Dilsen Colak

Long Term Survivors with Metastatic Pancreatic Cancer Treated with Gemcitabine Alone or Plus Cisplatin: a Retrospective Analysis of an Anatolian Society of Medical Oncology Multicenter Study

BACKGROUND The majority of patients with pancreatic cancer present with advanced disease. Systemic chemotherapy has limited impact on overall survival (OS) so that eligible patients should be selected carefully. The aim of this study was to analyze prognostic factors for survival in Turkish advanced pancreatic cancer patients who survived more than one year from the diagnosis of recurrent and/or metastatic disease and receiving gemcitabine (Gem) alone or gemcitabine plus cisplatin (GemCis). METHODS This retrospective evaluation was performed for patients who survived more than one year from the diagnosis of recurrent and/or metastatic disease and who received gemcitabine between December 2005 and August 2011. Twenty-seven potential prognostic variables were chosen for univariate and multivariate analyses to identify prognostic factors associated with survival. RESULTS Among the 27 variables in univariate analysis, three were identified to have prognostic significance: sex (p=0.04), peritoneal dissemination (p=0.02) and serum creatinine level (p=0.05). Multivariate analysis by Cox proportional hazard model showed only peritoneal dissemination to be an independent prognostic factor for survival. CONCLUSION In conclusion, peritoneal metastasis was identified as an important prognostic factor in metastatic pancreatic cancer patients who survived more than one year from the diagnosis of recurrent and/ or metastatic disease and receiving Gem or GemCis. The findings should facilitate pretreatment prediction of survival and can be used for selecting patients for treatment.

Pathologic and Clinical Characteristics of Elderly Patients With Breast Cancer: A Retrospective Analysis of a Multicenter Study (Anatolian Society of Medical Oncology)

There is very little information about breast cancer characteristics, treatment choices, and survival among elderly patients. The purpose of this multicenter retrospective study was to examine the clinical, pathologic, and biologic characteristics of 620 breast cancer patients age 70 years or older. Between June 1991 and May 2012, 620 patients with breast cancer, recruited from 16 institutions, were enrolled in the retrospective study. Patients had smaller tumors at diagnosis; only 15% of patients had tumors larger than 5 cm. The number of patients who had no axillary lymph node involvement was 203 (32.7%). Ninety-three patients (15.0%) had metastatic disease at diagnosis. Patients were characterized by a higher fraction of pure lobular carcinomas (75.3%). The tumors of the elderly patients were also more frequently estrogen receptor (ER) positive (75.2%) and progesterone receptor (PR) positive (67.3%). The local and systemic therapies for breast cancer differed according to age. An association between age and overall survival has not been demonstrated in elderly patients with breast cancer. In conclusion, the biologic behavior of older patients with breast cancer differs from younger patients, and older patients receive different treatments.

Hodgkin's disease in an elderly patient with B-cell chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia worldwide. It is an indolent disease, almost exclusively of B-cell origin. Some CLLs evolve into a more aggressive lymphoid malignancy. The most common of these is Richters syndrome. Transformation to acute lymphoblastic leukemia, plasma cell leukemia, multiple myeloma, or Hodgkins disease (HD) may also occur. CLL patients are also at a significantly increased risk of developing a second malignant neoplasm later in life. One of the most common of these is HD. Herein, we report a case of HD in an elderly man with a history of B-cell CLL.

Morphine: Patient Knowledge and Attitudes in the Central Anatolia Part of Turkey

BACKGROUND In Muslim majority countries (MMC) opioid use for pain management is extremely low. The underlying factors contributing to this are not well defined. AIM The aim of this study was to survey the attitudes of cancer patients towards morphine use for pain management in a MMC and identify the factors that influence patient decisions to accept or refuse morphine as treatment for cancer pain. SETTINGS/PARTICIPANTS Patients were questioned whether they had pain or not, the severity and the medications for pain management. Questions included what type of medication they thought morphine was, whether or not they would be willing to take morphine if recommended for pain management and the basis for their decision if they were against morphine use. RESULTS Four hundred and eighty-eight patients participated in the study. Some 50% of the patients who refused morphine use and 36.8% of the patients who would prefer another drug, if possible, identified fear of addiction as the basis for their decision. Reservation of morphine for later in their disease was the case for 22.4% of the patients who refused morphine use. Only 13.7 % of the patients refusing morphine and 9.7% of the patients who preferred another drug, if possible, cited religious reasons as the basis for this decision. CONCLUSIONS Identifying the underlying factors contributing to low opioid use for pain management in MMC is important. Once the underlying factors are identified, all efforts should be taken to overcome them as they are barriers to improving patient pain management.

