Effect of complementary Integrative Oncology on anxiety, depression and quality of life in thoracic cancer patients: A pilot study.

PURPOSE: Thoracic-cancer (TC) patients have an extensive toll taken in terms of health-related quality of life (HRQL). Integrative Oncology (IO) is recognized as a valid complement to any Standard-Therapy treatment to improve outcomes in TC patients. The objective of this pilot-study was to evaluate the effect of adding IO (acupuncture, Cognitive-Behavior Therapy and mindfulness) in terms of depression, anxiety and HRQL. METHODS: TC patients who attended the Thoracic Oncology-Unit from July to September 2018 were invited to participate. A total of 16 patients were included in the study, 8 patients were required to attend 5 weekly sessions of IO and 8 patients were invited as controls. Anxiety, depression and HRQL were measured at baseline and after completing 5 sessions of IO or 5 weeks, using the HADS scale and the QLQ-C30 scale. RESULTS: A total of 8 patients in the IO group attended the 5 sessions and 8 patients were followed as controls. Compliance with the therapies was high, none of the patients dropped out from the study. A tendency for improvement in anxiety, fatigue, pain and dyspnea was observed in patients attending IO, though not statistically significant likely due to sample size. CONCLUSIONS: IO therapies are well accepted among TC patients. Larger studies are necessary with robust sample sizes to improve conclusions regarding outcome improvements.

Holistic Needs of People with Thoracic Cancer Identified by the Sheffield Profile for Assessment and Referral to Care Questionnaire©.

Background: A holistic needs assessment is recommended in people with cancer at key stages, including soon after diagnosis. For people with thoracic cancer, there is a lack of data obtained routinely at this time point. Objective: To identify the most common and/or distressing supportive and palliative needs present soon after diagnosis using a specifically developed questionnaire. Methods: As part of a local rehabilitation service, patients within three to six weeks of a diagnosis of thoracic cancer were invited to complete the Sheffield Profile for Assessment and Referral to Care (SPARC©) questionnaire. Results: For a 26-month period, 738 patients completed the questionnaire, representing about 70% of all patients diagnosed with thoracic cancer during this time. Respondents had a median [interquartile range] of 15 (11-21) symptoms or issues, with 2 (0-5), 4 (2-7), and 7 (5-11) causing "very much," "quite a bit," and "a little" distress or bother, respectively. The top five most frequent needs causing any degree of distress or bother were physical, present in 68%-80% of patients: feeling tired, shortness of breath, cough, feeling sleepy in the day, changes in weight. Two psychological issues followed: worrying about effects of the illness on others, feeling anxious, both present in 67%. Despite most patients reporting talking to health professionals about their condition, 20%-30% wanted further information. Conclusions: These findings represent the largest cohort of patients with thoracic cancer completing the SPARC questionnaire soon after diagnosis, and provide detailed information on the high level of need that thoracic oncology services must be able to respond to.

Naturopathic Oncology Care for Thoracic Cancers: A Practice Survey.

BACKGROUND AND OBJECTIVES: There is a lack of information on therapies recommended by naturopathic doctors (NDs) for lung and gastroesophageal cancer care. Study objectives were to: (1) identify the most common interventions considered for use by NDs; (2) identify interventions NDs recommend to support key therapeutic goals; and (3) identify potential contraindications between integrative and conventional therapies. METHODS: Oncology Association of Naturopathic Physicians (OncANP) members (n = 351) were invited to complete an electronic survey. Respondents provided information on interventions considered for thoracic cancer pre- and postoperatively across 4 therapeutic domains (supplemental natural health products, physical, mental/emotional, and nutritional), therapeutic goals, and contraindications. This survey was part of the development of the Thoracic Perioperative Integrative Surgical Evaluation trial. RESULTS: Forty-four NDs completed the survey (12.5% response rate), all of whom were trained at accredited colleges in North America and the majority of whom were Fellows of the American Board of Naturopathic Oncology (FABNO) (56.8%). NDs identified significantly more interventions in the postoperative compared to preoperative setting. The most frequently identified interventions included modified citrus pectin, arnica, omega-3 fatty acids, vitamin D, probiotics, exercise, acupuncture, meditation, stress reduction, low glycemic index diet, and Mediterranean diet. Potential contraindications with conventional treatment (surgery, chemotherapy, radiotherapy) differed across natural health products. CONCLUSIONS: These findings highlight naturopathic interventions with a high level of use in thoracic cancer care, describe and characterize therapeutic goals and the interventions used to achieve these goals, and provide insight on how practice changes relative to conventional cancer treatment phase.

