Preferences regarding disclosure of prognosis and end-of-life care: A survey of cancer patients with advanced disease in a lower-middle-income country.

BACKGROUND: Cancer patients' preferences regarding disclosure of prognosis and end-of-life care remain under-reported from low- and middle-income countries where cancer poses an increasing demand on scarce healthcare resources. A better knowledge of these preferences can help in achievement of shared treatment goals. AIM: To survey preferences of adult cancer patients regarding disclosure of prognosis and end-of-life care DESIGN: A multidimensional questionnaire was developed to survey consecutively sampled patients. A fifth of the participants completed a repeat survey 3 months later. SETTING/PARTICIPANTS: Adult patients at a specialist cancer center in Pakistan. RESULTS: In total, 520 patients were surveyed initially (participation rate 98.6%) and 100 completed the repeat survey. Three in five respondents wanted a healthcare provider to give them detailed information about their prognosis and life expectancy. Those who wanted information withheld were significantly more likely to be female, to have a lower socioeconomic status, or to have lung cancer. Only two in five patients agreed that they wanted to die at home and more than 90% wanted all possible care till end-of-life. Yet, a little over half also agreed that they did not wish to be placed on a ventilator. In rank ordering preferences about end-of-life, respondents ranked "religious wellbeing" as the highest and "avoiding inappropriate prolongation of dying" as the lowest of six options. CONCLUSION: A majority of adult cancer patients surveyed in this study wanted a truthful disclosure about their disease prognosis and expressed a preference for hospital-based care at end-of-life. Healthcare providers should find ways to tailor prognostic information to patients' expressed information needs.

Differentiated thyroid carcinoma in a juvenile patient.

Juvenile differentiated carcinoma thyroid is a rare entity. It differs from adult differentiated thyroid carcinoma in a variety of ways, including large tumor volume at presentation with early involvement of the capsule, more frequent nodal and distant metastases, greater expression of sodium-iodide symporter and early recurrence. The overall survival seems to be better than for adult patients; however, due to high and early recurrence rates, prompt and adequate treatment is advocated. The mainstay of treatment includes total thyroidectomy, central lymphadenectomy with modified radical lateral lymphadenectomy, followed by ablation with radioactive iodine (RAI). Both modalities improve the final outcome, but RAI ablation decreases cause-specific death risk independent of the extent of surgery. We present the case of a 5-year-old girl, the youngest ever treated in our country with surgery and RAI therapy successfully after being diagnosed as papillary carcinoma of the thyroid, follicular variant.

Safety Analysis of Adjuvant Chemotherapy with Docetaxel Administered with or without Anthracyclines to Early Stage Breast Cancer Patients: Combined Results from the Asia- Pacific Breast Initiatives I and II.

BACKGROUND: The Asia-Pacific Breast Initiatives (APBI) I and II registries were established to collect safety data for patients with early stage breast cancer receiving adjuvant docetaxel-based regimens in the Asia-Pacific region. MATERIALS AND METHODS: Data from the two registries were combined to perform a safety analysis. Participants in the registry were women with early stage operable breast cancer with an intermediate or high risk of recurrence. These women received adjuvant chemotherapy that included docetaxel between 2006 and 2011. Adverse events (AEs) were recorded and analyzed. RESULTS: Data were collected from 3,224 patients from 13 countries. The mean dose intensity of docetaxel was 24.1, 22.7, 25.1 mg/m2/week among patients receiving docetaxel-based monotherapy, combination therapy and sequential therapy, respectively. Granulocyte colony-stimulating factor (G-CSF) was given with docetaxel to 41.8% of women and 20.6% of women receiving prophylactic antibiotics. Adverse events were reported in 86% of patients (anthracycline-containing regimens vs. non-anthracycline regimens; 87% vs. 80%). The most common adverse events were alopecia, nausea, neutropenia, vomiting, and myalgia. Adverse events NCI CTCAE ≥Grade 3 were reported in 45.4% of patients. Serious adverse events were reported in 13% of patients, of which 2.5% led to study discontinuation. Forty-six deaths (1.4%) were reported, with no significant difference between regimens. CONCLUSIONS: The safety parameters of adjuvant docetaxel therapy used to treat sequential Asian women were comparable to those reported in clinical trials evaluating the role of adjuvant docetaxel. No unusual adverse events linked to Asia-Pacific region patients were observed.

