Access to personal medical records increases satisfaction among new cancer patients

ScienceDaily (May 23, 2011) — A new analysis has found that allowing full access to personal medical records increases satisfaction without increasing anxiety in newly diagnosed cancer patients. Published early online in Cancer, a peer-reviewed journal of the American Cancer Society, the study indicates that providing accurate information to patients through medical records can be a beneficial complement to verbal communication with their physicians.

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Most cancer patients say they are eager to receive comprehensive information about their disease, but many physicians believe that providing it increases anxiety and may be deleterious for patients. To clarify the issue, Gwenaelle Gravis, MD, of the Paoli-Calmettes Institute in Marseille, France, and her colleagues compared two types of information delivery on cancer patients' anxiety, quality of life, and satisfaction: providing systematic full access to an organized medical record (OMR) versus "on request information."

The randomized study included 350 patients who were recently diagnosed with breast, colon cancer, or lymphoma, and who were treated with chemotherapy at the Paoli-Calmettes Institute's Regional Comprehensive Cancer Center. Patients who had the opportunity to accept an OMR could receive a briefcase (that the patient was advised to bring to each visit so that it could be updated) that included administrative information and reports on surgery, pathology, hospitalizations, nurse narratives, radiology, and biology as well as overall information concerning the patient's treatment. Patients also received a medical lexicon and a user guide, plus help from medical staff to understand the various documents. Most patients (98 percent) who had the opportunity to obtain an OMR chose to do so. Patients who received "on request information" were provided with information and medical records only at the physician's initiative or upon the patient's request.

After exclusions for various reasons, 295 patients were analyzed. Anxiety levels and quality of life scores were similar in both groups during the study; however patients with OMR access were 1.68 times more likely to be satisfied with information and were 1.86 times more likely to feel fully informed.

The investigators found that 70.4 percent of the patients who received an OMR said that in hindsight they would choose again to receive it, and 74.8 percent did not regret their choice. The majority of patients declared that the OMR had not been a source of anxiety for them, that they understood the information enclosed, and that they did not discover any unwanted information. Most patients also said that the OMR allowed them to understand their disease more thoroughly and that it helped them discuss their condition with their relatives and physicians.

"Information is crucial to make decisions regarding treatment options and, for the patient and his family, to better cope with the disease and its implications," said Dr. Gravis. "Having full access to his own medical record with the possibility to consult it only if desired increases the patient's trust in the physician and medical team," she added.

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Many patients fail to properly take oral chemo, leading to complications

ScienceDaily (May 25, 2011) — As the use of oral chemotherapy continues to rise, researchers from Michigan State University have discovered many patients fail to properly take the cancer-fighting medication, a significant clinical problem that can result in complications and premature death.

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That lack of adherence needs to be addressed by the health care community, said College of Nursing researcher Barbara Given, who led the study that is published in the May edition of Seminars in Oncology Nursing.

"Given the increasing use of oral chemotherapy in treating cancer, patient adherence is critical to successful outcomes," said Given, associate dean for research for the college. "Health care providers need to monitor and facilitate adherence by identifying barriers and implementing strategies to overcome them."

During the past decade, the use of oral cancer-fighting medication is transforming how oncology care is delivered, Given said: About 10 percent of cancer chemotherapy is provided to patients orally, and the National Comprehensive Cancer Network predicts that by 2013, the rate will increase to 25 percent.

"This phenomenon shifts the care from a safe, controlled process in hospitals or clinics to patients' homes where adherence becomes the patient's and family's responsibility," she said.

While patients benefit by avoiding trips to clinics and hospitals, complex dosing regimens and side effects are challenging to manage -- and poor adherence may lead to disease progression and premature death.

As part of the study, Given and her team identified the barriers that prevent optimal adherence, looking at factors ranging from age, race and gender to health literacy, social support, cost and how much communication there exists between health providers and patients.

Part of the overall problem, Given added, is that measuring and studying adherence to oral medications is difficult because patients are aware of being observed, and patients may adhere more than the average patient who is receiving the same therapy.

"Future research needs to develop better methods for measurement and intervention," she said. "We need to better understand what factors determine patients' adherence. Nurses play a crucial role in promoting adherence and will be key in adopting new treatment plans to help patients."

