CA: A Cancer Journal for Clinicians最新文献

Anew study raises an alarm over polypharmacy, an issue that is not new but may become more worrisome because of an aging population and a myriad of new drugs coming to market, including cancer drugs. The study appears in Cancer (doi:10.1002/cncr.34642).

Corresponding author Erika Ramsdale, MD, MS, geriatric oncologist and associate professor of hematology/oncology in the Department of Medicine at the University of Rochester in Rochester, New York, warns that although there is some evidence that cancer treatment outcomes may be affected by taking multiple medications and/or potentially inappropriate medications (PIMs), “the research is still very sparse.”

Dr Ramsdale says that the main goal of this new study was to examine the associations between polypharmacy, PIMs, and potential drug–drug interactions (PDIs) and adverse cancer treatment outcomes in a large national cohort of older adults with advanced cancer. The authors note that polypharmacy and PIMs have suspected roles in many adverse events in older patients with cancer, including toxicities, but cause and effect links have been unclear.

This secondary analysis uses data from an earlier nationwide, multicenter, cluster-randomized study by the same team that appeared in The Lancet (doi:10.1016/S01406736(21)01789-X). Known as the Geriatric Assessment for Patients 70 Years and Older (GAP70+) study, it assessed clinician-rated grade 3–5 chemotherapy toxicity in older adults with advanced cancer who were undergoing a new cancer treatment regimen.

In the Cancer study, the authors note that a host of variables exist beyond the age and possible disabilities of the patients. Other factors that can contribute to difficulties include health care system–level issues, such as poor transitions of care, interdepartmental communication, multiple pharmacies, and “prescribing cascades.”

There were 718 patients enrolled in the study between July 2014 and March 2019 who had provided written consent. The subjects ranged in age from 70 to 94 years, were predominantly male (56.4%) and non-Hispanic White (87.5%), and had a stage III/IV solid tumor or lymphoma (87.5%). Gastrointestinal cancer was the most common type (246 patients; 34.3%), and it was followed by lung cancer (180 patients; 25.1%).

Four hundred forty of the 718 patients (61.3%) were taking five or more medications, 198 (27.6%) were taking eight or more, and 104 (14.5%) were taking more than 10. The researchers found that 447 patients (62.3%) received one or more PIMs according to the 2019 American Geriatrics Society Beers Criteria (range, 0–8 PIMs), and 206 (28.7%) received at least one PIM according to the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria. All told, there were 482 patients (67.1%) with one or more PIMs.

There were 177 patients who had at least one potentially major PDI (category D or X).

The researchers found that the mean number of grade 2 or high

Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify, critically appraise, synthesize, and present the best available evidence to inform policy and planning regarding patient navigation across the cancer continuum. Systematic reviews examining navigation in cancer care were identified in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), Epistemonikos, and Prospective Register of Systematic Reviews (PROSPERO) databases and in the gray literature from January 1, 2012, to April 19, 2022. Data were screened, extracted, and appraised independently by two authors. The JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used for quality appraisal. Emerging literature up to May 25, 2022, was also explored to capture primary research published beyond the coverage of included systematic reviews. Of the 2062 unique records identified, 61 systematic reviews were included. Fifty-four reviews were quantitative or mixed-methods reviews, reporting on the effectiveness of cancer patient navigation, including 12 reviews reporting costs or cost-effectiveness outcomes. Seven qualitative reviews explored navigation needs, barriers, and experiences. In addition, 53 primary studies published since 2021 were included. Patient navigation is effective in improving participation in cancer screening and reducing the time from screening to diagnosis and from diagnosis to treatment initiation. Emerging evidence suggests that patient navigation improves quality of life and patient satisfaction with care in the survivorship phase and reduces hospital readmission in the active treatment and survivorship care phases. Palliative care data were extremely limited. Economic evaluations from the United States suggest the potential cost-effectiveness of navigation in screening programs.

