Evaluation of a risk-adapted visit for post-treatment cancer survivors

113

Background: The Living in the Future (LIFE) Cancer Survivorship Program at NorthShore University HealthSystem provides a risk adapted visit (RAV) directed by a physician and facilitated by an oncology nurse during which an electronic medical record documented LIFE survivorship care plan (SCP) is provided and discussed. We evaluated the degree to which a RAV promotes individualized healthcare and self-management as survivors transition from active treatment to follow-up care. Methods: Patients anonymously complete a post-RAV evaluation on the day of their RAV and then another at least one year after their RAV. Results: 1,713 RAVS, the majority for breast cancer, occurred from 1/2007 to 3/2014.There are 1,615 complete “day of” post- RAV evaluative data with a median time from completion of last therapy of < 6 months. Respondents scaled statements as strongly agree/ agree/disagree/ strongly disagree. Combined strongly agree/agree ratings are: 94% felt more confident in their ability to communicate information about their cancer treatments to other members of their healthcare team; 90% felt more comfortable recognizing signs and symptoms to report to their healthcare provider; 98% had a better appreciation for potentially helpful community programs and services. Of the 488 respondents (RAV between 1/2007 and 12/2012 n=1,366) to a questionnaire at least one year after the RAV, nearly 100%/97%/93%/91%/85% found the SCP useful in at least 1/2/3/4/5 ways: to summarize medical information, to reinforce follow up care, to recognize symptoms to report, to identify lifestyle practices that promote health, and for assistance in identifying local resources for support. 72% discussed their SCP with their PCP or another healthcare provider, 97% stated they made at least one positive lifestyle change, 89% attended at least one LIFE health promotion seminar, and 80% continue to work on wellness goals. Conclusions: Participation in a LIFE RAV following oncology treatment helps survivors construct a useful understanding of their cancer experience to guide self-care behavior. Data demonstrate that benefits persist one year after the visit and support the feasibility of a nurse-led RAV to establish a SCP in post-treatment cancer survivors.

A phase II study of 13-cis-retinoic acid in patients with advanced renal cell carcinoma

The aim of this study was to determine the antitumor activity of 13-cis-retinoic acid as a single agent in patients with advanced renal cell carcinoma. Eligible patients had advanced renal cell carcinoma with bi-dimensionally measurable disease, a Karnofsky performance status of at least 70, life expectancy of greater than three months, no evidence of brain metastases, and treatment with no more than one chemotherapy regimen. Patients were treated with one mg/kg/day of 13-cis-retinoic acid orally. Twenty-six patients were enrolled in this study and 25 were evaluable for response and toxicity. Of the twenty-five evaluable patients, no major responses were achieved. Toxicity was mild, with no patient requiring a dose reduction. At the dose administered in this trial, 13-cis-retinoic acid is inactive as a single agent in renal cell carcinoma.

Breast cancer in elderly women: presentation, survival, and treatment options

Recent data suggest that breast cancer in elderly women does not present as more advanced disease, nor is survival significantly inferior to that in younger women. Unfortunately, until recently, older women have been excluded from clinical trials that have determined survival benefit in both screening and treatment modalities. Unless co-morbid conditions adversely affect one's life expectancy or tolerance to therapy, older women should be treated with standard surgical procedures (including breast conservation, if so desired) for early-stage disease, as outcome is comparable to that in younger patients. Adjuvant tamoxifen therapy has proven survival benefit in women over 70 years of age with estrogen receptor-positive tumors and should be considered in all women with tumors greater than 1 cm in size. Older women may experience more chemotherapy-related toxicities. However, for those with a significant risk of recurrence due to tumor size or lymph node status, chemotherapy can be safely administered when factors such as age-related decline in creatinine clearance and co-morbid conditions are considered. Hormonal therapy (tamoxifen) is usually the first-line treatment option over chemotherapy for metastatic disease in the elderly unless the patient has an estrogen receptor-negative tumor, visceral-dominant disease, or significant disease-related symptoms. In the latter settings, chemotherapy can provide improved or more rapid response proportions but does not affect long-term survival.

Phase III randomized trial of interleukin-2 with or without lymphokine-activated killer cells in the treatment of patients with advanced renal cell carcinoma

BACKGROUND

Treatment with interleukin-2 (IL-2) and lymphokine-activated killer cells (LAK) resulted in responses in some patients with advanced renal cell carcinoma (RCC). However, the relative therapeutic benefit of the addition of LAK to IL-2 was unknown.

METHODS

A randomized Phase III trial was conducted in patients with RCC comparing continuous intravenous infusion (CI) IL-2 alone with CI IL-2 plus LAK. Interleukin-2 was administered at 3 x 10(6) U/m2/day on days 1-5, 13-17, 21-24, and 28-31. Patients on the LAK treatment arm underwent leukapheresis on days 8-10 and LAK cell reinfusion on days 13-15. The results are reported with long-term follow-up. The published experience with IL-2 alone or with the addition of LAK was investigated in a quantitative literature survey. The response proportions were studied by schedule (high dose bolus, moderate dose, low dose) and by concomitant administration of LAK.

