Formal adult infectious disease specialist consultations in the outpatient setting at a comprehensive cancer center (1998-2008): diverse and impactful.

PURPOSE: The literature on the impact of infectious disease (ID) consulations in the outpatient treatment of cancer is scarce. METHODS: The medical records of consecutive adult patients with cancer formally evaluated by two board-certified ID specialists in an outpatient setting at our institution over a 10-year period (1998-2008) were reviewed retrospectively. The patients' demographics, referring departments, purposes for consultation, ID specialist recommendations, and overall impact of consultations on outcome were analyzed. RESULTS: We identified 598 patients who underwent ID specialist consultations. Most of them had solid tumors (53%), predominantly breast cancer, whereas non-Hodgkin's lymphoma was the most common hematologic malignancy. Almost half of the patients (45%) had active malignancies, but few of them were severely neutropenic (8%) or had been receiving high doses of corticosteroids (17%). The most frequent requests for consultation were culture or serologic test (15%), and treatment of cellulitis and/or surgical wound infections (14%). Of 337 isolated pathogens, the most prevalent were methicillin-resistant Staphylococcus aureus (13%) and Pseudomonas aeruginosa (8%), as well as atypical mycobacteria (16%) and Aspergillus species (11%). ID specialists provided alternative diagnoses in 53% of the cases, including identification of a different infection (46%), a noninfectious etiology (29%), colonization (16%), and drug-related toxic effects (9%). Overall, we deemed the contribution of the ID specialist to be significant in 62% of the consultations. CONCLUSIONS: ID specialists contribute significantly to the outpatient care of individuals with cancer.

The outcome of elderly patients with advanced urothelial carcinoma after platinum-based combination chemotherapy.

BACKGROUND: The majority of patients with advanced urothelial cancer are elderly, but data regarding this specific age group are limited. We compared the tolerability and efficacy of first-line platinum (cisplatin or carboplatin)-based chemotherapy in elderly patients (> or =70 years) with those in younger patients. PATIENTS AND METHODS: A total of 381 patients with advanced urothelial carcinoma received CIMV (cisplatin, ifosphamide, methotrexate, vinblastine) (n=32), MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) (n=105), DC (docetaxel, cisplatin) (n=174), CaG (carboplatin, gemcitabine) (n=64) or other regimes (n=6) and were included in this analysis. RESULTS: A total of 116 patients were > or =70 years. Elderly patients experienced more frequent neutropenia grade 3/4 (55% versus 37%, P=0.087) and renal toxicity (28% versus 10%, P=0.033) among patients treated with CIMV/MVAC, and neutropenic infections (4% versus 0%, P=0.019) among patients treated with DC. Median survival did not differ significantly between elderly and younger patients (9.3 versus 10.5 months, P=0.16). Eastern Cooperative Oncology Group performance status (PS) and haemoglobin were independently associated with prognosis. Patients with PS <2 and haemoglobin > or =10 g/dl had a median survival of 14 months as opposed to 5 months for patients with PS > or =2 or haemoglobin <10 g/dl (P <0.001). CONCLUSION: Elderly patients with advanced urothelial cancer tolerate platinum-based chemotherapy well and derive the same benefit as their younger counterparts.

Survival and prognostic factors after initiation of treatment in Waldenstrom's macroglobulinemia.

BACKGROUND: Waldenstrom's macroglobulinemia (WM) is an unusual lymphoplasmacytoid lymphoma characterized by the presence of a serum monoclonal immunoglobulin M. Although several studies have evaluated possible prognostic factors of this disease, few have focused on the survival and prognosis of symptomatic patients after the initiation of treatment. PATIENTS AND METHODS: Our study included 122 previously untreated patients with a median age of 67 years who required systemic treatment. Multiple variables were analyzed for their prognostic value on survival after initiation of treatment using univariate and Cox regression multivariate analysis. RESULTS: The median overall survival was 106 months. Pretreatment factors associated with shorter survival were age >/=65 years, splenomegaly, B-symptoms (weight loss, fever or night sweats), hemoglobin <10 g/dl, platelets <100 x 10(6)/dl, albumin <3.5 g/dl and bone marrow lymphoplasmacytic infiltrate >/=50%. In the multivariate analysis, the two variables with independent prognostic value were age >/=65 years and hemoglobin <10 g/dl. Furthermore, we were able to divide our patients into three risk groups based on the presence of two, one or none of these two adverse prognostic factors. The median survival times in the high-, intermediate- and low-risk groups were 46 months, 107 months and 172 months, respectively (P <0.0001). DISCUSSION: Our findings suggest that advanced age and anemia appear to be the two dominant prognostic factors for survival after initiation of treatment in patients with WM. These two readily available parameters can stratify the patients into three distinct subgroups and may help the selection of appropriate treatment.

Treatment of Waldenstrom's macroglobulinemia with single-agent thalidomide or with the combination of clarithromycin, thalidomide and dexamethasone.

To evaluate the activity of thalidomide in Waldenstrom's macroglobulinemia (WM), 20 patients were treated on a dose schedule that escalated from 200 mg/d to 600 mg/d. On an intention-to-treat basis, five (25%) patients achieved a partial response, which was noted within 3 months of treatment. Adverse effects were common and prevented dose escalation of thalidomide in 75% of patients and led to premature discontinuation of treatment in 35%. We subsequently evaluated the oral combination of clarithromycin (500 mg twice per day), low-dose thalidomide (200 mg once daily), and dexamethasone (40 mg once per week). Our preliminary analysis on 12 previously treated patients indicate activity of this regimen in WM: three patients achieved a partial response and two patients demonstrated monoclonal protein reduction of greater than 25%. This combination was associated with a variety of side effects due not only to thalidomide, but also to corticosteroids and to clarithromycin. Our preliminary data indicate that this combination may be a useful salvage regimen for some patients with heavily pretreated macroglobulinemia.