Cancer statistics, 2000

Chronic myelogenous leukaemia

In the last decade, improvements in both non-transplant and transplant therapy have extended the lives of patients with CML, particularly those in chronic phase. The future will probably bring a greater understanding of molecular leukaemogenesis and options for treating CML. Non-transplant therapies in development include novel agents and combination therapy. Transplant strategies seek to decrease regimen-related toxicity and directly manipulate the immune system to eradicate disease. Clinical and laboratory science seems poised to add novel therapies to the armamentarium against CML. It is exciting to contemplate what reviews of CML written 10 years from now will discuss.

Changes in colorectal cancer over a 15-year period in a single United States city

OBJECTIVE

The aim of this study was to identify colorectal cancer trends in different patient groups in one region.

METHODS

We reviewed the records of all patients with colorectal cancer who were seen at two hospitals in Columbia, SC, between 1981 and 1995. Patients were divided into three 5-yr cohorts (cohort 1, 1981-1985; cohort 2, 1986-1990; and cohort 3, 1991-1995). We recorded demographic data, histological type, tumor stage, grade, and survival.

RESULTS

A total of 1395 patients were diagnosed, of whom 1252 had adenocarcinoma. Mean age of diagnosis was 64.5 yr in black and 66 in white patients (p = 0.036). Adenocarcinoma proximal to the splenic flexure was found in 62% of women and 49% of men (p < 0.001), and in 51% of black and 44% of white patients (p = 0.08). Proximal cancers accounted for 61%, 48%, and 32% of cohorts 1, 2, and 3, respectively. The proportions of patients with advanced stage (III and IV) adenocarcinoma in the three cohorts were 54%, 47%, and 40%, respectively (p = 0.001). Median survival for adenocarcinoma was 23.7, 23.5, and 23.1 months in cohorts 1, 2, and 3 (p = 0.9).

CONCLUSIONS

The prevalence and demographics of colorectal cancer have been fairly stable at this center. There has been a significant decrease in proximal cancers. Although adenocarcinoma is being diagnosed at an earlier stage, this has not affected survival. Colonoscopy may be the most appropriate screening method in women and in black patients, in whom proximal cancers are more often found.

Nodal stage after induction therapy for stage IIIA lung cancer determines patient survival

BACKGROUND

This study was undertaken to determine the predictive value of nodal status at resection in regards to long-term outcome of patients undergoing neoadjuvant therapy and resection for stage IIIA N2-positive non-small cell lung cancer (NSCLC).

METHODS

We reviewed the medical records of all patients found on surgical staging to have N2-positive NSCLC and who underwent induction therapy followed by resection between 1988 and 1996 at our hospital. Complete follow-up information was examined utilizing Kaplan-Meier survival analysis and Cox proportional hazards multivariate analysis.

RESULTS

One hundred three patients (59 men) with stage IIIA N2-positive NSCLC received neoadjuvant therapy before surgical resection. Preoperative therapy consisted of platinum-based chemotherapy (76), radiotherapy (18), or chemoradiation (9). Operations included pneumonectomy (38), bilobectomy (6), and lobectomy (59). There were four deaths and seven major complications. Eighty-five patients were followed until death. Median survival among 18 living patients is 60.9 months (range 29 to 121 months). Twenty-nine patients were downstaged to N0 and had 5-year survival of 35.8% (median survival 21.3 months). Seventy-four patients with persistent tumor in their lymph nodes (25 N1 and 49 N2) had significantly worse, 9%, 5-year survival, p = 0.023 (median survival 15.9 months). Other negative prognostic factors were adenocarcinoma and pneumonectomy.

CONCLUSIONS

Patients with N2-positive NSCLC whose nodal disease is eradicated after neoadjuvant therapy and surgery enjoy significantly improved cancer-free survival. These data support surgical resection for patients downstaged by induction therapy; however, patients who are not downstaged do not benefit from surgical resection. Direct effort should be made to improve the accuracy of restaging before resection.

Pancreatic cancer

Optimal therapy for pancreatic adenocarcinoma requires surgical removal with tumor-free margins. Superior outcomes have been reported for high-volume centers incorporating a multidisciplinary approach. Postoperative ("adjuvant") chemotherapy and radiation should be considered in patients with successfully resected primary tumors. Combined modality treatment with chemotherapy and radiation should be considered for locally advanced, unresectable tumors. Gemcitabine can provide symptom relief and a modest improvement in survival for patients with metastatic disease. Strict attention to relief of symptoms such as pain, depression, anorexia/cachexia, and jaundice is essential in all patients with pancreatic cancer. All patients with pancreatic cancer should be encouraged to enter clinical trials of new therapies, given that long-term survival for all stages remains poor.

Localized bladder cancer

Transitional cell carcinoma (TCC) of the bladder makes up 90% of bladder cancers. The approach to the management of localized TCC includes accurate clinical and histologic diagnosis and staging with pathologic material obtained through endoscopy. Once the diagnosis of superficial TCC has been established, histologically based prognostic factors guide which therapy or combination of therapies is indicated in the management of individual patients. Surgery alone (transurethral resection) is appropriate initial therapy for noninvasive papillary TCC. For lamina propria invasive tumors and carcinoma in situ, intravesical immunotherapy with bacille Calmette-Guérin (BCG) is often the first line of treatment to decrease tumor recurrence and to possibly decrease progression and improve survival. Intravesical chemotherapy and interferon are alternative therapies that can also decrease recurrence rates. For BCG-refractory TCC, durable response rates with alternative intravesical therapies are low. For superficial TCC that is refractory to endoscopic procedures and intravesical agents or for disease progression, radical cystectomy with neobladder formation or other forms of urinary diversion is the treatment of choice.