Treatment of Lymph Node-Negative, Early-Stage HER2-Positive Breast Cancer

TO THE EDITOR: O’Sullivan et al report a meta-analysis of five randomized trastuzumab trials with 4,221 patients who had early-stage breast cancers that were human epidermal growth factor receptor 2 (HER2) positive and 2 cm or smaller. The efficacy end points were disease-free and overall survivals. They concluded that patients with HER2positive, 2-cm or smaller tumors derive significant disease-free and overall survival benefits from the addition of trastuzumab to the treatment regimen. Although we appreciate this meta-analysis, several points warrant discussion. The prognosis of patients with T1a and T1b tumors that are node negative is uncertain even in cases of HER2 overexpression. Many studies have reported that HER2 overexpression is an independent factor of poor prognosis in patients with pT1abN0 breast tumors. The authors mentioned that the number of such occurrences had been too small to make a decision about efficacy end points and that almost all of the occurrences were obtained from the HERA trial, which used trastuzumab sequentially. In the whole study population, as in the T1a and T1b tumor groups, almost 50% of occurrences came from the HERA trial. Thus, the faith of this population may be declared, because this metaanalysis consisted of randomized trials. The same disputation is valid for the lymph node–negative group. The authors evaluated the clinical outcomes of the group of patients with one or fewer lymph nodes, including those in an N0 group. They stated that the reasons were that few events had occurred in this patient group and that greater than 90% of occurrences were from the HERA trial. We think that, because there were approximately 1,000 cases in this group, mostly from the largest prospectively designed adjuvant trastuzumab trial on which the backbone of the adjuvant treatment of HER2-positive breast cancer has been patterned, the results of this group also may be worth declaring for clinical practice. There are some conflicting data in the literature reported, not from randomized trials but instead from retrospective series. Fehrenbacher et al retrospectively investigated 234 patients with breast cancer that was HER2 positive, lymph node negative, and T1a or T1b; distant invasive recurrence was a primary end point, and locoregional recurrence was a secondary end point. They stated that the 5-year distant relapse–free interval was 98.2% for patients with T1a tumors, whereas it was 89.4% and 84.5% for those with T1b and 1-cm tumors, respectively. Of those patients, 174 (74%) did not receive any adjuvant treatment. This result raises the question of whether the use of adjuvant chemotherapy and trastuzumab is necessary in the T1a group of patients. However in the study by Rodriguez et al, 276 patients with node-negative and T1abHER2-positive breast cancer were evaluated retrospectively. A total of 47% of all patients were given adjuvant chemotherapy and trastuzumab. Of adjuvant chemotherapy protocols, 42.6% were antracycline and taxane based; 28.7% were antracycline based, and 27.9% were taxane-only based. The 40month disease-free survival was 93% for patients who had not received chemotherapy, whereas it was 99% for those who had received adjuvant therapy. In the multivariate analysis, tumor size was not associated with clinical outcomes, and the authors stated that adjuvant treatment should be discussed with all patients who have pT1ab node-negative HER2-positive breast cancer. Another important question is what type of chemotherapy is reasonable for this group of patients. The optimal regimen in patients in a T1abN0 HER2-positive group is still not precise. As was discussed in the meta-analysis, APT is a single-arm prospective study for the efficacy of adjuvant paclitaxel and trastuzumab in patients with HER2-positive, node-negative breast cancer of 3 cm or smaller. Because most of the patients in this meta-analysis received an anthracycline and taxane combination, it may be valuable, in our opinion, to compare these two patient groups (ie, those who receive paclitaxel and trastuzumab versus those who receive an anthracycline and a taxane) to decide whether it is necessary to add an anthracycline or whether it is reasonable to continue with just a taxane and trastuzumab, which could have a lower probability of adverse effects. It was stated that the number of patients who had T1abN0 tumors in the meta-analysis was low; however, the group of patients with 1to 2-cm tumors is a larger patient group, and it is also important to evaluate the chemotherapy regimens in this group. Finally, we agree that the results of APT trial do not apply to patients who have 2to 3-cmHER2-positive node-negative tumors, because the number of patients in this group is quite low. It may be possible to evaluate this subgroup from these adjuvant trials to decide upon a treatment suggestion for this subgroup. Still, the guidelines include both a regimen of anthracycline and taxane combinations with trastuzumab and a regimen of only a taxane with trastuzumab.

