Timothy J. Moynihan

Malignant primary cardiac tumors: review of a single institution experience.

Primary cardiac sarcomas are uncommon. The authors undertook to review the Mayo Clinics experience with primary cardiac sarcomas consisting of 34 patients seen over a 32‐year period.

Efficacy of Complementary and Alternative Medicine Therapies in Relieving Cancer Pain: A Systematic Review

PURPOSE Despite widespread popular use of complementary and alternative medicine (CAM) therapies, a rigorous evidence base about their efficacy for cancer-related pain is lacking. This is a systematic review of randomized controlled trials (RCTs) evaluating CAM therapies for cancer-related pain. METHODS RCTs using CAM interventions for cancer-related pain were abstracted using Medline, EMBASE, CINAHL, AMED, and Cochrane database. RESULTS Eighteen trials were identified (eight poor, three intermediate, and seven high quality based on Jadad score), with a total of 1,499 patients. Median sample size was 53 patients, and median intervention duration was 45 days. All studies were from single institutions, four had sample size justification, and none reported any adverse effects. Seven trials reported significant benefit for the following CAM therapies: acupuncture (n = 1), support groups (n = 2), hypnosis (n = 1), relaxation/imagery (n = 2), and herbal supplement/HESA-A (n = 1, but study was of low quality without control data). Seven studies reported immediate postintervention or short-term benefit of the following CAM interventions: acupuncture (n = 2), music (n = 1), herbal supplement/Ai-Tong-Ping (n = 1), massage (n = 1), and healing touch (n = 2). Four studies reported no benefit of CAM interventions (music, n = 2; massage, n = 2) in reducing cancer pain compared with a control arm. CONCLUSION There is paucity of multi-institutional RCTs evaluating CAM interventions for cancer pain with adequate power, duration, and sham control. Hypnosis, imagery, support groups, acupuncture, and healing touch seem promising, particularly in the short term, but none can be recommended because of a paucity of rigorous trials. Future research should focus on methodologically strong RCTs to determine potential efficacy of these CAM interventions.

Assessing Meaningful Change in Quality of Life Over Time: A Users' Guide for Clinicians

The objective of this article is to help clinicians interpret trial-based quality of life (QOL) changes over time. We address a series of questions and provide guidelines that are fundamental to assessing and interpreting change. The issues addressed are as follows: (1) What are the characteristics of the population for whom changes in QOL are reported? (2) Is the QOL questionnaire reliable, valid, and responsive to change? (3) Are the timing and frequency of assessments adequate? (4) Is the study adequately powered? (5) How are multiple QOL outcomes addressed in analyses? (6) How are multiple time points handled? (7) Can alternative explanations account for the observed change or lack of observed change (eg, handling of missing data, survival differences, and changes in patients QOL perspective over time)? and (8) How is statistical significance translated into meaningful change? These guidelines will support clinicians in reviewing the clinical trial literature, which in turn can help them use the data in the treatment decision process.

Oncologic Emergencies: Diagnosis and Treatment

Patients with malignancies are subject to developing a unique set of complications that require emergent evaluation and treatment. With the increasing incidence of cancer in the general population and improved survival, these emergencies will be more frequently encountered. Physicians must be able to recognize these conditions and institute appropriate therapy after a focused initial evaluation. The approach to definitive therapy is commonly multidisciplinary, involving surgeons, radiation oncologists, medical oncologists, and other medical specialists. Prompt interventions can be lifesaving and may spare patients considerable morbidity and pain. In this review, we discuss the diagnosis of and initial therapy for common emergencies in hematology and oncology.

Oncologic Emergencies: Pathophysiology, Presentation, Diagnosis, and Treatment

Oncologic emergencies can occur at any time during the course of a malignancy, from the presenting symptom to end‐stage disease. Although some of these conditions are related to cancer therapy, they are by no means confined to the period of initial diagnosis and active treatment. In the setting of recurrent malignancy, these events can occur years after the surveillance of a cancer patient has been appropriately transferred from a medical oncologist to a primary care provider. As such, awareness of a patients cancer history and its possible complications forms an important part of any clinicians knowledge base. Prompt identification of and intervention in these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. This article reviews hypercalcemia, hyponatremia, hypoglycemia, tumor lysis syndrome, cardiac tamponade, superior vena cava syndrome, neutropenic fever, spinal cord compression, increased intracranial pressure, seizures, hyperviscosity syndrome, leukostasis, and airway obstruction in patients with malignancies. Chemotherapeutic emergencies are also addressed. CA Cancer J Clin 2011.

