Current Oncology

This article provides an overview of recent advances in chemotherapy that may be used for the treatment of patients with locally advanced or metastatic breast cancer (mbc). Key phase ii and iii trial data for eribulin mesylate, ixabepilone, and nab-paclitaxel, published since 2006, are discussed on the basis of recency, depth, and quality. Eribulin mesylate is the first monotherapy to significantly increase overall survival in patients with pretreated mbc, but nab-paclitaxel offers a novel and safer mode of delivery in comparison with standard taxanes. By contrast, the use of ixabepilone will be limited for now, until the associated neurotoxicity can be better managed. Alongside a brief overview of the other major chemotherapies currently in use, we have aimed to provide a Canadian context for how these novel agents may be integrated into clinical practice.

Background: Participation in colorectal screening remains low even in countries with universal health coverage. Area-level determinants of low screening participation in Canada remain poorly understood. Methods: We assessed the association between area-level income and two indicators of colorectal screening (having never been screened, having not been screened recently) by linking census-derived local area-level income data with self-reported screening data from urban-dwelling respondents to the Canadian Community Health Survey (50–75 years of age, cycles 2005 and 2007, n = 18,362) who reported no known risk factors for colorectal cancer. Generalized estimating equation Poisson models estimated the prevalence ratios and differences for having never been screened and having not been screened recently, adjusting for individual-level income, education, marital status, having a regular physician, age, and sex. Results: About 53% of the study population had never been screened. Among individuals who had ever been screened, 35% had been screened recently. Adjusting for covariates, lower area-level income was associated with having never been screened [covariate-adjusted prevalence ratios: 1.24 for quartile 1; 95% confidence limits (cl): 1.16, 1.34; 1.25 for quartile 2; 95% cl: 1.15, 1.33; 1.15 for quartile 3; 95% cl: 1.08, 1.23]. Among individuals who had been screened in their lifetime, area-level income was not associated with having not been screened recently. Conclusions: Lower area-level income is associated with having never been screened for colorectal cancer even after adjusting for individual socioeconomic factors. Those findings highlight the potential importance of socioeconomic contexts for colorectal screening initiation and merit attention in both future research and surveillance efforts.

In Canada, self-reported data from the Canadian Community Health Survey 2008 and 2012 provide an opportunity to examine overall utilization of breast, cervical, and colorectal cancer screening tests for both programmatic and opportunistic screening. Among women 50–74 years of age, utilization of screening mammography was stable (62.0% in 2008 and 63.0% in 2012). Pap test utilization for women 25–69 years of age remained high and stable across Canada in 2008 and 2012 (78.9% in 2012). The percentage of individuals 50–74 years of age who reporting having at least 1 fecal test within the preceding 2 years increased in 2012 (to 23.0% from 16.9% in 2008), but remains low. Stable rates of screening mammography utilization (about 30%) were reported in 2008 and 2012 among women 40–49 years of age, a group for which population-based screening is not recommended. Although declining over time, cervical cancer screening rates were high for women less than 25 years of age (for whom screening is not recommended). Interestingly, an increased percentage of women 70–74 years of age reported having a Pap test. In 2012, a smaller percentage of women 50–69 years of age reported having no screening test (5.9% vs. 8.5% in 2008), and more women reported having the three types of cancer screening tests (19.0% vs. 13.2%). Efforts to encourage use of screening within the recommended average-risk age groups are needed, and education for stakeholders about the possible harms of screening outside those age groups has to continue.

Background: The prognosis of patients with brain metastases from non-small-cell lung cancer (NSCLC) is poor. However, some reports suggest that patients with brain metastases at the time of initial diagnosis have a more favourable survival than do patients with advanced NSCLC without brain metastases. Methods: In a retrospective cohort of all new lung cancer patients seen at a Canadian tertiary centre between July 2005 and June 2007, we examined survival after a diagnosis of brain metastases for patients with brain metastases at initial diagnosis and patients who developed brain metastases later in their illness. Results: During the 2-year period, 91 of 878 patients (10.4%) developed brain metastases. Median age in this cohort was 64 years. In 45, brain metastases were present at initial diagnosis, and in 46, brain metastases developed later in the course of the illness. Median survival in the entire cohort was 7.8 months. Survival after the diagnosis of brain metastases was similar for patients with brain metastases at diagnosis and later in the illness (4.8 months vs. 3.7 months, p = 0.53). As a result, patients who developed brain metastases later in their illness had a longer overall survival than did patients with brain metastases at diagnosis (9.8 months vs. 4.8 months). Among patients who received chemotherapy, the survival of patients with brain metastases at diagnosis was still poor (6.2 months). Conclusions: Our data show limited survival in patients with brain metastases from NSCLC. Careful patient selection for more aggressive treatment approaches is necessary.

Despite improvements in the diagnosis and treatment of cancers, the incidence of pituitary metastasis has increased. Prostate cancer metastasis to the pituitary, however, is rare, and these tumors usually grow rapidly. They are also more likely to be located in the posterior pituitary, and the presenting symptoms are often nonspecific, which makes early diagnosis challenging. The management of this condition is usually multidisciplinary, and requires careful assessment and decision making. We present a case of a patient who developed prostate cancer metastasis to the pituitary. In this report, we show that patients with prostate cancer on corticosteroid therapy who develop withdrawal symptoms or other endocrine symptoms should be assessed for pituitary and other brain metastasis. This case report also discusses the impact of switching from prednisone and abiraterone to dexamethasone and abiraterone. Our report shows that patients on abiraterone and prednisone whose PSA has increased, but who have no radiologic progression, may have their PSA controlled and thereby improved survival time when they are switched to abiraterone and dexamethasone.