Minimal adenocarcinoma in prostate needle biopsy tissue

One of the major diagnostic challenges in prostate needle biopsy interpretation is definitive establishment of a malignant diagnosis based on a minimal or limited amount of carcinoma in needle biopsy tissue. Major and minor diagnostic criteria should be used for interpretation of small foci of carcinoma. The constellation of findings and a combination of the major and minor diagnostic criteria permit a definitive diagnosis of focal adenocarcinoma. The differential diagnosis of minimal prostatic adenocarcinoma in needle biopsy tissue is broad and includes many benign lesions. The benign entities most likelty to be misdiagnosed as minimal prostatic adenocarcinoma are atypical adenomatous hyperplasia (adenosis) and atrophy. High-grade prostatic intraepithelial neoplasia and a descriptive diagnosis of focal glandular atypia or atypical small acinar proliferation also should be considered before diagnosing minimal adenocarcinoma. The most valuable adjunctive study for the diagnosis of minimal adenocarcinoma is immunohistochemistry using antibody 34 beta E12, reactive against basal cell-specific high-molecular-weight cytokeratins. Most cases can be diagnosed based on H&E-stained sections without this immunostain. Most minimal carcinomas in prostate needle biopsy tissue are of intermediate histologic grade, and most are indicative of pathologically significant carcinoma in the whole prostate gland.

Adjuvant therapy for gastric cancer: a reality at last

Gastric cancer remains a significant healthcare problem throughout the world and is usually diagnosed at a fairly advanced stage in the West. Despite complete resection of the primary tumor, most patients eventually experience a relapse and die of recurrent disease. Extended surgery has not been shown to improve survival in Western studies. There have been a large number of adjuvant chemotherapy trials over the past several decades, most with negative results. More recently, there is hope for improving these dismal results with a meta-analysis showing a benefit for adjuvant chemotherapy and a large randomized trial, INT-0116, which has just reported a significant survival advantage with combined chemoradiation. These results make adjuvant therapy for completely resected gastric carcinoma the new standard of care, except in the uncommon setting of early intramucosal cancers.

Biomarker distribution after injection into the canine prostate: implications for gene therapy

OBJECTIVE

To evaluate the distribution of biomarkers after transrectal injection into the canine prostate and to report a method for enhancing the distribution of gene expression.

MATERIALS AND METHODS

Carbon black was first used to evaluate the histopathological distribution in canine prostate of single or multiple injections via the transurethral, transperineal and transrectal routes. The distribution of canarypox virus (ALVAC) vector-delivered gene expression was then compared using both fluid-phase injection techniques and delivery in a solid carrier composed of a gelatine sponge matrix.

RESULTS

After transurethral administration, carbon black was detected as scattered particles in ducts and acini, mostly in the periphery of the gland. Direct transrectal injection of carbon black resulted in a localized collection at the site of injection, with only a minimal peri-acinar distribution. Transrectal injection of the fluid-phase (virus suspended in diluent) ALVAC vector encoding the beta-galactosidase gene resulted in a similar distribution, with limited gene expression at the site of injection and in the needle track. Delivery of the same number of virus particles in the gelatine sponge matrix resulted in qualitatively greater gene expression.

CONCLUSIONS

Direct injection of the canine prostate with biomarkers, including viral vectors, in the fluid-phase results in very localized gene expression, while the distribution was more widespread after delivery in a gelatine sponge matrix.

Effects of health insurance and race on breast carcinoma treatments and outcomes

BACKGROUND

The authors hypothesized that insurance payer and race would influence the care and outcomes for patients with breast carcinoma.

METHODS

The authors examined treatments and adjusted risk of death (through 1997) for all incident cases of breast carcinoma occurring in Florida in 1994 (n = 11,113) by using state tumor registry data.

RESULTS

Patients lacking health insurance were less likely to receive breast-conserving surgery (BCS) compared with patients who had private health insurance. Among patients insured by Medicare, those belonging to a health maintenance organization (HMO) were more likely to receive BCS but less likely to receive radiation therapy after BCS. Non-Hispanic African Americans had higher mortality rates even when stage at diagnosis, insurance payer, and treatment modalities used were adjusted in multivariate models (adjusted risk ratio [RR], 1.35; 95% confidence interval [CI], 1.12-1.61; P = 0.001). Patients who had HMO insurance had similar survival rates compared with those with fee-for-service (FFS) insurance. Among non-Medicare patients, mortality rates were higher for patients who had Medicaid insurance (RR, 1.58, 95% CI, 1.18-2.11; P = 0.002) and those who lacked health insurance (RR, 1.31; 95% CI, 1.03-1.68; P = 0.03) compared with patients who had commercial FFS insurance. There were no insurance-related differences in survival rates, however, once stage at diagnosis was controlled.

CONCLUSIONS

As a result of later stage at diagnosis, patients with breast carcinoma who were uninsured, or insured by Medicaid, had higher mortality rates. Mortality rates were also higher among non-Hispanic African Americans, a finding that was not fully explained by differences in stage at diagnosis, treatment modalities used, or insurance payer.

Management of locally advanced rectal cancer

The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.

Fenretinide therapy in prostate cancer: effects on tissue and serum retinoid concentration

PURPOSE

To examine the feasibility of using fenretinide (4-HPR) for the prevention and treatment of prostate cancer.

MATERIALS AND METHODS

We measured the impact of 4-HPR therapy on retinoid concentrations in vivo, in a mouse model of prostate cancer and clinically, in patients with prostate cancer who were given oral 4-HPR (200 mg/d) or placebo for 4 weeks before undergoing a radical prostatectomy.

