Hematology/oncology clinics of North America
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Hematol. Oncol. Clin. North Am. · Dec 2002
ReviewAdvance directives and life-sustaining treatment: a legal primer.
Advanced directives are a natural extension of a patient's right to self-determination of what actions will be taken upon his or her body. As such, instructional advanced directives such as living wills and DNR orders represent important patient preferences that must be adhered to in the health care context. ⋯ Overall, advanced directives provide health care providers, patients, and patient families with control over the kinds of care they do and do not desire at the end of life. Understanding the legal status of these instruments will provide the physician with another tool to advocate effectively for the patient.
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Hematol. Oncol. Clin. North Am. · Oct 2002
Review Case ReportsTargeting the molecular pathophysiology of gastrointestinal stromal tumors with imatinib. Mechanisms, successes, and challenges to rational drug development.
The development of imatinib as molecularly targeted therapy for GIST represents an important case study of rational drug development. It is a paradigm of how the molecular understanding of a cancer has resulted in a new effective therapy that targets the critical pathway upon which the GIST cells were dependent: the uncontrollably active KIT signaling pathway. Unresectable or metastatic GISTs have traditionally exhibited a rapid and fatal clinical course, with no evidence of benefit from any standard cytotoxic chemotherapy. ⋯ Imatinib therapy can induce objective responses and stabilization of disease and can provide clinical benefit in the majority of GIST patients treated with the drug. Other strategies are beginning to be explored, such as the use of imatinib earlier the in course of GIST (e.g., as adjuvant therapy after definitive surgical resection of early-stage disease). Integration of signal transduction inhibitors into the armamentarium of cancer therapeutics will undoubtedly continue based on this important paradigm of GIST.
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Depression is a common complication of advanced cancer. Methods of accurate assessment and recognition are available. Risk factors for the development of depression have been identified. Pharmacologic and nonpharmacologic treatments for depression are often effective even in patients with advanced cancer.
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Evaluation and treatment of fatigue in cancer patients requires a multidisciplinary approach because it has many possible etiologies and several contributing factors. A comprehensive approach is required, especially for patients with moderate to severe fatigue, so that all possible contributing factors can be determined and an appropriate treatment plan can be created. ⋯ The short- and long-term effects of an exercise program on the fatigue levels and overall physical performance of cancer patients should be assessed in new studies. Clearly, much more research is needed not only to identify factors responsible for the fatigue but also to develop effective interventions for cancer-related fatigue.
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There is a growing awareness and a WHO directive that the palliative care paradigm should be incorporated into the care of all children with cancer, irrespective of geographic location. The barriers to pediatric palliative care identified by pediatric oncologists [3] are lack of formal courses in pediatric palliative care, a high reliance on trial-and-error learning, lack of strong role models, and lack of access to a pain and palliative care service. These barriers must be overcome.