[Quality of treatment in operable breast carcinoma. Comparison of the years before 1987, 1987-1990 and 1991-1994]

BACKGROUND

Has progress in the treatment of breast cancer been translated into routine practice? What can be further ameliorated? We present a first step in quality assurance by examining the quality of care in early-stage breast cancer during recent years.

METHODS

Retrospective analysis of actual care in 300 patients with operable invasive breast cancer. Analysis and comparison of treatment in 3 time-periods based on date of diagnosis (before 1987, 1987-1991, 1991-6/1994).

RESULTS

Staging, surgical treatment and histopathological analysis have become more complete over these years. There is, however, no tendency to diagnose smaller tumors in our series. The percentage of patients undergoing breast-conserving surgery has not increased since 1987. Overall, 25% of cancers were treated by breast-conserving surgery. The rate of ipsilateral breast recurrences after breast-conserving surgery was 19% if the breast was irradiated, and 67% when radiation had been omitted (median follow-up 50 months). Adjuvant systemic therapy is now given to many node negative patients. Combined adjuvant therapy (endocrine plus chemotherapy) was rarely used. Early consultation of medical oncology has increased in recent years.

CONCLUSION

Progress in the treatment of early-stage breast cancer has only partially been translated into clinical practice. To ensure that treatment decisions conform to the most recent standards, quality controls are necessary. The simplest form of quality control is a multidisciplinary approach, which should be used early, in every case, and if necessary, repeatedly.

[Chemotherapy of gastrointestinal carcinomas and non-small-cell pulmonary carcinoma: a controversy]

Patients with metastatic gastrointestinal cancers and metastatic non-small cell lung cancer present an important challenge in medical oncology and palliative care. Symptoms caused by tumor progression should undoubtedly be treated. The management of asymptomatic patients, however, is still controversial. A clinical decision on whether an asymptomatic patient should be treated with chemotherapy at an early or at a late stage in the evolution of the disease must often be reached on an individual basis. Ongoing clinical research to improve treatment results is still urgently needed. Research programs should aim at (a) evaluating new drugs and (b) testing new multi-modal treatment strategies.

Malignant peritoneal mesothelioma after Thorotrast exposure

A case of a malignant peritoneal mesothelioma in a 63-year-old male patient with a history of exposure to Thorotrast in 1945 is presented. There was no history of exposure to asbestos. The clinical manifestation was a serosal effusion, which required weekly ascites puncture until therapy with intraperitoneal bleomycin was initiated. The latter treatment led to a significant reduction of ascites without any influence on tumor progression. Unfortunately, intraperitoneal bleomycin was accompanied by pulmonary toxicity, but at a higher total dose than known for intravenous administration. Three years after diagnosis the patient is still alive, without relapse of ascites production after bleomycin had to be stopped. Considering the risk of pulmonary fibrosis with high-dose intraperitoneal bleomycin and the lack of efficacy on tumor reduction, bleomycin seems to offer no advantage with respect to cisplatin.

[Hormone treatment of patients with breast carcinoma]

Endocrine treatments of breast cancer patients play an important role in the management of this common tumor of women. In this short review the most frequently applied drugs are discussed; thereafter, their use is shown in the curative (adjuvant) and in the palliative situation. In premenopausal women who suffer from a hormone-sensitive cancer, adjuvant treatments include either ovarian ablation or adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-fluoro-uracil. In post-menopausal women, the adjuvant treatment of choice is tamoxifen. The currently active protocols for adjuvant treatments of hormone-sensitive breast cancers of the International Breast Cancer Study Group (IBCSG) and the Swiss Group for Clinical Cancer Research (SAKK) should not be followed because of the anthracyclines administered to a high percentage of the involved patients. These drugs, known for their cardiotoxic side effects, have for the time being no place in the adjuvant treatment of hormone-sensitive breast cancers; therefore, the duty of the primary-care physician is to protect his patients from these protocols. In the palliative treatment, tamoxifen is the first choice. The success of this treatment is shown by a few examples.

Short-term weekly chemotherapy followed by high-dose therapy with autologous bone marrow transplantation for lymphoblastic and Burkitt's lymphomas in adult patients

BACKGROUND

Type and duration of treatment for highly aggressive non-Hodgkin's lymphoma has been a matter of debate over the past decade. To determine the therapeutic efficacy of an abbreviated treatment regimen, 26 patients with newly-diagnosed highly aggressive lymphomas, 17 of them belonging to the International Working Formulation (IWF) group I and 9 with Burkitt's lymphoma (IWF J), were entered in a study using short-term weekly chemotherapy followed by high-dose therapy and autologous bone marrow transplantation.

