Early Access to Electronic Health Records May Influence the Patient Experience.

In a recent Hot Topics column, Mehmet Sitki Copur, MD, FACP, et al discussed the pros and cons of patients receiving test results early through electronic medical records.

Complete Pathologic Response to Neoadjuvant Chemoimmunotherapy and Oxaliplatin-Induced Fever Associated With IL-6 Release in a Patient With Locally Advanced Colon Cancer

Neoadjuvant systemic therapy is a preferred treatment approach for a number of tumor types due to many potential advantages over upfront surgery, including tumor downstaging, early treatment of micrometastatic disease, and providing an in vivo test of tumor biology. For colon cancer, current standard of care is upfront surgery followed by adjuvant systemic therapy in high-risk patients. Concerns about inaccurate radiological staging and tumor progression during preoperative treatment, as well the lack of randomized data demonstrating benefit, are among the reasons for the limited use of neoadjuvant therapy in this disease. Locally advanced colon cancer, defined as primary colon cancer with direct invasion into the adjacent structures or extensive regional lymph node involvement, is not always amenable to pathological complete resection, and when attempted it comes with high incidence of postoperative morbidity and mortality because of the required multivisceral resection. Clinical trials of neoadjuvant chemotherapy for colon cancer to date have been promising with downstaging of disease and higher rates of R0 resection. Here, we report a case of a patient with locally advanced, unresectable, mismatch repair deficient sigmoid colon cancer who was treated with neoadjuvant chemoimmunotherapy followed by surgical resection leading to a complete pathologic response after preoperative systemic chemoimmunotherapy.

A 65-Year-Old Man With Back Pain and Imaging Findings of Spinal Cord Compression.

Spinal cord compression is a potentially devastating consequence of cancer. Early recognition of the signs and symptoms permit diagnosis prior to the development of irreversible neurological damage. This complication occurs in 5% to 10% of patients with malignancy, often at the end stages of the patient's illness; however, it can be the presenting manifestation of malignancy in up to 23% of patients. With the advances in surgical, radiation, and medical oncology approaches, the outcomes of patients with malignant spinal cord compression continue to improve. We discuss the case of a previously healthy man, aged 65 years, who presented with back pain and large T8 spinal mass, leading to a diagnosis of multiple myeloma with spinal cord compromise.

Recurrent EGFR-Mutated Non-Small Cell Lung Cancer Discovered by Abnormal Mammogram: Adjuvant/Frontline Metastatic Management Options.

Breast metastasis from extramammary malignancy is rare, with a reported incidence rate of 0.4% to 1.3% in the published literature. The primary malignancies that most commonly metastasize to the breast are leukemia, lymphoma, and malignant melanoma. Here, we report a very rare case of metastatic EGFR-mutated non-small cell lung cancer (NSCLC) in the breast detected by screening mammography. The patient had initially been diagnosed with a clinical stage IIIA NSCLC and had been treated with neoadjuvant chemoradiation followed by curative-intent surgery. Several interesting aspects of the case, along with a discussion of evolving adjuvant and frontline metastatic management options in EGFR-mutated NSCLC, will be presented.

Gastrointestinal Cancer Presentations Relevant to Clinical Practice.

The 2020 American Society of Clinical Oncology Virtual Scientific Program delivered many practice-influencing presentations. Here are some of the most notable research results in the field of gastrointestinal cancer that may guide oncologists in their day-today work.

Hereditary vs Familial Pancreatic Cancer: Associated Genetic Syndromes and Clinical Perspective.

Pancreatic ductal adenocarcinoma (PDAC) is a disease marked by high rates of mortality; it is mostly incurable at the time of diagnosis. Only about 7% of patients survive 5 years after diagnosis. Diagnosis at a late stage and rapid progression with minimal response to available treatments are the main reasons for this poor outcome. It is crucial to identify individuals at high risk of developing PDAC so preventive and early detection measures can be employed. Approximately 10% to 15% of PDAC cases have a hereditary or familial basis. In the majority of PDAC cases, no main causative gene has been identified, but several known germline pathogenic mutations have been shown to be related to an increased risk of this cancer. The presence of 2 or more patients with pancreatic cancer within the circle of first-degree relatives, without the presence of a causative germline mutation, is defined as familial pancreatic cancer; this accounts for 4% to 10% of PDAC. Based on the growing evidence supporting the benefit of germline genetic testing in patients with PDAC, both the American Society of Clinical Oncology and the National Comprehensive Cancer Network recently updated their guidelines to include recommendations around genetic testing for patients with pancreatic cancer. However, there is no general consensus on the group of patients and individuals who should be studied and screened. We present a demonstrative case and review the available data on hereditary and familial PDAC.

