The oncologist
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Small cell lung cancer (SCLC) is generally sensitive to first-line chemotherapy, but limited disease often recurs and extensive disease is rarely curable. The most common first-line therapy regimen is cisplatin (Platinol; Bristol-Myers Squibb; Princeton, NJ) plus etoposide (Etopophos; Bristol-Myers Squibb)--PE, which is associated with overall response rates >80% in patients with limited SCLC. Although it is associated with median survival times of approximately 18-20 months for limited disease, PE yields median survival times of only approximately 8-12 months in patients with extensive disease, and symptom palliation becomes the primary therapeutic goal. ⋯ Several recent phase II trials have generated promising results for topotecan-based combination regimens, including topotecan/paclitaxel (TAXOL; Bristol-Myers Squibb) (overall response rates 45%-100%), topotecan/etoposide (overall response, 95%), and topotecan, paclitaxel, and platinum agent triplets (overall response rates 51%-93%). The most frequent serious toxicity associated with these regimens was reversible and noncumulative neutropenia, which was generally manageable with supportive care. Additional clinical trials to investigate topotecan-based combination regimens and confirm their role in the first-line treatment of SCLC are under way.
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The principle of respect for patient autonomy and the importance of informed consent are well established in the conduct of clinical research. However, in actual clinical practice, how one applies this concept is not always clear. The provocative results of a randomized trial examining "consolidation/maintenance" therapy in women with advanced ovarian cancer who achieved a clinically defined complete response to primary chemotherapy have raised difficult issues for clinicians and clinical investigators regarding their obligations to provide patients with information that may interfere with the conduct of ongoing or future research studies.
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Should adjuvant chemotherapy for resected non-small cell lung cancer (NSCLC) be the standard of care? That question has been much debated since the presentation of results from the International Adjuvant Lung Cancer Trial (IALT) in May 2003 at the plenary session of the American Society of Clinical Oncology annual meeting. The IALT study showed a statistically significant survival advantage for patients treated with cisplatin-based adjuvant chemotherapy. The topic of adjuvant chemotherapy permeated the Tenth World Conference on Lung Cancer held from August 10-14, 2003 in Vancouver, Canada. ⋯ However, concerns have arisen about toxicity due to reports of interstitial pneumonitis from Japan. The observed incidence of interstitial pneumonitis from the data available to date is approximately 1%. Which patients derive the most benefit from gefitinib? It appears that lifetime nonsmokers and patients with bronchioloalveolar histology have the highest probability of disease response.
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Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. ⋯ Balancing the instinct to fight with words of healing and acceptance remains a challenge. The history of the military metaphor and how the humanities have illuminated cancer as a metaphor are reviewed. The advantages and disadvantages of the use of this metaphor are discussed, as well as the use of other metaphors in the psychosocial dynamic of care.
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The presence of hypoxic areas is a common feature of solid tumors and has been associated with decreased sensitivity of the tumors to radiation therapy and oxygen-dependent chemotherapeutic agents, as well as worsened outcomes, including survival. Anemia is also common in cancer patients and is believed to contribute to tumor hypoxia. Thus, the rationale exists for administering recombinant human erythropoietin (rHuEPO, epoetin alfa) in an effort to increase hemoglobin levels, correct anemia, and thereby possibly increase the sensitivity of tumors to standard cancer treatment and improve patient outcomes. ⋯ Additionally, epoetin alfa administration prolonged survival and reduced morbidity and mortality in the 5T33 MM tumor model. Those investigators suggested that epoetin alfa may have antitumor activity in addition to its hematopoietic effects. Overall, these preclinical findings suggest that correction of anemia by rHuEPO can increase tumor sensitivity to both radiation therapy and chemotherapy and that epoetin alfa may exert an immunomodulatory effect in multiple myeloma.