[Implementation of Hyperthermic Intrathoracic Chemotherapy (HITHOC) in Germany]. / Anwendung der hyperthermen intrathorakalen Chemotherapie (HITHOC) in Deutschland.

INTRODUCTION: For several years, hyperthermic intrathoracic chemotherapy (HITHOC) has been performed in a few departments for thoracic surgery in a multimodality treatment regime in addition to surgical cytoreduction. Specific data about HITHOC in Germany are still lacking. METHODS: Survey in written form to all departments of thoracic surgery in Germany. The objective is the evaluation of HITHOC with respect to number, indications, technique, perioperative protection measure and complications. RESULTS: A total of 116 departments of thoracic surgery were contacted, with a return rate of 43% (n = 50). HITHOC was not performed in 33 departments, due to lack of resources or experience (n = 17), missing efficacy of the procedure (n = 8) and fear of excessive complication rates (n = 3). Since 2008, a total of 343 HITHOC procedures have been performed in 17 departments. Eight departments have their own perfusion machine, whereas the remaining departments borrow the perfusion machine. Indications were malignant pleural mesothelioma in all departments (n = 17), thymoma with pleural spread (n = 11) and secondary pleural carcinosis (n = 7). The HITHOC was performed in nearly all departments after closing the chest (n = 16), with a temperature of 42 °C (n = 12) and for 60 minutes (n = 15). Cisplatin was always used, either alone (n = 9) or in combination (n = 8). In all the participating departments, the aims of the HITHOC were improvement in local tumor control and prolonged recurrence-free and overall survival. Relevant HITHOC-associated complications were low. CONCLUSIONS: HITHOC is performed in at least 17 departments of thoracic surgery in Germany, and is widely standardised with protective measures and a low rate of complications. The aims of the HITHOC are improvement in local tumor control in pleural malignancies combined with prolonged overall survival and better quality of life.

Re-irradiation of the chest wall for local breast cancer recurrence : Results of salvage brachytherapy with hyperthermia.

AIM: Following mastectomy and adjuvant external beam radiation therapy in patients with breast cancer, the incidence of local or locoregional recurrence is approximately 9 % (2-20 %). Alongside the often limited possibilities of surgical treatment, radiation therapy combined with superficial hyperthermia is the most effective local therapy. In the present work, a retrospective analysis of salvage brachytherapy combined with superficial hyperthermia for chest wall recurrences is presented. PATIENTS AND METHODS: Between 2004 and 2011, 18 patients with a total of 23 target volumes resulting from chest wall recurrences after previously mastectomy and external beam radiation therapy (median 56 Gy, range 50-68 Gy) were treated with superficial brachytherapy as salvage treatment: 8 patients (44 %) had macroscopic tumor, 3 (17 %) had microscopic tumor (R1), and 7 (39 %) had undergone R0 resection and were treated due to risk factors. A dose of 50 Gy was given (high-dose rate [HDR] and pulsed-dose rate [PDR] procedures). In all, 5 of 23 patients (22 %) received additional concurrent chemotherapy, and in 20 of 23 (87 %) target volumes additional superficial hyperthermia was carried out twice weekly. RESULTS: The 5­year local recurrence-free survival was 56 %, the disease-free survival was 28 %, and a 5-year overall survival was 22 %. Late side effects Common Toxicity Criteria (CTC) grade 3 were reported in 17 % of the patients: 2 of 18 (11 %) had CTC grade 3 fibrosis, and 1 of 18 (6 %) had a chronic wound healing disorder. CONCLUSION: Re-irradiation as salvage brachytherapy with superficial hyperthermia for chest wall recurrences is a feasible and safe treatment with good local control results and acceptable late side effects.

