Nature reviews. Clinical oncology
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Delirium is a frequent neurocognitive complication in patients with cancer, particularly in patients with advanced-stage disease (in whom a combination of factors might trigger an episode) and in patients with a high degree of predisposing vulnerability, such as the elderly or patients with dementia. The communicative impediments associated with delirium generate distress for the patient and their family, and substantive challenges for health-care practitioners, who might have to contend with agitation, and difficulty in assessing pain and other symptoms. ⋯ Although delirium is ominously associated with the terminal phase of life, part or complete reversal can be possible depending on the nature of the precipitating factors, and on whether investigation and treatment of these factors is consistent with the established goals of care. Pharmacological treatment for symptom control is indicated for most patients with delirium, and antipsychotics are the drugs of choice, but some patients with refractory and nonreversible delirium can require continuous deep sedation with agents such as midazolam.
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The results of several clinical trials in metastatic colorectal cancer presented in 2014 will influence clinical practice. These findings include definitive data from phase III trials comparing bevacizumab and cetuximab-based therapy in the first-line, studies elucidating the value of maintenance therapy after induction treatment, and data on new agents in this disease.
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Although the majority of patients with breast cancer have clinically negative axillary nodes at preoperative assessment, around 15-20% of these women will have metastatic disease within the lymph nodes at operative sentinel node biopsy, and additional selective treatment to the axilla might be required. Local treatment to the axilla can include axillary node clearance or axillary radiotherapy. ⋯ We review the evidence base for management of the axilla after detection of a positive sentinel node, discuss the evidence for why micrometastatic disease requires systemic but not axillary therapy, and present data suggesting that axillary irradiation for macrometastases gives equivalent control to axillary node clearance, but causes less morbidity such as lymphoedema. Ongoing trials will confirm whether any further therapy can be omitted for all patients with low volume, sentinel-node macrometastases.