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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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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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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