CA: A Cancer Journal for Clinicians最新文献

Although approximately half of patients with cancer receive symptom management and advance care planning (ACP), a new study reports that the percentage is much worse—only approximately 20%—for low-income and minority patients. The researchers note that this disparity results in not just reduced quality of life for the patients but also increased costs of care for individuals and overall.

The study found a slew of obstacles behind this imbalance, including inadequate time with clinicians, a lack of sufficient reimbursement, and social biases such as racism. “Yet few interventions address such disparate care,” wrote the researchers. The study appears in the Journal of Clinical Oncology (doi:10.1200/JCO.23.00309).

The randomized clinical trial was a collaboration between Unite Here Health (UHH) centers in Atlantic City, New Jersey, and Chicago, Illinois. UHH is an employer–union health fund that serves low-income and minority workers and their families.

The researchers developed a community advisory board and recruited 160 patients newly diagnosed with solid tumors and hematologic malignancies from the UHH membership who were considered to have poor health-related quality of life (HRQOL) and inadequate care. They called the program LEAPS (Lay Health Workers Educate, Engage, and Activate Patients to Share). They also included a study component that added patients with unaddressed health-related social needs (HRSNs).

The goal of the study was to evaluate the effectiveness of LEAPS in improving HRQOL outcomes. Patients self-reported their age, gender, race, ethnicity, education, and household income.

The median age of the patients was 58 years, and there were 83 females (51.8%). The study group included 82 Whites (51.3%), 47 Hispanics (29.4%), and 44 African Americans and other Blacks (27.5%). There were also two American Indians or Alaska Natives (1.3%), 31 Asians (19.4%), and one Native Hawaiian (0.6%). The annual household income for 127 of the patients (79.4%) was less than $35,000. Thirty-seven of the patients (23.1%) had breast cancer, and 64 of the patients (40.0%) had stage IV disease.

The patients were randomly assigned equally to a usual-care control group, which included outpatient oncology services and case management by a union-affiliated nurse, and to an intervention group, which comprised usual care plus access to a trained community health worker (CHW) for 12 months. The researchers ensured that the groups were similar in demographic and clinical variables.

The CHWs, who were bilingual and covered multiple languages, assisted participants with ACP, screened them for symptoms, and referred them to community-based resources for their individual HRSNs. Patients in the intervention group received weekly telephone calls for 4 months and then monthly calls for 1 year. ACP education in the preferred language of each patient was included.

The main end point evaluation was each patient’s

It has been more than 2 decades since the Women’s Health Initiative (WHI; https://www.whi.org/) alarmed clinicians with a report that found that the combination of conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA), when administered to postmenopausal women, increased breast cancer risk as well as the risks for coronary heart disease, stroke, and total mortality without improving quality of life. Since then, several researchers have questioned the findings, and the overarching conclusions have been revisited by WHI investigators themselves. Despite this, clinicians and their patients continue to take on a “safer rather than sorry” stance and often decide against taking the menopausal hormone therapy (HT), regardless of what symptoms may be present.

For example, in a study appearing in the journal Menopause: The Journal of The Menopause Society in April 2023 (doi:10.1097/GME.0000000000002154), WHI investigators conceded that HT yielded considerable benefits. However, they continued to assert that the associated increase in the risk of breast cancer with combined HT (CEE and MPA) remained a valid concern.

In response, a review published in the journal sought to rectify the association between breast cancer and HT—both CEE alone and CEE in combination with MPA, a large source of the misinterpretation (doi:10.1097/GME.0000000000002267). One of the authors, Avrum Z. Bluming, MD, an oncologist at the Keck School of Medicine at the University of Southern California in Los Angeles, explains it this way: “According to WHI’s own data, estrogen alone significantly decreases the risk of breast cancer development (by 23%) and the risk of breast cancer death (by 40%)—crucial information for women who have had hysterectomies.” In addition, “when started within 10 years of a woman’s final period (the ‘window of opportunity’), the WHI now agrees,” says Dr Bluming, that “it significantly decreases the risk for coronary heart disease, improves longevity, is the best and safest treatment for menopausal symptoms, and does not increase the risk of stroke. Further, it decreases the risk of osteoporotic hip fracture, colon cancer, and diabetes mellitus.” The sole issue at play is the association between combined HT (CEE plus MPA) and the risk of breast cancer.

