Current opinion in oncology
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Perioperative adjuvant treatment with chemotherapy or radiation therapy has been investigated for colon, rectal, gastric, esophageal, and pancreatic cancers. To date, conclusive benefit had been shown only for colon and rectal cancers. ⋯ Several factors complicate the assessment of adjuvant therapy for gastric, esophageal, and pancreatic cancers. Some regimens have appeared to offer promise of improved postsurgical outcome, but no adjuvant treatment has established benefit in these sites.
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Bowel obstruction is a common and distressing outcome in patients with abdominal or pelvic cancer. Patients may develop bowel obstruction at any time in their clinical history, with a prevalence ranging from 5.5% to 42% in those with ovarian cancer and from 10% to 28.4% in those with colorectal cancer. The causes of the obstruction may be benign postoperative adhesions, a focal malignant or benign deposit, or relapse or diffuse carcinomatosis. ⋯ Although surgery should be the primary treatment for malignant obstruction, it is now recognized that some patients with advanced disease or in generally poor condition are unfit for surgery and require alternative management to relieve distressing symptoms. A number of treatment options are now available for the patient with advanced cancer who develops intestinal obstruction. In this review, the indications for surgery are examined, the use of nasogastric tube and percutaneous gastrostomy evaluated, and the pharmacologic approach described.
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Pancreatic, gastric, and colorectal carcinomas are diagnosed in 200,000 Americans each year. Therapeutic options for patients with advanced disease are limited; conventional chemotherapy is palliative and produces complete responses in only a few patients. Clinical research has focused on the evaluation of investigational new drugs, combination regimens, and biochemical modulation of fluorouracil. ⋯ Modified regimens of fluorouracil and methotrexate with either doxorubicin alone or with epirubicin and cisplatin were associated with response rates approaching 50% in patients with gastric cancer, but appeared to be less toxic than previously published regimens. A randomized trial comparing fluororacil alone or with oral leucovorin allowed early dose escalation according to individual tolerance; the response rate to fluorouracil alone (23%) was higher than that reported in previous phase III trials, suggesting the importance of using adequate doses to produce toxicity in terms of clinical response. Hepatic arterial infusion of floxuridine was associated with a 39% response rate in colorectal cancer patients with disease confined to the liver for whom systemic fluorouracil therapy had failed, suggesting this approach is a reasonable therapeutic option in carefully selected patients.
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The recent literature on ambulatory supportive care for the cancer patient encompasses a wide area. Those topics that have been most dominant are reviewed in this article, including the roles of primary care physicians and specialists, symptom control in the palliative-care patient, quality-of-life issues, and economic considerations.
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With the use of hematologic support (colony stimulating factors and autologous bone marrow transplantation) for the control of chemotherapy-induced myelosuppression, more intensive strategies have been developed using higher doses, multidrug combinations, or more prolonged treatments. As a consequence of this approach, nonhematologic toxicities are more frequently dose-limiting and among them cardiotoxicity is of special concern. ⋯ Various directions have been explored in experimental and clinical research for a better understanding of the physiopathology of drug-induced cardiotoxicity and the clinical characterization of agents involved in order to accurately assess risk factors and to preclude or overcome cardiotoxicity by means of cardioprotective agents or other means. The recent developments surrounding anthracycline or 5-fluorouracil cardiotoxicity are remarkable examples of these different strategies.