Emad Shash

Short Androgen Suppression and Radiation Dose Escalation for Intermediate- and High-Risk Localized Prostate Cancer: Results of EORTC Trial 22991

PURPOSE Up to 30% of patients who undergo radiation for intermediate- or high-risk localized prostate cancer relapse biochemically within 5 years. We assessed if biochemical disease-free survival (DFS) is improved by adding 6 months of androgen suppression (AS; two injections of every-3-months depot of luteinizing hormone-releasing hormone agonist) to primary radiotherapy (RT) for intermediate- or high-risk localized prostate cancer. PATIENTS AND METHODS A total of 819 patients staged: (1) cT1b-c, with prostate-specific antigen (PSA) ≥ 10 ng/mL or Gleason ≥ 7, or (2) cT2a (International Union Against Cancer TNM 1997), with no involvement of pelvic lymph nodes and no clinical evidence of metastatic spread, with PSA ≤ 50 ng/mL, were centrally randomized 1:1 to either RT or RT plus AS started on day 1 of RT. Centers opted for one dose (70, 74, or 78 Gy). Biochemical DFS, the primary end point, was defined from entry until PSA relapse (Phoenix criteria) and clinical relapse by imaging or death of any cause. The trial had 80% power to detect hazard ratio (HR), 0.714 by intent-to-treat analysis stratified by dose of RT at the two-sided α = 5%. RESULTS The median patient age was 70 years. Among patients, 74.8% were intermediate risk and 24.8% were high risk. In the RT arm, 407 of 409 patients received RT; in the RT plus AS arm, 403 patients received RT plus AS and three patients received RT only. At 7.2 years median follow-up, RT plus AS significantly improved biochemical DFS (HR, 0.52; 95% CI, 0.41 to 0.66; P < .001, with 319 events), as well as clinical progression-free survival (205 events, HR, 0.63; 95% CI, 0.48 to 0.84; P = .001). In exploratory analysis, no statistically significant interaction between treatment effect and dose of RT could be evidenced (heterogeneity P = .79 and P = .66, for biochemical DFS and progression-free survival, respectively). Overall survival data are not mature yet. CONCLUSION Six months of concomitant and adjuvant AS improves biochemical and clinical DFS of intermediate- and high-risk cT1b-c to cT2a (with no involvement of pelvic lymph nodes and no clinical evidence of metastatic spread) prostatic carcinoma, treated by radiation.

Cancer education for medical students in developing countries: Where do we stand and how to improve?

BACKGROUND This article is a review of the literature regarding the state of oncology education for medical students in developing countries, and possible solutions to the problems at hand. METHODS Ovid MEDLINE, PubMed, ERIC, The Cochrane CENTRAL Register of Controlled Trials (CENTRAL) and Google Scholar were searched using the terms oncology, undergraduate, cancer, education and teaching. RESULTS The search resulted in 40 relevant articles in total. Ten articles showed that there is a lack of adequate knowledge in the scientific, clinical and psychological aspects of oncology and palliative care amongst students and physicians in developing countries. Eight articles describe the relevance and usefulness of summer schools, workshops and trainings. The rest of them discuss possible methods of addressing the issue, the most important of which is the inclusion of a clinical oncology rotation in the undergraduate syllabus. CONCLUSION Graduated physicians and medical students are a long way from reaching the standard knowledge and skills required in oncology. Thus, there is a pressing need to reform the undergraduate medical curricula in developing countries in order to increase cancer awareness for better graduated future physicians.

Sexuality in patients undergoing haematopoietic stem cell transplantation

McKee and Schover have suggested that sexuality is an aspect of intimacy that is frequently compromised by cancer and its treatments. Cancer, both in terms of diagnosis and treatments, may have a dramatic impact on both intimacy and sexuality. There is a body of published research addressing sexual concerns among patients with prostatic, testicular, breast, and rectal cancers. This issue seems to be less well documented in patients who have undergone haematopoietic stem cell transplantation (HSCT). In this review, we seek to elaborate different points regarding sexuality and how it is affected in patients undergoing HSCT, with the aim of identifying optimum solutions for such patients in confronting such problems in the course of cancer treatment.

