Curr. Oncol., Volume 17, Issue 2 (April 2010) – 14 articles

Tumour-induced hypercalcemia (TIH) and pain from bone metastases are common complications of advanced malignancy and have a significant negative impact on quality of life. Many cancer patients in the advanced stages of their palliative illness prefer to avoid hospitalization and to receive their care in the community setting. This small open-label prospective pilot study explored the feasibility of administering zoledronic acid intravenously in the community setting (home and residential hospices). It enrolled a convenience sample of 12 patients with advanced cancer and TIH (n = 7), malignant bone pain (n = 3), or TIH and malignant bone pain (n = 2). The mean duration of infusion was 15 minutes (range: 14–30 minutes). The total nursing time required was 95 minutes, and the mean total cost, including nursing time, travel time, and drug costs was $708.97 per infusion. This cost was compared with costs for clodronate and pamidronate ($402.52 and $406.12 respectively). Calcium fell from a mean of 2.97 mmol/L on day 0 to 2.63 mmol/L on day 4 and to 2.54 mmol/L on day 10. Delirium resolved in 2 of 5 patients with TIH-associated delirium. Intravenous zoledronic acid administered in the community to palliative patients at the end of life is feasible and safe, and the short duration of infusion offers advantages to patients and nursing resources alike. The higher cost of zoledronic acid per infusion may be offset by the advantage of its short infusion time. Full article

The treatment of metastatic breast cancer is challenging. We recently assisted in the development of targeted therapies (in combination with chemotherapy or as monotherapy) that have improved results for selected groups of patients. Lapatinib is a dual tyrosine kinase inhibitor that has shown efficacy in breast cancer. Consequently, its use has been approved, in combination with capecitabine, for the treatment of disease positive for the human epidermal growth factor receptor. Here, we present a case of complete clinical response to a combination of lapatinib and gemcitabine that was maintained for 1 year. Full article

Febrile neutropenia is a well-known entity in children with cancer, being responsible for the high risk for infection that characterizes this population. For this reason, cancer patients are hospitalized so that they can receive prophylactic care. Risk factors have been used to classify patients at a high risk for developing bacteremia. The present study evaluates whether those risk factors (C-reactive protein, hypotension, leukemia as the cancer type, thrombocytopenia, recent chemotherapy, and acute malnutrition) apply to patients at the Unidad Nacional de Oncología Pediátrica. We evaluated 102 episodes in 88 patients, in whom risk factors and blood cultures were tested. We observed no statistical relationship between the six risk factors and bacteremia. There was also no relationship between bacteremia and the simultaneous presence of two, three, or more risk factors. A significant relationship of C-reactive protein and platelet count with other outcome factors was observed. Full article

During the first three quarters of the twentieth century, radical mastectomy was an accepted and common procedure in the management of patients with earlystage cancer of the breast. After a lifetime of thinking about and working with patients with early-stage breast cancer, Vera Peters presented and published, in the mid-1970s, a retrospective historical case–control study that demonstrated the lack of a survival benefit for radical or modified radical mastectomy as compared with more conservative surgery with lumpectomy. In the years that followed, prospective randomized studies confirmed her findings. Full article

Objectives: Using primary and secondary data sources, we set out to estimate the Canadian wage loss from cancer for patients, caregivers, and parents from a patient and a societal perspective. Methods: First, a multiple-database literature search was conducted to find Canadian-specific direct surveys of wage loss from cancer. Second, estimates for wage loss were generated from the nationally representative Canadian Community Health Survey (CCHS) Cycle 3.1. In addition, both estimates were standardized to derive a friction-period estimate and were extrapolated to produce national annual estimates. Results: The literature search identified six direct surveys that included a total of 1632 patients with cancer. The CCHS Cycle 3.1 included 2287 patients with cancer. Overall, based on the direct surveys, newly diagnosed cancer patients reduced their labour participation in the friction period by 36% ($4,518), and caregivers lost 23% of their workable hours ($2,887). The CCHS estimated that annual household income was 26.5% lower ($4,978) for respondents with cancer as compared with the general population. For the year 2009, results from direct surveys indicated that new cancers in Canada generated a wage loss of $3.18 billion; the CCHS Cycle 3.1 estimate was $2.95 billion. Conclusions: Wage loss from cancer is a significant economic burden on patients, their families, and society in Canada, with direct surveys and the CCHS providing similar estimates. Full article

Colorectal carcinoma is the second most common cause of death in Canada. Because there is a precursor lesion (that is, the polyp), screening is critically important to prevent the disease through polyp removal—and failing that, to detect colorectal carcinoma at an early stage, when it can be cured. Several screening modalities are available, but colonoscopy is considered the best. People should avail themselves of such examinations, and physicians should encourage them to do so. Full article