RESULTS

Prostate tumors in mice treated with 4-HPR contained high levels of 4-HPR and of all-trans-retinoic acid (RA) and reduced levels of retinol (ROH). Patients given 4-HPR were found to have significantly higher concentrations of 4-HPR in the cancerous prostate as compared with the serum levels (463 nmol/L v 326 nmol/L; P =.049), but they were only 1/10 the levels found in mice and were far below the concentrations reported in human breast tissue. Serum and tissue ROH levels were reduced to less than half the concentrations found in untreated controls. RA concentrations in human serum and in cancerous prostates were not significantly affected by 4-HPR treatment, in contrast with the findings in mice.

CONCLUSION

The standard oral dose of 4-HPR proposed for breast cancer (200 mg/d) achieved only modest drug levels in the prostate and is unlikely to be effective for prostate cancer prevention or treatment. Higher doses need to be explored.

Prostatourethral-rectal fistula after prostate brachytherapy

BACKGROUND

Brachytherapy (BT) has seen increased utilization as a potentially curative treatment for patients with localized initial or recurrent prostate carcinoma. This modality can be delivered by palladium 103 (Pd(103)) or iodine 125 (I(125)) implant with or without external beam radiotherapy (EBRT). Prostatourethral-rectal fistula (PRF) is a serious complication of this approach, and its incidence, clinical presentation, and risk factors for occurrence have not been documented thoroughly. Thus, the authors sought to determine these factors in a large series of patients who were treated at two institutions.

METHODS

Seven hundred sixty-five patients received outpatient BT using a computed tomography (CT)-guided or transrectal ultrasound (TRUS)-guided technique between July 1994 and June 1999 using either Pd(103) or I(125) implants. Of the 754 patients with follow-up, 640 patients received BT monotherapy, 69 patients received BT monotherapy as a boost after EBRT, and 45 patients received BT as salvage therapy after locally recurrent prostate carcinoma that was treated initially with BT (20 patients), EBRT (20 patients), surgery plus EBRT (3 patients), surgery and high dose rate radiotherapy (HDR) (1 patient), or EBRT plus HDR (1 patient). CT dosimetry of the TRUS-guided implants was carried out in all patients 1-7 days postprocedure. Patient follow-up and clinical status were compiled in a data base.

RESULTS

Seven PRFs developed in 754 patients (1%) between 9 months and 12 months after treatment. One PRF (0.2%) occurred in patients who were treated with BT monotherapy. PRFs occurred in patients who were treated with combination therapy (2 of 69 patients; 2.9%) and in patients who underwent salvage BT (4 of 45 patients; 8.8%) patients. All six patients who developed fistulas in the context of combination BT/EBRT or salvage BT had biopsy of an anterior rectal lesion overlying the prostate noted on physical examination during routine follow-up. Gastrointestinal endoscopic evaluation alone was not associated with any PRF. Five of the seven PRFs resolved with either surgical repair (3 patients) or conservative management (2 patients).

CONCLUSIONS

There is a low incidence of PRF formation after BT monotherapy. Because all patients who developed PRF did so subsequent to prior rectal biopsies, the authors currently are discouraging such practices strongly if the rectal lesion is consistent with radiation-induced effects.

Risk-based management of solid tumors in children

BACKGROUND

During the past 25 years significant improvements in survival (56% to 75%) have been observed for children with malignant solid tumors. Multidisciplinary cooperative studies using combined therapy (surgery, chemotherapy, and irradiation) have played a major role. This report describes how recognition of biologic and genetic factors has permitted risk categorization and resulted in new treatment protocols that individualize care.

METHODS

Genetic alterations and biologic factors concerning the multiple endocrine neoplasia syndromes, Wilms' tumor, and neuroblastoma are described.

RESULTS

Using the these data new treatment protocols are designed according to whether a patient is categorized as having a low-, intermediate-, or high-risk tumor, which determines the intensity and type of treatment required.

CONCLUSIONS

Identification of biologic markers and specific gene alterations may be critical in establishing the behavior of tumors (low versus high-risk). Risk-based management permits individualized care for each patient, maximizes survival, minimizes morbidity, and improves the quality of life.

Second-Line Gemcitabine in Refractory Stage IV Non–Small-Cell Lung Cancer: A Phase II Trial

Two recent trials have suggested that docetaxel improves survival in the second-line treatment of non small-cell lung cancer (NSCLC) refractory to first-line platinum-based regimens. Given this, it is appropriate to continue to address the role of new agents in the second-line treatment of refractory NSCLC. Gemcitabine is a well-tolerated new agent that has been shown to have activity in NSCLC. Thirty-one previously treated patients with NSCLC were entered in this study. Eight patients had responsive disease (defined as response to first-line therapy lasting greater than or equal to 3 months) and 23 had refractory disease (defined as progressive disease on first-line therapy or progression less than 3 months from completing first-line therapy). Gemcitabine (1250 mg/m2) was infused over 30 minutes on days 1, 8, and 15 every 28 days. Quality of life (QOL) was assessed with each cycle using the Functional Assessment Cancer Therapy-Lung (FACT-L) questionnaire. Two patients (6.5%) had a partial response, and nine (29%) had disease stabilization. The most frequent grade 3/4 toxicity was myelosuppression, but this only occurred in 8% of doses delivered. Fifty-two percent of evaluable patients had stable or improved QOL over baseline, 10% had a decline in QOL, and the remainder completed only baseline questionnaires. Twenty-nine patients have died of progressive NSCLC; two patients remain alive. Overall, the 31 patients have a median survival of 5.1 months (95% confidence interval [CI]: 4.2-7.4 months) and 1-year survival rate of 16% (95% CI: 3%-29%). Gemcitabine was well tolerated in this patient population. An objective response rate of 6.5% was observed although a significant proportion of patients (29%) experienced stable disease, which may have impacted on their survival. QOL was improved or maintained in over half of the patients. Given these data, gemcitabine as a single agent is a therapeutic option for patients with refractory NSCLC.