The Evolution of Undergraduate Medical Student Research Activities: Personal Experience of a Developing Nation’s Uprise

Revolutions are swift, while evolution is typically a slow, incremental process. One of the most notable things that happened after the Egyptian 2011 revolution was the explosive uprising of youth. Regardless of the political turn of events, which is surely not the subject of this piece, it was becoming increasingly clear that something beyond politics was radically changing the academic landscape, particularly among university students. What started as a “revolutionary” interest in science and research quickly transformed into a continuously changing “evolutionary” process. As a finalyear medical student who spent half of his medical school before the revolution, and half of it after the political turmoil, I was lucky to be one of the earliest Bexperiments^ demonstrating the value of strong mentorship on developing an early aptitude for research. One year before the revolution, an oncology summer rotation was developed at the National Cancer Institute (NCI, Cairo University), designed to test the applicability of incorporating oncology rotations into the core medical curriculum in medical schools in developing countries [1]. I joined the course in its second year; the year of the revolution. The course instructor—who later became my long-term research mentor and is co-authoring this opinion piece—integrated an academic writing component into the rotation, as a way to stay in par with the thenbudding interest in research among the revolution youngsters. The result was a published literature review article that he and I co-authored on the very same topic that the oncology summer school addressed: oncology education for medical students in developing countries [2]. I cannot overstate the importance of early research exposure and continuing mentorship on developing my character and research understanding. Three years after my initial research exposure, I now have seven published papers in international peer-reviewed journals (six of which are in PubMedindexed journals), one local and two international conference abstracts and one co-authored book chapter on cancer epidemiology. I appear as the first author on three of the published papers, and as the second author on the other four. But what is it that caused such a paradigm shift? Was it the early sense of achievement? Was I simply lucky to have gained a head start? Perhaps luck had a role, but according to our latest metaanalysis on medical student research, about one in three research projects undertaken by medical students gets published in international peer-reviewed journals [3]. Clearly, I am no special case; I am simply a case study demonstrating the untapped potential of medical student involvement in research. Project after project, I saw my research competence rise and my research confidence grow. I became more systematic in my approach to the literature, understood the importance of good planning and note-taking, became more accustomed to mining for literature Bgaps^, and gained much proficiency in academic writing. Beside its impact on my scientific productivity, my early research experience taught me a lot about my own passions and career aspirations. I was fascinated by the research process so much that I decided to take a gap year to train in basic molecular and developmental biology. Eventually, I ended up learning basic MATLAB programming (which is a scientific computing language) and discovered a passion for integrating bioinformatics and computational tools in biomedical research and medical practice. * Emad Shash emad.shash@nci.cu.edu.eg

Management of Low and Intermediate Risk Adult Rhabdomyosarcoma: A Pooled Survival Analysis of 553 Patients

This is the second-largest retrospective analysis addressing the controversy of whether adult rhabdomyosarcoma (RMS) should be treated with chemotherapy regimens adopted from pediatric RMS protocols or adult soft-tissue sarcoma protocols. A comprehensive database search identified 553 adults with primary non-metastatic RMS. Increasing age, intermediate-risk disease, no chemotherapy use, anthacycline-based and poor chemotherapy response were significant predictors of poor overall and progression-free survival. In contrast, combined cyclophosphamide-based, cyclophosphamide + anthracycline-based, or cyclophosphamide + ifosfamide + anthracycline-based regimens significantly improved outcomes. Intermediate-risk disease was a significant predictor of poor chemotherapy response. Overall survival of clinical group-III patients was significantly improved if they underwent delayed complete resection. Non-parameningeal clinical group-I patients had the best local control, which was not affected by additional adjuvant radiotherapy. This study highlights the superiority of chemotherapy regimens –adapted from pediatric protocols- compared to anthracycline-based regimens. There is lack of data to support the routine use of adjuvant radiotherapy for non-parameningeal group-I patients. Nonetheless, intensive local therapy should be always considered for those at high risk for local recurrence, including intermediate-risk disease, advanced IRS stage, large tumors or narrow surgical margins. Although practically difficult (due to tumor’s rarity), there is a pressing need for high quality randomized controlled trials to provide further guidance.

Publisher Correction: Management of Low and Intermediate Risk Adult Rhabdomyosarcoma: A Pooled Survival Analysis of 553 Patients

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

New challenge of developing combined radio-drug therapy

Combined modality treatment can be used to improve control of the local disease at the expense of increased toxicity. Several randomized trials have demonstrated that this combined modality therapy is better than radiotherapy alone or chemotherapy alone in the treatment of locally advanced diseases. Several new targets as well as potential new radio-sensitizers have been identified. To speed-up the process of developing new combined modality treatments, good preclinical models for optimization of the ratio between efficacy and toxicity and a well established methodology within a network of advanced high-tech laboratories and clinical departments devoted to early phase trials, are mandatory. The Synergy of Targeted Agents and Radiation Therapy (STAR) platform of the European Organisation for Research and Treatment of Cancer (EORTC) is gathering these tools.