous treatment and tumor burden in the treatment of metastatic breast cancer.

AREAS COVERED

This present review summarizes the new treatment strategies and the chemotherapeutic agents currently available in the management of metastatic breast cancer with bone metastases.

EXPERT OPINION

Patients with bone metastases more often have hormone receptor-positive tumours. Although new treatment agents for metastatic breast cancer have been investigated, endocrine therapy is still considered as the treatment of choice for patients with bone metastases although chemotherapy still has an important place. In recent years, new chemotherapeutic agents such as etirinotecan and nab-paclitaxel have been established though there are few studies that have looked at particular types of metastases. In the last decade, therapies for bone metastasis resistant to endocrine therapy have predominantly focused on radiotherapy, surgical resection, chemotherapy, bone-targeting radiopharmaceuticals and targeted therapeutics. New targeted agents include: Src inhibitors, cathepsin K inhibitors, CXCR4 inhibitors, TGF-B blockade and integrin antagonists while drug delivery systems for chemotherapy have also been developed. These new treatment options could be future treatment options for bone metastatic disease if early promising results are confirmed by clinical trials.

Practical consensus recommendations on management of triple-negative metastatic breast cancer

Patients with breast cancer along with metastatic estrogen and progesterone receptor (ER/PR)- and human epidermal growth factor receptor 2 (HER2)-negative tumors are referred to as having metastatic triple-negative breast cancer (mTNBC) disease. Resistance to current standard therapies such as anthracyclines or taxanes limits the available options for previously treated patients with metastatic TNBC to a small number of non-cross-resistant regimens, and there is currently no preferred standard chemotherapy. Clinical experience suggests that many women with triple-negative metastatic breast cancer (MBC) relapse quickly. Expert oncologist discussed about new chemotherapeutic strategies and agents used in treatment of mTNBC and the expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Adhesion, proliferation, and apoptosis in different molecular portraits of breast cancer treated with silver nanoparticles and its pathway-network analysis

Background

Silver nanoparticles (AgNPs) have attracted considerable attention due to the variety of their applications in medicine and other sciences. AgNPs have been used in vitro for treatment of various diseases, such as hepatitis B and herpes simplex infections as well as colon, cervical, and lung cancers. In this study, we assessed the effect on proliferation, adhesion, and apoptosis in breast cancer cell lines of different molecular profiles (MCF7, HCC1954, and HCC70) exposed to AgNPs (2–9 nm).

Methods

Breast cancer cell lines were incubated in vitro; MTT assay was used to assess proliferation. Adhesion was determined by real-time analysis with the xCELLingence system. Propidium iodide and fluorescein isothiocyanate-Annexin V assay were used to measure apoptosis. The transcriptome was assessed by gene expression microarray and Probabilistic Graphical Model (PGM) analyses.

Results

The results showed a decreased adhesion in breast cancer cell lines and the control exposed to AgNPs was noted in 24 hours (p≤0.05). We observed a significant reduction in the proliferation of MCF7 and HCC70, but not in HCC1954. Apoptotic activity was seen in all cell lines exposed to AgNPs, with an apoptosis percentage of more than 60% in cancer cell lines and less than 60% in the control. PGM analysis confirmed, to some extent, the effects of AgNPs primarily on adhesion by changes in the extracellular matrix.

Conclusion

Exposure to AgNPs causes an antiproliferative, apoptotic, and anti-adhesive effect in breast cancer cell lines cultured in vitro. More research is needed to evaluate the potential use of AgNPs to treat different molecular profiles of breast cancer in humans.

Does palliative chemotherapy provide a palliative effect on symptoms in late palliative stages? An interview study with oncologists

BACKGROUND

The possible chemotherapy effects on symptoms in late stages of palliative chemotherapy are seldom registered in clinical practice or investigated as primary outcomes. The aim was therefore to study physicians' opinions and experiences about chemotherapy effects on symptoms.

MATERIAL AND METHODS

Thirty-five physicians (mainly oncologists) with variation as regards age, gender and experience were included in a qualitative study with semi-structured interviews. A qualitative content analysis was used for the 30-60 min long interviews.

RESULTS

According to all the informants, symptoms were possible to control in successful cases but the chances reduce rapidly with the number of chemotherapy lines. Symptoms possible to control included various types of pain (bone pain, neuropathic cranial as well as meningeal nerve pain, colic pain, "liver" pain, headache and pain from cutaneous metastases); nausea and vomiting caused by obstruction; dyspnoea due to pleural effusions or bronchial obstructions. Also fatigue and B-symptoms were possible targets, as were diagnosis-specific symptom clusters (e.g., liver metastasis causing pain, nausea, tumour fever and night sweats; or head-neck cancers resulting in nerve pain, ulcerations, odour, dysphagia and impaired breathing). Some of the oncologists discussed whether the effects were related to chemotherapy treatment only or partly to premedication with steroids. Despite the claimed effects, the physicians did not keep record on symptoms, they did not evaluate them with validated instruments.

