Early transplants are no better than chemotherapy followed by transplant for non-Hodgkin lymphoma patients, study finds

ScienceDaily (June 3, 2011) — Patients with a very aggressive form of non-Hodgkin lymphoma who receive a stem cell transplant after standard chemotherapy during their first remission have comparable survival rates to those who receive the same standard therapy alone and, if needed, a transplant when they relapse.

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These findings from a U.S. and Canadian clinical trial of 370 patients conducted at 40 clinical institutions were presented by Patrick Stiff, MD, lead investigator and director, Loyola Cardinal Bernardin Cancer Center, at the annual meeting for the American Society of Clinical Oncology (ASCO).

"The trial was based on several preliminary studies that indicated a survival benefit to early stem cell transplants," Dr. Stiff said. "These findings may save some patients from undergoing a stem cell transplant unnecessarily."

However, a subset with all of the possible poor risk factors with this form of non-Hodgkin lymphoma did seem to have a higher chance of survival in a sub- analysis.

"Additional research is necessary to determine the best plan of care for the highest-risk patients," Dr. Stiff said. "In the meantime, these patients will have to consult with their physician to carefully determine their treatment plan."

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Novel experimental agent is highly active in CLL patients, interim study shows

ScienceDaily (June 3, 2011) — An interim analysis of a phase II clinical trial indicates that a novel experimental agent for chronic lymphocytic leukemia (CLL) is highly active and well tolerated both in patients who are undergoing treatment for the first time and those who have relapsed and are resistant to other therapy.

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The agent, called PCI-32765, is the first drug designed to target Bruton's tyrosine kinase, whose function is essential for CLL-cell survival and proliferation.

Study leader Dr. John C. Byrd, director of the division of hematology at Ohio State University Comprehensive Cancer Center -- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC -- James) presented the findings June 5 at the 2011 American Society of Clinical Oncology annual meeting in Chicago.

The analysis involved the first 21 cases in the untreated-patient group and the first 27 individuals in the relapsed/refractory-patient group. One patient in each group had a complete remission, and 13 patients (62 percent) in the previously untreated group and 12 patients (44 percent) in the relapsed group had partial remissions.

"We are excited about these early findings because they suggest that PCI-32765 is a highly active oral therapeutic that produces a high rate of durable remissions -- the remissions last months on end -- with acceptable toxicity in relapsed and refractory CLL," Byrd says.

Complete remission means there is no detectable CLL in anywhere in the body; partial remission means that the individual's disease volume has decreased 50 percent or more in a sustained manner.

"It is exciting to see a drug that was shown to be active in the laboratory translate to clinical benefit for CLL patients," says researcher Dr. Amy Johnson, assistant professor of medicine at the OSUCCC -- James. Johnson co-led the pre-clinical CLL work at Ohio State with Byrd and now coordinates several correlative studies for this clinical trial.

Byrd stresses that the patients show several benefits of the treatment, such as higher platelet counts and hemoglobin levels, and that many report that they feel dramatically better overall with less fatigue, factors that are difficult to measure and report as a number.

"These responses last for many months in part because patients are willing to remain on the drug since the side effects are very tolerable," he notes.

The ongoing phase II clinical trial involves 78 patients with previously untreated or relapsed and refractory CLL or small lymphocytic leukemia. The previously untreated patients were all age 65 or older; individuals in the relapsed group all had two or more earlier treatments followed by recurrent disease.

"These are early findings, so patients with partial remissions could improve to complete remissions with further observation," Byrd says. "Usually patients with highly resistant and refractory CLL would have progressed and possibly died by this time, but 85 percent remain on PCI-32765 and continue to improve."

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U.S. Veterans Health Administration similar or better than private sector for cancer patients ages 65 plus, study finds

ScienceDaily (June 6, 2011) — A new study finds that the cancer care provided by the Veterans Health Administration (VHA) for men 65 years and older is at least as good as, and by some measures better than, Medicare-funded fee-for-service care obtained through the private sector. The study, reported in the June 7 issue of Annals of Internal Medicine, was led by Nancy Keating, an associate professor of health care policy at Harvard Medical School.

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Several factors could account for the high quality of VHA care. "Care in the VHA is much better coordinated than most other settings," said Keating, who is also an associate physician at Brigham and Women's Hospital. "The VHA has a good, integrated medical record. Their doctors all work together and communicate more effectively. There are no incentives for the overuse of cancer treatments because VHA physicians are not rewarded financially for prescribing more drugs or procedures. The VHA also measures quality across a wide range of conditions, so there is a culture of quality improvement."