In their review, Dr Bluming and his colleagues write that “the association between combined HT and an ‘increased breast cancer risk’ is actually not statistically significant. Further, even if one were to accept that the WHI’s claims of an increased risk were accurate, that increase would amount to one additional case of breast cancer for every 1,000 women treated per year but no increase in the risk of dying from breast cancer.” In addition, they argue that the assertion from WHI investigators that there is an association between the declining incidence of breast cancer and the reduction in HT prescriptions is not supported by several lines of data, including the fact that

Cancer mortality rates have declined during the last 28 years, but that process is not equitably shared. Disparities in cancer outcomes by race, ethnicity, socioeconomic status, sexual orientation and gender identity, and geographic location persist across the cancer care continuum. Consequently, community outreach and engagement (COE) efforts within National Cancer Institute-Designated Cancer Center (NCI-DCC) catchment areas have intensified during the last 10 years as has the emphasis on COE and catchment areas in NCI's Cancer Center Support Grant applications. This review article attempts to provide a historic perspective of COE within NCI-DCCs. Improving COE has long been an important initiative for the NCI, but it was not until 2012 and 2016 that NCI-DCCs were required to define their catchment areas rigorously and to provide specific descriptions of COE interventions, respectively. NCI-DCCs had previously lacked adequate focus on the inclusion of historically marginalized patients in cancer innovation efforts. Integrating COE efforts throughout the research and operational aspects of the cancer centers, at both the patient and community levels, will expand the footprint of COE efforts within NCI-DCCs. Achieving this change requires sustained commitment by the centers to adjust their activities and improve access and outcomes for historically marginalized communities.

The American Joint Committee on Cancer (AJCC) staging system for all cancer sites, including gastroenteropancreatic neuroendocrine tumors (GEP-NETs), is meant to be dynamic, requiring periodic updates to optimize AJCC staging definitions. This entails the collaboration of experts charged with evaluating new evidence that supports changes to each staging system. GEP-NETs are the second most prevalent neoplasm of gastrointestinal origin after colorectal cancer. Since publication of the AJCC eighth edition, the World Health Organization has updated the classification and separates grade 3 GEP-NETs from poorly differentiated neuroendocrine carcinoma. In addition, because of major advancements in diagnostic and therapeutic technologies for GEP-NETs, AJCC version 9 advocates against the use of serum chromogranin A for the diagnosis and monitoring of GEP-NETs. Furthermore, AJCC version 9 recognizes the increasing role of endoscopy and endoscopic resection in the diagnosis and management of NETs, particularly in the stomach, duodenum, and colorectum. Finally, T1NXM0 has been added to stage I in these disease sites as well as in the appendix.

The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019–2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Two important reports regarding cancer incidence in the United States¹ and globally² have been recently released. In summary, almost 20 million people worldwide were diagnosed with cancer in 2022, and almost 10 million died of their disease.² Lung cancer is the most common cancer globally, followed by female breast, colorectal, prostate, and stomach cancers. For women, breast cancer is the most common and is most often fatal; whereas, for men, the most common is lung cancer.² Cancer statistics from the United States released late last year indicated an alarming trend which was not covered in the global statistics: that colorectal and cervical cancers are increasing among individuals younger than 50 years and that colorectal cancer is now the first cause of cancer death among men and the second cause among women in this age group.¹ This is not an observation restricted to the United States; although the data are not as robust, increases in young-onset colorectal cancer have been documented from Chennai (India) to Korea.³ Siegel et al. reported that, for three countries in Europe (Netherlands, Cyprus, and Norway), the increase in colorectal cancer incidence was twice as rapid as that in older adults.³ Still, data are sparse when it comes to the Middle East and North African nations.

Recent reports from the United Arab Emirates (UAE) demonstrate that the issue is indeed global. The UAE National Cancer Registry (UAE-NCR) records cancer incidence rates stratified by age, sex, nationality (Emirati citizens vs. non-Emirati residents), and primary cancer site. The latest report published in February 2024 included all malignant and in-situ cases diagnosed in the UAE during the year 2021.⁴ Data were collected by registry staff at the Ministry of Health and Prevention and through focal points from stakeholders across the UAE (Department of Health Abu Dhabi central cancer registry, Dubai Health Authority central cancer registry, public and private hospitals [using codes from the International Classification of Diseases, Tenth Revision and International Classification of Diseases for Oncology], medical professionals, and pathology laboratories) through a standardized form and according to recommendations of the International Agency for Research on Cancer.⁴

Although the incidence rate for the most common cancers in the UAE are at or below global averages in countries with a high/very high Human Development Index, and although the age-specific incidence rates follow predicted trends and increase with advancing age across most cancers, a notable clustering of colorectal cancer incidence at early ages is similarly observed in the latest 2021 UAE-NCR report, which is consistent with available reports since 2014 from the sam