Given's research was funded by two grants from the Oncology Nursing Society Foundation.

The May edition of Seminars in Oncology Nursing, of which Given was a guest editor, focuses entirely on oral medications in treating cancer. Other MSU researchers with articles in the journal include Sandra Spoelstra, an assistant professor with the College of Nursing and a 2010 Ph.D. graduate, and Bill Given, a professor in the College of Human Medicine.

Spoelstra, also a co-author on Barbara Given's article on the challenges of taking oral chemotherapy, worked with Bill Given on papers focusing on how to best measure adherence to oral medications as well as the policy implications of such drugs.

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Advanced-stage prostate cancer patients experience 20-year survival rates with surgery, study suggests

ScienceDaily (May 15, 2011) — Long-term survival rates for patients with advanced prostate cancer suggest they can be good candidates for surgery, Mayo Clinic researchers have found. Their study found a 20-year survival rate for 80 percent of patients diagnosed with cancer that has potentially spread beyond the prostate, known as cT3 prostate cancer, and treated with radical prostatectomy, or surgery to remove the prostate gland. Previously, patients found to have cT3 prostate cancer were offered radiation or hormone treatment, but not radical prostatectomy.

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The researchers presented their findings during the American Urological Association Annual Meeting in Washington.

"We are doing a much better job of identifying and expanding candidates for surgery, which results in better, longer outcomes for so many of our patients," says R. Jeffrey Karnes, M.D., of Mayo Clinic's Department of Urology. "We have confirmed that patients diagnosed with locally advanced prostate cancer can enjoy a long, cancer-free interval."

The 80 percent survival rate for cT3 diagnoses at 20 years compares to 90 percent for cT2, or cancer confined to the prostate. This long-term follow-up of patients who underwent surgery between 1987 and 1997 is an important advance in understanding the quality outcomes for cT3 patients. The study sample included patients diagnosed and operated on between 1987 and 1997. Ongoing research will examine contemporary data.

Other study investigators include Christopher Mitchell, M.D., Eric Umbreit, M.D., Rachel Carlson and Laureano Rangel, all of Mayo Clinic.

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Researchers examine procedure utilization trends in patients with clinically localized renal masses

ScienceDaily (May 15, 2011) — New techniques in science and technology allow the medical community to continually improve patient care and experience, but as these new procedures are introduced, physicians must closely consider the relative risks and benefits for each patient. Laparoscopic surgery offers the short-term benefits of smaller incisions, shorter hospital stays, and less pain during recovery, but are there negative consequences in the long run for some patients? Certain groups of patients, like those with localized renal masses, may be more appropriately treated through surgical techniques that focus on preserving as much functional kidney as possible--especially since emerging data suggests that a loss of kidney function can lead to higher long-term risks of morbidity and mortality.

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A new study to be presented by researchers from Fox Chase Cancer Center on Saturday, May 14, 2011, at the AUA 2011 Annual Meeting, examines whether the rapid adoption of minimally invasive techniques on the national level has had a negative impact on utilization rates of partial nephrectomy for patients with clinically localized renal masses.

"The AUA guidelines for localized renal masses recommend that kidney preservation is paramount when treating localized masses, but the rise of the number of partial nephrectomies--procedures that remove only part of a person's kidney--over time is lower than expected," says Marc Smaldone, M.D., urologic oncology fellow and lead author on the study. "As patient care evolves over time, we would expect to see the number of kidney preserving procedures increasing. Unfortunately, our results demonstrate that radical nephrectomy rates have remained consistent, which may be due to the preferential adoption of laparoscopic nephrectomy over partial nephrectomy in community practice."

When treating a patient with a localized renal mass, doctors have many surgical options. In radical procedures, surgeons remove the entire kidney, while partial nephrectomy techniques focus specifically on tumor removal while preserving as much functional kidney as possible. Either procedure may be performed via an open procedure through a large incision or a minimally invasive (or laparoscopic) approach.