The VHA is the largest integrated healthcare system in the United States, and veterans who are part of the VHA get almost all of their care from this system. In contrast to the fee-for-service model of care common in the private health sector, the VHA operates on a set budget to provide coordinated and comprehensive healthcare services, and its doctors are salaried. Congress has mandated periodic assessments of the VHA's performance in various domains of health care. In contracting out the VHA's cancer care evaluation, the Office of Policy and Planning of the U.S. Department of Veteran Affairs turned to Keating and her colleagues.

Keating's team pooled registry and administrative data from 2001-2004 for men 65 years and older diagnosed with the three most common cancers in men -- colorectal, lung and prostate cancers -- or hematologic cancers, such as lymphoma and multiple myeloma. The researchers used sophisticated analyses to ensure unbiased comparisons between the VHA and fee-for-service Medicare patients, and compared how well various guideline-recommended criteria for care were met in these two settings.

When compared with fee-for-service Medicare patients, Keating and colleagues found that veterans in the VHA were diagnosed with colorectal cancers at earlier-stages and had higher adjusted rates of certain recommended treatments, including surgery for colon cancer, chemotherapy for lymphoma, and bisphosphonates for myeloma. With regard to other treatments studied, care was fairly equal in quality between the VHA and fee-for-service Medicare.

Keating conducted additional analyses to further account for differences that may exist between veterans and the Medicare population that they could not measure. For example, veterans are often in worse health than the general population. When they updated their results to account for these likely differences in health status, care in the VHA was better than that in fee-for-service Medicare for most indicators. One exception was a likely delay in the adoption of certain new and expensive radiation therapy technologies for prostate cancer.

Overall, rates of recommended care were relatively low in both settings for some of the treatments studied. This may result from lack of data on the benefits versus risks of these drugs in older patients. Keating recommended that cancer clinical trials include older individuals as well as those with comorbid illnesses.

"While the ongoing national health care debate centers on expanding insurance coverage, ensuring a coordinated health care delivery system that provides high-quality care at good value is equally important to improve outcomes and keep rising health care costs in check," said Keating.

This research was funded by the Department of Veterans Affairs Office of Policy and Planning.

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Bankruptcy rates among cancer patients increase along with survival time, study finds

ScienceDaily (June 6, 2011) — An analysis linking federal bankruptcy court records to cancer registry data from nearly 232,000 adult cancer cases in western Washington during a 14-year period has found a hidden cost to survival: Insolvency rates increase along with the length of survival.

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"Patients diagnosed with cancer may face significant financial stress due to income loss and out-of-pocket costs associated with their treatment," said Scott Ramsey, M.D., Ph.D., a health care economist and internist at Fred Hutchinson Cancer Research Center who led the study. "On average, bankruptcy rates increased fourfold within five years of diagnosis." Ramsey presented the findings June 6 at the 2011 annual meeting of the American Society of Clinical Oncology in Chicago.

The study found that compared to the general population, bankruptcy rates were nearly twice as high among cancer patients one year after diagnosis, and that the median time to bankruptcy was two and a half years after diagnosis.

"The risk of bankruptcy for cancer patients is not well known, and previous studies have relied on individual self-reports about medically related reasons for bankruptcy filing," said Ramsey, a member of the Hutchinson Center's Public Health Sciences Division. "By linking two irrefutable government records of cancer and bankruptcy, we are able to determine how financial insolvency risk varies by cancer type, treatment and other factors," he said.

For the study, Ramsey and colleagues linked Washington state cancer registry data with federal bankruptcy court records in 13 western Washington counties. They measured the rate of bankruptcy after a first cancer diagnosis and identified factors that increased bankruptcy risk among people with common cancers.

They found that bankruptcy risk varies widely across cancer types. The risk is highest for lung, thyroid and leukemia/lymphoma cancer patients. In contrast, patients over 65, who are typically on Medicare, have a much lower risk of bankruptcy than younger patients. The researchers also found that bankruptcy rates among cancer patients have increased significantly since the U.S. financial crisis.

Ramsey and colleagues in the Hutchinson Center's Public Health Sciences Division, along with researchers at the University of Washington, conducted the study in collaboration with the U.S. Bankruptcy Court, Western District of Washington, Seattle.

The National Cancer Institute funded the research.

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Arthritis patients taking newer treatments do not have an overall increased cancer risk, research finds

ScienceDaily (May 27, 2011) — Newer biologic treatments, including infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), golimumab (Simponi) and etanercept (Enbrel), used in patients with arthritis do not increase the risk of cancer, according to data from over 13,000 patients presented at the EULAR 2011 Annual Congress.

