Oncologist's knowledge and implementation of guidelines for breakthrough cancer pain in Spain: CONOCE study

Purpose. Breakthrough cancer pain (BTcP) has been shown to be a prevalent and poor prognostic factor for oncologic patients, which remain under diagnosed and undertreated. In 2012, the Spanish Society of Medical Oncology (SEOM) published a clinical practice guideline (CPG) for the treatment of cancer pain which specifically addressed the management of BTcP. Methods. Fundación ECO designed a qualitative study using an Internet-based survey to investigate the attitudes toward, compliance with, and use of SEOM Guideline. Results. A total of 83 oncologists with a mean experience of 13 years responded. Overall, 82% were aware of different guidelines to manage BTcP. Notably, attitudes toward guidelines were highly positive and there was nearly unanimous agreement that CPG provided the best scientific evidence available (99%), on the minimum information to be gathered for the medical history (100%), on the need for a specific treatment for BTcP (100%), and fentanyl as the first-choice drug (99%). Interestingly, there were discrepancies between what oncologists agreed with and what they do in clinical practice. In fact, 87.6% declare full compliance with SEOM guideline, although adherence to registration of BTcP data in medical records ranged from 30.1 to 91.6% (mean 64.5%); therapeutic management compliance was higher ranging from 75.9 to 91.6%. Main barriers identified were time pressure together with vague statements and limited dissemination of the guidelines. Conclusion. Despite oncologist’s clinical practice is increasingly guided by GPC, it suffers from limited compliance, at least in part due to suboptimal statements. Improved dissemination and education are needed to enhance guideline implementation

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Oncologist's knowledge and implementation of guidelines for breakthrough cancer pain in Spain: CONOCE study.

PURPOSE: Breakthrough cancer pain (BTcP) has been shown to be a prevalent and poor prognostic factor for oncologic patients, which remain under diagnosed and undertreated. In 2012, the Spanish Society of Medical Oncology (SEOM) published a clinical practice guideline (CPG) for the treatment of cancer pain which specifically addressed the management of BTcP. METHODS: Fundación ECO designed a qualitative study using an Internet-based survey to investigate the attitudes toward, compliance with, and use of SEOM Guideline. RESULTS: A total of 83 oncologists with a mean experience of 13 years responded. Overall, 82% were aware of different guidelines to manage BTcP. Notably, attitudes toward guidelines were highly positive and there was nearly unanimous agreement that CPG provided the best scientific evidence available (99%), on the minimum information to be gathered for the medical history (100%), on the need for a specific treatment for BTcP (100%), and fentanyl as the first-choice drug (99%). Interestingly, there were discrepancies between what oncologists agreed with and what they do in clinical practice. In fact, 87.6% declare full compliance with SEOM guideline, although adherence to registration of BTcP data in medical records ranged from 30.1 to 91.6% (mean 64.5%); therapeutic management compliance was higher ranging from 75.9 to 91.6%. Main barriers identified were time pressure together with vague statements and limited dissemination of the guidelines. CONCLUSION: Despite oncologist's clinical practice is increasingly guided by GPC, it suffers from limited compliance, at least in part due to suboptimal statements. Improved dissemination and education are needed to enhance guideline implementation.

Tumoral angiogenesis and breast cancer.

Breast cancer (BC) is the most common neoplasm in women in Western countries. Tumoral angiogenesis (TA) is essential for the growth and spread of BC cells. There are at least 6 different angiogenic growth factors associated with TA in BC. The major mediator of TA is vascular endothelial growth factor (VEGF), a homodimeric heparin-binding glycoprotein. VEGF signals through VEGF receptor-2 (VEGFR-2), the major VEGF signalling receptor that mediates sprouting angiogenesis. Recently, different antiangiogenic agents have shown efficacy in the treatment of advanced BC. Bevacizumab, a humanised monoclonal antibody against VEGF, in combination with taxanes improves progression-free survival and overall response rate in first-line therapy. Other new antiangiogenic agents, called multi-kinase inhibitors (sunitinib and pazopanib), are under investigation. Finally, a schedule of treatment called metronomic chemotherapy, with antiangiogenic activity, has also demonstrated efficacy in the treatment of advanced BC.