In their study, researchers at Fox Chase demonstrated a dramatic 58 percent decrease in the percentage of open radical nephrectomy procedures performed from 1995 to 2005. However, they also observed more than a two-fold increase in laparoscopic nephrectomies in comparison to kidney sparing procedures over the same time period. These results suggest that more urologists are opting for laparoscopic nephrectomy, which may be due to increased familiarity and technical ease over more complex open or laparoscopic kidney preserving procedures. As a result, there is not the expected increase in the number of kidney preserving operations being performed, and more patients than necessary are being exposed to the adverse long-term consequences of chronic renal insufficiency.

"Knowing what we do about the long-term risks associated with removing a person's kidney, such as higher rates of long-term morbidity, it is crucial that, as physicians, we are doing all we can to spare as much of the organ as possible," says Robert G. Uzzo, M.D., F.A.C.S., chairman of the department of surgery at Fox Chase and member of the AUA Guidelines Council. "In this study, we're seeing a preference for laparoscopic procedures when we should be seeing a preference for nephron-sparing procedures."

To investigate this issue, Fox Chase identified 6,716 patients who underwent surgery for clinically localized renal masses between 1995 and 2005, drawn from linked SEER-Medicare data. They then compared utilization rates over time of four differing surgical procedures: open radical nephrectomy (ORN), laparoscopic radical nephrectomy (LRN), open partial nephrectomy (OPN), and laparoscopic partial nephrectomy (LPN). Their results demonstrate that over the ten-year period, utilization of nephron-sparing techniques--or partial nephrectomy--only increased by 15.5%, whereas 77% of patients with localized tumors were still managed with radical nephrectomy in 2005.

"Studies like these highlight that practice patterns evolve slowly over time, but more research is necessary," says Smaldone. "We now need to further investigate which types of institutions are performing specific procedure types and which patients have access to kidney preserving surgeries. These studies will ultimately help to ensure that we are providing all patients access to the best possible care."

"It is important that patients seek out care from physicians with expertise in kidney preservation techniques," adds Uzzo. "The benefits of laparoscopy don't offset the consequences of removing a patient's entire kidney if it's avoidable, and often, at most expert centers, a patient can receive the benefits of both through a laparoscopic partial nephrectomy."

Co-authors on the study include Fox Chase researchers Alexander Kutikov, Daniel J. Canter, Brian L. Egleston, Rosalia Viterbo, Ervin Teper, David Y.T. Chen, Richard E. Greenberg, and Robert G. Uzzo.

Statistical support for this project was supported by Fox Chase Cancer's Keystone Program in Personalized Kidney Cancer Therapy. Established in 2008, this collaborative program brings researchers and clinicians from multiple disciplines together to investigate the biological mechanisms that lead to kidney cancer metastasis and to uncover the molecular signals that predict how an individual patient's kidney tumor will respond to therapies. Ultimately, the research supported by this privately-funded program will allow clinicians to optimize therapies for a given patient based on the unique molecular characteristics of his or her tumor.

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Rapid growth may be appropriate trigger for treatment in patients with renal masses

ScienceDaily (May 15, 2011) — With an increase in abdominal imaging over the past decade, there has been an increase in the detection of incidental kidney cancer, which has led to concerns that we may be over-treating indolent disease. As part of this effort, clinicians have started to investigate the effectiveness of active surveillance (AS), or close observation as opposed to immediate surgery, for select patients with small renal masses (SRMs).

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Fox Chase Cancer Center researchers have announced the results of its systematic review and pooled analysis, which for the first time combined several institutions' experience with active surveillance of small renal masses. Their goal was to identify trends in radiographic tumor growth rates and progression to either treatment or metastasis, and found that in select patients, active surveillance may be a viable option when surgery is risky due to poor health or advanced age.

Marc Smaldone, M.D., urologic oncology fellow at Fox Chase and lead author on the study, will present the results at the AUA 2011 Annual Meeting on Tuesday, May 17, 2011.

"Kidney cancer is most often a surgically treated disease, so studies such as this one, which help to confirm that active surveillance with curative intent can be an effective strategy for certain patients, are crucial," says Smaldone. "Surgery has substantial consequences for many patients with competing risks such as heart or lung disease. The ability to offer a management strategy that avoids the risks of potentially unnecessary surgery is an attractive concept in contemporary cancer treatment."

