Bachir J. Sakr

Addressing clinical trials: Can the Multidisciplinary Tumor Board improve participation? A study from an academic women's cancer program☆

OBJECTIVE The Tumor Board (TB) allows for an interdisciplinary approach to cancer treatment designed to encourage evidence-based treatment. However, its role in facilitating clinical trial participation has not been reported. We aimed to determine whether a prospective TB is an effective strategy for trial recruitment and to identify steps within the TB process that facilitate discussion of trial eligibility and optimize accrual. METHODS We conducted a retrospective cross-sectional analysis of women presented to Gynecologic Oncology TB between March and December 2008. Patient demographics, TB recommendations, and post-TB patient discussions were abstracted. These were compared to data derived from the Department of Oncology Research to determine research team awareness of eligible patients and confirm trial enrollment(s). Data analysis was completed with Chi-square test; risk ratios and confidence intervals were calculated as summary measures. RESULTS We reviewed 1213 case presentations involving 916 women. Overall, 358 TB recommendations (30%) identified eligible patients, of which enrollment consisted of 87 (24%) trials (6% therapeutic trials and 18% non-therapeutic trials). Compared to other types of TB recommendations, those involving trials were discussed less frequently at post-TB patient visits (79% vs. 44%). Documentation of trial discussion at the post-TB visit was more likely to result in trial participation, versus solely relying on the research staff to communicate enrollment eligibility with the treating team (RR 2.5, p=0.006). CONCLUSIONS Patients identified by the TB were 2.5-times as likely to enroll in a clinical trial, but trials were mentioned only 44% of the time. Interventions that facilitate trial discussions during post-TB meetings are needed to improve trial participation.

Medical Marijuana Use in Oncology: A Review

Importance Medicinal marijuana use is currently legal in 23 states and the District of Columbia. As more states approve marijuana use for medical indications, physicians will be asked by their patients for more information regarding the risks and benefits of use. This article reviews the history, adverse effects, and proposed mechanisms of action of marijuana and summarizes the available literature regarding symptom relief and therapeutic value in patients with cancer. Observations Marijuana in oncology may have potential for use as an antiemetic, for refractory cancer pain, and as an antitumor agent. However, much of the data are based on animal data, small trials, or are outdated. Conclusions and Relevance More research is needed in all areas related to the therapeutic use of marijuana in oncology.

Adjuvant chemotherapy in T1a/bN0 HER2-positive or triple-negative breast cancers: Application and outcomes

We assessed practice patterns and the impact of systemic adjuvant therapy on human epidermal growth factor receptor 2 (HER2)-positive or triple-negative, node-negative breast cancers up to 10 mm in size. Records of 161 patients identified among 1415 cases diagnosed in our institutions between 2000 and 2010 were assessed for factors associated with recommendation for chemotherapy and survival outcomes. Adjuvant chemotherapy was recommended in 53% of patients, more commonly in patients with younger age, stage T1b, high grade, HER2+/ER- status and diagnosis after 2006. With a median follow-up of 54 months, the 5-year cumulative incidence of recurrence was 5.3% and overall survival was 93.2%. Age less than 40 and presence of lymphovascular invasion (LVI) were associated with higher risk of recurrence. In a univariate analysis administration of adjuvant chemotherapy was not associated with a significantly better recurrence rate (P = 0.33).

Advances in Medical Management of Early Stage and Advanced Breast Cancer: 2015

Standard management of early stage and advanced breast cancer has been improved over the past few years by knowledge gained about the biology of the disease, results from a number of eagerly anticipated clinical trials and the development of novel agents that offer our patients options for improved outcomes or reduced toxicity or both. This review highlights recent major developments affecting the systemic therapy of breast cancer, broken down by clinically relevant patient subgroups and disease stage, and briefly discusses some of the ongoing controversies in the treatment of breast cancer and promising therapies on the horizon.