Tumoral angiogenesis and breast cancer

Breast cancer (BC) is the most common neoplasm in women in Western countries. Tumoral angiogenesis (TA) is essential for the growth and spread of BC cells. There are at least 6 different angiogenic growth factors associated with TA in BC. The major mediator of TA is vascular endothelial growth factor (VEGF), a homodimeric heparin-binding glycoprotein. VEGF signals through VEGF receptor-2 (VEGFR-2), the major VEGF signalling receptor that mediates sprouting angiogenesis. Recently, different antiangiogenic agents have shown efficacy in the treatment of advanced BC. Bevacizumab, a humanised monoclonal antibody against VEGF, in combination with taxanes improves progression-free survival and overall response rate in first-line therapy. Other new antiangiogenic agents, called multi-kinase inhibitors (sunitinib and pazopanib), are under investigation. Finally, a schedule of treatment called metronomic chemotherapy, with antiangiogenic activity, has also demonstrated efficacy in the treatment of advanced BC (AU)

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[Mediastinal germ-cell tumours]. / Tumores germinales mediastínicos.

Germ-cell tumours of male ussually arise from the testis. However, in 2-5% of the cases, they also occur outside of the testis as a primary site without evidence of testicular primary tumour. This infrequent entity often appears in the body midline, predominantly in mediastinum and retroperitoneum. Mediastinal germ-cell tumours (MGCT) shall be included in the differential diagnosis of any mediastinic tumour of unknown origin. An accurate diagnosis is essential, due to the fact that these tumours are curable with chemotherapy. The histopathologic and clinical features, and its differences with germ-cell tumours from testicular origin are revised in this article.

[Effectivity of cetuximab monotherapy in the treatment of refractory advanced cancer of the head and neck]. / Efectividad de Cetuximab en monoterapia en el tratamiento de cánceres de cabeza y cuello avanzado refractario.

INTRODUCTION: More than 90% of carcinoma of the head and neck (CHN) have an overexpression of the EGFR gene, and that overexpression is associated with a worse prognosis. Cetuximab is a monoclonal antibody against EGFR. PATIENTS AND METHODS: We have conducted a retrospective study of 10 consecutive cases with metastatic and/or recurrent CHN treated with cetuximab monotherapy as second line therapy, with the main objective of analyzing the progression-free survival (PFS); we also analyzed the response rate, the overall survival (OS), and toxicity profile as second end points. RESULTS: The median age was 55 years, and 100% of patients were males. Fourty percent of the patients received cetuximab as second line, and 60% as third line therapy. With a median follow-up of 13.5 months, the median PFS was 4 months (95%CI: 3.4-4.6 months), with a median OS of 9.7 months (95%CI: 2.9-16.6 months).The objective response rate was 10%, and the disease control rate was 60% (Partial response = 10% and stable disease for > 16 weeks = 50%). Thirty percent of patients had grade 3 rash. CONCLUSIONS: Cetuximab monotherapy has a modest effectivity in the treatment of refractory CHN, but with a limited toxicity. Future studies should use combinations of cetuximab with others effective chemotherapeutic drugs in the treatment of CHN, such as taxanes.

Angiogénesis neoplásica / Neoplastic angiogenesis

La angiogenésis neoplásica es un proceso esencial en el crecimiento progresivo de las neoplasias, y en la producción de metástasis. La angiogénesis consiste en una serie de complejos pasos consecutivos que conducen en último término al desarrollo de neovasos que aportan sangre a la masa tumoral. El VEGF tiene un papel primordial en la angiogénesis neoplásica, y por tanto es una importante diana en el tratamiento de las neoplasias. Bevacizumab, un anticuerpo monoclonal humano, inhibe el VEGF, y podría mejorar el transporte de la quimioterapia a las masas tumorales. Los inhibidores multi-kinasas (sorafenib y sunitinib) son pequeñas moléculas de administración oral, que inhiben diferentes receptores (esenciales en la angiogénesis neoplásica), como VEGFR o PDGFR. Estos agentes son útiles en el tratamiento del carcinoma de células renales avanzado, y están en investigación en muchos otros tumores

Neoplastic angiogenesis is an essential process in the progressive growth of neoplasms and the production of metastasis. Angiogenesis consists of a series of linked and sequential steps that ultimately leads to the development of a neovascular blood supply to the tumor mass. VEGF has got an essential role in neoplastic angiogenesis, there fore it is an important target in the treatment of neoplasms. Bevacizumab, a humanized monoclonal antibody, inhibits VEGF, and may also improve the delivery of chemotherapy to the tumor mass. Multi-kinase ihibitors (sorafenib and sunitinib) are orally administered small-molecules, that inhibit different receptors (essentials in the neoplastic angiogenesis), such as the VEGFR or PDGFR. These agents are useful in the treatment of advanced renal-cell carcinoma, and are under investigation in several tumors

[Adrenal failure caused by primary adrenal non-Hodgkin lymphoma: a case report and review of the literature]. / Insuficiencia suprarrenal causada por un linfoma no-Hodgkin B primario suprarrenal: presentación de un caso y revisión de la literatura.