PATIENTS AND METHODS

Besides histology, requirements for entry into to the study were age between 16 and 60 years, stage 1 bulky disease and elevated LDH or stage II to IV disease with or without bulk or elevated LDH, and an absence of HIV infection or CNS involvement at diagnosis. The treatment plan was 12 weeks of MACOP-B or VACOP-B chemotherapy followed by high dose therapy and autologous bone marrow transplantation in first complete remission.

RESULTS

Twenty patients (76%), 16 (62%) of those on MACOP-B or VACOP-B, 1 who had received 2 cycles of ProMACE-CytaBOM prior to MACOP-B and 3 after a first salvage regimen, achieved complete remissions. Seventeen patients (65%) were transplanted in first remission, and 15 (58%) after induction treatment with only MACOP-B or VACOP-B. Reasons for not being given high dose therapy and autologous bone marrow transplantation (ABMT) were failure to achieve complete remission in 6 patients, early relapse in 2 and severe pulmonary toxicity associated with chemotherapy in 1. The median time of follow-up was 45 months. At 3 years, the estimated event-free survival was 31% (CI 14%-50%) and the overall survival 48% (CI 25%-67%). There were no deaths from toxic effects of treatment. Pretreatment factors associated with relapse were stage III or IV disease, age over 30 years and bone marrow involvement. Logrank analysis showed that age was the only factor significantly associated with poor event-free survival.

CONCLUSION

Short-term weekly chemotherapy followed by high-dose therapy with the CBV regimen in first remission is not a higly effective treatment for advanced lymphoblastic and Burkitt's lymphomas. The 30% rate of failure to achieve partial remission after 6 weeks and/or complete response after 12 weeks of MACOP-B or VACOP-B treatment, as well as the 42% failure rate to undergo ABMT in first remission, suggest that more aggressive chemotherapy should be used in the beginning.

Combined-modality treatment of small-cell lung cancer: randomized comparison of three induction chemotherapies followed by maintenance chemotherapy with or without radiotherapy to the chest. Swiss Group for Clinical Cancer Research (SAKK)

BACKGROUND

From 1980 to 1983 the Swiss Group for Clinical Cancer Research (SAKK) performed a randomised phase III trial in patients with small-cell lung cancer with the objective of improving the results of induction chemotherapy and defining the role of consolidating chest irradiation.

PATIENTS AND METHODS

Patients were initially randomised to induction arms AVP (adriamycin, etoposide and cisplatin given every four weeks for four cycles), EVA (cyclophosphamide, etoposide and adriamycin given every four weeks for four cycles) or MOC/AVP (methotrexate, vincristine, cyclophosphamide alternating with adriamycin, etoposide and cisplatin given for two cycles). All patients received prophylactic cranial irradiation with 30 Gy, and after four months of induction chemotherapy were randomized to maintenance chemotherapy with or without consolidating chest irradiation. The patients in the combined-modality maintenance arm first received radiation therapy to the chest (45 Gy) followed by MOC/EVA chemotherapy.

RESULTS

266 patients were eligible and evaluable. An overall response rate of 70% with 21% of complete remissions, a median survival of 9.3 months and survival of 8% of the patients at two years were observed. The highest objective response rate was achieved with the AVP-induction chemotherapy with an 80% response rate and 32% complete remissions. Similar results were achieved with the alternating regimen of MOC/AVP. In contrast, patients treated with the EVA induction regimen had significantly lower overall remission (56%) and complete remission rates (7%). The role of consolidating chest irradiation could not be clarified in limited-disease patients due to the small number of them who were randomised to the maintenance part of the study. However, in patients with extensive disease in partial remission after induction treatment, combined maintenance therapy had a more significant adverse effect on survival than maintenance chemotherapy alone (median survival in the maintenance phase of 148 days versus 239 days, p = 0.011).

CONCLUSION

We conclude that the combination of adriamycin, etoposide and cisplatin is an active induction treatment. Consolidating chest irradiation is contraindicated in patients with extensive disease in partial remission after induction when given in a sequential manner, as in our trial.