Inactivation of MMAC1 in bladder transitional-cell carcinoma cell lines and specimens

We recently limited the location of a candidate tumor suppressor gene in invasive (T3a/b) bladder transitional-cell carcinoma (TCC) to a 2.5-cM region at chromosome 10q23.3. This region harbors the MMAC1/PTEN/TEP1 gene (referred to hereafter as MMAC1), a dual-phosphatase tumor-suppressor gene frequently inactivated in variety of malignant tumors. In the present study, we examined whether MMAC1 is a target for inactivation by mutations and deletions in bladder TCC cell lines and specimens. MMAC1 was inactivated by homozygous deletions and mutations in three (27%) of 11 bladder cancer cell lines. One cell line, UC-3, had homozygous deletions, and two other cell lines, T-24 and UC-9, had missense mutations. T-24 had also a nonsense mutation. However, none of the 33 bladder TCC specimens examined had a mutation or deletion in the coding region. These results suggest that MMAC1 is not the primary target for inactivation in bladder TCC and that another gene, in close proximity to the MMAC1 locus, within this region of frequent allelic losses, may be the target for inactivation.

Spirituality, demographic and disease factors, and adjustment to cancer

PURPOSE

The purpose of this study was to examine the relationship between demographic-disease variables, spirituality, and psychosocial adjustment in a heterogeneous sample of patients with cancer.

DESCRIPTION OF STUDY

Participants (N = 83) accrued through the Rhode Island Hospital and the American Cancer Society completed questionnaires, and structural equation modeling was used to examine the relationships among disease and demographic factors, spirituality, and psychosocial adjustment to cancer.

RESULTS

Of five models tested, a mediational model received the strongest support (chi-square(35)-66.61; P = .005; comparative fix index = .90; root mean square error of approximation = .09), explaining 64% of the variance in psychosocial adjustment. Being a woman, having a longer illness duration, and having a lower disease stage were related to greater levels of purpose in life and religious beliefs, which, in turn, were associated with higher levels of family and social adjustment and psychological health.

CLINICAL IMPLICATIONS

The results indicate that spirituality can influence how patients with cancer adjust to their diagnosis and treatment and, thus, support the need for interventions that target spirituality to promote psychosocial adjustment in this population.

Educational and psychosocial issues related to new treatment advances for metastatic breast cancer

OBJECTIVES

To explore educational issues as well as psychosocial issues relating to finances, family, and hope that may arise with the introduction of new treatment strategies for metastatic breast cancer.

DATA SOURCES

Review articles, textbooks, and personal communications.

CONCLUSIONS

New treatment advances in metastatic breast cancer are multifaceted and complex. Nurses must provide a holistic approach to patients and are in an excellent position to guide patients towards treatment advances.

IMPLICATIONS FOR NURSING PRACTICE

Patients look to nurses to provide answers and to serve as resources as new treatment advances develop.

Gastric cancer

Gastric adenocarcinoma is the most common malignancy of the upper gastrointestinal tract. During the past two decades it has migrated toward the gastroesophageal junction. Gastroesophageal reflux and obesity may play a role. Recent research suggests that a number of biologic and molecular differences exist in patients with gastric cancer. Further investigation in these areas may help in predicting outcome and directing therapy. Gastric cancer is not a curable condition when metastases are present. However, postoperative chemotherapy plus chemoradiotherapy, in the Intergroup trial 0116, prolonged the overall and disease-free survival rates of patients after a curative (R0) resection. It should be considered the new standard of care in patients with gastric cancer who have undergone curative resection with stage Ib-IV disease. Preoperative therapy strategies may increase the likelihood of R0 resection and remain an area of active investigation. Finally, development of more active agents is needed for the treatment of metastatic tumors.

Epidemiology, prevention, and early detection of breast cancer

Decreases in the incidence of breast cancer have not been achieved, but there is a downward trend in age-adjusted breast cancer mortality rates in the United States. Recent epidemiologic investigations continue to refine our understanding of the role of established breast cancer risk factors, such as reproductive characteristics and body mass index, and in the process advance understanding of the etiology of breast cancer. Important strides are being made in the chemoprevention of breast cancer, but clarifying the potential contributions of factors such as diet, physical activity, and cigarette smoke to the breast cancer burden is a high priority because these lifestyle behaviors also have important implications for primary prevention. The role of both environmental and endogenous exposures in breast carcinogenesis will be more clearly elucidated by studies that account for genetic polymorphisms, some of which may lead to differential susceptibility to harmful agents.