In this issue of CA: A Cancer Journal for Clinicians, Chan and colleagues¹ describe an umbrella review of 61 systematic reviews published between 2012 and 2022, along with a review of 53 primary studies published globally since 2021. Patient navigation (PN) has many definitions, and, in this, review PN was defined according to the definition of Wells et al.² combined with that of Dalton et al.,³ which expanded the definition of PN to also include care coordination. Their primary research question focused on evaluating the effectiveness and cost-effectiveness of different cancer navigation models and programs. Multiple databases were searched to find quantitative PN intervention studies with any comparator as well as qualitative, mixed-methods, and systematic reviews. The Joanna Briggs Institute’s JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used to examine the risk of bias for each of the systematic reviews. Findings of this umbrella review indicated that the risk of bias of the included systematic reviews seemed low; however, fewer than one half of the included reviews reported the likelihood of publication bias. The review concluded that PN is effective in increasing uptake or adherence to cancer screening, reducing the time from screening abnormality to diagnosis, increasing rates of diagnostic resolution, reducing the time from diagnostic resolution to treatment initiation, increasing treatment completion, increasing treatment adherence, increasing survivorship surveillance appointments for breast or cervical cancer, increasing quality of life, and increasing satisfaction with care. Furthermore, the review pointed to a lack of evidence regarding PN in palliative care and end-of-life phases. The review also concluded that most effectiveness and cost-effectiveness data for PN interventions were collected in the United States; therefore, Chan and colleagues call for additional research to evaluate the effectiveness and cost-effectiveness of PN outside of the United States, in survivorship and palliative care phases of the cancer continuum, for indigenous populations, and for individuals affected by rare cancers, hematologic malignancies, as well as advanced or metastatic cancer.¹

Although this review has many important contributions to the literature, there are points that need to be addressed. First, although Chan and colleagues updated the more recent literature, their conclusions do not differ from those of the myriad of other reviews. Now is the time for the implementation of PN in health care because the amount and consistency of evidence is sufficient demonstrating the impact of PN across the cancer continuum. This report solidifies the evidence—when can we all agree that enough evidence is enough and that PN needs to be an integral part of usual clinical care with reimbursement? The next phas

The standard for cancer staging in the United States for all cancer sites, including primary carcinomas of the appendix, is the American Joint Committee on Cancer (AJCC) staging system. AJCC staging criteria undergo periodic revisions, led by a panel of site-specific experts, to maintain contemporary staging definitions through the evaluation of new evidence. Since its last revision, the AJCC has restructured its processes to include prospectively collected data because large data sets have become increasingly robust and available over time. Thus survival analyses using AJCC eighth edition staging criteria were used to inform stage group revisions in the version 9 AJCC staging system, including appendiceal cancer. Although the current AJCC staging definitions were maintained for appendiceal cancer, incorporating survival analysis into the version 9 staging system provided unique insight into the clinical challenges in staging rare malignancies. This article highlights the critical clinical components of the now published version 9 AJCC staging system for appendix cancer, which (1) justified the separation of three different histologies (non-mucinous, mucinous, signet-ring cell) in terms of prognostic variance, (2) demonstrated the clinical implications and challenges in staging heterogeneous and rare tumors, and (3) emphasized the influence of data limitations on survival analysis for low-grade appendiceal mucinous neoplasms.

In July 2020, the American Cancer Society (ACS) released an updated cervical cancer screening guideline calling for primary human papillomavirus (HPV) screening as the preferred strategy.¹ Primary HPV screening refers to cervical cancer screening with an HPV test alone as the initial screening modality. Under this strategy, cervical cytology is reserved for use as one option for a triage test should the HPV test result be positive. The scientific data supporting this recommendation have been reviewed both in the United States and in other countries that have transitioned to primary HPV screening.^{2, 3}

The Primary HPV Screening Initiative (PHSI), nested under the ACS National Roundtable on Cervical Cancer, is a national consortium supported by the ACS that convenes key partners and experts on six workgroups and a Steering Committee charged with identifying critical barriers and opportunities for transitioning to primary HPV screening. The workgroups engage approximately 100 volunteers who began their activities in the fall of 2021. Workgroup members are multiprofessional and include leaders in health care policy, health care delivery, and patient care as well as patient advocates. The project is overseen by a Steering Committee (Figure 1) made up of the co-chairs of each of the six workgroups and other experts identified for their leadership in the areas of cervical cancer screening and health care policy. The final deliverable is an implementation report (roadmap), complete with tools and recommendations to support health systems, laboratories, providers, patients, and payors as they make this transition.