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Only three percent (n

Attitudes toward end-of-life care: A survey of cancer patients and others in Korea

ScienceDaily (May 30, 2011) — Attitudes toward end-of-life care for cancer patients vary, but most patients, family members, oncologists and members of the public are receptive to withdrawing futile life-sustaining treatments in people who are dying, found a Korean study in CMAJ (Canadian Medical Association Journal).

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The study, by researchers in Korea, aimed to determine attitudes towards end-of-life care, as most previous studies looked only at euthanasia and physician-assisted suicide. The researchers surveyed 3840 people, including 1242 cancer patients, 1289 family caregivers, 303 oncologists from 17 hospitals from across the country and 1006 members of the general Korean population.

"In this survey of attitudes toward critical interventions at the end of life of terminally ill patients, the most interesting finding was that most of the participants in each of the four study groups -- patients, family caregivers, oncologists and members of the general public -- showed a positive attitude toward the withdrawal of futile life-sustaining treatment and active pain control," writes Dr. Young Ho Yun, National Cancer Center, Goyang, Korea, with coauthors.

Palliative care in Korea is still fairly rare, and oncologists and family physicians in institutions provide medical care.

"In the absence of effective palliation, it is no surprise that patients and others would choose a route that avoids the prolongation of suffering," write the authors.

Patients and the general public generally favoured patient autonomy and hastening the dying process but oncologists and family caregivers were more opposed to this option. Age, sex and religious beliefs were associated with acceptance of euthanasia and physician-assisted suicide.

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Targeted testing offers treatment hope for ovarian cancer patients

ScienceDaily (May 31, 2011) — Women with ovarian cancer could be helped by a new test that identifies the specific type of tumour they have, a conference will hear this week.

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Researchers at the University of Edinburgh hope this improved diagnosis will help doctors to personalise treatment programmes so that patients receive the most effective drugs.

The Edinburgh team worked with scientists from Ireland to identify six subgroups of the disease, each of which had a different genetic signature.

To do this, they analysed tissue samples from more than 350 ovarian cancer patients and compared this information with the patients' medical records.

The results show how genetic profiling of ovarian cancers might predict a person's response to drug treatments.

Researchers say the development may be particularly helpful for women with an aggressive form of ovarian cancer, which is typically caught late by current diagnostic tests.

This type of aggressive -- or 'high grade' -- cancer can respond well to a recently-developed drug that targets the blood supply of the cancer cells.

The team hopes that by identifying the women with this type of cancer at the earliest opportunity, they could use the drug more effectively and help to improve survival rates.

The findings will be presented at the American Society of Clinical Oncology (ASCO) conference, being held in Chicago this week.

Dr Charlie Gourley of the University of Edinburgh, who led the study, said: "This research shows that by conducting a detailed analysis of the genes of ovarian cancers we may be able to identify those patients who will respond well to new drug treatments. This could bring valuable improvements in survival rates for the disease and would help us to personalise a patient's care to ensure the greatest possible success."

Ovarian cancer is the fifth most common cancer in women, with around 6,800 women being diagnosed every year in the UK.

Of these, nearly two-thirds will not live beyond five years of their diagnosis.

Chemotherapy and surgery can be effective treatments, but women could have a greater chance of surviving the disease if it is identified earlier on.

The findings will be presented at ASCO on the 4th of June.

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Facelift incision offers safe option for some thyroid patients

ScienceDaily (May 31, 2011) — A facelift incision and robotics can help surgeons safely remove a portion of a diseased thyroid from some patients without the characteristic neck scar.

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Georgia Health Sciences University surgeons developed the technique utilizing the remote access capabilities of robots, experience gained from another no-neck-scar approach through the armpit and earlier success removing the largest salivary gland from the lower jaw region.

"It is outpatient, it doesn't require a surgical drain and it has the advantage of no neck scar," said Dr. David Terris, Chairman of the GHSU Department of Otolaryngology-Head and Neck Surgery.

The goal was a no-neck-scar technique that's as safe as conventional thyroidectomy, which involves an incision at the base of the neck to gain immediate access to the thyroid, the surgeons report in The Laryngoscope. Two articles detail experiences developing the technique in human cadavers and using it on 14 patients.

"The overarching principle is customizing the surgery to the patient and their disease as opposed to one size fits all. Our advice to patients and surgeons is to do what works best for you," said the studies' corresponding author Terris, who lays out all options for his patients.