CONCLUSIONS

Palliative chemotherapy has a substantial potential to reduce agonizing symptoms especially in first line treatments, but the effect is limited in late stages. The actual awareness of and knowledge about situations where the treatment has a reasonable potential, should be improved and symptoms should be monitored during treatment.

Treatment outcome of radiation therapy and concurrent targeted molecular therapy in spinal metastasis from renal cell carcinoma

PURPOSE

To evaluate the clinical outcomes of patients who underwent radiation therapy with or without targeted molecular therapy for the treatment of spinal metastasis from renal cell carcinoma (RCC).

MATERIALS AND METHODS

A total of 28 spinal metastatic lesions from RCC patients treated with radiotherapy between June 2009 and June 2015 were retrospectively reviewed. Thirteen lesions were treated concurrently with targeted molecular therapy (concurrent group) and 15 lesions were not (nonconcurrent group). Local control was defined as lack of radiographically evident local progression and neurological deterioration.

RESULTS

At a median follow-up of 11 months (range, 2 to 58 months), the 1-year local progression-free rate (LPFR) was 67.0%. The patients with concurrent targeted molecular therapy showed significantly higher LPFR than those without (p = 0.019). After multivariate analysis, use of concurrent targeted molecular therapy showed a tendency towards improved LPFR (hazard ratio, 0.13; 95% confidence interval, 0.01 to 1.16). There was no difference in the incidence of systemic progression between concurrent and nonconcurrent groups. No grade ≥2 toxicities were observed during or after radiotherapy.

CONCLUSION

Our study suggests the possibility that concurrent use of targeted molecular therapy during radiotherapy may improve LPFR. Further study with a large population is required to confirm these results.

A Review of Systemic Treatment in Metastatic Triple-Negative Breast Cancer

Patients with breast cancer along with metastatic estrogen and progesterone receptor (ER/PR)- and human epidermal growth factor receptor 2 (HER2)-negative tumors are referred to as having metastatic triple-negative breast cancer (mTNBC) disease. Although there have been many new treatment options approved by the Food and Drug Administration for ER/PR-positive and Her2/neu-amplified metastatic breast cancer, relatively few new agents have been approved for patients with mTNBC. There have been several head-to-head chemotherapy trials performed within the metastatic setting, and much of what is applied in clinical practice is extrapolated from chemotherapy trials in the adjuvant setting, with taxanes and anthracyclines incorporated early on in the patient's treatment course. Select synergistic combinations can produce faster and more significant response rates compared with monotherapy and are typically used in the setting of visceral threat or symptomatic disease. Preclinical studies have implicated other possible targets and mechanisms in mTNBC. Ongoing clinical trials are underway assessing new chemotherapeutic strategies and agents, including targeted therapy and immunotherapy. In this review, we evaluate the standard systemic and future treatment options in mTNBC.

Are there efficacious treatments for treating the fatigue-sleep disturbance-depression symptom cluster in breast cancer patients? A Rapid Evidence Assessment of the Literature (REAL(©))

Purpose

While fatigue, sleep disturbance, and depression often co-occur in breast cancer patients, treatment efficacy for this symptom cluster is unknown. A systematic review was conducted to determine whether there are specific interventions (ie, medical, pharmacological, behavioral, psychological, and complementary medicine approaches) that are effective in mitigating the fatigue–sleep disturbance–depression symptom cluster in breast cancer patients, using the Rapid Evidence Assessment of the Literature (REAL^©) process.

Methods

Peer-reviewed literature was searched across multiple databases; from database inception – October 2011, using keywords pre-identified to capture randomized controlled trials (RCT) relevant to the research question. Methodological bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) 50 checklist. Confidence in the estimate of effect and assessment of safety were also evaluated across the categories of included interventions via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology.

Results

The initial search yielded 531 citations, of which 41 met the inclusion criteria. Of these, twelve RCTs reported on all three symptoms, and eight of these were able to be included in the GRADE analysis. The remaining 29 RCTs reported on two symptoms. Studies were of mixed quality and many were underpowered. Overall, results suggest that there is: 1) promising evidence for the effectiveness of various treatment types in mitigating sleep disturbance in breast cancer patients; 2) mixed evidence for fatigue; 3) little evidence for treating depression; and 4) no clear evidence that treatment of one symptom results in effective treatment for other symptoms.