Applying Quality-of-Life Data Formally and Systematically Into Clinical Practice

The systematic integration of quality-of-life (QOL) assessment into the clinical setting, although deemed important, infrequently occurs. Barriers include the need for a practical approach perceived as useful and efficient by patients and clinicians and the inability of clinicians to readily identify the value of integrating QOL assessments into the clinical setting. We discuss the use of QOL data in patient care and review approaches used to integrate QOL assessment into the clinical setting. Additionally, we highlight select QOL measures that have been successfully applied in the clinical setting. These measures have been shown to identify key QOL issues, improve patient-clinician communications, and improve and enhance patient care. However, the work done to date requires continued development. Continued research is needed that provides information about benefits and addresses limitations of current approaches.

NeoPalAna: Neoadjuvant Palbociclib, a Cyclin-Dependent Kinase 4/6 Inhibitor, and Anastrozole for Clinical Stage 2 or 3 Estrogen Receptor–Positive Breast Cancer

Purpose: Cyclin-dependent kinase (CDK) 4/6 drives cell proliferation in estrogen receptor–positive (ER+) breast cancer. This single-arm phase II neoadjuvant trial (NeoPalAna) assessed the antiproliferative activity of the CDK4/6 inhibitor palbociclib in primary breast cancer as a prelude to adjuvant studies. Experimental Design: Eligible patients with clinical stage II/III ER+/HER2− breast cancer received anastrozole 1 mg daily for 4 weeks (cycle 0; with goserelin if premenopausal), followed by adding palbociclib (125 mg daily on days 1–21) on cycle 1 day 1 (C1D1) for four 28-day cycles unless C1D15 Ki67 > 10%, in which case patients went off study due to inadequate response. Anastrozole was continued until surgery, which occurred 3 to 5 weeks after palbociclib exposure. Later patients received additional 10 to 12 days of palbociclib (Cycle 5) immediately before surgery. Serial biopsies at baseline, C1D1, C1D15, and surgery were analyzed for Ki67, gene expression, and mutation profiles. The primary endpoint was complete cell cycle arrest (CCCA: central Ki67 ≤ 2.7%). Results: Fifty patients enrolled. The CCCA rate was significantly higher after adding palbociclib to anastrozole (C1D15 87% vs. C1D1 26%, P < 0.001). Palbociclib enhanced cell-cycle control over anastrozole monotherapy regardless of luminal subtype (A vs. B) and PIK3CA status with activity observed across a broad range of clinicopathologic and mutation profiles. Ki67 recovery at surgery following palbociclib washout was suppressed by cycle 5 palbociclib. Resistance was associated with nonluminal subtypes and persistent E2F-target gene expression. Conclusions: Palbociclib is an active antiproliferative agent for early-stage breast cancer resistant to anastrozole; however, prolonged administration may be necessary to maintain its effect. Clin Cancer Res; 23(15); 4055–65. ©2017 AACR.

Palliative Care Consultations in Patients With Cancer: A Mayo Clinic 5-Year Review

PURPOSE We sought to characterize the aggregate features and survival of patients who receive inpatient palliative care consultation, particularly focusing on patients with cancer, to identify opportunities to improve clinical outcomes. METHODS We reviewed prospectively collected data on patients seen by the Palliative Care Inpatient Consult Service at Mayo Clinic (Rochester, MN) from January 2003 to September 2008. Demographics, consultation characteristics, and survival were analyzed using Kaplan-Meier survival curves and Cox survival models. RESULTS Cancer was the most common primary diagnosis (47%) in the 1,794 patients seen over the 5-year period. A significant growth in the annual number of palliative care consultations has been observed (113 in 2003 v 414 in 2007), despite stable total hospital admissions. Frequently encountered reasons for consultation included clarification of care goals (29%), assistance with dismissal planning (19%), and pain control (17%). Although patients with cancer had the highest median survival after consultation in this cohort versus patients with other diagnoses, we observed a 5-year trend of decreasing survival from admission to death and from consultation to death. Median time from admission to death for patients with cancer was 36 days in 2003 and only 19 days in 2008 (P < .01). Median time from consultation to death decreased from 33 days in 2003 to only 11.5 days in 2008 (P < .01). CONCLUSION Patients with cancer often have complex needs that must be met within a short window for intervention. We highlight opportunities for improved multidisciplinary care for patients with advanced cancer and their families, including opportunity for earlier palliative care involvement, even in the outpatient setting.