Minorities, women, and clinical cancer research: the charge, promise, and challenge

Significant progress has been made since the war against cancer was launched. Discoveries in molecular medicine, genetics, and epidemiology have led to the recognition that certain cancers are potentially preventable and that elements of lifestyle, along with genetic, hormonal, and metabolic factors can be altered to reduce cancer risk. Advances in medical technology have led to the development of new imaging methods and computer technologies that can aid in efforts to detect, diagnosis, and treat cancer. Since the offensive against cancer was initiated, cancer treatments have become more powerful, more precise, less drastic, and safer. As a result, cancer incidence and mortality have begun to decline. Yet, while the nation boasts of the progress being achieved relative to cancer incidence and mortality, and federal research agencies retort that research applies to all populations, it is apparent that the declines do not translate to all populations in the United States. Clinical research is essential to cancer prevention and control. Within the oncology community, clinical cancer research trials are viewed as an efficient and economical way for patients to secure state-of-the-science medical care. Recognizing the need to improve access to state-of-the-science cancer treatment and control programs, minority and female participation in clinical cancer research trials has been encouraged. This recommendation is based on the belief that increased participation in well-designed clinical cancer research trials adhering to strict protocols and quality controls will, not only help validate the application of research findings to minority and female populations, but also result in better patient outcomes. Born out of a commitment to social equity, justice, beneficence, and the desire to ensure that data relevant to cancer prevention and control are both valid and generalizable to populations across the United States, several programs of research aimed toward increasing the representation of women and minorities in clinical cancer research have been pursued by the National Cancer Institute. This issue of the Annals of Epidemiology Minorities, Women, and Clinical Cancer Research presents issues and challenges that face the research community and descriptions of effective models, strategies, and practices that may be used to increase the participation of minorities and women in clinical cancer research trials and facilitate the conduct of research directed toward reducing the cancer burden within the United States.

Phenotypically different cells with heterogeneous nuclear ribonucleoprotein A2/B1 overexpression show similar genetic alterations

Immunocytochemical studies have revealed that overexpression of heterogeneous nuclear ribonucleoprotein (hnRNP) A2/ B1 in exfoliated epithelial cells is a potentially useful marker of early lung cancer. This study analyzed the correlation of hnRNP A2/B1 expression with molecular alterations in phenotypically different epithelial cells of paraffin-embedded pulmonary tissues. Sections from 20 human subjects were analyzed immunohistochemically for expression of hnRNP A2/B1. Normal-appearing, hyperplastic, and malignant epithelial cells with and without hnRNP A2/B1 expression (n = 78) were microdissected and assessed for microsatellite alterations (MA) and loss of heterozygosity (LOH) (n = 14 markers) as well as for clonality. Results showed that (1) hnRNP A2/B1 immunoreactive cells contained a significantly higher frequency of MA and LOH than did comparable cells that lacked detectable hnRNP A2/B1; (2) over 80% of MA and LOH seen in hnRNP A2/B1 immunoreactive normal-appearing and hyperplastic cells persisted in malignant cells; (3) preliminary analysis of methylation status of the androgen receptor gene in non-neoplastic cells was suggestive of hnRNP A2/B1-expressing cells being of clonal origin; and (4) cells with cytoplasmic hnRNP A2/B1 immunoreactivity had a 3-fold higher frequency of MA and LOH than did cells with nuclear hnRNP A2/B1 immunoreactivity. These findings suggest that phenotypically different respiratory epithelial cells with hnRNP A2/B1 overexpression might be clonally derived, and that the subcellular localization of hnRNP A2/B1 might be an important factor associated with tumor progression.

Cognitive consequences and central nervous system injury following treatment for childhood leukemia

OBJECTIVES

To determine the relationship between membrane damage and intellectual and academic abilities in children with acute lymphoblastic leukemia (ALL) and pilot test a math intervention for children with ALL who were affected.

DATA SOURCES

Research studies and review articles.

CONCLUSIONS

Despite the prophylactic central nervous system (CNS) treatment for long-term disease-free survival, many children with ALL subsequently experience declines in intellectual and academic skills.

IMPLICATIONS FOR NURSING PRACTICE

Improving academic abilities in children who have received CNS treatment is of high priority and may have longlasting implications on quality of life.

Nursing management considerations with trastuzumab (herceptin)

OBJECTIVES

To review nursing management consideration for patients with advanced breast cancer who are candidates for trastuzumab.

DATA SOURCES

Research articles and the trastuzumab product insert.

CONCLUSIONS

Identification of appropriate candidates for trastuzumab therapy should include a review of HER2 status, previous treatments, presence of comorbid diseases, and determination of cardiac function.

IMPLICATIONS FOR NURSING PRACTICE

Nurses will manage the administration of trastuzumab. Therefore, they must understand how antibodies work at the cellular level, how to treat infusion-related events, and how to choose the best candidates for biological therapy.

Multivariate analysis of race and adverse pathologic findings after radical prostatectomy

OBJECTIVES

Adverse pathologic features that predict disease recurrence after radical prostatectomy (RP) include positive surgical margins, non-organ-confined disease, and seminal vesicle invasion. Given that black men have a higher incidence of, and mortality from, prostate cancer compared with white men, we sought to determine whether race was an independent predictor of adverse pathologic findings among men who underwent RP at an equal access health care center. Results from previous studies evaluating whether race predicts positive surgical margins have been conflicting. No prior studies have evaluated whether race is an independent predictor of non-organ-confined disease or seminal vesicle invasion.

METHODS

A retrospective survey of 274 patients (126 black, 148 white) who underwent RP at the West Los Angeles Veterans Affairs Medical Center between 1991 and 1999 was undertaken. Multivariate analysis was used to determine the preoperative clinical variables that were most significant in predicting positive surgical margins, non-organ-confined disease, and seminal vesicle invasion. The preoperative variables analyzed were race, age, serum prostate-specific antigen, clinical stage, and biopsy Gleason score.

RESULTS

No differences in the incidence of positive surgical margins, non-organ-confined disease, or seminal vesicle invasion were found between black and white men undergoing RP. After controlling for the preoperative variables of age, serum prostate-specific antigen level, clinical stage, and biopsy Gleason score, race was not an independent predictor of positive surgical margins, non-organ-confined disease, or seminal vesicle invasion.