79-year Old Man on Nivolumab with Itchy Erythematous Patches.

A 79-year-old white man presented with an ulcerated chest wall lesion developing from an existing mole. After definitive surgery, it proved to be a malignant melanoma and staged as T4N1M0. He received 1 year of adjuvant therapy with nivolumab. Starting on the last month of adjuvant nivolumab treatment, he developed itchy erythematous patches on his left posterior shoulder that spread over his trunk, arms, and thighs.

Synchronous Bilateral Lung Cancer With Discordant Histology.

Synchronous multiple primary lung cancer (SMPLC) is a rare occurrence affecting 0.5% to 2% of patients with lung cancer. Synchronous discordant histology with small cell and non-small cell lung carcinoma is an even less common entity. There have been several presentations of synchronous or metachronous multiple primary lung cancers in the literature. However, reports discussing treatment options and prognosis in patients with SMPLC of discordant histology with small cell and non-small cell carcinoma in the same patient are scarce. We report a case of SMPLC presenting with a limited stage left upper lobe small cell lung cancer and an operable right upper lobe non-small cell lung adenocarcinoma. Diagnostic, surgical, and medical treatment options for the patient along with a review of SMPLC topics are presented.

Locally Advanced Rectal Cancer, What is the Standard of Care?

Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one-third of newly diagnosed cases. A comprehensive trimodality approach involving neoadjuvant chemoradiotherapy, total mesorectal excision, and systemic chemotherapy has been the standard of care for medically operable patients with nonmetastatic, locally advanced rectal cancer. Despite a marked reduction in local recurrence rates with good local control, systemic recurrence rates of as high as 35% constitute the leading cause of death in this population. This has led to increasing interest in neoadjuvant systemic therapy before or after neoadjuvant chemoradiation a new approach called total neoadjuvant therapy. This case study will review the current status of clinical stage II or III locally advanced rectal cancer (T3/4, N0, or node-positive) treatment regarding neoadjuvant therapy.

Recurrent Small Cell Carcinoma of the Lung With Cutaneous Metastasis in Breast.

Lung cancer remains the leading cause of cancer-related deaths and the second leading cause of new cancer cases in the United States. Although more commonly involving hilar nodes, the liver, adrenal glands, bones, and the brain, lung cancer can metastasize to almost any organ. Metastases, although rare in the skin may be the first sign of a lung cancer or cutaneous metastases may present as a sign of recurrent disease. The incidence of cutaneous metastases from lung cancer has been reported in approximately 1% to 12 % of cases and was associated with poor prognosis. Although cutaneous metastasis from small cell lung cancer is a rare occurrence, cutaneous metastasis involving the breast is even less common. Here, we present a case of recurrent small cell lung cancer presenting with a firm purplish cutaneous metastatic nodule in the right breast.

Pancreatic Neuroendocrine Tumor With Humoral Hypercalcemia and High Tumor PD-L1 Score.

Pancreatic neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms. They can be functioning tumors with secretion of a variety of peptide hormones, or nonfunctioning tumors with metastases to the liver at the time of diagnosis. Well-differentiated tumors tend to be slow-growing and characterized by low tumor mutational burden (TMB) and lower propensity to express PD-L1. Hypercalcemia due to malignancy can occur in about 20% to 30% of patients with cancer. The secretion of parathyroid hormone-related protein (PTH-rP) is among the causes of malignant hypercalcemia and has seldom been associated with hypercalcemia of NETs. Although the therapeutic landscape for neuroendocrine neoplasms has evolved substantially over the past decade, the role of immunotherapy has not yet been completely explored in this group of patients. We present a rare case of a metastatic pancreatic NET with high TMB, high PD-L1 tumor proportion score, and high PTH-rP related hypercalcemia.

Burnout in Oncology.