The 2022 update on cancer statistics provides a staggering figure: 20 million will receive a new diagnosis of cancer, and nearly 10 million will die. The data are derived from estimates provided by the Global Cancer Observatory, which relies on the best available sources of both incidence and mortality from cancer in each country.¹ Population-based cancer survival is a key metric of the effectiveness of health systems in how cancer is managed in individual countries. The monitoring of trends and inequalities in cancer survival is an important metric of overall health system performance, is used to guide investment priorities within oncology, and can help advance locally informed, cost-effective interventions to improve early diagnosis and treatment.

However, we believe there is a major caveat in these figures, which should serve as a flag for all who seek to prevent cancer from occurring or aim to convert it from a deadly disease to one that people live through, if not with; the data are only as valid as they are representative of a true country's burden. As such, the quality of the source information matters greatly, yet only 1% of African countries and 4% of Asian, South American, and Central American countries collect sufficient data for use.² For now, the Global Cancer Observatory does its best with what it has and thus can provide estimates for all parts of the world. To be frank, the lack of high-quality, country-specific cancer registries, particularly in low-income and middle-income countries (LMICs), affects the accuracy of these figures, raising the concern that these estimates are in fact underestimating both the incidence of and mortality from cancer. Moreover, whether trends in cancer by age at diagnosis are mirrored across countries is important to understand. For example, as the report notes, high Human Development Index (HDI) countries are reporting a rise in colorectal cancer diagnoses before age 50 years. Whether people living in lower HDI countries are experiencing the same trend is not known.

These issues are brought to the forefront when one looks at two countries in different parts of the world: Bangladesh and the Republic of Georgia. In Bangladesh, cancer incidence and mortality are based on cancer registries at the hospital level, hiding from view those who are not able to access specialized care, which is often centered in the major cities, like Dakha. As such, conclusions in this report that suggest the risk of developing cancer trends with increasing HDI, although firmly backed by the available data, need to be read with this important restriction in mind. In Georgia, the lack of a nationwide registry was recognized as a significant unmet need over a decade ago; and, in 2011, the Georgian government funded the State Program of Modern Cancer Registry Implementation. With significant support from the International Agency for Researc

This article presents global cancer statistics by world region for the year 2022 based on updated estimates from the International Agency for Research on Cancer (IARC). There were close to 20 million new cases of cancer in the year 2022 (including nonmelanoma skin cancers [NMSCs]) alongside 9.7 million deaths from cancer (including NMSC). The estimates suggest that approximately one in five men or women develop cancer in a lifetime, whereas around one in nine men and one in 12 women die from it. Lung cancer was the most frequently diagnosed cancer in 2022, responsible for almost 2.5 million new cases, or one in eight cancers worldwide (12.4% of all cancers globally), followed by cancers of the female breast (11.6%), colorectum (9.6%), prostate (7.3%), and stomach (4.9%). Lung cancer was also the leading cause of cancer death, with an estimated 1.8 million deaths (18.7%), followed by colorectal (9.3%), liver (7.8%), female breast (6.9%), and stomach (6.8%) cancers. Breast cancer and lung cancer were the most frequent cancers in women and men, respectively (both cases and deaths). Incidence rates (including NMSC) varied from four-fold to five-fold across world regions, from over 500 in Australia/New Zealand (507.9 per 100,000) to under 100 in Western Africa (97.1 per 100,000) among men, and from over 400 in Australia/New Zealand (410.5 per 100,000) to close to 100 in South-Central Asia (103.3 per 100,000) among women. The authors examine the geographic variability across 20 world regions for the 10 leading cancer types, discussing recent trends, the underlying determinants, and the prospects for global cancer prevention and control. With demographics-based predictions indicating that the number of new cases of cancer will reach 35 million by 2050, investments in prevention, including the targeting of key risk factors for cancer (including smoking, overweight and obesity, and infection), could avert millions of future cancer diagnoses and save many lives worldwide, bringing huge economic as well as societal dividends to countries over the forthcoming decades.