[Models of communication to integrate early palliative care in thoracic oncology]. / Kommunikationsmodell zur frühen Integration der Palliativmedizin in der thorakalen Onkologie.

The recent development in optimising palliative care standards in thoracic oncology is associated with an increased demand in specialized communication skills. Standardised and integrated assessments of the palliative care need of the patient is met by limited health care resources. The model of communication described in this article emphasizes the need to structure palliative distress assessment of the patient. Communication pathways are shown as a platform to evaluate and support patient and caregivers. Standards to establish algorithms of communication in palliative care will improve the very important interaction between patient and caregivers.

Modulated electro-hyperthermia enhances dendritic cell therapy through an abscopal effect in mice.

The aim of this study was to assess whether modulated electro-hyperthermia (mEHT) can induce an abscopal effect and thereby enhance the antitumor effects of immunotherapy. We used an intratumoral dendritic cell (DC) injection and mEHT to treat C3H/He mice inoculated with squamous cell carcinoma SCCVII cells in the left leg, and we assessed the whole body antitumor effects. Tumors were examined every two or three days in order to assess growth inhibition. The tumor-draining lymph nodes were removed to enable flow cytometric analysis of CD3+ and CD8+ cells, whereas immunohistochemistry was used to assess CD8, S100 and Foxp3 expression in the tumors. Additionally, GP96 expression in the tumors from the different treatment groups was measured. In the control group, the mean tumor volume was larger than that in other groups. These results indicated that the combination therapy of an intratumoral DC injection and mEHT evoked systemic antitumor activity. A larger number of CD3+ and CD8+ cells were detected by flow cytometric analysis in the DC plus mEHT treatment group. Tumor tissue immunostaining showed that CD8 and S100 were more strongly expressed in the DC plus mEHT treatment group, although Foxp3 expression was much higher in the control group. The GP96 gene expression level in the mEHT group was significantly different from the expression level in the control group. An abscopal effect may be induced by mEHT, and the effect of immunotherapy with DCs was strongly enhanced by the overexpression of GP96. GP96 is thought to be one of the molecules explaining the abscopal effect. Direct intratumoral administration of DCs and mEHT may be a feasible future treatment strategy.

Adjuvant chemotherapy after esophagectomy: is there a role in the treatment of the lymph node positive thoracic esophageal squamous cell carcinoma?

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) patients with regional lymph node metastases have poor prognosis after surgery. The purpose of this study was to investigate the impact of various treatment modalities on survival in these patients. METHODS: We retrospectively reviewed data from 349 patients who had undergone left transthoracic esophagectomy for thoracic ESCC from January 2008 to December 2010 at our institute. All patients had lesions in the mid or lower third of the thoracic segment and had pathological positive lymph node metastasis. Of these patients, 143 patients received surgery alone, 154 patients underwent postoperative radiotherapy alone, and 52 patients underwent taxane-based chemotherapy. Univariate and multivariate Cox regression analyses were used to analyze prognostic factors and survival. RESULTS: At a median follow-up of 53.1 months, the 3-year OS were 47.7% for the patients with surgery alone, 44.0% for the patients with adjuvant radiotherapy, and 58.9% for the patients with adjuvant chemotherapy. Multivariate analysis showed that postoperative therapy with adjuvant chemotherapy was significant positive predictor of survival. CONCLUSIONS: Postoperative taxane-based adjuvant chemotherapy improved survival of patients with lymph node positive thoracic ESCC compared with surgery alone. Further randomized prospective studies to confirm these findings are warranted.