Burnout is defined as an occupational-related syndrome characterized by physical and emotional exhaustion, cynicism/depersonalization, and low sense of professional accomplishment. Multiple oncology-specific risk factors are associated with an increased susceptibility for the development of burnout. On a daily basis, oncologists are faced with life and death decisions and grieving much more frequently than are physicians in other specialties. Continuous exposure to fatal illnesses with limited success in curing them, exceedingly long work hours with more administrative time demands, limited autonomy over daily responsibilities, endless electronic documentation requirements, and a shifting medical landscape seem to be making oncologists more vulnerable to suffering from burnout. Evidence suggests that burnout can impact quality of care in a variety of ways and have potentially profound personal implications. In this review, the definition, prevalence, causes, and management of oncologist burnout are analyzed. Steps oncologists can take to promote personal well-being and professional satisfaction are also explored.

Biliary Cancer: Current Multimodality Treatment and Future Directions.

Biliary cancer is a highly aggressive malignancy arising from the biliary tree, with its incidence increasing steadily on a global level. Most biliary cancers are diagnosed in the advanced and metastatic stages due to the paucity of signs and symptoms in the early presentation. Only about one-third of the patients can be treated with curative intent with an overall median survival of less than 24 months for all-comers from the time of diagnosis. This fact and the poor results of the currently available local and systemic therapies, are responsible for the disappointing outcome of biliary cancer patients. There is an unmet need for novel therapeutic approaches. Surgery, the backbone of curative treatments for biliary cancer, is effective in early, completely-resectable stages or in combination with neoadjuvant or adjuvant chemotherapy and/or radiation therapy for locally advanced stages. Systemic therapies in unresectable and recurrent cases are associated with poor outcomes. The introduction of next-generation sequencing technologies has opened new horizons for a better understanding of the molecular basis of this cancer with potential identification and evaluation of new treatment options.

Immunotherapy in Colorectal Cancer.

Colorectal cancer (CRC) is the third leading cause of cancer deaths, with only 15% of patients surviving 5 years in the metastatic setting. Recent exciting developments in cancer immunotherapy, which involves priming the host's natural immune defenses to recognize, target, and destroy cancer cells effectively, have brought some glimpse of hope in fighting this deadly disease. Although CRC has been shown to evade immune detection like many other cancers do, immunotherapy has been noted to produce some very impressive results in a select group of patients. Patients with mismatch repair-deficient and microsatellite instability-high type CRC have benefited most from recent immunotherapy approaches, leading to US Food and Drug Administration approval of new immunotherapeutic agents in recurrent refractory metastatic disease. Research continues to explore and hopefully define the role of immunotherapy in CRC as single-agent therapy or in combination with other agents in neoadjuvant, adjuvant, and first-line metastatic setting, and to find the optimal combination and sequencing of this new therapeutic approach. One of the most challenging tasks is to find ways to expand the use of immunotherapy to not only a select group of CRC patients but also to all patients with this disease. This article will provide a practical concise overview of the current landscape of immunotherapy in CRC for the practicing oncologist along with a representative case presentation from our community oncology practice.

Universal Genetic Testing for All Breast Cancer Patients.

Women with pathogenic BRCA1/2 mutations are more likely to develop breast cancer than are women without the mutation and they typically develop cancer at an earlier age. If women are aware of their BRCA1/2 status, however, they can make timely decisions about preventive measures such as chemoprevention with hormonal agents or undergoing prophylactic surgery, all of which have been shown to reduce the risk of cancer and overall mortality. The US Preventive Services Task Force and the National Comprehensive Cancer Network have recommended that women with a family history of breast, ovarian, and certain other cancers consider BRCA1/2 testing. Discovery of additional genes that increase breast cancer risk, coupled with the gradually decreasing cost of performing these tests, has led to the utilization of multigene panels over individual gene testing. Multigene panel testing for hereditary cancer may detect additional mutations that might possibly alter clinical management. Accuracy of current guidelines for genetic testing of breast cancer patients has become a topic of debate due to two studies suggesting these guidelines may miss half the patients with pathogenic variants or genetic mutations. Although the cost of genetic screening has dropped in recent years, there are other costs associated with population screening, including genetic counseling. There is also a lack of evidence in terms of proper procedures and risk management strategies following multigene panel testing, especially when mutations are found in moderate penetrance genes with a high percentage of Variants of Unknown SignificanceVUS and, if a mutation is discovered regarding the most accurate type of medical care. Universal genetic testing in women with newly diagnosed breast cancer has been proposed by some, stirring up strong views on both sides of the issue.