Prognostic factors for gemcitabine-refractory patients with advanced pancreatic cancer: a retrospective analysis of a multicentre study (Anatolian Society of Medical Oncology).

Aim of the study Systemic chemotherapy for patients with pancreatic cancer has limited impact on overall survival (OS). Patients eligible for chemotherapy should be selected carefully. The aim of the study was to search for prognostic factors for survival in patients with gemcitabine (Gem)-refractory or with gemcitabine and cisplatin (GemCis)-refractory advanced pancreatic cancer. Material and methods We retrospectively evaluated patients with Gem- or GemCis-refractory advanced pancreatic cancer. Sixteen potential prognostic variables were chosen for analysis in this study. Univariate and multivariate analyses were conducted to identify prognostic factors associated with survival. Univariate and multivariate statistical methods were used to determine prognostic factors. Results Multivariate analysis included the four prognostic significance factors in univariate analysis. Multivariate analysis showed that liver metastasis and second-line chemotherapy were considered independent prognostic factors for survival. Conclusions Liver metastasis and second-line chemotherapy were identified as important prognostic factors in advanced pancreatic cancer patients refractory to treatment with Gem or GemCis. This prognostic factors may also facilitate pretreatment prediction of survival and can be used for selecting patients for treatment.

Recurrence risk and prognostic parameters in stage I rectal cancers

BACKGROUND The standard therapy for stage I rectum cancer is surgical resection. Currently, there is no strong evidence to suggest that any type of adjuvant therapy is beneficial. The risks of local relapse and distant metastasis are higher in rectal tumors. Therefore, while there is no clearly defined absolute indication for adjuvant therapy in lymph node negative colon cancers, rectum tumors that are T3N0 and higher require adjuvant treatment. Due to the more aggressive nature of rectal cancers, we explored the clinical and pathologic factors that could predict the risk of relapse in Stage I (T1-T2) disease and whether there was any progression-free survival benefit to adjuvant therapy. MATERIALS AND METHODS This multicenter study was carried out by the Anatolian Society of Medical Oncology. A total of 178 patients with rectal cancers who underwent curative surgery between January 1994 and August 2012 in 13 centers were included in the study. Patient demographics, including survival data and tumor characteristics were obtained from medical charts. RESULTS The median age was 58 years (range 26-85 years). Most tumors were well or moderately differentiated. For adjuvant treatment, 13 patients (7.3%) received radiotherapy alone, 12 patients (6.7%) received chemotherapy alone and 15 patients (8.4%) were given chemoradiotherapy. Median follow up was 29 months (3-225 months). Some 42 patients (23.6%) had relapse during follow up; 30 with local recurrence (71.4%) whereas 12 (28.6%) were distant metastases. Among the patients, 5-year DFS was 64% and OS was 82%. Mucinous histology and receiving adjuvant therapy were found to have statistically insignificant correlations with relapse and survival. CONCLUSIONS In our retrospective analysis, approximately one quarter of patients exhibited either local or systemic relapse. The rates of relapse were slightly higher in the patients who had no adjuvant therapy. There may thus be a role for adjuvant therapy in high-risk stage I rectal tumors.