Conclusion

More high-quality studies are needed to determine the impact of varied treatments in mitigating the fatigue–sleep disturbance–depression symptom cluster in breast cancer patients. Furthermore, we encourage future studies to examine the psychometric and clinical validity of the hypothesized relationship between the symptoms in the fatigue–sleep disturbance–depression symptom cluster.

PLGA-PLL-PEG-Tf-based targeted nanoparticles drug delivery system enhance antitumor efficacy via intrinsic apoptosis pathway

Chemotherapy offers a systemic cancer treatment; however, it is limited in clinical administration due to its serious side effects. In cancer medicine, the use of nanoparticles (NPs) drug delivery system (DDS) can sustainedly release anticancer drug at the specific site and reduce the incidence of toxicity in normal tissues. In the present study, we aimed to evaluate the benefit of a novel chemotherapeutic DDS and its underlying mechanisms. Daunorubicin (DNR) was loaded into poly (lactic-co-glycolic acid) (PLGA)-poly-L-lysine (PLL)-polyethylene glycol (PEG)-transferrin (Tf) NPs to construct DNR-PLGA-PLL-PEG-Tf-NPs (DNR-loaded NPs) as a DDS. After incubating with PLGA-PLL-PEG-Tf-NPs, DNR, and DNR-loaded NPs, the leukemia K562 cells were collected and the intracellular concentration of DNR was detected by flow cytometry, respectively. Furthermore, the effect of drugs on the growth of tumors in K562 xenografts was observed and the relevant toxicity of therapeutic drugs on organs was investigated in vivo. Meanwhile, cell apoptosis in the excised xenografts was measured by transferase-mediated dUTP nick-end labeling assay, and the expression of apoptosis-related proteins, including Bcl-2, Bax, Caspase-9, Caspase-3, and cleaved-PARP, was determined by Western blotting analysis. Results showed that DNR-loaded NPs increased intracellular concentration of DNR in K562 cells in vitro and induced a remarkable improvement in anticancer activity in the xenografts in vivo. The expression of Bcl-2 protein was downregulated and that of Bax, Caspase-9, Caspase-3, and cleaved-PARP proteins were obviously upregulated in the DNR-loaded NPs group than that in other ones. Interestingly, pathological assessment showed no apparent damage to the main organs. In summary, the results obtained from this study showed that the novel NPs DDS could improve the efficacy of DNR in the treatment of leukemia and induce apoptosis via intrinsic pathway. Thus, it can be inferred that the new drug delivery may be a useful clinical tool.

A cross-sectional survey of the diagnosis and management of bone metastasis in breast cancer patients in Turkey

Purpose

This study aimed to report the practice of managing breast cancer with bone metastasis in Turkey and to determine the adherence to the British Association of Surgical Oncology (BASO) guidelines.

Methods

This multicenter, cross-sectional epidemiological survey was conducted in 38 centers across Turkey. Data from 1,026 breast cancer patients with bone metastases (mean age 54.0 ± 11.9 years) were analyzed.

Results

Over 30 % of patients had a diagnosis of metastatic breast cancer (stage IV) at the time of primary diagnosis. The imaging modalities used for diagnosing bone metastases were bone scintigraphy (57.8 %), radiography (22.8 %), and bone survey (4.4 %). Tumor markers were detected in 94.9 %, and markers of bone metabolism were measured in 90.4 % of patients. A total of 3.5 % of patients underwent surgery for bone metastasis, 26.4 % underwent palliative chemotherapy (most commonly docetaxel + capecitabine), and 56.5 % endured radiotherapy. Most patients (96 %) also received bisphosphonate. Radiography, bone scintigraphy, and CT were the main imaging tools used for postoperative follow-up of bone metastasis. Our results were >95 % in line with the BASO guidelines for the management of bone metastasis, except that interventional procedures, such as biopsy, were applied less frequently in our survey.

Conclusions

The diagnosis and management practices of breast cancer with bone metastasis in Turkey were generally compatible with international guidelines. However, the awareness and knowledge of physicians on the current guidelines should be increased, and equipment for the appropriate interventional procedures should be provided in every clinic to obtain optimal and standard management of bone metastases.

Usefulness of palliative prognostic score in the treatment of patients with non-resectable gastric cancer

The aim of this study was to evaluate the clinical usefulness of the palliative prognostic (PaP) score in patients with non-resectable advanced gastric cancer. The PaP score was calculated prior to each course of chemotherapy in 44 consecutive patients with non-resectable advanced gastric cancer between 2003 and 2010 at the Tottori University Hospital, Yonago, Japan. The prognosis was evaluated according to the PaP score and the different chemotherapeutic agents. The median survival time (MST) was 10 months. The PaP score classified the heterogeneous patient sample into three isoprognostic groups with regard to the possibility of a 1-month survival period, with 28 patients in group A (>70% chance), 12 in group B (30-70% chance) and 4 in group C (<30% chance). The MST of the three groups was 11, 3 and 1 months for group A, B and C, respectively. In group A, chemotherapeutic regimens did not affect patient survival, although the docetaxel regimen prolonged survival of patients in group B. In conclusion, the PaP score may be useful in selecting the best chemotherapeutic regimen in patients with non-resectable gastric cancer.