Surgery has been done through a multi-inch neck incision for more than 100 years on the thyroid, the endocrine gland just under the Adam's apple that controls the body's metabolic rate. In the last decade, Terris and others have pioneered minimally invasive approaches that can reduce the incision to less than an inch.

In 2004, Terris and colleagues published another Laryngoscope paper that indicated, at least in pigs, the armpit approach worked for avoiding neck scars altogether. While this approach is used selectively in other countries, reports have surfaced of serious side effects such as damage to the brachial plexus, the main nerve to the arm and hand; blood loss; and perforation of the esophagus. After using it on small number of patients, Terris envisioned a more direct, logical route. That's when he thought about his earlier success at removing the large salivary gland through a facelift incision in the hairline.

The daVinci Surgical System, in which surgeons sitting at a console maneuver through tight spaces and around corners, enables remote access, via the armpit or a facelift incision, Terris said. He makes a small incision in the scalp line, burrows under the skin, then moves under the muscle as he nears the thyroid. A retractor developed by Korean surgeons keeps the skin and muscle out of the way while the long, flexible arms and three- dimensional perspective provided by the robot enables removal of up to half of the two-sided thyroid gland. Patients with known cancers or large thyroids are not candidates for this approach but Terris said advances in robotic technology may soon enable surgeons to reach around to access both sides of the thyroid through a single incision.

He notes the hairline approach takes longer and, primarily because of increased time under anesthesia, costs more than minimally invasive surgeries. He's now done more than 30 cases, but greater patient numbers are needed to increase confidence in the safety and feasibility of the approach, he said.

Unlike minimally invasive approaches that are easier on thin patients, the facelift thyroidectomy is actually easier on heavier patients. A common, transient side effect of this approach is temporary, localized numbness because of surgical contact with the nerve that innervates skin in the region.

Problems with the thyroid gland tend to occur in women in their 30s, 40s and 50s. Growths or goiters can result in a hyperactive thyroid gland and jittery, sweaty patients who can't gain weight. Typically if there is a single growth, the surgeons take out that half of the gland, rule out cancer and that is the end of the problem. If it is cancer, the good news is the thyroid can be completely removed, cure rates are high and the gland's function can be replaced by a single, daily pill, Terris said. Known causes of thyroid cancer include radiation exposure.

GHSU's Drs. Michael Singer and Melanie Seybt are study co-authors.

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Gene change identifies brain cancer patients that respond better to treatment

ScienceDaily (May 31, 2011) — New research proves that a change in a particular gene can identify which patients with a specific kind of brain cancer will respond better to treatment. Testing for the gene can distinguish patients with a more- or less-aggressive form of glioblastoma, the most common and an often-fatal type of primary brain cancer, and help guide therapy, the researchers say.

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The prospective study looked at a gene called MGMT in tumors removed from 833 glioblastoma patients. It showed that when the gene promoter is altered by a chemical change called methylation, patients respond better to treatment.

"We show that MGMT methylation represents a new genetic test that can predict clinical outcomes in glioblastoma patients who have been treated with radiation combined with the chemotherapeutic drug temozolomide," says coauthor Dr. Arnab Chakravarti, chair and professor of Radiation Oncology and co-director of the brain tumor program at the Ohio State University Comprehensive Cancer Center -- Arthur G. James Comprehensive Cancer Center and Richard J. Solove Research Institute (OSUCCC -- James).

"Clearly, all glioblastomas are not the same. Rather, they are a collection of different molecular and genetic entities that behave uniquely and require personalized treatment," says Chakravarti, who is the translational-research study chair for the study.

Principal investigator Dr. Mark Gilbert, professor of neuro-oncology at M.D. Anderson Cancer Center, will present the research June 5, 2011, at the 2011 American Society of Clinical Oncology annual meeting in Chicago. It comes from a prospective international phase III clinical trial sponsored by the Radiation Therapy Oncology Group (RTOG).

"Our study confirms the prognostic significance of MGMT gene methylation and demonstrates the feasibility of prospective tumor-tissue collection, molecular stratification and collection of patient outcomes in a large transatlantic intergroup trial," Gilbert says.

A tentative indication that MGMT methylation status might have prognostic importance emerged from an earlier retrospective study sponsored by the European Organisation for Research and Treatment of Cancer (EORTC).

The current study (RTOG 0525) validates that finding. Patients with tumors carrying the methylated gene had an overall survival of 21 months versus 14 months for those with the unmethylated gene. The difference in progression-free survival -- the period after treatment during which cancer does not worsen -- was 8.7 months and 5.7 months for methylated versus unmethylated tumors respectively. The narrow difference, Chakravarti says, indicates that patients with the methylated gene had slower growing tumors.