CONCLUSIONS

This is the first study to show that black race was not an independent predictor of non-organ-confined disease or seminal vesicle invasion among patients undergoing RP. Furthermore, race was not an independent predictor of positive surgical margins.

Elevated topoisomerase I activity in cervical cancer as a target for chemoradiation therapy

OBJECTIVE

The aim of this study was to determine whether the activity of topoisomerase I (topo I), the target of the anti-neoplastic drug camptothecin (CPT), is elevated in cervical cancer and whether CPT can radiosensitize cervical tumors.

METHODS

The topo I activity of 11 normal cervix and 30 cervical carcinoma tumors was assayed by measuring the relaxation of supercoiled DNA. Subconfluent or postconfluent CaSki human cervical carcinoma cells were exposed to CPT (1-5000 ng/ml) and immediately X-irradiated (0-800 cGy). Cell survival was determined by clonogenic assay.

RESULTS

Mean topo I activity in cervical cancer (3.0 +/- 0.06 h(-1)) was significantly greater than in normal cervix tissue (0.29 +/- 0.06 h(-1)). Stage 3 and 4 cervical carcinoma specimens displayed a trend of greater topo I activity (5.88 +/- 3.7 h(-1)) than stage 1 and 2 tumors (2.57 +/- 0.47 h(-1)). No correlation between topo I protein levels and catalytic activity was found. Combined treatment of subconfluent CaSki cells with CPT and ionizing radiation resulted in additive killing of cells. Combined treatment of postconfluent CaSki cells with low doses of radiation (200 and 400 cGy) and 1 or 10 ng/ml CPT for 2 or 48 h produced significant cytotoxicity compared to CPT or radiation alone, which were ineffective at these doses.

CONCLUSIONS

Topo I activity is elevated in cervical cancer compared to normal cervix. The radiosensitivity of noncycling cells within cervical tumors may be increased by simultaneous treatment with low doses of CPT or other topo I inhibitors.

Early detection for colorectal cancer: new aspects in fecal occult blood screening

The authors report on promising diagnostic methods of occult intestinal bleeding and discusses the potential new strategy of early detection of colorectal carcinomas in respect to old and new diagnostic measures available. Because of the limited sensitivity and specificity of classical methods used for the demonstration of occult fecal blood, the authors recommend the introduction of new techniques and markers in screening practice. It is presumed that new discoveries in molecular biology will improve the accuracy of early colorectal cancer prevention. Their implementation into routine screening, however, will not take place in the near future. Until their realization, improved screening efficacy is expected from the use of more specific and sensitive blood tests.

The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

OBJECTIVES

Although nurse practitioners and physician assistants form a large and growing portion of the primary care workforce, little is known about their colorectal cancer screening practices. The aim of this study was to assess the colorectal cancer screening practices, training, and attitudes of nurse practitioners and physician assistants practicing primary care medicine.

METHODS

All nurse practitioners (827) and physician assistants (1178) licensed by the Medical Board of the State of North Carolina were surveyed by mail. Both groups were further divided into primary care versus non-primary care by self-described roles. Self-reported practices, training, and attitudes with respect to colorectal cancer screening were elicited.

RESULTS

Response rates were 71.4% and 61.2%, for nurse practitioners and physician assistants respectively. A total of 51.3% of nurse practitioners and 50.3% of physician assistants described themselves as adult primary care providers. No primary care nurse practitioners and only 3.8% of primary care physician assistants performed screening flexible sigmoidoscopy. However, 76% of primary care physician assistants and 69% of primary care nurse practitioners reported recommending screening flexible sigmoidoscopy. A total of 95% primary care physician assistants and 92% of primary care nurse practitioners reported performing fecal occult blood testing. Only 9.4% of physician assistants and 2.8% of nurse practitioners received any formal instruction in flexible sigmoidoscopy while in their training. Additionally, 41.4% of primary care physician assistants and 27.7% of primary care nurse practitioners reported that they would be interested in obtaining formal training in flexible sigmoidoscopy.

CONCLUSIONS

Physician assistants and nurse practitioners are motivated, willing and underutilized groups with respect to CRC screening. Efforts to increase education and training of these professionals may improve the availability of CRC screening modalities.

Preventable cancers: the role of obstetrician gynecologists in colorectal cancer screening

Colorectal cancer is second only to lung cancer as a cause of cancer deaths in the United States, and is the third most common cause of cancer deaths in U.S. women. Effective screening and intervention programs exist and, if followed, could halve the number of annual deaths from this disease. Detection of early-stage disease and, more important, premalignant polyps, is possible by following the recommendations of several national societies, including the American College of Obstetricians and Gynecologists. Recommended screening consists of identification of special risk factors, annual fecal occult blood testing, and flexible sigmoidoscopy every 5 years. Alternatively, a dual-contrast barium enema every 5 to 10 years or colonoscopy every 10 years are options. This article reviews the evidence underlying current screening guidelines, highlights emerging trends in screening, and analyzes the growing need for women's health care providers to understand and promote colorectal cancer screening as part of an optimal health maintenance program.