Evaluating the role of nab-paclitaxel (Abraxane) in women with aggressive metastatic breast cancer

Nab-paclitaxel (Abraxane(®)) is an albumin-bound form of paclitaxel that utilizes the natural properties of albumin to improve paclitaxel delivery to the tumor. It is licensed for use in metastatic breast cancer (MBC) at a dose of 260 mg/m(2) Q3W based on its superior therapeutic index versus conventional paclitaxel 175 mg/m(2) Q3W demonstrated in a Phase III study. In a post-hoc analysis, nab-paclitaxel treatment was associated with rapid and dramatic tumor responses in patients with poor prognostic factors (visceral dominant disease, ≥3 metastatic lesions), suggesting it may be a preferred treatment for these patients. Moreover, significant efficacy has been seen with nab-paclitaxel 100 and 150 mg/m(2) QW 3/4, suggesting it may be possible to tailor use of this agent in the future.

Pancreatic solitary and synchronous metastasis from breast cancer: a case report and systematic review of controversies in diagnosis and treatment

Background

Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare, and more frequently discovered after a primary diagnosis of breast cancer. Solitary pancreatic metastases from breast cancer, without widespread disease, are actually unusual, and only 19 cases have been previously described; truly exceptional is a solitary pancreatic metastasis becoming evident together with the primary breast cancer.

Case presentation

A 68-year-old woman reported general fatigue, lethargy, and jaundice. Abdominal ultrasound (US) and magnetic resonance imaging (MRI) showed an ampulloma of Vater’s papilla; moreover, a neoplastic nodule in the left breast was diagnosed. She underwent surgery for both breast cancer and ampulloma of Vater’s papilla. Pathological examination of pancreatic specimen, however, did not confirm primary carcinoma of the duodenal papilla, but showed a metastatic involvement of pancreas from lobular breast cancer. Immunohistochemistry has been essential to confirm the origin of the malignancy: hormone receptors and mammaglobin were expressed in both the primary breast tumor and the pancreatic metastasis.

Conclusions

This is one of the few reported cases in literature of an isolated and synchronous pancreatic metastasis from breast cancer, where the definitive diagnosis was obtained only after surgery. We discuss the controversies in this diagnosis and the choice of correct treatment. The surgical resection of solitary metastases can be performed in the absence of disseminated disease.

Sequential Metastatic Breast Cancer Chemotherapy: Should the Median be the Message?

Background: Counseling and anticipatory guidance of the expected course of treatment for women newly diagnosed with metastatic breast cancer (MBC) are difficult due to multiple factors influencing survival following MBC therapy. In order to better tailor counseling at the onset and through the duration of MBC we used non-clinical trial data to better characterize real life experience of sequential MBC treatment. We examined the following aims: (1) What demographic and tumor characteristics are predictive of survival in MBC? (2) What is the median duration of each sequential chemotherapy regimen and subsequent survival of women following each sequence of chemotherapy regimen in MBC?

Methods: Retrospective study included 792 women diagnosed from January 1999 through December 2009 at the University of Pittsburgh Cancer Institute Breast Cancer Program.

Results: Median duration of sequential chemotherapy regimen and median survival from completion of sequence of chemotherapy regimens were relatively short with a wide range of treatment duration and survival. Characteristics for poor survival included hormone status, human epidermal growth factor receptor-2 (HER 2/neu) status, and increased number and type of metastatic sites. Women who took more than the second sequential chemotherapy regimens had no more than median 3 months of treatment duration and 6 months survival from treatment termination.

Discussion: Median clinical response and survival shorten with sequential chemotherapy regimen but with wide ranges. The rare clinical response of the minority should not set the standard for treatment expectations. All cancer clinicians, including oncology nurses, must ensure that patients are receiving tailored counseling regarding their specific risks and benefits for sequential MBC chemotherapy.