About 18,500 new cases of glioblastoma multiforme are expected annually in the U.S., and 12,760 Americans are expected to die of the disease. Symptoms often include headache, seizures and motor or sensory changes. A brain scan detects the tumor. After a surgeon removes the tumor, it can be tested for MGMT methylation.

"Patients with the methylated gene could receive the standard treatment, radiation therapy plus the chemotherapeutic drug temozolomide," Chakravarti says. "Those with an unmethylated gene might receive an experimental treatment through a clinical trial."

Research is now needed, he says, to learn whether MGMT contributes directly to tumor aggressiveness, or whether it is just an indicator of other changes that cause tumor aggressiveness. "If the gene itself helps cause aggressive disease, MGMT or related DNA repair pathways might be an important targets for a novel therapies," Chakravarti says.

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Less toxic combination of erlotinib and bevacizumab is effective non-small cell lung cancer patients, study suggests

ScienceDaily (June 1, 2011) — The standard treatment for patients with advanced non-small cell lung cancer (NSCLC) is a combination of two old-fashioned cytotoxic chemotherapy drugs. The combination, however, comes with substantial toxicity. Now, Fox Chase Cancer Center researchers report that a combination of two molecularly-targeted agents may provide similar therapeutic benefit with less toxicity.

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"These results seem to be better than standard of care," says Hossein Borghaei, DO, medical oncologist at Fox Chase, who will present the results at the 2011 Annual Meeting of the American Society of Clinical Oncology on June 4. "Of course, the problem with a phase II trial always is that the patients tend to be a select patient population. But when you look at the numbers, the patients appear to be benefiting from the treatment. They stay on treatment longer and the time to progression on average was a little bit better. And we don't have a lot of toxicities, like major hair loss or nausea, and we don't have a lot of neutropenia or anemia."

"So overall it looks like a well tolerated regimen and it appears to be an effective front-line therapy in this patient population," he says.

Until recently, clinicians assumed that older patients were more likely to suffer from serious toxicities associated with standard chemotherapy. Therefore, Borghaei's team focused their current study on patients 65 years and older, enrolling 33 patients with a median age of 74 years. All patients had previously untreated, advanced NSCLC. Patients received standard dose erlotinib (a small molecule inhibitor of the epidermal growth factor receptor) and bevacizumab (an antibody that blocks the vascular endothelial growth factor pathway) every 21 days until patients either progressed or stopped treatment due to adverse events.

Six patients remain on therapy and have received 4 to 40 cycles of treatment. Of the 24 patients off therapy, the median number of cycles received was 4, with a range of one to 40. The estimated progression-free survival for all patients is 6.6 months. The estimated one-year survival is 56.6%, with 12 patients remaining alive, and the estimated median overall survival is 14.1 months.

"With standard chemotherapy we can only give four to six cycles," Borghaei says. "But with this biologic regimen we can continue therapy because there is less toxicity. They are on continuous drugs, which might be one reason that they appear to have longer progression free survival. We have to wait for the final data and analyze it before we know -- and the big test would be a head-to-head phase III trial with chemotherapy."

The most common serious adverse events in the trial were grade 3 hypertension, which occurred in five patients, and grade 3 rash, which occurred in three patients. Additionally, the following grade 3 toxicities affected one patient each, fatigue, anorexia, neutropenia with infection, bowel perforation, and abnormal blood tests. Two patients had grade 3 diarrhea and one patient had grade 4 diarrhea.

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Lymphocyte count indicates the prognosis of patients with renal cell carcinoma

ScienceDaily (June 1, 2011) — Each year, kidney cancer is diagnosed in nearly 60,000 people in the U.S. Many of these patients undergo surgery to remove the affected kidney, but this procedure can be risky for the elderly and those who have other health problems. Unfortunately, the prognosis of kidney cancer patients often cannot be determined until tumor samples are surgically removed and evaluated. Now, researchers at Fox Chase Cancer Center have discovered that the lymphocyte count--which is routinely measured in laboratory tests--is a simple and effective prognostic indicator in patients with renal cell carcinoma (RCC).

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Sunil Saroha, MD, medical oncology fellow at Fox Chase and lead author on the study, will be presenting the findings at the 2011 Annual Meeting of the American Society of Clinical Oncology on Sunday, June 5.

"There has been this need for looking at prognostic markers that are available prior to surgical procedures," says Saroha. "It would be nice to know before the surgery if the tumor is going to be aggressive and how aggressive we need to be, with the goal of individualizing therapies."

