Curr. Oncol., Volume 13, Issue 2 (April 2006) – 6 articles

Carcinoid tumours are relatively rare and, in general, slow growing. They can be “non-functioning” tumours, presenting as a tumour mass, or “functioning” tumours secondary to the production of several biopeptides leading to the carcinoid syndrome. Though these tumours represent 0.25% of an oncology practice, a proper understanding of the clinical course of the disease and of the importance of appropriate diagnostic and therapeutic measures is very important. Proper patient management can lead to cure, particularly if the tumour can be fully resected, or to long-term palliation with medical treatment or cytoreductive surgery, or both, with significant prolongation of survival. A good understanding of the use of somatostatin analogues to achieve effective symptomatic control and of the importance of adequate follow-up and cardiac monitoring to prevent or effectively treat cardiac complications can contribute significantly to optimal control of this complex disease, ultimately improving the quality of life of affected patients. This article, developed by a group of Canadian experts, provides a framework that will assist clinicians in taking an optimal approach to managing their patients with carcinoid tumour. Full article

We compared the effect of set-up error and uncertainty on two radiation therapy treatment plans for head and neck cancer: one using intensity modulated radiation therapy (IMRT) and one using conventional three-dimensional conformal radiation therapy (3D-CRT). We used a Pinnacle3 (Philips Medical Systems, Markham, Ontario) system to create the two treatment plans (7-beam IMRT and 5-beam 3D-CRT) for the same volumetric data set, based on the objectives and constraints defined in the Radiation Therapy Oncology Group H-0022 protocol. In both plans, the dose–volume constraints for the targets and the organs at risk (OARS) were met as closely as the beam geometries would allow. Monte Carlo–based simulations of set-up error and uncertainty were performed in three orthogonal directions for 840 simulated “courses of treatment” for each plan. A systematic error (chosen from distributions characterized by standard deviations ranging from 0 mm to 6 mm) and random uncertainties (2 mm standard deviation) were incorporated. We used a probability approach to compare the sensitivities of the IMRT and the 3D-CRT plans to set-up error and uncertainty in terms of equivalent uniform dose (EUD) to targets and OARS. Based on the EUD analysis, the targets and OARS showed considerably greater sensitivity to set-up error with the IMRT plan than with the 3D-CRT plan. For the IMRT plan, target EUDS were reduced by 4%, 7.5%, and 10% for 2-mm, 4-mm, and 6-mm set-up errors respectively. However, even with set-up error, the mandible, spinal cord, and parotid EUDS always remained lower with the IMRT plan than with the 3D-CRT plan. We conclude that, when quantified by EUD, IMRT plan doses to OARS and targets are more sensitive to set-up error than are 3D-CRT-plan doses. However, as judged by the differences between target and OAR doses, IMRT retains its superiority over 3D-CRT, even in the presence of set-up error. Full article

Clinical research with human subjects is an ethically challenging task requiring ultimate trust on the part of patients and ultimate respect for persons on the part of clinical researchers. The author provides a simple framework to help researchers ensure the ethical integrity of a clinical trial in oncology. Full article

Patients with symptomatic metastases referred for outpatient palliative radiotherapy for symptom control at the Rapid Response Radiotherapy Program (rrrp) and the Bone Metastases Clinic (bmc) at the Toronto–Sunnybrook Regional Cancer Centre have a limited life expectancy. Relevant medical information is missing from the files of many referred patients when they arrive at the clinics, potentially causing delayed treatment and ambiguity in the best management of their needs in situations of worsening condition. Clear documentation of the do-not-resuscitate (dnr) order is imperative to avoid panic and the taking of unnecessarily aggressive measures in situations in which cardiopulmonary resuscitation (cpr) has no benefit or is not desired. Here, we report the current practices of cpr code status documentation for patients referred to the rrrp and the bmc for outpatient palliative radiotherapy. We reviewed referral notes and accompanying medical records for 209 consecutive patients seen in the rrrp and the bmc during May–August 2004 for documentation of cpr-related advance directives. Patient demographics and cancer history were also recorded. Only 13 (6.2%) of the 209 patients had any documented reference to cpr code status. Of these 13 patients, 8 were dnr-coded, and 5 were full code. As compared with patients having no documented cpr code status, patients with documented status were significantly older (median age: 77 years; p = 0.0347), had poorer performance status (median Karnofsky performance status score: 40; p = 0.0001), and were more likely to be referred hospital inpatients (69%, p = 0.0004). Only a small proportion of symptomatic advanced cancer patients had any documentation of cpr code status upon referral for outpatient palliative radiotherapy. In future, our clinics plan to request information about cpr code status on our referral form. Full article