Cancer treatment of severely-III patients not eligible for chemotherapy.

BACKGROUND: Despite having disseminated cancer, not all patients are eligible for palliative chemotherapy or targeted therapies. AIM: To study reasons for withholding palliative chemotherapy, to survey which alternatives were offered and to study survival outcomes. MATERIALS AND METHODS: Medical records of 346 patients with disseminated cancer were collected. Univariate and multivariate statistics were applied. RESULTS: In total, 48% (n=164) of patients were not offered palliative chemotherapy, mainly depending on diagnosis, age and performance status. Instead, palliative radiotherapy (44%) or endocrine treatments (25%) (breast and prostate cancer) were prescribed. The mean survival for these patients was 216 days, with median survival of only 77 days. In the Cox multivariate analysis survival, prospects were better if the patient was ambulatory and living at home at the first consultation (p<0.01), if performance status was acceptable (p<0.01) and if endocrine treatment was an option (p<0.05). CONCLUSION: The prognosis is quite variable, even in cases where palliative chemotherapy is not an option. A hormone-sensitive tumour and a good performance status are significant factors affecting survival in this patient group.

Unfavorable cancers of unknown primaries: presentation and prognostic factors. A population-based 8-year experience.

Cancer of unknown primary is a mostly disseminated malignancy where detailed investigations cannot reveal a probable origin. A few subsets may respond to specific therapy, but the large majority of cases have a median survival of 3-4 months in the few population-based reports, which, however, did not use current investigations and therapy. It is not known if survival can be prolonged by chemotherapy or if supportive care is preferable, especially in the most unfavorable cases in whom chemotherapy may impair the quality of life without prolonging it. We therefore studied prognosis of 134 recent population-based consecutive unfavorable patients. Multiple involvements of the liver, nodes, lungs and skeleton, polysymptomatology, and biochemical abnormalities were common. The median survival time was 103 days, and the 1-year survival was 19%. Hypoalbuminemia, weight loss, and anemia in this order were the strongest negative prognostic factors in multivariate analysis, but univariate analysis added involvement of multiple sites or of the liver, high age, male gender, adenocarcinoma histology, and tobacco use as unfavorable factors. About 10% of patients became long-term survivors, sometimes in the presence of one or more of negative prognostic factors but in particular those with limited nodal spread. A previously unreported finding was that nodal involvement of squamous cell carcinoma limited to the iliacoinguinal region could seemingly be cured by surgery ± radiotherapy. In the absence of efficient treatment and controlled therapeutic trials, supportive care alone seems justified for patients with the worst prognostic factors.

Treatment decisions and discontinuation of palliative chemotherapy near the end-of-life, in relation to socioeconomic variables.

UNLABELLED: During the last decades, the possibilities to prolong survival with chemotherapy even in metastatic disease have increased. Our aim was to study treatment decisions and treatment discontinuation decisions in the proximity of death. METHODS: The medical records of 346 patients with disseminated cancer and a recorded death during 2009 were assessed in relation to demographic and clinical variables and documented treatment decisions were recorded. RESULTS: Palliative chemotherapy was offered in 54% or these cases and generally one or two regimens were administered, before ending treatment. During the last month of life, 32% received treatment and much more often as an oral (instead of intravenous) treatment than in earlier stages (p < 0.001). Younger patients (p = 0.02) and those with young children (p < 0.001) were treated to a higher degree and also closer to death (p = 0.03). Other variables associated with a higher probability of treatment were high education level (p = 0.001), living with a partner (p = 0.001), female gender (p = 0.023) and ethnicity of non-European origin (p = 0.031). In a multivariate analysis, young age and high education remained as independent factors. In 57% of the cases there was no formal documentation of treatment discontinuation or end-of-life discussions with the patient. CONCLUSION: Socioeconomic status (SES) is of importance for the treatment decisions. About half of the patients with disseminated disease receive palliative chemotherapy and of these, about one third are treated even during the last month of life. In a majority of cases, there is no formal documentation of treatment discontinuation or end-of-life discussions.

Gene expression profiling guiding diagnosis and therapy of rare mammary-like anogenital gland carcinomas.

Cancers derived from anogenital mammary-like glands are rare, and their identification and selection of treatment for dissemination may be difficult. We encountered two such tumors, which both presented as occult primaries with nodal and hematogenous metastases. They were studied by immunohistochemistry, HER2 receptor assay, and gene expression profiling. Both tumors had some microscopical and immunohistochemical features in common with breast cancer, but lacked estrogen and progesterone receptors. Taxane-platinum-based systemic chemotherapy did not stop progression in a male patient, in whom a developing inguinal skin lesion was the likely primary tumor. The same regimen gave partial remission in a later, female, patient. After the mammary-like, HER2 positive nature of her tumor was confirmed by gene expression profiling using CupPrint and TargetPrint assays, treatment with vinorelbine-trastuzumab induced complete remission that is maintained by trastuzumab alone for almost 4 years after initial diagnosis. Molecular and immunohistochemical characterization of these rare tumors may identify them and sometimes guide systemic chemotherapy away from a non-specific and "broad spectrum" regimen toward a targeted therapy, resulting in greater effectiveness with less side effects.

Cancer patients without a known primary: incidence and survival trends in Sweden 1960-2007.

BACKGROUND: Metastatic cancer from an unknown primary tumour (CUP) is a common and heterogeneous clinical entity. In Sweden like in many other countries, the continuum of care for such patients remains to be established. MATERIAL AND METHODS: Data on CUP cases reported to the Swedish Cancer Registry during 1960 through 2007 was used to assess time trends for incidence, survival, and histological tumour type. RESULTS: There was an upward trend for the age-adjusted incidence until the late 1990s. This roughly paralleled the increase for all reported cancers during the same period. The increase of CUP mainly concerned patients aged above 50 years, and tumours classified as adenocarcinomas. The relative survival at 12 months after a diagnosis of CUP was estimated at 20%. However, after 12 months the relative survival levelled of and the 5-year estimate was 10-15% which suggests that a small proportion of CUP cases may be cured. Relative survival was highly dependent on age with substantially better outcome for young patients, particularly those aged below 30 years. We observed no time trend for survival. DISCUSSION: Cases diagnosed as CUP includes patients with metastatic spread from a wide variety of tumours although certain tumour types probably are overrepresented, for example, cancers in sites that are difficult to examine clinically. Incidence trends probably represent the sum of trends for these cancers as well as diagnostic trends. The decreased incidence observed during the last decade might thus be explained in terms of a combination of improved diagnostic methods to detect primary tumours and decreasing incidence for e.g. pancreatic cancer and lung cancer among males. There is a need of evidence-based programs that define the continuum of care for CUP patients. Such a program is currently being developed through collaboration between all health care regions in Sweden.