To further investigate the risks of cancer progression in patients undergoing active surveillance, Fox Chase researchers combined all the available individual data published by institutions examining the observation of small renal masses. The team identified and pooled a total of 18 institutional series, of which Fox Chase's experience represented the largest published series. The researchers then examined the pooled experience for trends in radiographic growth rates, tumor size at presentation, and progression to treatment or metastasis.

They found that, of the observed 936 SRMs in 880 patients, only a very small proportion -- 2.1% (18 patients) -- progressed to metastasis. Pooled analysis of progressors and non-progressors revealed significant trends including increased age, increased tumor size at presentation, and increased growth rates in the progression group. These metrics can be used to help determine if a patient should stop surveillance and undergo surgical intervention for his or her SRM. However, Fox Chase researchers learned that growth kinetics alone cannot predict a tumor's natural growth history. Therefore, active surveillance should not be considered an equivalent alternative to definitive surgical therapy, but it can be used as an initial short-term option for select patients who are poor surgical candidates.

"There is a perception that all cancers, once detected, should be treated immediately because they are all equally lethal, but what we've seen in this study is that small, asymptomatic kidney cancers can be managed through active surveillance," says Robert G. Uzzo, M.D., F.A.C.S., chairman of the department of surgery at Fox Chase and member of the AUA Guidelines Council. "As a medical community, we need to recognize this shift and begin to risk stratify patients and counsel them based on criteria other than the presence of small renal masses on scans."

While more research is necessary, this study suggests that growth kinetics may be the best measurement currently available for determining which patients should undergo immediate intervention and which should not. As a supplement to radiographic data, future biomarker discovery in conjunction with percutaneous -- or renal biopsy -- might ultimately influence management decisions on an individual patient basis. Based on these findings patients should seek out urologic oncology experts to help them understand the implications of small kidney cancers and avoid overtreatment.

Co-authors on the study include Fox Chase researchers Alexander Kutikov, Daniel J. Canter, Brian L. Egleston, Rosalia Viterbo, David Y.T. Chen, Richard E. Greenberg and Robert G. Uzzo.

Statistical analysis for this research was supported by Fox Chase Cancer Center's Keystone Program in Personalized Kidney Cancer Therapy. Established in 2008, this collaborative program brings researchers and clinicians from multiple disciplines together to investigate the biological mechanisms that lead to kidney cancer metastasis and to uncover the molecular signals that predict how an individual patient's kidney tumor will respond to therapies. Ultimately, the research supported by this privately-funded program will allow clinicians to optimize therapies for a given patient based on the unique molecular characteristics of his or her tumor.

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Marker identifies breast cancer patients likely to respond to tamoxifen

ScienceDaily (May 22, 2011) — Cancer researchers at the Kimmel Cancer Center at Jefferson and an international team of collaborators have discovered a biomarker in breast cancer that may help identify which women will respond to anti-estrogen therapy.

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The research appears in the May 16 online issue of the Journal of Clinical Oncology.

Anti-estrogen drugs, most notably tamoxifen, are widely used in patients diagnosed with estrogen receptor-positive breast cancer. However, as many as a third of the women given tamoxifen fail to respond.

In this new study, the investigators found that women whose tumors retain the active form of the protein biomarker Stat5 have an increased likelihood of responding to tamoxifen. In contrast, women treated with tamoxifen whose tumors lacked active Stat5 had up to a 20-fold increased risk of dying from breast cancer after adjustment for effects of standard hormone receptor markers and other pathology data.

"Identification of predictive biomarkers present in breast cancer will lead to improved individualized therapies tailored specifically towards each woman's cancer," said Hallgeir Rui, M.D., Ph.D., professor of oncology, Kimmel Cancer Center at Thomas Jefferson University, and principal investigator of the study. "Absence of the active form of Stat5 could help identify a group of patients unlikely to respond to tamoxifen so they may be offered alternative and more aggressive treatments."

Stat5 protein is a DNA-binding factor that regulates expression of certain genes, many of which remain unknown. During pregnancy, Stat5 is activated by the hormone prolactin, and stimulates milk production in the breast. Active Stat5 is also detectable at lower levels in healthy breast tissue of non-pregnant women. This study further showed that active Stat5 was lost in the majority of more aggressive tumors and when those tumors metastasized to lymph nodes.