The level of lymphocytes, a type of white blood cell, was one possible prognostic indicator considered by Saroha, Tahseen Al-Saleem, MD, a cancer pathologist at Fox Chase, and their colleagues. RCC patients generally have a worse prognosis if they have a suppressed immune system, which is indicated by low lymphocyte levels.

By evaluating data from more than 500 patients with the most common form of RCC -- called clear cell RCC -- who had their kidneys surgically removed at Fox Chase between 1994 and 2009, Al-Saleem and his colleagues found a clear relationship between low lymphocyte counts within three months prior to surgery and a poor prognosis.

The researchers found that lower lymphocyte levels were associated with a higher tumor grade, a higher pathologic tumor stage, the presence of distant metastases, and a higher TNM stage -- a combined indicator of tumor stage, spread to regional lymph nodes, and distant metastasis. They also found that low counts were associated with a lower overall survival rate, even when they accounted for patient age, tumor stage and metastasis.

Although these findings should be explored further in prospective research studies, the researchers suggest that the lymphocyte count could factor into doctors' treatment decisions. "This simple test can really help us identify patients at the outset who are at risk of very aggressive disease and who may not do well with current therapies," Saroha says. For example, if a young RCC patient has a low lymphocyte count but is otherwise healthy, a doctor may decide to pursue more aggressive therapies, such as surgery and chemotherapy.

"On the other hand, the test may also identify patients who may not need as aggressive therapies as usual," Saroha adds. For example, about half of RCC patients are over 60 years old, and if one of these patients has other health problems and a normal lymphocyte count, a doctor may decide to monitor the patient rather than perform surgery. "The test may help individualize therapies, change clinical decisions and add therapies before or after the surgery," Saroha says.

Saroha also emphasizes the need for more studies that focus on only one subtype of RCC, as in this study. Previous studies have clumped together different subtypes of RCC patients, even though there could be significant differences between them.

Co-authors on the study include Robert Uzzo, Gary Hudes, Elizabeth Plimack, and Karen Ruth from Fox Chase.

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Two-thirds of newly diagnosed U.S. cancer patients unable to obtain oncology appointments, study suggests

ScienceDaily (June 1, 2011) — Newly diagnosed cancer patients frequently face hurdles in obtaining an appointment for care with an oncologist, according to new research from the Perelman School of Medicine at the University of Pennnsylvania that will be presented on June 4 at the 2011 annual meeting of American Society of Clinical Oncology. Even callers with private health insurance had difficulty scheduling an appointment, with just 22 percent of them obtaining a slot, compared to 29 percent of uninsured patients and 17 percent of patients on Medicaid, according to results of a study in which research assistants posed as patients seeking an initial evaluation.

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"Although healthcare reform is likely to expand health insurance coverage to more Americans, our research shows that even with insurance, patients face barriers when they try to access cancer care," says lead author Keerthi Gogineni, MD, an instructor in the division of Hematology-Oncology at Penn's Abramson Cancer Center. "Given the typical pre-appointment expectations for new patients -- which typically involve referral requirements, paperwork and routing of medical records and test results -- both insured and uninsured patients must contend with many challenges that delay care with a specialty cancer provider."

In the study, research assistants attempted to call 160 U.S. hospitals under three different circumstances each, varying only their insurance status as they explained their scripted patient situation, which involved a new diagnosis of an inoperable liver cancer. Callers reached a scheduler 79 percent of the time, but only 29 percent of those callers received appointments. Of the appointments ultimately scheduled, 35 percent required multiple calls to complete the process. In nearly a quarter of cases, callers failed to reach staff even after three attempts. Among reasons for denial of appointments or inability to schedule: Demand for medical records (39 percent), not being able to reach appropriate schedulers (24 percent), and referral requirements (18 percent).

The authors note that the access problems revealed in the study may become more urgent in the coming years, given Institute of Medicine and ASCO projections showing a widening gap between the number of people living with cancer and the number of practicing oncologists available to care for them.

Gogineni and her co-author, Katrina Armstrong, MD, MSCE, chief of the division of General Internal Medicine and associate director of Outcomes and Delivery in the Abramson Cancer Center, suggest that more patient navigator programs could play a critical role at coaching patients through this initial phase of their care. Since literacy issues or lack of guidance from a referring physician may impede patients' ability to locate the proper number to call for help at some hospitals, they also urge centers to train staff at locations other than appointment hotlines or intake centers to point new patients to the proper location.

"Patients who are newly diagnosed with cancer may be confused or frightened," Armstrong says. "Asking them to find their way through the complex process of obtaining imaging studies and other tests or collecting records from another doctor prior to scheduling an appointment may pose an undue burden, and cancer centers should be prepared to provide help with those preliminary steps."