[Multimodal management in soft tissue sarcoma of the trunk and extremities]. / Multimodales Management bei Weichteilsarkomen des Stammes und der Extremitäten.

Soft tissue sarcoma (STS) is a rare, extremely heterogeneous group of malignant tumors of mesodermal origin. With an incidence of 1-5 per 100,000/year they account for only 1 % of all human malignancies. The STSs occur predominantly in the lower extremities and the trunk. To date 100 different histopathological subentities can be defined. The prognosis varies substantially depending on the localization and histology. Whereas local recurrence rates and overall survival of sarcomas of the extremities have benefited from the introduction of multimodal therapies, only marginal progress has been made in the management of trunk STSs. This manuscript gives an overview of preoperative diagnostics, pathology and neoadjuvant as well as adjuvant therapeutic options for soft tissue sarcoma.

Complementary and alternative medicine use among patients with thoracic malignancies.

PURPOSE: Complementary and alternative medicine (CAM) use has been increasing among cancer patients. This study characterizes the use of CAM among patients with thoracic malignancies. METHODS: This cross sectional study was conducted at a National Cancer Institute-designated comprehensive cancer center among adult patients diagnosed with thoracic malignancies. The primary outcome was a self-reported use of CAM, defined as the use of any type of CAM beyond routine vitamin/mineral supplementation alone. A logistic regression model was developed to explore predictors of CAM use. RESULTS: A total of 108 patients completed a standardized survey (59% response rate). Overall, 42% of respondents reported the use of at least one type of CAM. Users and non-users of CAM did not differ based upon demographics, diagnosis, staging, smoking status, quality of life, or perceived understanding of cancer diagnosis. In the multivariate analysis, patients who reported feeling fearful about their future were four times more likely to be CAM users when compared to those who did not specify this emotion (odds ratio=4.18; 95% CI=1.23-14.12; p=0.02). Commonly cited reasons for CAM use were to support one's self, boost immunity, and for improvements in emotional and/or spiritual well-being. CONCLUSIONS: Prevalence of CAM use among cancer patients in this study was similar to the general US population. Feeling fearful about the future was associated with CAM use. Results suggest that patients may be turning to CAM as a therapeutic adjunct to actively cope with emotional distress surrounding the cancer experience.

[Managing nutritional support in thoracic oncology]. / Spécificités de la prise en charge nutritionnelle en oncologie thoracique.

INTRODUCTION: Cancer treatments are based on specific anticancer chemotherapy. However, there is increasing interest in general aspects of care, which are increasingly evidence based. STATE OF THE ART: The importance of muscle mass is becoming increasingly evident. Its role is not only limited to the maintenance of physical performance and quality of life. In oncology, recent studies have shown a close link between sarcopenia (low muscle mass) and mortality as well as between sarcopenia and chemotherapy toxicity. To treat malnutrition and the lack of energy intake, nutritional support is considered, whether through the prescription of oral nutritional supplements, enteral nutrition or even parenteral nutrition. Scientific arguments are often absent and few studies have been carried out in patients with lung cancer. PERSPECTIVES: There are many experimental arguments and a few clinical trials that support using omega 3 fatty acids to modulate inflammatory reaction and to reduce its consequences on muscular proteolysis. The benefit of regular physical activity has already been proven in chronic respiratory disease and its use in association with nutritional support must be recommended in oncologic care. CONCLUSION: Given the increasing recognition of the role of muscle mass in cancer, the purpose of any nutritional support must be focused on increasing muscle anabolism and decreasing proteolysis.

REG1A expression status suggests chemosensitivity among advanced thoracic esophageal squamous cell carcinoma patients treated with esophagectomy followed by adjuvant chemotherapy.