The Provider Needs Workgroup is developing resources in a variety of formats both to educate providers and to help them educate their patients about the benefits and safety of primary HPV screening. The deliverables include tools to aid in the management of patients with abnormal screening results. Success will be defined by change in provider behavior and will depend in large part on the degree to which major professional organizations (e.g., American College of Obstetricians and Gynecologists, American Academy of Family Physicians, Nurse Practitioners in Women's Health, and American Society for Colposcopy and Cervical Pathology) promote primary HPV screening as the standard for excellent care. The US Preventive Services Task Force recommends primary HPV screening as one of three strategies to screen for cervical cancer starting at age 30 years but does not give preference to modality.⁴ As of this writing, updated recommendations from the US Preventive Services Task Force are pending. It is desirable that all organizations agree on preferred screening guidelines to facilitate prevention efforts that are supported by evidence and widely accessible. Providers are most likely to follow guidelines promoted by their professional societies, so t

Small cell lung cancer (SCLC) is characterized by rapid growth and high metastatic capacity. It has strong epidemiologic and biologic links to tobacco carcinogens. Although the majority of SCLCs exhibit neuroendocrine features, an important subset of tumors lacks these properties. Genomic profiling of SCLC reveals genetic instability, almost universal inactivation of the tumor suppressor genes TP53 and RB1, and a high mutation burden. Because of early metastasis, only a small fraction of patients are amenable to curative-intent lung resection, and these individuals require adjuvant platinum-etoposide chemotherapy. Therefore, the vast majority of patients are currently being treated with chemoradiation with or without immunotherapy. In patients with disease confined to the chest, standard therapy includes thoracic radiotherapy and concurrent platinum-etoposide chemotherapy. Patients with metastatic (extensive-stage) disease are treated with a combination of platinum-etoposide chemotherapy plus immunotherapy with an anti-programmed death-ligand 1 monoclonal antibody. Although SCLC is initially very responsive to platinum-based chemotherapy, these responses are transient because of the development of drug resistance. In recent years, the authors have witnessed an accelerating pace of biologic insights into the disease, leading to the redefinition of the SCLC classification scheme. This emerging knowledge of SCLC molecular subtypes has the potential to define unique therapeutic vulnerabilities. Synthesizing these new discoveries with the current knowledge of SCLC biology and clinical management may lead to unprecedented advances in SCLC patient care. Here, the authors present an overview of multimodal clinical approaches in SCLC, with a special focus on illuminating how recent advancements in SCLC research could accelerate clinical development.

There remains a need to synthesize linkages between social determinants of health (SDOH) and cancer screening to reduce persistent inequities contributing to the US cancer burden. The authors conducted a systematic review of US-based breast, cervical, colorectal, and lung cancer screening intervention studies to summarize how SDOH have been considered in interventions and relationships between SDOH and screening. Five databases were searched for peer-reviewed research articles published in English between 2010 and 2021. The Covidence software platform was used to screen articles and extract data using a standardized template. Data items included study and intervention characteristics, SDOH intervention components and measures, and screening outcomes. The findings were summarized using descriptive statistics and narratives. The review included 144 studies among diverse population groups. SDOH interventions increased screening rates overall by a median of 8.4 percentage points (interquartile interval, 1.8–18.8 percentage points). The objective of most interventions was to increase community demand (90.3%) and access (84.0%) to screening. SDOH interventions related to health care access and quality were most prevalent (227 unique intervention components). Other SDOH, including educational, social/community, environmental, and economic factors, were less common (90, 52, 21, and zero intervention components, respectively). Studies that included analyses of health policy, access to care, and lower costs yielded the largest proportions of favorable associations with screening outcomes. SDOH were predominantly measured at the individual level. This review describes how SDOH have been considered in the design and evaluation of cancer screening interventions and effect sizes for SDOH interventions. Findings may guide future intervention and implementation research aiming to reduce US screening inequities.

