Decision-making in patients with advanced cancer compared with amyotrophic lateral sclerosis.

AIM: Patients with advanced cancer need information about end-of-life treatment options in order to make informed decisions. Clinicians vary in the frequency with which they initiate these discussions. PATIENTS AND METHODS: As part of a long-term longitudinal study, patients with an expected 2-year survival of less than 50% who had advanced gastrointestinal or lung cancer or amyotrophic lateral sclerosis (ALS) were interviewed. Each patient's medical record was reviewed at enrollment and at 3 months for evidence of the discussion of patient wishes concerning ventilator support, artificial nutrition and hydration (ANH), resuscitation (DNR) and hospice care. A Kaplan-Meier analysis was also performed and 2-year survival calculated. RESULTS: 60 cancer and 32 ALS patients were enrolled. ALS patients were more likely than cancer patients to have evidence of discussion about their wishes for ventilator support (31% vs 0%, p<0.001), ANH (38% vs 0%, p<0.001), DNR (25% vs 0%, p<0.001) and hospice care (22% vs 5%, p = 0.03). At 6 months, 91% of ALS patients were alive compared with 62% of cancer patients; at 2 years, 63% of ALS patients were alive compared with 23% of cancer patients (p<0.001). CONCLUSIONS: Cancer patients were less likely than ALS patients to have had documented advanced care planning discussions despite worse survival. This may reflect perceptions that ALS has a more predictable course, that advanced cancer has a greater number of treatment options, or differing views about hope. Nevertheless, cancer patients may be less adequately prepared for end-of-life decision-making.

Adjuvant therapy of colon cancer.

The primary curative therapy of colorectal cancer is surgical resection. However, within the last 15 years, prospectively randomized appropriately powered clinical trials have convincingly demonstrated that adjunctive postoperative adjuvant chemotherapy is of benefit to all patients with node-positive disease (stage III) and arguably to high-risk node-negative (stage II) cases. In the United States, the clinical trials encompassing greater than 5,000 cases have demonstrated that fluorouracil (5-FU)/leucovorin used in a variety of doses and schedules improves disease-free and overall survival in resected node-positive (stage III) colorectal cancer. The postoperative use of 5-FU/leucovorin for approximately 6 months represents standard of care for such patients. Current clinical trials are evaluating the role of nonfluorinated pyrimidine chemotherapeutic agents in adjuvant chemotherapy for resected large bowel cancer. 5-FU/leucovorin combined with irinotecan (CPT-11) versus 5-FU/leucovorin are being tested in a national intergroup clinical trial. Another trial is evaluating 5-FU/leucovorin plus oxaliplatin versus 5-FU/leucovorin alone. These clinical trials will be important in defining the appropriate standard of care for patients with resected colorectal cancer, since recent studies in advanced colorectal cancer in the United States and in Western Europe have demonstrated that combinations of 5-FU/leucovorin and CPT-11 or 5-FU/ leucovorin and oxaliplatin are superior to 5-FU/leucovorin alone.

Long-term survival after locally aggressive anorectal melanoma.

Anorectal melanoma is a rare disease and, unlike cutaneous melanoma, there are few guidelines regarding optimal management. It has a reputation for having a poor prognosis, which has been attributed to a delay in diagnosis and to a lack of effective systemic therapy. It has also been suggested that the biology of this tumor may differ from that of cutaneous melanoma. An interesting case of anorectal melanoma is presented which highlights the unique considerations and challenges encountered by medical oncologists and surgeons who treat this disease.