Phase I/II study of liposome-complexed mitoxantrone in patients with advanced breast cancer

The toxicity of escalating doses of liposome-complexed mitoxantrone (LCM) was evaluated in 22 women with histological/cytological diagnosis of metastatic breast cancer (21 pts) or adenocarcinoma of unknown primary origin (1 pt). All patients but one had been pretreated with chemotherapy. LCM was given IV as a 1h-infusion, repeated every 3 weeks, from a starting dose of 3 mg/m2, corresponding to 1/3 of the MELD10. An intra-patient dose escalation scheme, with an increase per cycle of 3 mg/m2 up to 12 mg/m2, and then by 2 mg/m2 was applied, treatment being continued until tumour progression, or toxicity, or up to a maximum of 6 cycles, whichever occurred first. Granulocytopenia was dose-limiting, with a GNC count of less than 0.5 x 10(3)/microliters after 30%, 28%, 50% and 50% of the cycles given at 16, 18, 20 and 22-24 mg/m2, respectively. The lowest GNC count occurred usually 2 weeks after treatment, with recovery in the following week. Gastro-intestinal toxicity, mucositis and alopecia were rare and of mild degree. Two patients, with a subtotal neoplastic involvement of the liver and a pretreatment grade 4 liver impairment, died because of acute liver failure a few days after treatment. The maximum tolerable dose was defined at 22 mg/m2 and 18 mg/m2, given every 3 weeks for 6 cycles, was the regimen recommended for phase II studies. Seven previously untreated patients with metastatic breast cancer have been so far treated. The pattern of toxicity of LCM (specific, short-lasting granulocytopenia; negligible, non cumulative non hematological toxicity) was confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

Routine bone marrow punctures during remission of acute myelogenous leukemia

To determine whether serial examinations of the peripheral blood can replace regular bone marrow punctures in the diagnosis of a relapse of acute myelogenous leukemia (AML), the peripheral blood of 40 AML patients in remission undergoing regular bone marrow punctures was studied. Within three months prior to bone marrow examination proving relapse in 97% of the relapses, at least one of the following values of the peripheral blood was pathological: blasts (84%), neutrophil granulocytes (72%), thrombocytes (64%), and hemoglobin (58%). The simultaneous appearance of abnormalities in the peripheral blood and the bone marrow occurs in such high incidence that routine bone marrow punctures are rendered obsolete in the follow-up of AML patients. Needless pain and anxiety can therefore be avoided for many AML patients.

[Interactions of cytostatic agents with other drugs]

With the degree of polypharmacy currently practiced in the field of oncology, there are undoubtedly many drug interactions. In the present study the influence of "non-cytotoxic" drugs on anticancer drugs is discussed, but not the reverse. Not only is the augmentation (reversal of multidrug resistance) or the reduction of antitumor properties of cytotoxic drugs observed, but also cytostatic activities of "non-cytotoxic" drugs themselves. Examples are calmodulin inhibitors such as phenothiazines and tricyclic antidepressants. Interactions may also increase side effects of cytostatic drugs or even neutralize the antitumoral activity. To ensure that interactions are not overlooked, all medicaments being administered should be listed. It is, however, not feasible yet to determine serum concentrations of all the drugs given to the patient. The antitumor activity of supportive care could be evaluated in randomized studies (e.g. cytostatic drugs +/- antidepressants).

[Interdisciplinary follow-up in patients with tumors]

There are two main reasons for routine follow-up examinations after treatment of cancer patients: the assessment of treatment efficacy and detection of relapse and the rating of drug side-effects. Routine controls can only efficiently be performed with a profound knowledge of the biology of the tumor and of the therapeutic efficacy of the available treatments. The frequency and the type of the follow-up examinations depend mainly on the curative or the palliative treatment possibilities. Interdisciplinarity is important again only in case of new therapeutic considerations. Examples of useless controls are mentioned. Through the prevention of unnecessary examinations the primary-care physician could play an important role in the cut-down of healthcare costs.

[The significance of gamma-glutamyltransferase in the evaluation of the results of chemotherapy of liver metastasis]

The serum concentration of gamma-glutamyltransferase (gamma-GT) was serially measured in 26 cancer patients undergoing chemotherapy for liver metastases. 20 patients were studied retrospectively and 6 prospectively with emphasis on the first few days of cytostatic treatment. The gamma-GT determinations during the first days of treatment gave no indication of the prognosis of remission. Serial measurements during treatment do, however, serve to objectify the success of the chemotherapy. In most patients the gamma-GT concentrations paralleled the general condition as well as palpation and ultrasound examination of the liver. Direct interactions of cytotoxic drugs with gamma-GT could not be demonstrated. gamma-GT determinations are therefore of help in phase II studies in evaluating new drugs for their cytostatic activity against liver metastases.

Distinction of influenza viruses of different host cell origin

Influenza A viruses grown in different animal or human cells retain their antigenic make-up as tested by the usual immunological assays. With the aid of a Sambucus nigra (L.) extract containing its lectins the viruses can be distinguished after one single passage in a different cell type by a change in their hemagglutinating properties. Binding of such lectins to influenza viruses may be a means for a more subtle classification, relating to the host cell origin of the virus.