Cancer-Related Insomnia

Insomnia increases cancer symptom burden and impairs quality of life. The lack of standard definitions and treatment guidelines makes management difficult. Insomnia is common in most cancers but appears particularly so in lung, breast, and head and neck tumors. Older women seem most susceptible. Insomnia not only affects patients with cancer but also caregivers and families. Systematic screening is important. Few validated assessment scales are available. Nonpharmacologic therapies like cognitive behavioral therapy may help. New nonbenzodiazepine hypnotics may have some therapeutic advantages over older agents. Management of associated or contributory symptoms like fatigue, pain, and hot flashes with appropriate symptom-specific agents is important. Successful management may have a significant positive impact on global quality of life.

Nanocarriers for diagnosis and targeting of breast cancer

Breast cancer nanotherapeutics is consistently progressing and being used to remove the various limitations of conventional method available for the diagnosis and treatment of breast cancer. Nanoparticles provide an interdisciplinary area for research in imaging, diagnosis, and targeting of breast cancer. With advanced physicochemical properties and better bioavailability, they show prolonged blood circulation with efficient tumor targeting. Passive targeting mechanisms by using leaky vasculature, tumor microenvironment, or direct local application and active targeting approaches using receptor antibody, amplification in the ability of nanoparticles to target specific tumor can be achieved. Nanoparticles are able to reduce cytotoxic effect of the active anticancer drugs by increasing cancer cell targeting in comparison to conventional formulations. Various nanoparticles-based formulations are in the preclinical and clinical stages of development; among them, polymeric drug micelles, liposomes, dendrimer, carbon nanotubes, and nanorods are the most common. In this review, we have discussed the role of nanoparticles with respect to oncology, by particularly focusing on the breast cancer and various nanodelivery systems used for targeting action.

Oncology nurses' recognition of supportive care needs and symptoms of their patients undergoing chemotherapy

OBJECTIVE

To assess the accuracy of oncology nurses' recognition of supportive care needs and symptoms of their patients undergoing chemotherapy.

METHODS

The participants comprised randomly selected cancer outpatients receiving chemotherapy in an ambulatory setting and 17 oncology nurses working in two chemotherapy units in Japan. For assessment of the patients' supportive care needs and symptoms, the patients were asked to respond to a validated self-administered questionnaire. The oncology nurses completed a survey in which they indicated their perception of the level of the same set of needs or symptoms. The two data sets obtained from the patients and nurses were compared statistically to assess the accuracy of the oncology nurses' recognition of their patients' needs and symptoms.

RESULTS

Complete data sets were available for 439 patients. The most common primary cancers were breast cancer (36.0%), followed by colorectal (24.4%) and lung (12.3%) cancers. Nurses' awareness of their patients' supportive care needs and physical and psychological symptoms were less than optimal in routine care. In particular, psychological symptoms and support needs for these symptoms were markedly under-recognized. Physical symptoms associated with chemotherapy, such as hair loss, appetite loss and fatigue, were better recognized than symptoms not specific to chemotherapy, such as constipation, insomnia, dyspnea and pain.

CONCLUSIONS

Oncology nurses' recognition may not accurately reflect their patients' supportive care needs and symptoms in routine practice. In clinical practice, it may be beneficial to conduct routine screening of patients' perceived needs and symptoms comprehensively using self-administered questionnaires.

Combination drug delivery approaches in metastatic breast cancer

Disseminated metastatic breast cancer needs aggressive treatment due to its reduced response to anticancer treatment and hence low survival and quality of life. Although in theory a combination drug therapy has advantages over single-agent therapy, no appreciable survival enhancement is generally reported whereas increased toxicity is frequently seen in combination treatment especially in chemotherapy. Currently used combination treatments in metastatic breast cancer will be discussed with their challenges leading to the introduction of novel combination anticancer drug delivery systems that aim to overcome these challenges. Widely studied drug delivery systems such as liposomes, dendrimers, polymeric nanoparticles, and water-soluble polymers can concurrently carry multiple anticancer drugs in one platform. These carriers can provide improved target specificity achieved by passive and/or active targeting mechanisms.

Extending the duration of first-line chemotherapy in metastatic breast cancer: a perspective review

The treatment of metastatic breast cancer is mainly palliative, but optimal management might result in survival improvement as well. For this reason, many trials have attempted to optimize the therapeutic approach in this disease setting. Among the possible options, chemotherapy represents the backbone of the treatment and survival improvements that have been shown by the use of modern chemotherapeutic agents. Whereas the type of chemotherapy is generally dictated by patient characteristics and those of their disease, substantial controversy still remains on how long chemotherapy should be administered after disease control is achieved. In this review, we have analysed all available evidence on the duration of first-line chemotherapy in advanced breast cancer.

