Disease severity and radioactive iodine use for thyroid cancer.

CONTEXT: Although variation in radioactive iodine (RAI) use for thyroid cancer has been demonstrated, the role of region and nonclinical correlates of use within risk groups has not been investigated. OBJECTIVE: The objective of the study was to determine the correlates of RAI use within risk groups. DESIGN/SETTING/PATIENTS: Use of RAI was evaluated across 9 US regions in 85 948 patients with well-differentiated thyroid cancer diagnosed between 2004 and 2008 at 986 hospitals associated with the US National Cancer Database. Cancers were then categorized as low risk (tumor size ≤ 1 cm and American Joint Committee on Cancer stage I disease), medium risk (neither low nor high-risk), and high risk (American Joint Committee on Cancer stage III or IV). Within each risk stratum, the role of region and nonclinical correlates of RAI use were evaluated using hierarchical logistic regression. MAIN OUTCOME MEASURE: Use of RAI was measured. RESULTS: Rates of RAI use varied across geographic regions from 49% to 66%. Regional differences persisted after controlling for patient and hospital characteristics and evaluating less vs more intensive regions within low-risk [odds ratio (OR) 0.36 (95% confidence interval [CI] 0.25-0.53)], medium-risk [OR 0.23 (95% CI 0.16-0.34)], and high-risk cancers [OR 0.30 (95% CI 0.19-0.49)]. Patterns of RAI use were similar in medium- and high-risk patients. The most nonclinical correlates of use were in low-risk patients. CONCLUSION: Similar treatment patterns for the heterogeneous medium-risk thyroid cancer patients compared with the high-risk patients suggest more intensive management in patients with medium-risk disease. The large number of nonclinical correlates of RAI use, including region, imply controversy over indications for RAI.

Personalized medicine: a perk of privilege?

Advances in molecular testing and genomic technology offer promise in helping identify people at risk of developing disease and those most (or least) likely to benefit from risk reduction and treatment strategies. Yet not all of those who are eligible for such technologies have access to the benefits of these advances. Given the inequities in our health-care system, there is no assurance that expanding research into molecular and genomic testing will benefit everyone equally. Moreover, widespread adoption of new and emerging technologies poses challenges for an already overtaxed health-care system.

Family communication and mental health after breast cancer.

In the context of a traumatic event, such as a breast cancer diagnosis, talking with others about the event can facilitate emotional adjustment and meaning-finding. Among women with a history of breast cancer, open communication is likely to be of particular importance in the family setting, as the family is frequently a primary source of support. The goal of this cross-sectional survey study was to determine the association between open family communication about cancer and breast cancer survivors' mental health. Responses from 230 women at various stages post-treatment suggest that the majority of women are able to talk openly with their family about breast cancer. Multivariate regression analysis further indicates that open family communication is independently associated with better mental health outcomes. Given that many women live long after a breast cancer diagnosis, maintaining mental health functioning is an important long-term goal. Efforts to enhance productive communication between patients and their family members may help women cope with and overcome the challenges of breast cancer survivorship.

Reducing the toxicity of anticancer therapy: new strategies.

Cytoprotective agents offer opportunities to reduce the treatment-related toxicity of anticancer therapy and perhaps to increase the dose and dose intensity of radiation and chemotherapy. One such agent is amifostine, an organic thiophosphate. Amifostine selectively protects normal tissues and provides broad-spectrum protection for a variety of organs while remaining minimally toxic. Clinical studies have demonstrated that amifostine protects against myelotoxicity, nephrotoxicity, neurotoxicity, mucositis and esophagitis in patients treated with alkylating and platinum agents, paclitaxel and radiation therapy. In addition, preclinical studies suggest the possibility of protection against anthracycline-induced cardiotoxicity and radiation- and chemotherapy-induced mutagenicity. Preclinical and clinical studies have not demonstrated any diminution of antitumor efficacy. Amifostine is well tolerated in doses of 740 or 910 mg/m2. The most common side effects requiring treatment are transient hypotension, which responds to intravenous fluids, and nausea and vomiting, effectively treated with 5-HT3 antagonists and dexamethasone.

Ciprofloxacin plus piperacillin is an equally effective regimen for empiric therapy in febrile neutropenic patients compared with standard therapy.