Parotid sparing irradiation for the head and neck cancers.

Several authors have shown that xerostomia restricts nutritional intake and limits the ability of patients to maintain normal weight. When both parotids are irradiated, patients never fully regain their normal weight, however if one parotid is irradiated the patients are able to fully recover their weight with in the year. There are certain sites in the head and neck where small and lateralized cancers with diminished risk of contralateral neck metastases can be treated with parotid sparing techniques, i.e., oral cavity, retromolar trigone, anterior tonsillar pillar, tonsillar fossa, and true vocal cord. In these sites it is appropriate to spare the opposite parotid and closely observe the un-irradiated neck. Based on Dr. O' Sullivans long term follow up of patients with cancers of the oral cavity and tonsil, we are encouraged that patients can be irradiated with homo-lateral parotid techniques with out jeopardizing loco-regional control. Hazuka et al and Maesa et al suggested that three dimensional treatment planning may allow the use of parotid sparing techniques in patients who otherwise would not have been considered candidates using conventional radiotherapy techniques.

Resectability rates in locally advanced esophageal carcinoma following neo-adjuvant chemoradiotherapy.

BACKGROUND: Purpose of this study was to assess the resectability rates in un-resectable (Stages III and IV) cancers of the esophagus, to assess the complete pathological response and to compare the efficacy between two chemotherapy regimens. METHODS: From January 1999 to June 2002, medical records of the patients with un-resectable esophageal cancers were reviewed, who received radiation-therapy with concomitant chemotherapy using following regimens:- Arm A:- 5 FU 500 mg/m2 intravenous push (IVP) on first 5 and last 5 days of radiation. Arm B:- 5 FU 1 Gm/m2/Day 96 hour continuous infusion (CIV) and Cisplatin 70 mg/m2 on day one and twenty eight of radiation. At completion of neoadjuvant chemoradiation patients were offered surgery after four to six weeks. RESULTS: 35 patients had unresectable esophageal cancer. Twenty-six received arm A, and 9 arm B treatment. Of 26 patients in arm A, in 13 the disease was made resectable and two of them showed complete pathological response in surgical specimen, thirteen had progressive disease. On the other hand, of 9 patients receiving arm B treatment, in 7 the disease was made resectable and out of them 5 showed complete pathological response in surgical specimen and two had progressive disease. CONCLUSION: Resectability in patients receiving arm B treatment was better than the patients treated arm A. The data is not mature enough to assess the effect on disease free survival or overall survival, this will be seen and published later.

Comparison between early and late onset breast cancer in Pakistani women undergoing breast conservative therapy: is there any difference?

BACKGROUND: Early onset breast cancer is associated with poor outcomes but variable results have been reported. It is a significant problem in Pakistani women but remains under reported. Breast conservation plays an important role in surgical management of this younger patient group. The objective of this study was to determine the outcome of breast conservative therapy in patients with early onset breast cancer in our population and compare it with their older counterparts. MATERIALS AND METHODS: A review of patients with invasive breast cancer who underwent breast conservation surgery at Shaukat Khanum Cancer Hospital from 1997 to 2009 was performed. Patients were divided into two groups i.e. Group I age ≤ 40 and Group II >40 years. A total of 401 patients with breast cancer were identified in Group I and 405 patients in Group II. Demographics, histopathological findings and receptor status of the two groups were compared. The Chi square test was used for categorical variables. Outcome was assessed on basis of 10 year locoregional recurrence free survival (LRRFS), disease free survival (DFS) and overall survival (OS) . For survival analysis Kaplan Meier curves were used and significance was determined using the Log rank test. Cox regression was applied for multivariate analysis. RESULTS: Median follow up was 4.31 (0.1-15.5) years. Median age at presentation was 34.6 years (17-40) and 51.9 years (41-82) for the two groups. Groups were significantly different from each other with respect to grade, receptor status, tumor stage and use of neoadjuvant therapy. No significant difference was present between the two groups for estimated 10 year LRRFS (86% vs 95%) (p=0.1), DFS (70% vs 70%) (p=0.5) and OS (75% vs 63%) (p=0.1). On multivariate analysis, tumor stage was an independent predictor of LRRFS, DFS and OS. CONCLUSIONS: Early onset breast cancer is associated with a distinct biology but does not lead to poorer outcomes in our population.