The incidence of intraductal papillary mucinous tumors of the pancreas(1)

To review a population-controlled single institution experience with intraductal papillary mucinous tumors (IPMTs) of the pancreas treated in the United States and generate an incidence of this recently described disease process.First decribed in 1982, mucin-secreting pancreatic cancer constituted a newly recognized category of pancreatic exocrine tumors distinct from mucinous cystic neoplasms. Since that time, several small series of IPMTs of the pancreas have been reported. Most studies come from Asia and Europe, with limited data from American institutions and no description of the incidence.The authors retrospectively reviewed all patients who underwent pancreatic resections at Madigan Army Medical Center from October 1992 through November 1999. Cases suggestive of IPMTs underwent re-examination by a staff pathologist. Clinical presentation, imaging studies, treatment, histopathology, and outcomes were reviewed for those with IPMTs. The data base of all patients eligible for care was evaluated to obtain a population denominator and determine an incidence for this neoplasm.Over 7 years, 78 patients underwent pancreatic resections. Forty-two had pancreatic neoplasms and, of those, 8 (19%) had IPMTs. The mean age was 67 years, with equal numbers of males and females. All patients were symptomatic (abdominal pain, 75%; jaundice, 25%; weight loss, 25%). Abnormal computed tomography scans were noted in 7/8 (88%) cases. Mucin was visualized during endoscopic retrograde cholangiopancreatography in 5/7 (71%) patients. Preoperative diagnosis of IPMT was made in 5 (62%) cases. The locations of the tumors were head (63%), tail (12%), head and body (12%), and body and tail (12%). All lesions were resectable, and procedures included 5 pancreatoduodenectomies, 2 distal pancreatectomies, and 1 total pancreatectomy. Main duct tumors were noted in 63%, whereas the remainder had both main and branch duct lesions. Tumor invasion was discovered in 2 (25%) cases. Mean follow-up was 29 months. Those without invasion were all alive (follow-up, 6 to 86 months). One patient with tumor invasion died 4 months after surgery and the other was living 20 months later. The incidence of IPMTs was 1 case/281,000 patients/year.The incidence of IPMTs of the pancreas may be higher than previously recognized. Aggressive resection is warranted based on the favorable prognosis of patients without tumor invasion.

Physician perspectives on increasing minorities in cancer clinical trials: an Eastern Cooperative Oncology Group (ECOG) Initiative

PURPOSE

This paper describes the ECOG-NMA Minority Accrual Initiative to assure minority participation in cancer clinical trials.

METHODS

Focus groups were held to identify physician-reported barriers to the enrollment of minority patients in Cleveland, OH, Indianapolis, IN, Santa Clara County, CA, and Philadelphia, PA. Community physicians affiliated with the National Medical Association (NMA), and Eastern Cooperative Oncology Group (ECOG) investigators participated in the focus groups. A four-step process consisting of focus group workshops were conducted to (i) identify barriers, (ii) develop potential solutions to the barriers, (iii) define solutions to barriers involving specific clinical trials, and (iv) implement the solutions.

RESULTS

Focus group participants identified physician lack of information, patient fears and suspicion, the fear of losing patients, and distrust of the health care system as the major barriers to enrollment of African Americans. We found significant differences between community physicians and cancer program physicians in several areas. Community physicians emphasized personal contacts to address the lack of information and to overcome patient fears and suspicions, while the cancer program physicians emphasized printed materials. There was no difference by region in the barriers identified in the focus group workshops; however, the proposed solutions to overcoming the barriers were specific to each site.

CONCLUSION

The four-step process developed by the ECOG and the NMA used the focus group methodology to identify and overcome barriers to participation of African Americans in cancer clinical trials. Outreach efforts to educate patients, their families, and community physicians about cancer clinical trials should be directed at overcoming patient suspicions and providing practical information to physicians about specific trials and how to enroll patients.

Digital rectal examination and prostate-specific antigen abnormalities at the time of prostate biopsy and biopsy outcomes, 1980 to 1997

OBJECTIVES

To assess the temporal trends in the prevalence of pre-biopsy abnormalities in digital rectal examination (DRE) findings, serum prostate-specific antigen (PSA) levels, and cancer detection rates by abnormality in all men from the community who had a prostate biopsy.

METHODS

All Olmsted County, Minnesota residents who had their first prostate biopsy performed between January 1980 and December 1997 were identified (n = 1729). The complete medical records of these men were reviewed to determine the clinical findings at the time of the biopsy and the biopsy outcome.

RESULTS

The prevalence of an abnormal DRE decreased from 69% in 1980 to 1986 to 45% in 1993 to 1997 (P <0.001). The prevalence of an isolated elevated PSA level (normal DRE) increased from 28% in 1987 to 1992 to 42% in 1993 to 1997 (P <0.001). In men diagnosed with cancer, 55% had an abnormal DRE in 1993 to 1997 (P <0.001). Prostate cancer was detected in 471 (37%) of 1280 men with an abnormal DRE or elevated PSA level noted within 6 weeks of the biopsy. The positive predictive value for prostate cancer was 61% (229 of 373) in men with an abnormal DRE and elevated PSA, 34% (166 of 494) in men with an elevated PSA only, and 18% (60 of 327) in men with an abnormal DRE only.

CONCLUSIONS

The prevalence of an abnormal DRE at the time of biopsy has declined and that of an isolated elevated PSA has increased. However, nearly 40% of men with abnormalities in both PSA and DRE at the time of biopsy had a negative biopsy for prostate cancer. An increase in both the sensitivity and specificity of screening tests may further enhance the early detection of prostate cancer and potentially decrease the high negative biopsy rate.

