Curr. Oncol., Volume 16, Issue 1 (January 2009) – 9 articles

Brain metastasis is increasingly common, affecting 20%–40% of cancer patients. After diagnosis, survival is usually limited to months in these patients. Treatment for brain metastasis includes whole-brain radiation therapy, surgical resection, or both. These treatments aim to slow progression of disease and to improve or maintain neurologic function and quality of life. Although less common, primary brain tumours produce symptoms that are similar to those of brain metastasis. Glioblastoma, the most common malignant tumour of the brain, has a median survival of less than 12 months. Patients are often treated with surgical resection followed by radical radiation therapy and chemotherapy. Here, we present 2 separate cases of lesions in the brain radiologically compatible with brain metastasis. In both cases, no primary cancer site had been established, and neurosurgical intervention was sought to obtain a pathologic diagnosis. Both cases were pathologically confirmed as glioblastoma. These cases demonstrate the importance of differentiation between brain metastases and primary brain tumours to ensure that the appropriate management strategy is implemented. Full article

Cancer cells are characterized by aberrant growth arising from deregulated signalling pathways. The mammalian target of rapamycin (mtor) pathway integrates multiple growth signals coming from both intracellular and extracellular cues. In this short review, we summarize what is known about the efficacy of targeting the mtor pathway to treat cancer patients, and we explain the rationale behind promising new inhibitors that could show more potent tumour growth inhibition than did the first generation of these drugs. Full article

Background: Systematic symptom reporting by patients and the use of questionnaires such as the Edmonton Symptom Assessment System (ESAS) have potential to improve clinical encounters and patient satisfaction. We review findings from published studies of the ESAS to guide use of the system and to focus research. Methods: A systematic search for articles from 1991 through 2007 found thirty-nine peer-reviewed papers from 25 different institutions, thirty-three of which focused on patients with cancer. Observations, data, and statistics were collated according to relevance, reliability, validity, and responsiveness. Results: Findings apply predominantly to symptomatic palliative patients with advanced cancer who were no longer receiving active oncologic therapies. Uncertainty about summarizing findings arises from frequent modification of the ESAS (altered items, scales, and time periods). Overall, reliability is established for daily administration. Scores are skewed, with a floor effect, but the relative order of symptoms by mean scores is similar across studies. Emotional symptoms are poorly captured by the depression and anxiety items. An equally weighted summation of scores may estimate a construct of “physical symptom distress,” which in turn is related to performance status, palliative goals, quality of life, and well-being. Conclusions: The ESAS is reliable, but it has restricted validity, and its use requires a sound clinical process to help interpret scores and to give them an appropriate level of attention. Research priorities are to further develop the ESAS for assessing a greater number of important physical symptoms (and to target “physical symptom distress”), and to develop a similar instrument for emotional symptoms. Full article

Background: Canadian data describing inpatient palliative care unit (PCU) utilization are scarce. In the present study, we performed a quality assessment of a 24-bed short-term PCU with a 3-months-or-less life expectancy policy in a tertiary care setting. Methods: Using a retrospective chart review, we explored wait time (WT) for admission (May 2005 to April 2006), length of stay [LOS (February 2005 to January 2006)], and patient demographics. Results: The WT data showed 508 referrals, with 242 resulting in admissions (92% malignant diagnoses) and 266 not (82% malignant). The most common malignancies in both groups were gastrointestinal, lung, and genitourinary. Median WT for admitted patients was 6 days, varying with referral source, such as the same hospital, home, or another hospital (6, 4, and 8.5 days respectively). Most admissions (93%) occurred in 21 or fewer days. Patient death (52%), admission to another PCU (25%), and declined offer (10%) were common reasons for no admission. Median LOS for 219 admitted patients was 19 days (range: 0–249 days). Most patients (94%) died in the PCU; a minority were discharged. Conclusions: Many patients requiring PCU services are admitted within a few days of referral, especially patients with the least available support: those at home. However, half of the non-admitted patients die while waiting—a potential area for improvement. The LOS for admitted patients complied with the 3-month “expected lifespan” PCU policy. Results are significant, because ensuring quality of life for palliative care patients includes timely PCU access and sufficient LOS to address end-of-life needs. Full article