BACKGROUND: Regenerating gene 1A (REG1A) plays an important role in tissue regeneration and in cell proliferation in the mucous membrane of the gastrointestinal tract. We previously reported that the positive expression status of REG1A was predictive of chemoradiosensitivity in patients treated with preoperative chemoradiotherapy before esophagectomy or with definitive chemoradiotherapy. To further confirm the utility of REG1A as a chemosensitivity marker, we carried out an additional retrospective clinical study aimed at determining whether REG1A is a reliable chemosensitivity marker in patients treated with esophagectomy followed by adjuvant chemotherapy. METHOD: A total of 177 patients with T2-4 thoracic esophageal squamous cell carcinoma received curative surgery without preoperative treatment at Akita University Hospital between 2001 and 2011. A tissue microarray was constructed, and REG1A expression status was analyzed immunohistochemically. We then statistically analyzed the relationships between REG1A expression status and 5-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). RESULTS: In the adjuvant group (n=105), REG1A-positive patients showed significantly better prognoses than REG1A-negative patients. (5-year OS, p=.0022; DSS, p=.0004; and DFS, p=.0040). However, there were no significant differences between REG1A-positive and REG1A-negative patients in the surgery group (n=72). Univariate and multivariate analyses showed REG1A expression status to be a significant prognostic factor affecting 5-year DSS, comparable to lymph node metastatic status. CONCLUSION: The present study suggests REG1A expression status has the potential to be a highly reliable and clinically useful chemosensitivity marker in patients treated with advanced thoracic esophageal squamous cell carcinoma. REG1A expression status will provide a good indication of treatment strategy and enable more individualized treatment for patients.

Effect of a combined surgery, re-irradiation and hyperthermia therapy on local control rate in radio-induced angiosarcoma of the chest wall.

PURPOSE: Radiation-induced angiosarcoma (RAS) of the chest wall/breast has a poor prognosis due to the high percentage of local failures. The efficacy and side effects of re-irradiation plus hyperthermia (reRT + HT) treatment alone or in combination with surgery were assessed in RAS patients. PATIENTS AND METHODS: RAS was diagnosed in 23 breast cancer patients and 1 patient with melanoma. These patients had previously undergone breast conserving therapy (BCT, n = 18), mastectomy with irradiation (n=5) or axillary lymph node dissection with irradiation (n = 1). Treatment consisted of surgery followed by reRT + HT (n = 8), reRT + HT followed by surgery (n = 3) or reRT + HT alone (n = 13). Patients received a mean radiation dose of 35 Gy (32-54 Gy) and 3-6 hyperthermia treatments (mean 4). Hyperthermia was given once or twice a week following radiotherapy (RT). RESULTS: The median latency interval between previous radiation and diagnosis of RAS was 106 months (range 45-212 months). Following reRT + HT, the complete response (CR) rate was 56 %. In the subgroup of patients receiving surgery, the 3-month, 1- and 3-year actuarial local control (LC) rates were 91, 46 and 46 %, respectively. In the subgroup of patients without surgery, the rates were 54, 32 and 22 %, respectively. Late grade 4 RT toxicity was seen in 2 patients. CONCLUSION: The present study shows that reRT + HT treatment--either alone or combined with surgery--improves LC rates in patients with RAS.

Efficacy analysis of simplified intensity-modulated radiotherapy with high or conventional dose and concurrent chemotherapy for patients with neck and upper thoracic esophageal carcinoma.