Phase I Versus Palliative Care: Striking the Right Balance

DOI: 10.1200/JCO.2008.20.7803 Freireich and Kurzrock highlight the extraordinary promise of investigational therapies through two patient case presentations of a rare disease, known as “the disease with hope,” that accounts for just 0.62 patient cases per 100,000 person-years. They chose the patient cases of young, fit, and resourceful men diagnosed with hairy cell leukemia, years before effective therapies were available or known. Both of these individuals drew tremendous personal benefit from participating in early-phase clinical trials. The authors correctly ask the key question, “When is it too soon to abandon the prospects for a favorable outcome from investigational therapy?” They go on to note that many oncologists have dismissed the option of referring patients for investigational therapies because of a low likelihood of personal benefit. Even though they acknowledge that when a patient receives a “hopeless” diagnosis it is important for the physician to discuss palliative care, they emphasize the need to be “knowledgeable about...options for participating in clinical research at major research centers.” Oncologists are rightly trained to refer patients for whom there is no effective standard therapy to seek care at major cancer centers and explore the option of treatment on a clinical trial. All of us have rejoiced in the formidable breakthroughs in oncology and celebrate the discoveries of platinum compounds in the treatment of testicular cancer, or the great advances in the use of targeted therapies that help patients live longer and better quality lives. This is our passion. These anecdotes, however, do not address the harsher reality experienced by the vast majority of patients with advanced metastatic malignancy. It is important to acknowledge that solid epithelial cancers are, at present, different from hematologic malignancies. The more typical clinical scenario involves an individual with a solid tumor who has tried more than one chemotherapeutic regimen and has experienced little benefit and considerable toxicity in the process. The patient may, for many reasons, avoid asking the physician to explain his or her prognosis, even as the oncologist may be reluctant to provide details of expected outcomes. Physicians commonly fail to provide vital prognostic information as a result of multiple factors, including a lack of training in communication skills, and the perceived desire to avoid “removing hope.” Such patients are often more comfortable receiving treatment near home, and perhaps cannot afford a trip to a distant city for consideration of a novel treatment. For such individuals, having access to early palliative care represents an opportunity to maintain the hopes of avoiding undue toxicity and fulfilling whatever tasks are important as they near the end of their lives. Failure to prepare patients for death deprives them and their survivors of meaningful interactions that can never be replaced. Recent research shows quite clearly that talking about imminent death does not lead to despair or depression and allows for appropriate care near the end of life— avoiding futile chemotherapy, intubations, and hospitalizations, and leading to longer enrollment in hospice. Other research also shows clearly that patients who overestimate their prognosis do not live longer, but rather just have more chemotherapy, intubations, and deaths in the hospital. Honest communication between patients and their oncologists as to the underlying prognosis and the potential risks and benefits of standard or experimental therapies is essential to clarify goals and options specific to individual patients and their current circumstances. This serves to strengthen the therapeutic alliance. We need improved assessments that include a patient’s performance status, comorbid illnesses, goals and desires, and ability to understand the investigational nature and uncertain benefit of receiving treatment on an early-phase clinical trial. Oncologists need the skills to convey this information in a supportive and empathetic fashion, but also need to recognize when standard treatments no longer hold any promise of improved outcome, be it cure, longevity, or symptom relief. Addressing opportunities for treatment on early-phase clinical trials should be part of routine conversations between eligible cancer patients and their physicians. Ideally, referrals should be made as early as possible in the course of the disease, and not in the last weeks of life. JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 27 NUMBER 2 JANUARY 1

Palliative communications: addressing chemotherapy in patients with advanced cancer

Patients with advanced cancers often endure chemotherapy late in their disease course leading to unnecessary adverse effects, loss of quality of life, and delay in hospice referral. Compassionate and honest communication about the use of chemotherapy can facilitate better patient care. This manuscript will explore communication issues regarding palliative-intent chemotherapy.