Long-term course of pain in breast cancer survivors: a 4-year longitudinal study

After successful treatment of early breast cancer, many women still report pain symptoms, and attribute them to the previous illness or its treatment. However, knowledge about the long-term course of pain in breast cancer is limited. Baseline assessment included 3,088 women who received a breast cancer diagnosis on average 2 years prior to enrollment, and who completed typical medical treatments. After 4 years, a subsample of 2,160 recurrence-free women (70%) was re-assessed. The major outcome variable was the composite index for general pain symptoms. Over the 4-year course, a slight but significant increase in pain was reported. If only medical variables were examined, a triple interaction between surgery type, breast cancer stage, and time indicated that pain scores increased in most subgroups, while they decreased in stage II women after mastectomy and stage III women after lumpectomy. Using a regression analytical approach, psychological and other variables added significantly to the prediction of pain persistence. Regression analysis revealed that pain symptoms increased in those women taking tamoxifen at baseline, in those reporting depression at baseline or stressful life events during the first 12 months after enrollment. Exercise at baseline had a beneficial effect on pain recovery. The persistence or increase of pain symptoms in women surviving breast cancer is associated with some medical factors (surgery type, tamoxifen use), but also with psychological factors. Pain should be a standard outcome variable in the evaluation of cancer treatment programs.

Evaluating health-related quality-of-life therapeutic effectiveness in a clinical trial with extensive nonignorable missing data and heterogeneous response: results from a phase III randomized trial of gemcitabine plus paclitaxel versus paclitaxel monotherapy in patients with metastatic breast cancer

PURPOSE

This manuscript presents health-related quality of life (HRQL) results from a phase III trial of gemcitabine-paclitaxel (GT) versus paclitaxel (T) in metastatic breast cancer patients.

METHODS

Patients completed the Rotterdam Symptom Checklist (RSCL) and Brief Pain Inventory (BPI) at baseline and at the end of each cycle. Sensitivity analyses for six longitudinal pattern mixture models (PMMs) assessed potential bias due to informative dropout. Cumulative probability plots with 50% confidence intervals indicated the proportion of patients whose HRQL was likely to improve, decline, or stay the same.

RESULTS

Sensitivity analyses addressing nonignorable missing RSCL data included 351 patients. The mean RSCL global HRQL score for GT was significantly and consistently better than that for T (all PMMs P < 0.040). The slope estimate of 1.5 points (100-point scale) per cycle from one PMM translated to a clinically significant 9-point improvement over six cycles with GT versus T. For GT, ~25% of patients were more likely than not to have improved HRQL, whereas that proportion for T was ~5%. PMMs showed no consistent treatment arm differences for BPI or other RSCL outcomes.

CONCLUSIONS

Adding gemcitabine to paclitaxel for the treatment of metastatic breast cancer is more likely to improve global HRQL over time compared to monotherapy treatment.

Duration of Chemotherapy for Metastatic Breast Cancer: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Purpose

To evaluate the effect of different first-line chemotherapy durations in patients with metastatic breast cancer (MBC) on overall survival (OS) and progression-free survival (PFS).

Methods

We searched literature databases to identify randomized controlled trials that compared different chemotherapy durations in the first-line treatment of MBC. Only trials with unconfounded comparisons of additional cycles of chemotherapy were included. The main outcome measures for this analysis were OS and PFS. Published data from retrieved studies were analyzed according to standard meta-analytic techniques.

Results

We found 11 randomized clinical trials including 2,269 patients. Longer first-line chemotherapy duration resulted into a significantly improved OS (hazard ratio [HR], 0.91; 95% CI, 0.84 to 0.99; P = .046) and PFS (HR, 0.64; 95% CI, 0.55 to 0.76; P < .001). There were no differences in effects on either OS or PFS between subgroups defined by time of random assignment, study design, number of chemotherapy cycles in the control arm or concomitant endocrine therapy.

Conclusion

Longer first-line chemotherapy duration is associated with marginally longer OS and a substantially longer PFS.

Clinical efficacy and value of redistributed subclavian arterial infusion chemotherapy for locally advanced breast cancer

PURPOSE

The aim of this study was to evaluate the efficacy and safety of redistributed subclavian arterial infusion chemotherapy (RESAIC). We have focused on the local response, quality of life (QOL), and complications. We have also investigated factors that influence the local response of RESAIC.

MATERIALS AND METHODS

The subjects were patients with locally advanced breast cancer whose tumors were resistant to standard systemic chemotherapy (at least more than two regimens), those who were physically unable to tolerate systemic chemotherapy, and patients with locally recurrent breast cancer. The registration period was between April 2006 and May 2009.

RESULTS

A total of 24 cases in 22 patients (mean age 59.5 years, range 36-82 years) were entered in the study. The local response rate of RESAIC was 77.3% (17/22). The QOL score showed improvement on average. There were no serious complications during catheter port implantation, and there was hematological toxicity over grade 3 in 27.3% (6/22) of patients. A significant difference between responders and nonresponders was seen in patients with a replaced type tumor (on imaging, diffuse contrast enhancement was seen in whole quadrants) (P = 0.043), and the patients underwent radiotherapy (P = 0.043).