In 2004, Rui and colleagues reported that women with early stage breast cancer had higher survival rates when their tumors expressed active Stat5. Therefore, in two independent groups of breast cancer patients that were not treated with chemotherapy or anti-estrogen therapy, they further investigated the relationship between active Stat5 in the tumor and whether the patient had breast cancer recurrence or died of breast cancer over periods as long as 30 years. The team found consistent favorable breast cancer outcomes when tumors retained active Stat5.

The studies presented in this publication utilized a retrospective analysis of five large, independent breast cancer patient materials that included 1,000 patients, giving the studies a solid statistical basis. A benefit of optimizing a marker like Stat5 is that the assay for Stat5 is simple, inexpensive, and can be rapidly adapted to routine analysis in pathology laboratories using standard procedures.

"More work remains to be done, but we are optimistic about the utility of Stat5 as a biomarker," said Amy Peck, PhD, and lead author of the study. "The team is moving forward with plans for a randomized, prospective study with larger patient numbers to further evaluate the utility of Stat5 in managing and treating breast cancer."

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End of life care for cancer patients differs in US and Canada

ScienceDaily (May 18, 2011) — In the United States, older patients with advanced lung cancer make much less use of hospital and emergency room services at the end of life than their counterparts in Ontario but use far more chemotherapy, according to a study published May 18th online in the Journal of the National Cancer Institute.

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Government-financed health care covers elderly patients in both Canada and the U.S., but coverage at the end of life differs. In the U.S., Medicare covers hospice care for qualified patients. Ontario, the most populous Canadian province, has no hospice program comparable to what exists in the U.S. but provides palliative care through inpatient acute care units, outpatient services and home health care.

To compare end-of-life care between the two systems, Joan L. Warren, Ph.D., of the National Cancer Institute and colleagues used U. S. Surveillance, Epidemiology, and End Results (SEER)-Medicare data and data from the Ontario Cancer Registry. They identified patients age 65 and older who died with non-small cell lung cancer (NSCLC) during 1999-2003 and reviewed health claims from their last 5 months of life to collect data on chemotherapy, emergency room use, hospitalizations, and supportive care in both short-term (less than 6 months) and longer-term (6 months or more) survivors.

Patients in both countries used health-care services extensively, particularly in the last month of life. Ontario patients had hospital admissions and used emergency room services at rates that were statistically significantly greater than those of U.S. patients. More than twice as many Ontario patients died in hospital (e.g., 48.5% of short-term survivors compared to 20.4% in the U.S.) even though a majority of Ontario patients have reported that they would prefer to die at home. In each of the last 5 months, chemotherapy rates were statistically significantly higher among SEER-Medicare patients than among the Ontario patients.

The authors note that these findings partly support the commonly held view that U.S. physicians have a more aggressive attitude toward treatment and that patients in the U.S. tend to receive more intensive health-care services. However, U.S. patients can enroll in hospice services, an option not readily available in Ontario. The authors conclude that the lack of hospice services contributes to higher rates of hospital and emergency room visits and in-hospital deaths among Ontario patients.

The findings, they write, "will inform health planners and policy makers in each country regarding current patterns of end-of-life care and where there may be opportunities for changing practice patterns or programs."

In an editorial, David Goodman, M.D., of the Dartmouth Institute for Health Policy and Clinical Practice, notes that end-of-life care varies not only between the U.S. and Ontario, but also from region to region within the U.S. and Canada. Even more important, he writes, patient preferences varies from one individual to another and these preferences are often unheard: "Quality in end-of-life care will continue to elude us if we assume that societal average preferences indicate the care individual patients want and need," he writes.

Goodman argues that the best care at the end of life is care in which the patient participates in the decision-making. "The solution…is not to blindly drive systems towards greater use of hospice and palliative care services. It is to improve decision quality so that patients can make an informed choice with an understanding of the patient experiences associated with active curative care, with supportive care, or with concurrent

Lymphocyte count indicates prognosis of patients with renal cell carcinoma, researchers find

ScienceDaily (May 18, 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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