We report a case of 78-year old man who presented with symptoms of adrenal insufficiency. The computed tomography (CT) scan showed the presence of bilateral adrenal masses. A CT-scan guided needle biopsy revealed diffuse large- B cell lymphoma. The absence of pathological findings in clinical, bone marrow and CT scan examinations supported the diagnosis of primary non-Hodgkin Lymphoma of the adrenal glands. The patient was treated with four cycles of R-CHOP chemotherapy with Rituximab, liposomal Doxorubicin, Cyclophosphamide, Vincristine and Prednisolone. At the end of fourth cycle there was radiological improvement but the chemotherapy was stopped because of IV grade toxicity. He completed treatment with radiotherapy of right adrenal mass. Few days after finishing radiation therapy the patient died due to a disseminated infection. No progressive disease was founded.

Nuevos fármacos en el cáncer de mama / New drugs in breast cancer

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Tumores germinales mediastínicos / Mediastinal germ-cell tumours

Los tumores de células germinales del varón habitualmente se originan en los testículos. Sin embargo, en el 2-5% de los casos pueden aparecer de forma primaria en localizaciones extragonadales, sin evidencia de un tumor testicular. Esta infrecuente entidad suele aparecer en la línea media corporal, predominántemente en el mediastino y en el retroperitoneo. Los tumores germinales extragonadales mediastínicos (TGEM) deben incluirse en el diagnóstico diferencial de cualquier tumor mediastínico de origen desconocido. Un diagnóstico exacto es fundamental, debido a que son tumores potencialmente curables con quimioterapia. En este artículo se revisan las características histopatológicas y clínicas de losTGEM, y sus diferencias los tumores germinales de origen testicular

Germ-cell tumours of male ussually arise from the testis. However, in 2-5% of the cases, they also occur outside of the testis as a primary site without evidence of testicular primary tumour. This infrequent entity often appears in the body midline, predominantly in mediastinum and retroperitoneum. Mediastinal germ-cell tumours (MGCT) shall be included in the differential diagnosis of any mediastinic tumour of unknown origin. An accurate diagnosis is essential, due to the fact that these tumours are curable with chemotherapy. The histopathologic and clinical features, and its differences with germ-cell tumours from testicular origin are revised in this article

[Adjuvant treatment of operable breast cancer]. / Tratamiento adyuvante en el cáncer de mama operable.

Breast cancer(BC) is the most frequent neoplasm in women of the west countries. The treatment of BC is very complex, and include the combination of surgery, chemotherapy, radiotherapy, hormone therapy and immunotherapy. Surgery is the gold standard in the radical treatment of BC. Anthracyclines and taxanes are very important in the adjuvant treatment of BC. These drugs have shown an increased disease-free-survival and overall survival in several studies. Tamoxifen has been the gold standard adjuvant hormone therapy for the treatment of postmenopausal women with hormone-receptor-positive early BC for many years, but the third-generation aromatase inhibitors (letrozole, anastrozole, and exemestane) are now recommended as the preferred therapy. Trastuzumab in combination with adjuvant chemotherapy has changed the natural history of early Her-2 positive BC. New drugs are under investigation in the treatment of BC.

[Efficiency of bortezomib and dexamethasone in relapsed multiple myeloma treatment: retrospective study in consecutive cases]. / Efectividad de bortezomib y dexametasona en el tratamiento de mieloma múltiple refractario: estudio retrospectivo de una serie de casos consecutivos.

INTRODUCTION: Multiple myeloma (MM) is a plasm-cell neoplasm, that is characterized by a monoclonal protein in the serum or urine. Bortezomib is an efficacy drug for the second line treatment of MM. PATIENTS AND METHOD: We conducted a retrospective study of 21 consecutive cases with refractory MM treated with bortezomib and dexamethasone as second line therapy, with the objective of analyzing the overall response rate (primary end point), the progression-free survival (PFS), the overall survival (OS), the duration of response (DR) and toxicity profile (second end points). RESULTS: In our study we found an overall response rate of 70%. With a median follow-up of 15 months, we had a median PFS of 12 months (95% CI: 2-21 months), with a median OS of 17 months (95% CI: 2-32 months), and a median DR of 9 months (95% CI: 5-13 months). Fourty-seven percent of patients had neuropathy, the 33% thrombocytopenia, 13.33% anemia and 26.66% diarrhea. CONCLUSIONS: The combination of bortezomib and dexamethasone is an effective and safe treatment in second line of refractory MM, with a manageable toxicity.