CONCLUSION

RESAIC is an effective, safe treatment for locally advanced breast cancer. Because it was reviewed in only a few cases, however, large-scale studies are warranted.

Toxicity and quality of life outcomes in ovarian cancer patients participating in randomized controlled trials

MAIN PURPOSE

The objective of this study was to determine the relationship between clinician-graded symptoms based on the common toxicity criteria (CTC) and patient-reported quality of life (QoL). We hypothesized that toxicity symptoms that are objective or observable would have a higher correlation with QoL than subjective data.

MATERIAL AND METHODS

A retrospective analyses of data from three closed randomized chemotherapy trials was performed. A total of 2,110 patients with ovarian cancer (stage IIB-IV) who had complete toxicity and QoL data at cycles 3 and 6 were included. Toxicities were graded according to the National Cancer Institute Common Toxicity Criteria. Quality of life was assessed every other cycle by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30).

MAIN RESULTS

Correlations between CTC grading and the QLQ-C30 functioning scales were weak (<0.30); correlation coefficients between CTC ratings and the QLQ-C30 symptom scales including nausea, vomiting, constipation, pain, and dyspnea ranged from 0.32 to 0.49 except for constipation (0.55). On a symptom level exact agreement between clinician and patient reporting ranged from 54.2% (pain) to 80.8% (emesis/vomiting). When symptom grading differed, patients reported greater severity for pain, constipation, and dyspnea, whereas clinicians graded emesis/vomiting and nausea as more severe than the grading by patients.

CONCLUSION

Patient experience is not routinely captured by CTC toxicity scales. Therefore, clinicians should not entirely rely on the CTC grading but consider patient-reported outcomes as well.

Added value of health-related quality of life measurement in cancer clinical trials: the experience of the NCIC CTG

Health-related quality-of-life (HRQoL) data are often included in Phase III clinical trials. We evaluate and classify the value added to Phase III trials by HRQoL outcomes, through a review of the National Cancer Institute of Canada Clinical Trials Group clinical trials experience within various cancer patient populations. HRQoL may add value in a variety of ways, including the provision of data that may contrast with or may support the primary study outcome; or that assess a unique perspective or subgroup, not addressed by the primary outcome. Thus, HRQoL data may change the study's interpretation. Even in situations where HRQoL measurement does not alter the clinical interpretation of a trial, important methodologic advances can be made. A classification of the added value of HRQoL information is provided, which may assist in choosing trials for which measurement of HRQoL outcomes will be beneficial.

Antineoplastic therapy use in patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center: a simultaneous care model

BACKGROUND

Cancer patients admitted to a palliative care unit generally have a poor prognosis. The role of antineoplastic therapy (ANT) in these patients remains controversial. In the current study, the authors examined the frequency and predictors associated with ANT use in hospitalized patients who required admission to an acute palliative care unit (APCU).

METHODS

Included in the study were all 2604 patients admitted over a 5-year period to a 12-bed APCU located within a National Cancer Institute comprehensive cancer center, in which patients had access to both palliative care and ANT. Institutional databases were used to retrospectively retrieve data regarding patient demographics, cancer diagnosis, ANT use, length of hospital stay, and survival from time of admission.

RESULTS

The median hospital stay was 11 days, and the median survival was 22 days. During hospitalization, 435 patients (17%) received ANT, including chemotherapy (N = 297; 11%), hormonal agents (N = 54; 2%), and targeted therapy (N = 155; 6%). No significant change in the frequency of ANT use was detected over the 5-year period. Multivariate logistic regression analysis revealed that younger age, specific cancer diagnoses, and longer admissions were independently associated with ANT use.

CONCLUSIONS

The use of ANT during hospitalization that included an APCU stay was limited to a small percentage of patients and did not increase over time. ANT use was associated with younger age, specific cancer diagnoses, and longer admissions. The APCU facilitates simultaneous care for patients receiving ANT.

Chemotherapy with low-dose capecitabine as palliative treatment in a patient with metastatic breast cancer: a case report

Chemotherapeutic agents are rarely used for symptom management in patients under palliative care setting. This is because chemotherapeutic agents not only have limited efficacy in palliative treatment but are also known to exert severe adverse effects. We describe our experience with a patient with metastatic breast cancer who was successfully treated with low-dose capecitabine, without the development of any severe toxicities and with significant improvement in activities of daily living (ADL) and quality of life (QOL).