The patient is a 19-year-old female who had an incidental thyroid nodule discovered on magnetic resonance imaging (MRI) in July 2020 during the work-up of a superficial, midline neck cellulitis. She reported having noticed a bulge in her neck a few years prior but had never been concerned about it. She began seeing an endocrinologist and underwent a thyroid ultrasound in July 2020, which revealed a solid, hypoechoic nodule in the left upper thyroid lobe measuring 2.2 cm in greatest dimension, classified as American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) 4 (Figure 1). Multiple, enlarged, abnormal-appearing lymph nodes were also noted in the left cervical lymph node chain in level IV (Figure 2). The lower pole of the left thyroid lobe was heterogeneous, with scattered calcifications and subcentimeter cystic areas, and no abnormal findings were noted in the isthmus or right lobe of the thyroid gland. Her thyroid function tests were normal, with a thyroid-stimulating hormone (TSH) level of 2.34 mU/L (reference range, 0.45–5.33 mU/L) and a T4 (thyroxine) level of 0.88 ng/dL (reference range, 0.58–1.64 μg/dL), with negative thyroid peroxidase antibodies and normal blood cell counts.

A fine-needle aspiration (FNA) of the left thyroid nodule was performed in September 2020 and revealed papillary thyroid cancer (PTC). The patient was then referred to the endocrine surgery clinic for evaluation and further management. An FNA biopsy of the concerning left lateral cervical lymph nodes (Figure 2) was conducted in the endocrine surgery clinic because it had not previously been performed. Given the concerning appearance of the lymph nodes on ultrasound, a total thyroidectomy with possible left central and lateral neck dissections was discussed as the likely operation pending pathology results from the lymph node biopsy. The patient agreed with the treatment plan, and FNA results from the lymph nodes returned as metastatic PTC.

Given the evidence of metastatic lymph node disease, the patient underwent a total thyroidectomy along with left central and lateral neck dissections in October 2020. Intraoperatively, a very firm nodule in the left lobe of the thyroid gland was encountered that was unable to be cleanly separated from the overlying sternothyroid muscle. Given concern for extrathyroidal extension, the muscle was resected en bloc with the thyroid specimen. During the dissection, there was concern for devascularization of the left superior parathyroid gland, so it was excised and re-implanted. However, there was significant lymphadenopathy low in cervical level VI surrounding the left inferior parathyroid gland, making clear identification of the inferior gland difficult. A frozen section was obtained that confirmed the identification of the left inferior parathyroid gland, so it was also re-implanted into the left sternocleidomastoid muscle. Bulky lymphadenopathy was found throughout the left central and

In February 2022, the White House announced the reignition of the Cancer Moonshot Initiative with the goals of reducing the death rate from cancer by at least 50% over the next 25 years and improving the experience of people and their families living with and surviving cancer. A core component of the Cancer Moonshot Initiative is the facilitation of multisector partnerships to solve the compelling challenges faced in cancer care delivery. The American Cancer Society (ACS) has a longstanding tradition of convening partners across the cancer landscape, most notably through conferences, partner meetings, advocacy coalitions, and coalescing of thought leaders through roundtables. For example, the ACS and several patient advocacy organizations, scientific organizations, and pharmaceutical partners came together in October 2022 to launch the new ACS National Breast Cancer Roundtable and the ACS National Cervical Cancer Roundtable as “all-hands-on-deck” coalitions to reshape cancer care.¹ These Roundtables aim to both (1) identify the leading challenges in detection and treatment within these cancers and (2) provide expert guidance to providers, patients, payers, and policy makers regarding evolutions needed to increase access and patient centricity of cancer care. Beyond disease-specific issues, the ACS and its partners have also explored topics that span the cancer care continuum.