Insuficiencia suprarrenal causada por un linfoma no-Hodgking B primario suprarrenal: presentación de un caso y revisión de la literatura / Adrenal failure caused by primary adrenal non-hodking lymphoma: a case report and review of the literature

Presentamos el caso de un varón de 78 años que ingresa por un cuadro de debut de insuficiencia suprarrenal. Se realizó un estudio TC que mostró masas suprarrenales bilaterales de hasta 10 cm. Se completó estudio con biopsia percutanea de masa suprarrenal y biopsia de médula ósea, siendo diagnosticado de Linfoma no Hodgkin B difuso de células grandes primario suprarrenal con afectación suprarrenal bilateral. El paciente fue tratado con quimioterapia según esquema R-CHOP (Rituximab, Ciclofosfamida, Doxorrubicina liposomal, Vincristina y Prednisona).Tras 4 ciclos de quimioterapia se objetivo una respuesta parcial radiológica. Se suspendió la quimioterapia por toxicidad grado IV, completándose el tratamiento con RT sobre masa suprarrenal derecha. El paciente falleció por cuadro séptico pocos días después de finalizar la radioterapia, sin objetivarse progresión de la enfermedad

We report a case of 78-year old man who presented with symptoms of adrenal insufficiency. The computed tomography (CT) scan showed the presence of bilateral adrenal masses. A CT-scan guided needle biopsy revealed diffuse large- B cell lymphoma. The absence of pathological findings in clinical bone marrow and CT scan examinations supported the diagnosis of Lymphoma of the adrenal glands.The patient was treated with four cycles of R-CHOP chemotherapy with Rituximab, liposomal Doxorubicin, Cyclophosphamide, Vincristine and Prednisolone. At the end of fourth cycle there was radiological improvement but the chemotherapy was stopped because of IV grade toxicity. He completed treatment with radiotherapy of right adrenal mass. Few days after finishing radiation therapy the pacient died due to a disseminated infection. No progressive disease was founded

Efectividad de bortezomib y dexametasona en el tratamiento de mieloma múltiple refractario: estudio retrospectivo de una serie de casos consecutivos / Efficiency of Bortemozib and dexamethasone in relapsed multiple myeloma treatment: retrospective study in consecutive cases

Introducción: El mieloma múltiple (MM) es una neoplasia de células plasmáticas, que se caracteriza por la presencia de una proteína monoclonal en suero u orina. Bortezomib es un fármaco eficaz en el tratamiento de segunda línea del MM. Pacientes y métodos: Hemos realizado un estudio retrospectivo de una serie de 21 casos consecutivos de MM refractario a los que hemos tratado con bortezomib y dexametasona en segundas líneas, con el objetivo de analizar la tasa de respuesta (objetivo primario), la supervivencia libre de progresión (SLP), la supervivencia global (SG), la duración de respuesta (DR) y la toxicidad (objetivos secundarios). Resultados: En nuestro estudio hemos encontrado una tasa de respuesta total de 70%. Con una mediana de seguimiento de 15 meses, hemos obtenido una mediana de SLP de 12 meses (IC95%: 2-21 meses), una mediana de SG de 17 meses (IC95%:2-32 meses) y una mediana de DR de 9 meses (IC95%: 5-13 meses). El 47 % de los pacientes presentaron neuropatía,el 33% trombocitopenia, 13,33% anemia, y 26,66% diarrea. Conclusiones: La combinación de bortezomib y dexametasona es un tratamiento efectivo y seguro en segundas líneas de MM refractario, con una toxicidad manejable

Introduction: Multiple myeloma (MM) is a plasm-cell neoplasm, thatis characterized by a monoclonal protein in the serum or urine. Bortezomib is an efficacy drug for the second line treatment of MM. Patients and method: We conducted a retrospective study of 21 consecutive cases with refractory MM treated with bortezomib and dexamethasone as second line therapy, with the objective of analyzing the overall response rate (primary end point), the progression-free survival (PFS), the overall survival (OS), the duration of response (DR) and toxicity profile (second end points). Results: In our study we found an overall response rate of 70%. With a median follow-up of 15 months, we had a median PFS of 12 months (95% CI: 2-21 months), with a median OS of 17 months (95% CI: 2-32 months), and a median DR of 9 months (95% CI: 5-13 months). Fourtyseven percent of patients had neuropathy, the 33% thrombocytopenia,13.33% anemia and 26.66% diarrhea. Conclusions: The combination of bortezomib and dexamethasone is an effective and safe treatment in second line of refractory MM, with amanageable toxicity