Background: Sunitinib is approved for treatment of advanced renal cell carcinoma (RCC). Based on a clinical observation that patients receiving sunitinib developed macrocytosis, we undertook a study to further define this observation. Methods: In a retrospective review of RCC patients treated at a single centre, data on treatment duration, hematology parameters, concomitant medications, vitamin B₁₂ and folate levels, and thyroid function were recorded. Results: The 43 patients reviewed had received a median of 5 cycles of sunitinib. Overall, 21 patients (49%) developed macrocytosis after a median of 3 cycles. Of the 9 patients that received 2 or fewer cycles, none developed macrocytosis. Among patients with macrocytosis, 9 (43%) had anemia at the time macrocytosis was first documented. In patients who did not develop macrocytosis, 82% showed a trend of increasing mean corpuscular volume. Conclusions: Treatment with sunitinib in patients with rcc can cause macrocytosis. The frequency of macrocytosis increases with duration of treatment. The mechanism of sunitinib-associated macrocytosis remains to be elucidated. Full article

Background: Based on the TAX 327 phase iii trial, docetaxel-based chemotherapy is the standard first-line treatment for hormone-resistant prostate cancer (HRPC); however, there is some heterogeneity in the use of this agent in routine clinical practice. The aim of the present study was to examine the patterns of docetaxel use in routine clinical practice at our institution and to compare them with docetaxel use in the TAX 327 clinical trial. Methods: We conducted a retrospective chart review of HRPC patients treated with first-line docetaxel between 2005 and 2007 at the Princess Margaret Hospital. Results: In the first-line setting, 88 patients with HRPC received docetaxel. The main reasons for initiating docetaxel were rising prostate-specific antigen (PSA, 98%) and progressive symptoms (77%). The PSA response rate was 67%; median time to response was 1.5 months, and duration of response was 6.8 months. Median survival was 15.9 months (95% confidence interval: 12.4 to 20.5 months). Patients received a median of 7 cycles of treatment, and the main toxicities were fatigue (35%) and neuropathy (24%). Post docetaxel, 36 patients received second-line treatment with a 22% response rate. Conclusions: In routine clinical practice, HRPC patients received docetaxel mainly because of symptomatic disease progression. Overall response rates and toxicities were comparable to those in the TAX 327 trial. However, our patients received a median of only 7 cycles of treatment versus the 9.5 administered on trial, and survival was slightly shorter in our single-institution study. A larger prospective multicentre analysis, including performance status and quality-of-life parameters, may be warranted to determine if docetaxel performs as well in routine clinical practice as it does in the clinical trial setting. Full article

Historically, first-line treatment of non-small-cell lung cancer (NSCLC) has been based on giving a limited number of cycles of chemotherapy to achieve tumour response or stable disease. Patients are then observed without active therapy until disease progresses, at which point, subsequent lines of therapy are given. In recent years, two new concepts have been introduced to the management of NSCLC: maintenance therapy and therapy with targeted agents. Maintenance therapy—with either a chemotherapeutic or biologic agent—is given immediately after first-line therapy to patients who have achieved tumour response or stable disease. Choice of therapy may include continuation of the agents included in the induction regimen or introduction of different agents (early second-line treatment) with the aim of preventing progression and prolonging progression-free survival. Targeted agents such as bevacizumab and erlotinib target critical molecular signalling pathways and provide several advantages over chemotherapy, including fewer toxicities and the possibility of a longer duration of therapy. This review examines the treatment options in all lines of therapy for metastatic nsclc, focusing particularly on targeted therapies that have been approved in the United States, Canada, or Europe. Full article

Hepatocellular carcinoma (HCC) is an uncommon tumour, but its incidence is increasing in Canada and elsewhere. Currently, there are no Canadian recommendations for diagnosis and treatment of HCC, and possible options may have regional limitations. A consensus symposium was held in the Ottawa region to consider current diagnostic and management options for HCC. These recommendations were developed: Diagnosis—with adequate imaging, a biopsy is not required pre-surgery, but is required before the start of systemic therapy; lesions smaller than 1 cm should be followed and not biopsied; repeat biopsies should be core tissue biopsies; magnetic resonance imaging is preferred, but triphasic computed tomography imaging can be useful Resection—recommended for localized hcc Radiofrequency ablation—recommended for unresectable or non-transplantable HCC; should not be performed in the presence of ascites Trans-arterial chemoembolization (TACE)—doxorubicin with lipiodol is the agent of choice; trans-catheter embolization is an alternative for patients if tace is not tolerated or is contraindicated Medical management—first-line sorafenib should be considered the standard of care Transplantation—suitable patients meeting Milan criteria should be assessed for a graft regardless of other treatments offered. The authors feel that the recommendations from this consensus symposium may be of interest to other regions in Canada. Full article