Amenorrhea, fertility preservation, and counseling among young women treated with anthracyclines and taxanes for early-stage breast cancer, a retrospective study.

Chemotherapy may cause ovarian toxicity and infertility. Cancer patients are usually overwhelmed, and focus exclusively on cancer diagnosis and may not pay attention to fertility-related issues. In this paper we look at the rate of amenorrhea and fertility counseling among such young patients.Premenopausal women with early-stage breast cancer treated with adjuvant or neoadjuvant chemotherapy were recruited. Amenorrhea was defined as absence of menstruation for ≥12 months after the completion of chemotherapy.A total of 94 patients met the eligibility criteria and were included in this analysis. Median age at diagnosis was 35.7 (range, 22-44) years. Seventy-nine (85.9%) respondents were counseled about amenorrhea and 37 (40.2%) were considering having children. Long-term amenorrhea was reported by 51 (54.3%) patients. The addition of taxanes to anthracyclines, in 2 different regimens, increased the risk of amenorrhea to 69.2% and 66.7% compared to 38.9% with anthracycline-alone, P < .0001. Longer duration of chemotherapy (≥24 weeks) might also be associated with higher rate of amenorrhea (67.7%) compared to 43.4% in those who had shorter duration (<24 weeks), P = .031.The addition of taxanes to anthracycline-based chemotherapy increased the risk of amenorrhea. However, shorter duration of chemotherapy, even with taxanes, may lower such risk. Our study highlights the importance of fertility counseling to improve fertility preservation rates. Given the importance of taxanes, shorter regimens are associated with lower amenorrhea rates and should be preferred over longer ones.

Incidental pulmonary embolism in cancer patients: clinical characteristics and outcome--a comprehensive cancer center experience.

BACKGROUND AND OBJECTIVES: Cancer patients undergo routine imaging studies much more than others. The widespread use of the recently introduced multi-detector CT scanners has resulted in an increasing number of incidentally diagnosed pulmonary embolism (PE) in asymptomatic cancer patients. The significance and clinical outcome of such incidental PE is described. METHODS: Both radiology department and hospital databases were searched for all cancer patients with a diagnosis of incidental PE. CT scans were performed using a 64-slice scanner with a 5.0 mm slice thickness. RESULTS: During the study period, 34 patients with incidental PE were identified. The mean age (±SD) was 57.7 (±12.4) years. All patients had active cancer, gastric, lung, colorectal, and lymphomas being the most frequent. Most patients had advanced-stage disease at the time of PE diagnosis; 26 (77%) patients had stage IV, whereas only 3 patients had stages I or II disease. Twenty-seven (79%) patients had their PE while undergoing active treatment with chemotherapy (68%) or radiotherapy (12%); none, however, were on hormonal therapy. Most (74%) patients had their PE diagnosed without history of recent hospital admission. Except for 5 (15%), all other patients were anticoagulated. With follow-up, 2 patients developed recurrent PE, 2 others had clinical and echocardiographic evidence of pulmonary hypertension, and 9 (26%) died suddenly within 30 days of the diagnosis of incidental PE; 2 of these where among the 5 patients who were not anticoagulated. CONCLUSION: Incidental PE in cancer patients is increasingly encountered. Similar to symptomatic PE, many were diagnosed in patients with advanced stage disease and while undergoing active anti-cancer therapy. A significant percentage of patients had recurrent emboli, pulmonary hypertension, and sudden death.

Ximelagatran, the new oral anticoagulant: would warfarin survive the challenge?

The last decade witnessed major advances in the prevention and treatment of venous as well as of arterial thrombosis. Limitations of existing anticoagulants led to the development of novel therapeutic approaches. Ximelagatran is a new direct thrombin inhibitor (DTI) that is given orally, without the need for close monitoring. This compound was tried in the treatment of active venous thromboembolism, and the results were encouraging. Randomized trials suggest that ximelagatran is not inferior to warfarin in the prevention of stroke in patients with nonvalvular atrial fibrillation. Multiple controlled, prospective trials compared ximelagatran with low molecular weight heparin or warfarin in prevention of venous thromboembolism in patients undergoing major orthopedic procedures. The results of these clinical trials are reviewed in this article. Because of certain safety concerns (increased liver enzymes, potential hepatonecrosis, and increased coronary events) ximelagatran has not yet been approved by the FDA. Additional studies may be required to address these concerns. Ximelagatran has been approved, however, by the European regulatory authorities for short-term thromboprophylaxis. The success of ximelagatran or other oral antithrombin agents would provide significant proof of the concept for the long-term use of oral antithrombins in the prevention and treatment of both arterial and venous thrombosis.

Treating heparin-induced thrombocytopenia. The unconventional way!

Heparin-induced thrombocytopenia HIT is a potentially devastating complication of heparin therapy. The severe form of HIT has been associated with both venous and arterial thrombosis manifested by myocardial infarction, cerebrovascular occlusion, skin necrosis or limb ischemia. Several agents are now available as alternatives to heparin in patients with suspected HIT, including the thrombin specific inhibitors lepirudin and argatroban as well as the low molecular weight heparinoid known as danaparoid. When lacking these agents, here we report the use of plasmapheresis to create an artificial state of anticoagulation; exchanging patient's plasma with albumin rather than fresh frozen plasma, to allow the safe introduction of warfarin.

Cancer-related anemia.

Anemia is the most common hematological abnormality in cancer patients, unfortunately, it is often under-recognized and under-treated. The pathogenesis of cancer anemia is complex and most of the time multifactorial; involving factors related to the tumor itself or its therapy. While anemia can present in a wide range of symptoms, involving almost every organ, it is believed that it contributes much to cancer-related fatigue, one of the most common symptoms in cancer patients. In addition, there is increasing evidence to suggest that anemia is an independent factor adversely affecting tumor response and patient survival. While blood transfusion was the only option to treat cancer-related anemia, the use of recombinant human erythropoietin (rHuEPO) is becoming the new standard of care, more so with the recent studies demonstrating the feasibility of a single weekly injection. Things are even getting better with the recent approval of a new form of rHuEPO; Darbepoetin, an analogue with a 3-fold longer half-life. In addition to its effect in raising hemoglobin, several well-controlled studies demonstrated decrease in transfusion requirements and better quality of life assessed objectively using standard assessments scales.