Purpose: Multidisciplinary cancer conferences (mccs) are designed to optimize patient outcomes. It appears intuitive that mccs are essential to clinical decision-making and patient management; however, it is unclear whether that belief is supported by evidence. Our objectives were to assess the currently published literature addressing the impact of mccs on clinical decision-making and patient outcomes. Methods: Ovid medline was searched from 1950 to June 2010 using these keywords: “multidisciplinary/interdisciplinary/clinical meeting$/conference$/round$/team$,” “decision making,” “neoplasms$/cancer$/oncology/tumo(u)r conference$/board$/meeting$,” “multidisciplinary/interdisciplinary cancer conference$/meeting$.” All trials, guidelines, metaanalyses, reviews, and prospective and retrospective studies were included. Results: The keywords retrieved 595 abstracts, and 30 manuscripts were obtained. Most of the studies assessed the impact of mccs on clinical decision-making rather than on patient outcomes. Conclusions: Available evidence supports the belief that mccs significantly influence clinical decision-making and treatment recommendations. In contrast, scant evidence suggests that mccs improve patient outcomes. Unfortunately, the current literature is substantially heterogeneous and therefore does not allow for firm conclusions.

Background: Radiation therapy (RT) after mastectomy for breast cancer can improve survival outcomes, but has been associated with inferior cosmesis after breast reconstruction. In the literature, RT dose and fractionation schedules are inconsistently reported. We sought to determine the pattern of RT prescribing practices in a provincial RT program for patients treated with mastectomy and reconstruction. Methods: Women diagnosed with stages 0–III breast cancer between January 2012 and December 2013 and treated with curative-intent rt were identified from a clinicopathology database. Patient demographic, tumour, and treatment information were extracted. Of the identified patients, those undergoing mastectomy were the focus of the present analysis. Results: Of 4016 patients identified, 1143 (28%) underwent mastectomy. The patients treated with mastectomy had a median age of 57 years, and 37% of them underwent reconstruction. Treatment with more than 16 fractions of rt was associated with autologous reconstruction [odds ratio (OR): 37.2; 95% confidence interval (CI): 11.2 to 123.7; p < 0.001], implant reconstruction (OR: 93.3; 95% CI: 45.3 to 192.2; p < 0.001), and treating centre. Hypofractionated treatment was associated with older age (OR: 0.94; 95% CI: 0.92 to 0.96; p < 0.001), and living more than 400 km from a treatment centre (OR: 0.37; 95% CI: 0.16 to 0.86; p = 0.02). Conclusions: Prescribing practices in breast cancer patients undergoing mastectomy are influenced by reconstruction intent, age, nodal status, and distance from the treatment centre. Those factors should be considered when making treatment decisions.

Objectives: In cancer patients, chemotherapy-induced peripheral neuropathy (cipn) is a common complication, characterized by pain, loss of sensation, and numbness. Medical treatment for peripheral neuropathies has been shown to be ineffective for cipn. Acupuncture has been shown to be safe and effective in treating cancer-related symptoms and other peripheral neuropathies. For the present review, we aimed to evaluate the efficacy of acupuncture for the treatment of cipn. Design: Comprehensive searches for relevant studies were conducted in Ovid embase, the Web of Science, Ovid medline, the Cochrane Central Register of Controlled Trials (central), cinahl (ebsco Information Services, Ipswich, MA, U.S.A.), and the ClinicalTrials.gov Web site. References from previous systematic reviews were also searched. Additional trials were found in the reference lists of relevant papers and in searches of Google Scholar and acupuncturespecific Web sites. Included studies were randomized controlled trials (rcts) of any type of acupuncture used to treat patients with cipn. Results: Three clinical trials (203 participants) were included. Two studies found acupuncture to be effective in alleviating cipn pain and improving quality of life. One study found no benefit in improving neuropathic pain, symptoms, or quality of life. Study quality was variable and included a moderate overall risk of bias. Conclusions: The evidence is insufficient to recommend acupuncture for the treatment or prevention of cipn. Further research is needed to evaluate the effects of acupuncture in the treatment of cipn. Given that acupuncture is considered safe and might provide relief for patients, it can be considered at the clinician’s discretion.

The discovery of immune checkpoint proteins such as PD-1/PDL-1 and CTLA-4 represents a significant breakthrough in the field of cancer immunotherapy. Therefore, humanized monoclonal antibodies, targeting these immune checkpoint proteins have been utilized successfully in patients with metastatic melanoma, renal cell carcinoma, head and neck cancers and non-small lung cancer. The US FDA has successfully approved three different categories of immune checkpoint inhibitors (ICIs) such as PD-1 inhibitors (Nivolumab, Pembrolizumab, and Cemiplimab), PDL-1 inhibitors (Atezolimumab, Durvalumab and Avelumab), and CTLA-4 inhibitor (Ipilimumab). Unfortunately, not all patients respond favourably to these drugs, highlighting the role of biomarkers such as Tumour mutation burden (TMB), PDL-1 expression, microbiome, hypoxia, interferon-γ, and ECM in predicting responses to ICIs-based immunotherapy. The current study aims to review the literature and updates on ICIs in cancer therapy.