Effect of complete response on outcome following autologous stem cell transplantation for myeloma

We studied the effect of complete response (CR) among 126 consecutive patients who underwent stem cell transplantation (SCT) for myeloma. The CR rate with SCT was 33%. Median overall survival (OS) from diagnosis of myeloma was 56 months. OS following SCT was 22 months. Progression-free survival (PFS) was 12 months. OS was not different between patients who achieved CR and those who did not, median survival 25 vs 24 months, P = 0.5. Corresponding median times for PFS were 15 and 11 months, P = 0.2. The plasma cell labeling index (PCLI) was high (> or = 1%) in 36% (high risk group) and was associated with poor OS and PFS (P < 0.001). Achieving CR did not influence OS or PFS in either the high or the low risk group. In contrast, OS and PFS were significantly influenced by high PCLI both in patients who achieved CR and those who did not. OS was poor (< 30 months) in high risk patients regardless of CR status and in low risk patients who did not achieve CR, compared to low risk patients achieving CR (57 months), making them candidates for novel post-transplant treatment options. Outcome following SCT is dependent more on biological variables such as the PCLI than on CR status.

Effective treatment of pancreatic tumors with two multimutated herpes simplex oncolytic viruses

Pancreatic cancer is an aggressive, rapidly fatal disease against which current nonsurgical therapy has minimal impact. This study evaluates the efficacy of two novel, replication-competent, multimutated herpes viruses (G207 and NV1020) in an experimental model of pancreatic cancer. Four human pancreatic carcinoma cell lines were exposed to G207 or NV1020, and cell survival and viral progeny production were determined. Flank tumors in athymic mice were subjected to single or multiple injections of 1 x 10(7) G207 or NV1020, and tumor volume was evaluated over time. For all of the cell lines, G207 and NV1020 produced infection, viral replication, and cell lysis (P < 0.05). NV1020 resulted in a higher production of viral progeny compared to G207. The efficacy of viral tumor cell kill was greatest in those cells with the shortest in vitro doubling time. For flank tumors derived from hs766t, single or multiple injections of both viruses were equally effective and significantly reduced flank tumor burden (P < 0.05). Complete hs766t flank tumor eradication was achieved in 25% (5 of 20) of animals treated with G207 and 40% (8 of 20) of animals treated with NV1020. In vivo efficacy correlated with in vivo tumor doubling time. There were no adverse effects related to viral administration observed in any animal. NV1020 and G207 effectively infect and kill human pancreatic cancer cells in vitro and in vivo. Given the lack of effective nonoperative treatments for pancreatic cancer, oncolytic herpes viruses should be considered for clinical evaluation.

Clinical significance of microsatellite instability in endometrial carcinoma

BACKGROUND

The purpose of this study was to compare the clinical characteristics of endometrial carcinomas with and without microsatellite instability (MSI).

METHODS

The authors prospectively acquired DNA from patients with endometrial carcinomas at Washington University Medical Center. Tumors were assigned MSI (+) status when two or more of five microsatellite repeat markers revealed novel bands in tumor DNA not present in the corresponding normal DNA. Clinical characteristics and survival data of patients with and without MSI were abstracted from patient charts. Statistical significance was calculated with the chi-square test, and survival was assessed with Kaplan-Meier methods.

RESULTS

The authors found 65 of 70 (93%) patients with MSI (+) tumors to be of white race, whereas only 124 of 159 (78%) patients with MSI (-) tumors were white (P = 0.012). Advanced disease (International Federation of Gynecology and Obstetrics Stage III-IV) was observed in 9 of 70 (13%) MSI (+) patients and 44 of 159 (28%) MSI (-) patients (P = 0.017). In addition, aggressive histologic subtypes were observed less frequently in MSI (+) tumors (6/70 [8%]) than in MSI (-) tumors (30 of 159 [19%]) (P = 0.034). Race and stage were shown by multivariate analysis to be different in MSI (+) and MSI (-) patients. Recurrence and overall survival were similar in the two groups.

CONCLUSIONS

Patients with MSI (+) tumors were more likely to be of white race and to present with early stage disease. Further investigation is needed to explain why patients with MSI (+) tumors have similar survival to patients with MSI (-) tumors, despite presenting at earlier stages, being of white race, and being less likely to be associated with virulent histologic subtypes.

Human colorectal cancers express a constitutively active cholecystokinin-B/gastrin receptor that stimulates cell growth

Although ectopic expression of the cholecystokinin B/gastrin receptor (CCK-BR) is widely reported in human colorectal cancers, its role in mediating the proliferative effects of gastrin1-17 (G-17) on these cancers is unknown. Here we report the isolation of a novel splice variant of CCK-BR that exhibits constitutive (ligand-independent) activation of pathways regulating intracellular free Ca(2+) ([Ca(2+)](i)) and cell growth. The splice variant (designated CCK-BRi4sv for intron 4-containing splice variant) is expressed in colorectal cancers but not in normal colonic mucosa adjacent to the cancer. Balb3T3 cells expressing CCK-BRi4sv exhibited spontaneous, ligand-independent, oscillatory increases in [Ca(2+)](i), whereas cells expressing wild-type CCK-BR did not. Primary cultures of cells isolated from resected colorectal cancers also exhibited a similar pattern of spontaneous [Ca(2+)](i) oscillations. For both Balb3T3 and primary tumor cells, application of G-17 (10 and 200 nm, respectively) caused an increase in [Ca(2+)](i). Selective CCK-BR antagonists blocked the G-17-stimulated Ca(2+) responses but not the spontaneous [Ca(2+)](i) oscillations. Cells expressing CCK-BRi4sv exhibited an increased growth rate ( approximately 2.5-fold), in the absence of G-17, compared with cells expressing wild-type CCK-BR. The selective pattern of expression, constitutive activity, and trophic action associated with CCK-BRi4sv suggest that this variant may regulate colorectal cancer cell proliferation though a gastrin-independent mechanism.