Currently, much of the attention given to innovation in oncology is centered upon creating and delivering a rapidly expanding armamentarium of anticancer treatments. Efforts to develop more novel, personalized, and targeted therapies have been fruitful but also continue to further highlight issues related to access. How treatments are selected and delivered and how outcomes are monitored require additional focus. Furthermore, how such efforts align with increasing calls for patient centricity, meeting patients where they are both figuratively and literally, requires a national discussion. Herein, we describe the findings from the first effort of the ACS in convening national leaders across multiple stakeholders, including the provider, payer, government, and technology communities, to discuss cancer care delivery at home.

This ACS Cancer Care at Home Summit convened in Cambridge, Massachusetts, on October 26, 2022, using a “design-thinking” framework to identify the major issues in decentralized cancer care delivery and plan for the next steps forward. The Summit convened 30 national leaders at the Philips North America campus using Chatham House rules during which participants were guided in building a shared mental model, framing the challenges and ideating around barriers, defining opportunities, and sharing findings with each other to determine next steps. To ensure that the ACS optimally used the time dedicated by these senior leaders, untapping the immense potential of the combination of participants in the room, and really gettin

A man aged 45 years with hypertension and hyperlipidemia presented to his primary care physician with a 3-month history of a golf ball-sized right upper back mass. Ultrasound was performed, revealing a well defined lesion with mixed echogenicity, thought to be consistent with a lipoma. Clinically, however, the mass rapidly enlarged and became painful. The patient was referred to dermatology and subsequently to a surgeon. He underwent surgery at his local institution 2 months after initial presentation.

The mass was excised in two fragments measuring 8 × 7 cm and 6 × 6 cm. Pathology revealed a high-grade pleomorphic liposarcoma (PLPS). Necrosis was observed, and the mitotic rate was 26 per 10 high-power fields. The tumor involved the margins of the piecemeal excision specimens. Computed tomography (CT) imaging of the chest, abdomen, and pelvis was notable for tiny, indeterminate pulmonary nodules and a 4.3 × 2.4 × 4.7 cm, well circumscribed area with central low density in the right posterolateral chest wall soft tissues, possibly reflecting a postoperative seroma (Figure 1A). The patient noted progressive enlargement of the operative site; therefore, repeat CT imaging of the chest was performed 3 weeks later and showed an enlarging soft tissue mass concerning for residual disease (Figure 1B). Magnetic resonance imaging (MRI) of the chest showed a 4.2 × 5.0 × 6.0 cm solid mass with enhancement and diffusion restriction contiguous with the latissimus dorsi muscle (Figure 1C,D). The patient was referred to our sarcoma specialty center and had a multidisciplinary evaluation with medical oncology, radiation oncology, and surgical oncology. Preoperative radiation therapy (RT) and surgery followed by adjuvant chemotherapy with doxorubicin and ifosfamide were recommended.

Ultrasonography (US) is often the first imaging examination performed to evaluate palpable, superficial soft tissue masses because of its wide availability, low cost, and ease of performance. US is most useful in distinguishing solid from cystic lesions without additional intravenous contrast, and it can identify specific benign lesions. However, the US findings of benign and malignant solid soft tissue tumors overlap, and accurate tissue diagnosis is not feasible in most instances.^{1, 2} In this case, the US findings were reported as likely lipoma; therefore, the mass was resected because of rapid growth and pain. Findings concerning for malignancy are rapid growth, vascularity, and pain, which should prompt further workup with MRI or CT.² MRI is the imaging modality of choice for soft tissue tumors or tumor-like masses because of its superior contrast, allowing for tissue characterization and multiplanar capability without radiation exposure. In cases of suspected myxofibrosarcoma, MRI can be helpful diagnostically because these tumors are often infiltrative and extend along the fascial planes, referred to on MRI as the t