The patient, a 43-year-old female, had breast cancer with liver, bone, and cutaneous metastases. She visited our clinic after a year-long hiatus during which she underwent alternative therapy. She presented with ulcerated lesions on the anterior chest and dyspnea due to malignant pleural effusion. After treatment for the latter, we administered capecitabine (600 mg/day) in accordance with the wishes of the patient and her attendants. The ulcerated lesions on the anterior chest, dyspnea, ADL and QOL improved significantly, without the development of any serious adverse effects. The findings of this case indicate that chemotherapy in the form of low-dose capecitabine monotherapy may be considered in patients under palliative care setting.

Usefulness of chemotherapy beyond the second line for metastatic breast cancer: a therapeutic challenge

PURPOSE

Several lines of chemotherapy can be proposed for patients with metastatic breast cancer, but beyond the second line, agreement is lacking concerning the most appropriate therapeutic strategy.

METHODS

We conducted a retrospective analysis of the files of 162 patients, who had received at least 3 lines of chemotherapy (CT3) for metastatic breast cancer during a 5-year period (2000-2004), in order to analyze management practices and search for factors affecting survival from CT3 and predictive factors of non-progressive disease (NPD) after CT3.

RESULTS

Multivariate analysis identified seven factors which had a positive influence on survival from CT3 (SBR grade I, absence of adjuvant hormone therapy, free interval >or=2 years, absence of cerebromeningeal metastasis before CT, unique focus at initiation of CT3, use of polychemotherapy for CT2, and complete response to CT1 or CT2) and two predictive factors of NPD (histology and drug group used for CT3).

CONCLUSIONS

These factors should help determine the appropriate strategy for proposing a third line of chemotherapy.

Maintenance treatment in metastatic breast cancer

Metastatic breast cancer (MBC) occurs in 20-30% of women with breast cancer and is an incurable disease. Treatment is palliative and directed to prolong survival, decrease symptoms and improve patients' quality of life. For patients with hormone receptor-negative disease or for hormone receptor-positive disease that has become resistant to endocrine therapy, or is progressing rapidly and life threatening, cytotoxic chemotherapy is indicated. However, the optimal duration of chemotherapy treatment for MBC is still a matter of debate. Studies using maintenance chemotherapy regimens standard in the 1990s showed a consistent benefit with a more prolonged time to progression, although an improvement in survival was only demonstrated in one study. Two recent trials with newer cytotoxic agents showed controversial results; whereas one study concluded that the policy of prolonging treatment in chemotherapy-sensitive patients, after aggressive, modern combination chemotherapy, cannot be recommended for women with MBC, the other study showed that maintenance therapy with pegylated liposomal doxorubicin significantly prolonged time to progression in MBC patients after first-line chemotherapy without significant clinical toxicity. Initial data regarding metronomic chemotherapy indicate that continuously low-dose cyclophosphamide and methotrexate is minimally toxic and effective in heavily pretreated breast cancer patients. In daily practice, maintenance chemotherapy is a reasonable strategy that prolongs time to progression in patients with MBC who did not show progression after first-line chemotherapy. However, this benefit should be considered together with toxicities of treatment and the patient's preference.

Temporal patterns of fatigue predict pathologic response in patients treated with preoperative chemoradiation therapy for rectal cancer

PURPOSE

To investigate whether symptom burden before and during preoperative chemoradiation therapy (CRT) for rectal cancer predicts for pathologic tumor response.

METHODS AND MATERIALS

Fifty-four patients with T3/T4/N+ rectal cancers were treated on a Phase II trial using preoperative capecitabine and concomitant boost radiotherapy. Symptom burden was prospectively assessed before (baseline) and weekly during CRT by patient self-reported questionnaires, the MD Anderson Symptom Inventory (MDASI), and Brief Fatigue Inventory (BFI). Survival probabilities were estimated using the Kaplan-Meier method. Symptom scores according to tumor downstaging (TDS) were compared using Student's t tests. Logistic regression was used to determine whether symptom burden levels predicted for TDS. Lowess curves were plotted for symptom burden across time.

RESULTS

Among 51 patients evaluated for pathologic response, 26 patients (51%) had TDS. Fatigue, pain, and drowsiness were the most common symptoms. All symptoms increased progressively during treatment. Patients with TDS had lower MDASI fatigue scores at baseline and at completion (Week 5) of CRT (p = 0.03 for both) and lower levels of BFI "usual fatigue" at baseline.

CONCLUSION

Lower levels of fatigue at baseline and completion of CRT were significant predictors of pathologic tumor response gauged by TDS, suggesting that symptom burden may be a surrogate for tumor burden. The relationship between symptom burden and circulating cytokines merits evaluation to characterize the molecular basis of this phenomenon.