Is Tumor Board Relevant

To the Editor: Multidisciplinary tumor boards (MTB) have been shown to impact the surgical and medical management of oncology patients and are a requirement for accreditation by the American College of Surgeons Commission on Cancer (1–6). In addition, to the interdisciplinary consultation afforded to oncology patients they also serve to educate physicians and other health professionals. The prospective evaluation of patients is also required for accreditation by the National Accreditation Program of Breast Centers (NAPBC), and is a measure of quality of the National Quality Measures for Breast Centers (NQMBC) (2,3). In two small studies, TB recommendations were reportedly followed into practice and were more likely to be implemented (4,5). However, one question not addressed in these studies is whether or not the MTB follows consensus-based recommendations for cancer care, such as those put out by the National Comprehensive Cancer Network (NCCN). We performed a study to (a) determine whether TB recommendations at our academic breast center were followed by the primary physician caring for the patient at that time and (b) whether these same recommendations adhere to NCCN guidelines. Following Institutional Review Board approval, breast TB letters from cases of interest presented between January 1 and September 30, 2005 were collected and reviewed. Demographic data, tumor-specific data, TB recommendations, and all office notes were reviewed. For purposes of defining adherence to NCCN guidelines, two specific scenarios were reviewed: nodepositive breast cancer and hormone-receptor positive breast cancer. The NCCN guidelines for node-positive disease include chemotherapy with exceptions for patients with a favorable prognosis and women age 60 or greater, especially in those women with comorbid conditions. For those with hormone-receptor positive disease, the NCCN recommends endocrine therapy. For this study, we defined concordance between the TB and the NCCN if recommendations were made for node-positive patients to be referred for chemotherapy (with some exceptions for age and comorbid illness) and hormone positive patients referred for endocrine therapy (6). Demographics of the patients presented were analyzed by descriptive statistics. For purposes of concordance, t-test was used to determine statistical significance. A p-value <0.05 was considered statistically significant. During the study period, 428 cases were identified. Cases with incomplete data or those that did not fit into TNM staging were excluded from analysis leaving 380 cases (88.7%). There were data available on provider recommendations for 242 (63.7%) patients. The median age was 57 years; 69% of patients were HR positive; 44% were node-positive. Overall, the tumor board and provider recommendations agreed (p-value of <0.0001). Of 198 patients for whom the tumor board recommended surgery, the provider agreed in 195 cases (98.5%). In 3 of 10 cases the tumor board recommended chemotherapy and the provider agreed (30.0%) and in 4 of 23 (17.4%) cases, the tumor board and the provider made multiple recommendations. One patient went to surgery when the tumor board recommended radiation therapy. In 19 cases, where multiple recommendations were made by the tumor board the patients went to surgery. These data suggest that the provider did not bring up all the recommendations made by the tumor board before the patient went for surgery. The NCCN Guidelines recommend endocrine therapy in the majority of patients with ER positive tumors and chemotherapy in most patients with node-positive disease. Of 167 patients with a positive ER/PR status, the tumor board recommended endocrine therapy in 121 (72.5%). Of the 46 patients with no recommendations for endocrine therapy: 36 were referred for Address correspondence and reprint requests to: Tina Rizack, MD, MPH; Program in Women’s Oncology, Women & Infants’ Hospital, 101 Dudley Street, Providence, RI 02905, USA, or e-mail: trizack@wihri.org

Breast cancer: adjuvant modalities.

The mortality rate due to breast cancer has declined over the preceding decades to a great extent, secondary to the development and use of effective adjuvant therapy. Tamoxifen remains the standard of care in premenopausal women, whereas aromatase inhibitors have become standard therapy after menopause for women with hormone-sensitive disease. Tumor gene profiling assays are being increasingly used to identify women with hormone-sensitive disease, who would benefit from adjuvant chemotherapy. For those women with hormone negative cancer, systemic chemotherapy provides substantial reduction in the risk of disease recurrence and death.

Treating Endometrial Adenocarcinoma—Do Data Support the Use of Pegylated Liposomal Doxorubicin?

Most women who are diagnosed with endometrial carcinoma present at an early stage and are usually cured of their disease by surgery with or without adjuvant radiation therapy and/or chemotherapy. For those patients who present with advanced disease or develop recurrent disease, survival is greatly diminished. Chemotherapy plays an important role in the management of these patients. Doxorubicin is one of the most active chemotherapy drugs in the advanced or recurrent setting, with response rates in the order of 25%. The use of doxorubicin is limited by its cumulative dose-dependent cardiotoxicity. Pegylated liposomal doxorubicin is a newer formulation of conventional doxorubicin. Its altered pharmacokinetics result in a longer half-life, decreased exposure in healthy tissues, and enhanced delivery of the active drug to the tumor bed. Pegylated liposomal doxorubicin has a relatively milder toxicity profile and a lower incidence of cardiac adverse events. In this article the data on the use of pegylated liposomal doxorubicin in advanced or recurrent endometrial cancer, including the serous papillary histologic variant, are reviewed.

Is tumor board relevant

e19654 Background: There are limited studies looking at whether tumor board (TB) recommendations are followed into practice and whether they follow guidelines set forth by the National Comprehensiv...