RESULTS

Seventy-one patients were treated, 36 on the IL-2 arm and 35 on the IL-2 plus LAK arm. Four patients (6%) had major responses (two complete, two partial). The median survival of all patients was 13 months (95% confidence interval [CI], 9-18 months). There were no differences between treatment arms with regard to response (P = 0.61) and survival (P = 0.67). More patients on the LAK arm experienced pulmonary toxicity (P = 0.008). The overall weighted response proportion was 16% (95% CI, 8%-24%) for the 39 published series of 1291 patients treated with IL-2. The 95% confidence intervals for response proportion overlapped when compared by schedule and by administration of LAK.

CONCLUSIONS

The dose and schedule of IL-2 used in this study resulted in a low level of antitumor activity and the addition of LAK did not improve the response rate against RCC. Given the infrequent, but reproducible, responses with IL-2 and interferon-based regimens, continued investigation of these agents is warranted as is the study of new cytokines. Alternative treatment strategies should be studied in RCC and new agents and treatment regimens that appear promising in Phase II studies must be studied in randomized trials.

Interferon alfa-2a and 13-cis-retinoic acid in renal cell carcinoma: antitumor activity in a phase II trial and interactions in vitro

PURPOSE

A phase II trial of interferon alfa-2a (IFN) and 13-cis-retinoic acid (CRA) was conducted in patients with renal cell carcinoma (RCC). In vitro studies were performed to investigate potential mechanisms of interaction.

PATIENTS AND METHODS

Forty-four patients were treated. IFN was given daily at 3 MU and escalated to 6 and 9 MU if tolerated. The dose of CRA was 1 mg/kg/d. The effects of combining CRA and IFN on the proliferation of five RCC cell lines were examined, and retinoid sensitivity was correlated to the expression of retinoic acid receptors.

RESULTS

Thirteen (30%) of 43 assessable patients achieved a major response (three complete and 10 partial). Responding sites included bone metastases and renal primary tumors. Seven responding patients remain progression-free at 10+ to 19+ months. The response proportion was higher than in our prior experience with IFN, which was 10% in 149 patients. Eleven of 12 renal cancer cell lines were resistant to CRA alone; one, SK-RC-06, showed 90% inhibition of cell growth. CRA augmented the antiproliferative effect of IFN in several IFN-sensitive cell lines, but not in IFN-resistant lines. Northern blot analysis showed that expression of retinoic acid receptor-beta (RAR-beta) was repressed and not induced by retinoic acid in retinoic acid-insensitive RCC lines. However, RAR-beta expression was induced by retinoic acid in SK-RC-06 cells.

CONCLUSION

IFN and CRA showed antitumor activity in patients with advanced RCC, and the proportion and nature of response suggested CRA added therapeutic benefit to IFN. A phase III randomized trial of IFN plus CRA versus IFN alone and a phase II trial of single-agent CRA have been initiated.

The management of patients with advanced germ cell tumors. Seminoma and nonseminoma

Treatment strategies for germ cell tumors have evolved substantially during the last decade and are directed by pretreatment prognostic factors that include histology (seminoma versus nonseminoma), primary site of disease, serum concentrations of lactate dehydrogenase and human chorionic gonadotropin, and the number of metastatic sites of disease. Patients with a high likelihood of achieving a complete response to therapy (CR0.5) are considered "good risk" and receive three or four cycles of cisplatin-based chemotherapy. Patients with a low likelihood of achieving a complete response (CR0.5) are considered "poor risk" and should be considered for innovative treatment strategies with the intent of increasing the proportion of patients who are cured. One approach in patients with "poor risk" disease uses early treatment with high-dose chemotherapy and autologous bone marrow transplantation. In addition, effective salvage regimens are available for those patients who fail first-line therapy.

Phase II trial of topotecan in patients with advanced renal cell carcinoma

Fifteen patients with advanced renal cell carcinoma were treated on a phase II trial with topotecan. None of the fourteen evaluable patients achieved a complete or partial response. Myelosuppression was the most common toxicity. Eighty percent (12 of 15) of patients experienced grade III or IV neutropenia and/or anemia. Topotecan is not efficacious in the treatment of advanced renal cell carcinoma.

Phase II trial of liposomal encapsulated doxorubicin in patients with advanced renal cell carcinoma

Fourteen patients with advanced renal cell carcinoma were treated on a phase II trial with liposomal encapsulated doxorubicin (Lipodox, LED). None of the fourteen evaluable patients achieved a complete or partial response. Myelosuppression was the most common toxicity and no cardiac toxicity was evident. Seventy-nine percent (11 of 14) of patients experienced grade III or IV neutropenia. In summary, LED did not show antitumor activity in the treatment of advanced renal cell carcinoma.