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Drug combination extends survival in refractory lung cancer patients, study finds

ScienceDaily (June 2, 2011) — Scientists have identified a drug combination, when used in advanced lung cancer patients, shows a survival advantage in patients who no longer respond to existing therapies. They found that bexarotene and erlotinib can each repress the critical cell cycle regulator: cyclin D1. The drug combination also broadened the reach to include a specific subset of patients, such as those resistant due to the presence of a ras mutation in their cancer.

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The study was published in the June issue of Cancer Prevention Research.

"Erlotinib has been found to be most effective in women of Asian descent who are never smokers with bronchioalveolar carcinoma, and who tend to have activating mutations of the epidermal growth factor receptor," said Ethan Dmitrovsky, M.D., an Associate Scientific Director of the Samuel Waxman Cancer Research Foundation and a senior author on the study. "None of the patients in our study fit that demographic profile."

In fact, the patients in the cohort who exhibited the greatest response included non-Asian men who were smokers. Advanced lung cancer patients with refractory disease have a survival of four months or less with traditional chemotherapy. The results of the study showed a median survival of five and a half months and longer. Three patients from the trial are now living two to four years beyond the expected average.

The study's results were recently duplicated by a group of MD Anderson scientists, noted Konstantin Dragnev, M.D., who led this trial and is an associate professor at Dartmouth Medical School, in Hanover, N.H.

The most exciting part of the research, which was funded in part by the Samuel Waxman Cancer Research Foundation, "is that scientists were able to make a dent in the ras mutation subset of patients," said Dmitrovsky, who is a professor at Dartmouth Medical School. "This area is an unmet medical need. These are often times the most difficult lung cancers to treat."

"This study gives hope to a large group of lung cancer patients who currently have very few options," said Linda Wenger, the Executive Director of Uniting Against Lung Cancer. "It's critical for nonprofit foundations to continue supporting research in underserved areas to bring new ideas to the clinic."

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Experimental vaccine made from frozen immune cells shows promise for prostate cancer patients

ScienceDaily (June 3, 2011) — Metastatic prostate cancer patients who received an investigational vaccine made from their own frozen immune cells lived 10 months longer than those not treated with it, according to data being presented by researchers from the Kimmel Cancer Center at Jefferson at the 2011 American Society of Clinical Oncology annual meeting in Chicago.

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In an exploratory, multi-institutional analysis, researchers administered the vaccine APC8015F to a group of patients from the control arm of three randomized, Phase 3 clinical trials evaluating sipuleucel-T, a similar, FDA-approved cancer vaccine for metastatic castrate resistant prostate cancer.

APC8015F is made from immune system cells taken from a patient with prostate cancer; however, unlike sipuleucel-T, which is never frozen, APC8015F is cryopreserved at a time before the disease progressed.

Results from the analysis showed that patients treated with APC8015F had improved survival relative to the patients who were not treated in the control arm. Following disease progression, the median survival of patients treated with APC8015F was 20.0 months compared to 9.8 months for control patients.

"The study is important because it suggests that the sipuleucel-T therapy may have extended survival for a longer time than estimated in the clinical trials due to the beneficial effects of the frozen product on some men who initially received the placebo," said Leonard Gomella, M.D., Chair of Urology at Jefferson's Kimmel Cancer Center in Philadelphia. "Further, the clinical activity of the frozen-activated product is maintained."

Post-progression treatment with APC8015F, which is not FDA approved, may have extended survival of subjects, potentially reducing the magnitude of survival difference observed between sipuleucel-T and controls in randomized controlled trials.

Sipuleucel-T is FDA approved under the brand name Provenge to treat men with advanced prostate cancer that is asymptomatic or minimally symptomatic and no longer responding to hormonal therapy.

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Glioblastoma in the 21st century: Wealthier patients living longer than poorer patients

ScienceDaily (June 2, 2011) — Survival rates of wealthier patients and those younger than 70 with glioblastoma, the most common and aggressive malignant brain tumor, have improved since 2000, whereas rates for those living in poorer areas and older than 70 have remained stagnant, according to an abstract being presented at the American Society of Clinical Oncology annual meeting in Chicago by Thomas Jefferson University Hospital researchers.

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The addition of concurrent and adjuvant temozolomide, a chemotherapy drug also referred to as TMZ, to post-operative radiation therapy has been shown to improve overall survival in randomized trials for patients younger than 70, but it was unknown if this benefit translated down to the population-based level.