A man aged 41 years who had a past medical history significant for bilateral lower extremity varicosities and a prior 20-pack-year smoking history reported several days of fatigue to his primary care physician. His family history was notable for metastatic kidney cancer in his father. On laboratory testing, he was anemic (hemoglobin, 11.2 g/dL), with iron studies suggestive of iron-deficiency anemia. He denied any melena, hematochezia, or hematuria and underwent a full workup, including colonoscopy and capsule endoscopy, which were negative for sources of occult bleeding. The patient eventually underwent computed tomography (CT) scans of the chest, abdomen, and pelvis, which demonstrated a large, heterogeneously enhancing right renal mass measuring 9.5 × 8.2 × 6.8 cm with tumor thrombus invasion of the right renal collecting system, right renal vein, and inferior vena cava (IVC) above the hepatic veins. In addition, there was a pulmonary nodule in the left lower lobe measuring 0.8 cm, which was believed to be concerning for metastatic disease and subcentimeter retroperitoneal lymph nodes. One month later, he proceeded with a CT-guided biopsy of the pulmonary nodule at an outside hospital, with pathology revealing metastatic renal cell carcinoma (RCC). The tumor cells were positive for PAX8 and CAIX and negative for TTF1, which were suggestive of clear cell RCC (ccRCC) histology. He proceeded with a fluorodeoxyglucose F18 positron emission tomography (PET) scan for further evaluation, which demonstrated abnormal uptake in the right renal mass, a soft tissue mass in the IVC, and several small pulmonary nodules in bilateral lower lobes. His Eastern Cooperative Oncology Group (ECOG) performance status was 0. The patient was started on nivolumab plus ipilimumab (3 mg/kg and 1 mg/kg every 3 weeks, respectively), both of which are immune checkpoint inhibitors (ICIs), for intermediate-risk, metastatic RCC (according to the International Metastatic Renal Cell Carcinoma Database Consortium [IMDC] risk model) by an outside medical oncology team before presentation at Emory University Hospital.

After completing four cycles of combination immunotherapy, the patient was re-evaluated for potential cytoreductive surgery. He underwent magnetic resonance imaging (MRI) of the abdomen and pelvis for presurgical planning, most importantly as it related to the extent of the caval thrombus. The right renal mass was unchanged in size (8.8 × 6.3 × 8.7 cm); however, there was progression of the IVC tumor thrombus up to the right atrium, along with multiple (>10) new arterially enhancing lesions in the liver measuring up to 1.4 cm, compatible with metastasis (Figure 1). Transesophageal echocardiogram showed a large mass in the right atrium originating from the IVC; however, right ventricular size and function were normal, and the left ventricular ejection fraction was 60%.

In April 2023, after a multidisciplinary genitourinary tumor board, the consensus w

The concept of blood-based multicancer early detection (MCED) tests has generated much excitement, in part because of the potential of such tests to reduce cancer mortality by encompassing cancers for which screening is currently not available. A review in this issue of CA: A Cancer Journal for Clinicians, largely authored by members in the Division of Cancer Prevention at the National Cancer Institute (NCI), addresses the current status of the field.¹ The authors convey a reluctance to refer to the field as MCED. In their view and that of others, the evidence to date does not support substantial performance in detecting cancer at an early stage.² Therefore, instead, they use the designation multicancer detection (MCD) tests. The authors describe a strategy for MCD tests adopted by developers, consisting of first detecting a cancer signal based on shared biomarkers across cancer types, followed by assessment of the tissue of origin based on another set of biomarkers. The review includes a list of developers of MCD tests and the performance of tests for which data have become publicly available based on their positive and negative predictive values. The authors also provide details of the NCI Vanguard program aimed, in the short term, at testing the performance of MCD platforms they have selected among applicants and, in the longer term, at conducting prospective, randomized clinical studies.

Although the review provides an assessment of the current status of the MCD/MCED field, there is much that we do not know and that remains to be determined. From an effectiveness point of view, the optimal number of cancer types to be included may be debated. Currently, screening is available in the United States for lung, breast, colon, cervical, and prostate cancers. Screening is also available for gastric cancer in Asian countries, where the incidence is high. Although MCD tests have the potential to encompass a much broader range of cancers, notably including cancers for which screening is not available, it is clear that a relatively small number of cancers account for the vast majority of cancer deaths. American Cancer Society cancer statistics 2024 data for US cancer mortality project that five cancer types account for greater than 50% of cancer deaths.³ For men, they include pancreas and hepatobiliary cancers and, for women, pancreas and ovarian cancers. Given that an MCD test may vary in its performance by cancer type in terms of sensitivity and specificity, overall test performance may degrade with attempts to universally cover a vast number of cancer types. Moreover, for common cancers for which screening strategies are recommended, should MCD tests result in improved positive predictive value of screening programs? For other malignancies, the underlying cancer biology or treatment approaches may obviate any benefit of an MCD test. For example, the