Tratamiento adyuvante en el cáncer de mama operable / Adjuvant treatment of operable breast cancer

El cáncer de mama (CM) es la neoplasia más frecuente en las mujeres de los países occidentales. El tratamiento del CM es muy complejo, e incluye la combinación de la cirugía, quimioterapia, radioterapia, hormonoterapia e inmunoterapia. La cirugía continúa siendo el “gold estándar”en el tratamiento radical de CM. Las antraciclinas y los taxanos son esenciales en el tratamiento adyuvante de CM. Estos fármacos han demostrado un incremento significativo de la supervivencia libre de enfermedad y global en múltiples estudios. El tamoxifeno ha sido el “gold estándar” en la hormonoterapia adyuvante de las mujeres posmenopáusicas con receptores hormonales positivos durante muchos años, pero los inhibidores de aromatasas de tercera generación (letrozol, anastrozol y exemestano) se han convertido en el tratamiento recomendado actualmente. Trastuzumab en combinación con la quimioterapia adyuvante ha modificado la historia natural del CM localizado Her-2 positivo. Nuevos fármacos están en investigación en el tratamiento del CM

Breast cancer (BC) is the most frequent neoplasm in women of the west countries. The treatment of BC is very complex, and include the combination of surgery, chemotherapy, radiotherapy, hormonetherapy and immunotherapy. Surgery is the gold standard in the radical treatment of BC. Anthracyclines and taxanes are very important in the adjuvant treatment of BC. These drugs have shown an increased disease free-survival and overall survival in several studies. Tamoxifen has been the gold standard adjuvant hormonetherapy for the treatment of postmenopausal women with hormone-receptor-positive early BC for many years, but the third-generation aromatase inhibitors (letrozole, anastrozole, and exemestane) are now recommended as the preferred therapy.Trastuzumab in combination with adjuvant chemotherapy has changed the natural history of early Her-2 positive BC. New drugs are underinvestigation in the treatment of BC

[Neoplastic angiogenesis]. / Angiogénesis neoplásica.

Neoplastic angiogenesis is an essential process in the progressive growth of neoplasms and the production of metastasis. Angiogenesis consists of a series of linked and sequential steps that ultimately leads to the development of a neovascular blood supply to the tumor mass. VEGF has got an essential role in neoplastic angiogenesis, therefore it is an important target in the treatment of neoplasms. Bevacizumab, a humanized monoclonal antibody, inhibits VEGF, and may also improve the delivery of chemotherapy to the tumor mass. Multi-kinase ihibitors (sorafenib and sunitinib) are orally administered small-molecules, that inhibit different receptors (essentials in the neoplastic angiogenesis), such as the VEGFR or PDGFR. These agents are useful in the treatment of advanced renal-cell carcinoma, and are under investigation in several tumors.

Subtipos clínicos y genéticos de cáncer de mama: individualización del tratamiento / No disponible

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Manejo del dolor oncológico / Management of cancer pain

El dolor es un problema muy frecuente en los pacientes con cáncer, con una prevalencia del 90% en los estadios avanzados. El manejo del dolor oncológico es complejo, y un enfoque multidimensional es preciso para su manejo óptimo. Tres tipos de dolor ha sido descrito en base a la neurofisiología del dolor (Dolor somático, visceral y neuropático). Numerosas guías clínicas para el manejo del dolor oncológico han sido editadas por diversos investigadores y organizaciones. La guía clínica de la OMS es el más usado en el manejo del dolor oncológico. Los opioides, de los cuales la morfina es el prototipo, son los fármacos más importantes en el tratamiento del dolor oncológico. Los fármacos coadyuvantes son usados en el tratamiento del dolor oncológico, con el objetivo de potenciar la eficacia de los opioides, y para tratar algunos tipos específicos del dolor (dolor neuropático y óseo)

Pain is a very frequent problem in patients with cancer, with a prevalence of 90% in advanced disease. The management of cancer painis complex, and a multidimensional approach is necessary for its optimal treatment. Three types of pain have been described based on the neurophysiology of pain pathways (somatic, visceral and neuropathic pain). Numerous guidelines for the management of cancer pain have been issued by various organizations and researchers. The WHO guideline is the most used in the management of pain cancer. The opioids analgesics, of which morphine is the prototype, are the most important drugs in the treatment of cancer pain. Adjuvant drugs are used in the treatment of cancer pain, in order to enhace opioid analgesia, and provide analgesia for certain specific types of pain (neuropathic pain, and bone pain)

Sobrecarga de hierro en síndromes mielodisplásicos y terapia quelante de hierro / No disponible

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