To answer this, researchers performed a population-based survival analysis of newly diagnosed glioblastoma patients (from 2000 to 2007) covering the period before and after the introduction of temozolomide. They further analyzed the impact of mean regional income on any improvements in overall survival during this time period.

Survival statistics and pertinent clinical and demographic variables were extracted from the Survival, Epidemiology and End Results (SEER) Database for patients diagnosed. Patients were divided into income quartiles based on mean household income in their county of residence.

From 2001 to 2007, the median survival time increased from 7 to 9 months for the entire population. One-year survival rate increased from 29 percent to 39 percent.

Outcomes in patients older than 70 years did not improve over this period, even amongst patients who had gross total resection and radiation therapy. Over the study period, the absolute disparity in one-year survival between economically poor-and-affluent areas increased from 6.6 percent to 10.1 percent.

"The management of patients with glioblastoma continues to be a challenge for treating oncologists," said Mark Mishra, M.D., of the department of radiation oncology at Thomas Jefferson University Hospital. "The results of this large, population-based analysis indicate that recent advances in the treatment of glioblastoma patients have resulted in a small, but significant improvement in overall survival over the past decade.

"However, these improvements have also been accompanied with a widening of the health disparities gap for these patients."

Future efforts should be made to identify and mitigate factors contributing to the widening economic disparities gap, according to the researchers.

There are approximately 17,000 primary brain tumors diagnosed in the United States each year, 60 percent of which are gliomas. The most common and malignant glioma is glioblastoma, the type of brain cancer Senator Ted Kennedy was diagnosed with and died from.

Other authors include Adam Dicker, M.D., Ph.D., Chair of Radiation Oncology at Thomas Jefferson University Hospital, Maria Werner-Wasik, M.D., David W. Andrews, M.D., Xinglei Shen, M.D., Timothy Showalter, M.D., John Glass, M.D., all from Thomas Jefferson University, and Zvi Symon, of Sheba Medical Center in Israel, and Yaacov R. Lawrence, M.D., a resident in radiation oncology at Jefferson and director of the Center for Translational Research in Radiation Oncology, Sheba Medical Center in Israel.

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Patients referred to dermatologists skin lesions evaluations also found to have other skin cancers

ScienceDaily (May 17, 2011) — Among patients referred by non-dermatologists to dermatologists for evaluation of skin lesions suspected of being malignant, only apparently one-fifth were found to be cancerous, although dermatologists identified and biopsied other incidental lesions, approximately half of which were malignant, according to a report in the May issue of Archives of Dermatology, one of the JAMA/Archives journals.

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"More than one million skin cancers are diagnosed annually in the United States , with one in five Americans developing skin cancer during their lifetime," the authors write as background information in the article. "Non-dermatologists, particularly primary care physicians, play an important role in skin lesion assessment and initiation of referrals to the dermatologist."

Kate V. Viola, M.D., of the Robert Wood Johnson Clinical Scholars Program and Yale University School of Medicine, New Haven , Conn. , and colleagues sought to evaluate the proportion of suspicious lesions identified by non-dermatologists that are found to be malignant compared to the number of secondary skin lesions identified at the time of dermatology referral.

The authors evaluated medical records of 400 patients who were referred by a non-dermatologist to the dermatology service at the Veterans Affairs (VA) Connecticut Health System for evaluation of suspicious skin lesions between January 1, 2006 and December 31, 2009.

Of the 400 patients included in the study, the average age was 77.7 years, 98 percent were white men and 74 (18.5 percent) had a history of skin cancer. Most lesions (224 of 400 or 56 percent) were considered to be non-malignant by the consulting dermatologist, requiring no biopsy. Of the 176 lesions that needed biopsies, 88 were malignant according to the dermatopathology report, meaning 88 of 400 patients (22 percent) had an index lesion (lesions that prompted the referral) that was positive for cancer.

Dermatologists biopsied an additional 111 incidental lesions (secondary lesions identified, not the reason for referral), of which 61 (55 percent) were malignant. Twelve of 61 patients (19.7 percent) with a malignant incidental lesion had an index lesion that was not biopsied. Nearly half of all skin cancers identified were not the referral lesion, and 9.8 percent of the incidental lesions discovered by the dermatologist were melanomas.

In the present study, "a substantial proportion of malignant lesions was incidentally identified by the consulting dermatologist in addition to the primary lesion of concern," the authors write. The authors also suggest that "non-dermatologists may benefit from focused educational initiatives on skin cancer detection, particularly the significance of the total body skin examination and the expectations for and limitations of teledermatology."

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