The purpose of this study was to test the comparative efficacy and toxicity of empiric gentamicin and ciprofloxacin, in combination with piperacillin, in febrile patients with treatment-induced neutropenia. Fifty patients were prospectively randomized to receive piperacillin plus gentamicin (PG), and 46 were randomized to receive piperacillin plus ciprofloxacin (PC). The groups were similar in age, sex, diagnosis, duration of neutropenia, and incidence of positive cultures. The two antibiotic regimens were associated with comparable rates of defervescence in the patients with gram-positive bacteremia. In the patients with gram-negative bacteremia and those with negative cultures, however, defervescence was more prompt in the PC group. In particular, 27% of the culture-negative patients on PC, compared to only 5% of those on PG, defervesced within 72 hr (P = 0.015). Because of the more prompt defervescence in the PC group, amphotericin B was used less frequently; 78% of the patients on PG compared with only 56% of those on PC were started on amphotericin B (P = 0.025). PC is an effective alternative to the more traditional PG for treatment of febrile neutropenic hosts who have not been given prophylactic quinolones. More important, PC appears to hasten defervescence compared with PG, especially in culture-negative patients and those with gram-negative bacteremia, and may decrease the necessity of additional antimicrobial agents such as amphotericin B.

Recombinant erythropoietin and blood transfusions in cancer chemotherapy-induced anemia.

Anemia represents a common side effect of cancer chemotherapy, and results in diminished overall well-being as well as side effects such as dyspnea, fatigue and decreased appetite. Treatment options for chemotherapy-induced anemia are transfusion of red blood cells and s.c. erythropoietin. Although transfusion is generally well tolerated, patients usually experience fluctuating hemoglobin levels because of hesitancy to transfuse to normal hemoglobin levels. Additionally, concerns persist related to the safety of blood products, including the transmission of blood-borne pathogens, immunomodulation by transfusion and severe allergic reactions, despite advances in transfusion medicine. Erythropoietin is an effective alternative to transfusion in many patients and allows for a more consistent hemoglobin level. The costs associated with the drug have limited its use. In addition, patient preferences for the two treatment options have not been investigated. Economic analyses, including consideration of the costs associated with medical care as well as the consequences, will be essential in evaluating the potential of transfusions and erythropoietin in treating the anemia associated with cancer chemotherapy.

Chronic inflammatory demyelinating polyneuropathy in non-Hodgkin's lymphoma.

A 42-year-old man was diagnosed with large cell non-Hodgkin's lymphoma 3 years after autologous bone marrow transplantation for Hodgkin's disease. The day before beginning systemic chemotherapy, the patient began to have symptoms of a sensorimotor neuropathy characterized by proximal and distal weakness, lower-extremity areflexia, elevated cerebrospinal fluid protein level, and evidence of demyelination on nerve conduction studies. Symptoms progressed despite two courses of intrathecal methotrexate, for possible lymphomatous meningitis, as well as systemic chemotherapy. The diagnosis of chronic inflammatory demyelinating polyneuropathy was made. Daily plasma exchange was performed for a total of 10 treatments with immediate improvement and eventual complete recovery in strength, sensation, and gait. A review of the literature confirms that inflammatory demyelinating polyneuropathy is a highly unusual but important cause of peripheral nervous system dysfunction. The potential for complete response to plasma exchange should be recognized in patients with symptoms, signs, and nerve conduction studies suggestive of chronic inflammatory demyelinating polyneuropathy.

Treatment of refractory undifferentiated acute myelogenous leukemia with all-trans-retinoic acid.

A patient is described with undifferentiated acute myeloblastic leukemia refractory to two courses of daunorubicin and cytosine arabinoside. Because some the myeloblasts developed morphologic features of promyelocytes, the patient was treated with all-trans-retinoic acid (ATRA) in an attempt to promote maturation. Cytogenetic studies and sensitive molecular analysis did not reveal any abnormality classically associated with acute promyelocytic leukemia. Serial bone marrow biopsies demonstrated myeloid maturation, and the patient uneventfully went into a sustained complete remission. A review of the literature confirms this to be an apparently hitherto undescribed response to ATRA that may have therapeutic implications in similar patients.