For patients with neck and upper thoracic esophageal carcinoma, it is difficult to control lymph node metastases with conventional dose therapy. In this study, we assessed the feasibility of simplified intensity-modulated radiotherapy (sIMRT) and concurrent chemotherapy for 44 patients and boosted high-dose to metastatic lymph nodes.Three radiation treatment volumes were defined: PGTVnd, with which 68.1 Gy was delivered in high dose group (hsIMRT group), and 60 Gy in the conventional dose group (csIMRT group); PTV1, featuring 63.9 Gy in the hsIMRT group and 60Gy in the csIMRT group; PTV2, with 54 Gy given to both groups. The sIMRT plan included 5 equi-angular coplanar beams. All patients received the cisplatin and 5-FU regimen concurrently with radiotherapy. The treatment was completed within six weeks and one case with grade three acute bronchitis was observed in hsIMRT group. For esophageal lesions, 80% complete response (CR) and 20% partial response (PR) rates were found in the hsIMRT group, and 79.2% CR, with 20.8% PR, in the csIMRT group; for lymph node lesions, 75% CR and 25% PR rates were observed in the hsIMRT group, with 45.8% and 37.5% respectively in the csIMRT group (P <0.05). The differences in 1-, 2- and 3-year relapse-free survival rates were all statistically significant (P <0.05). The major toxicity observed in both groups was Grade I~II leucopenia. sIMRT can generate a desirable dose distribution in treatment of neck and upper thoracic esophageal carcinoma with a better short-term efficacy. Boosted high dosing to metastatic lymph nodes can increase the relapse-free survival rate.

A roundup of recently published articles relevant to thoracic oncology.

We selected six publications for the "best of the month," published recently in peer-reviewed journals, covering a broad range of topics including second-hand smoking, intensive care unit admissions for patients with lung cancer, role of aspirin in preventing lung cancer, bleeding events in patients undergoing treatment with bevacizumab and requiring full anticoagulation, level of evidence used to support the National Comprehensive Cancer Network guidelines, and the use of prophylactic cranial irradiation in patient with locally advanced non-small cell lung cancer.

The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with esophageal cancer.

BACKGROUND: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This review compares the experiences of patients with esophageal cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy conference (TMC). METHODS: The records of patients with carcinoma of the esophagus at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation before the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy, and adherence to national treatment guidelines. Summary data were compared for patients treated before and after the TMC was initiated. RESULTS: Between 2001 and 2007, 117 patients were treated before the initiation of the TMC and 138 patients within the TMC. The number of patients receiving, respectively, a complete staging evaluation (67% and 97%, p < 0.0001), multidisciplinary evaluation before therapy (72% and 98%, p < 0.0001), and adherence to National Comprehensive Cancer Network treatment guidelines (83% and 98%, p < 0.0001) all increased significantly, whereas mean days from diagnosis to treatment significantly decreased (27 and 16, respectively; p < 0.0001). CONCLUSIONS: A multidisciplinary TMC increased the percentage of patients receiving complete staging, a multidisciplinary evaluation, and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with esophageal cancer benefit from being evaluated in a prospective, multidisciplinary manner.

Durable palliation of breast cancer chest wall recurrence with radiation therapy, hyperthermia, and chemotherapy.

BACKGROUND AND PURPOSE: Chest wall recurrences of breast cancer are a therapeutic challenge and durable local control is difficult to achieve. Our objective was to determine the local progression free survival (LPFS) and toxicity of thermochemoradiotherapy (ThChRT) for chest wall recurrence. METHODS: Twenty-seven patients received ThChRT for chest wall failure from 2/1995 to 6/2007 and make up this retrospective series. All received concurrent superficial hyperthermia twice weekly (median 8 sessions), chemotherapy (capecitabine in 21, vinorelbine in 2, and paclitaxel in 4), and radiation (median 45 Gy). Patients were followed up every 1.5-3 months and responses were graded with RECIST criteria and toxicities with the NCI CTC v4.0. RESULTS: Twenty-three (85%) patients were previously irradiated (median 60.4 Gy) and 22 (81%) patients received prior chemotherapy. Median follow-up was 11 months. Complete response (CR) was achieved in 16/20 (80%) of patients with follow-up data, and 1 year LPFS was 76%. Overall survival was 23 months for patients with CR, and 5.4 months in patients achieving a partial response (PR) (p=0.01). Twenty-two patients experienced acute grade 1/2 treatment related toxicities, primarily moist desquamation. Two patients experienced 3rd degree burns; all resolved with conservative measures. CONCLUSIONS: ThChRT offers durable palliation and prolonged LPFS with tolerable acute toxicity, especially if CR is achieved.