Outcomes of triple-negative versus non-triple-negative breast cancers managed with breast-conserving therapy.

BACKGROUND: Triple negative breast cancer is associated with aggressive behavior and high risk of local and regional failure. Aggressive surgical intervention is considered suitable. This makes role of breast conserving therapy (BCT) debatable in these patients. The objective of this study was to compare outcome of BCT for triple negative versus non-triple negative breast cancer. MATERIALS AND METHODS: Medical records of patients who underwent breast conserving therapy from 1999 to 2009 at Shaukat Khanum Cancer Hospital and had complete receptor status information were extracted. Patients were divided into triple negative breast cancer (TNBC) and non-TNBC. Patient characteristics, medical treatment modalities and adverse events were compared. Expected five year locoregional recurrence free, disease free and overall survival was calculated. The Cox proportional hazard model was used to identify independent predictors of outcome. RESULTS: A total of 194 patients with TNBC and 443 with non-TNBC were compared. Significant difference was present for age at presentation (p<0.0001), family history (p=0.005), grade (p<0.0001) and use of hormonal therapy (p<0.0001). The number of locoregional failures, distant failures and mortalities were not significantly different. No significant difference was present in 5 year locoregional recurrence free (96% vs 92%, p=0.3), disease free (75% vs 74%, p=0.7) and overall survival (78% vs 83%, p=0.2). On multivariate analysis, tumor size, nodal involvement and hormonal treatment were independent predictors of negative events. CONCLUSIONS: Breast conserving therapy has comparable outcomes for triple negative and non-triple negative breast cancers.

Judicious use of recombinant TSH in the management of differentiated thyroid carcinoma.

OBJECTIVE: To evaluate the feasibility of using recombinant human TSH (rhTSH) in conjunction with ¹³¹I to treat patients with differentiated thyroid carcinoma. METHODS: Between July 2003 and April 2009, 14 patients [mean age, 39.1 years (range 14-71 years)], of whom seven were treated for remnant ablation and seven for irresectable or metastatic disease, received rhTSH-aided ¹³¹I therapy. None had an adequate rise in TSH. The mean ¹³¹I dosage administered was 5206.3 MBq. Baseline thyroglobulin/anti-thyroglobulin (Tg/anti-Tg) and TSH levels were documented. rhTSH (0.9 mg) was given intramuscularly on days 1 and 2, and TSH levels were recorded. ¹³¹I was given when the TSH level rose to >30 µIU/ml. Tg/anti-Tg levels were measured at 3-month intervals. A ¹³¹I whole-body scan (¹³¹I scan) was performed 6 or 12 months after treatment. RESULTS: The baseline median valid Tg and TSH levels were 76.2 ng/ml (range 14.1 to >30000) and 3.63 µIU/ml (range 1.36-11.0), respectively. The rise in TSH level was 34.8-96.9 µIU/ml after the first rhTSH injection and 33.1 to >75 µIU/ml after the second injection. The post-therapy ¹³¹I scan showed uptake at disease sites in all patients, indicating the initial empirical adequacy of treatment. Follow-up ¹³¹I scan was positive for four patients, but negative for three of these patients after subsequent therapy. Complete resolution of disease was seen in eight patients and partial resolution in four after 3 months of therapy; one had stable disease; and in one patient with progressive disease, complete resolution was achieved after repeated ¹³¹I doses with thyroxine withdrawal. After a median follow-up of 39.2 months, all patients were alive and no disease recurrence was observed. The overall response rate at 3 months was 86% and had improved to 93% at the time of this review. The final ablation rate in seven patients was 100%. Apart from notable neck swelling in four patients, which was responsive to medication, and headache in two patients, no significant short-term side-effects of therapy were seen. CONCLUSION: In our setting, the use of rhTSH-aided ¹³¹I ablation and treatment was safe and effective.