Purpose: To provide consensus recommendations on the use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIS) in patients with advanced or meta-static non-small-cell lung cancer (NSCLC). Methods: Using a systematic literature search, phase II trials, randomized phase III trials, and meta-analyses were identified for inclusion. Results: A total of forty-six trials were included. Clear evidence is available that EGFR-TKIS should not be administered concurrently with platinum-based chemotherapy as first-line therapy in advanced or metastatic NSCLC . Evidence is currently insufficient to recommend single-agent EGFR-TKIS as first-line therapy either in unselected populations or in populations selected on the basis of molecular or clinical characteristics. Following failure of platinum-based chemotherapy, the evidence suggests that second-line EGFR-TKIS or second-line chemotherapy result in similar survival. Quality of life and symptom improvement for patients treated with an EGFR-TKI appear better than they do for patients treated with second-line docetaxel. Sequence of therapy may not appear to be important, but if survival is the outcome of interest, the goal should be to optimize the number of patients receiving three lines of therapy. Based on available data, molecular markers and clinical characteristics do not appear to be predictive of a differential survival benefit from an EGFR-TKI and therefore those factors should not be used to select patients for EGFR-TKI therapy. Conclusions: The EGFR-TKIS represent an additional therapy in the treatment of advanced or metastatic NSCLC. The results of ongoing clinical trials may define the optimal role for these agents and the effectiveness of combinations of these agents with other targeted agents. Full article

The epidermal growth factor receptor (EGFR) is often overexpressed or dysregulated in a variety of solid tumours, including gastrointestinal (GI) malignancies. Agents targeting the EGFR-mediated signalling pathway are increasingly part of the therapeutic armamentarium for the treatment of advanced lung, head-and-neck, and colorectal carcinoma. The EGFR inhibitors (EGFRIS) approved in Canada include the tyrosine kinase inhibitors erlotinib and gefitinib (in selected cases), and the monoclonal antibodies (mAbs) panitumumab and cetuximab. Although EGFRIS have been proven effective in the treatment of a variety of malignancies, the entire class of agents is associated with a high prevalence of dermatologic side effects, most commonly skin rash. This reversible condition requires intervention in approximately one third of patients. A proactive, multidisciplinary approach to management can help to improve skin rash and optimize clinical outcomes by preventing EGFRI dose reduction or discontinuation. In addition, effective management and patient education may help to alleviate the significant social and emotional anxiety related to this manageable side effect, thus resulting in improved quality of life. The present article focuses on EGFR-targeted mAbs for the treatment of GI malignancy, addressing the pathophysiology, clinical presentation, and incidence of skin rash caused by this class of agents. Recommendations aimed at establishing a framework for consistent, proactive management of skin rash in the Canadian setting are presented. Full article

Background: Increasing systemic treatment and shortages of oncology professionals in Canada require innovative approaches to the safe and effective delivery of intravenous (IV) cancer treatment. We conducted a systematic review of the clinical and scientific literature, and an environmental scan of models in Canada, the United Kingdom, Australia, and New Zealand. We then developed a framework for the organization and delivery of IV systemic treatment. Methods: The systematic review covered the MEDLINE, EMBASE, CINAHL, and HealthStar databases. The environmental scan retrieved published and unpublished sources, coupled with a free key word search using the Google search engine. The Systemic Treatment Working Group reviewed the evidence and developed a draft framework using evidence-based analysis, existing recommendations from various jurisdictions, and expert opinion based on experience and consensus. The draft was assessed by Ontario stakeholders and reviewed and approved by Cancer Care Ontario. Results: The poor quantity and quality of the evidence necessitated a consensus-derived model. That model comprises four levels of care determined by a regional systemic treatment program and three integrated structures (integrated cancer programs, affiliate institutions, and satellite institutions), each with a defined scope of practice and a specific organizational framework. Interpretation: New models of care are urgently required beyond large centres, particularly in geographically remote or rural areas. Despite limited applicable evidence, the development and successful implementation of this framework is intended to create sustainable, accessible, quality care and to measurably improve patient outcomes. Full article