A 70-year-old woman with metastatic small-cell lung cancer was referred for isolated left optic disc edema that was incidentally discovered. She had normal visual function, and dilated fundus ...examination revealed a small, cupless optic nerve in the right eye and moderate optic disc edema in the left eye. Magnetic resonance imaging (MRI) of the orbits with contrast was normal, and MRI brain and magnetic resonance venography were normal without signs of raised intracranial pressure. Lumbar puncture showed a normal opening pressure and normal cerebrospinal fluid contents. A diagnosis of incipient non-arteritic anterior ischemic optic neuropathy (NAION) was made, and the optic disc edema resolved after 4 months. Incipient NAION is an uncommon cause of unilateral optic disc edema with preserved visual function and is a diagnosis of exclusion. In diagnosing incipient NAION, other causes of optic disc edema must first be ruled out. These alternative causes include papilledema, optic nerve sheath meningioma or other orbital masses, and vitreopapillary traction. Incipient NAION is thought to be caused by subclinical ischemia. This case indicates that incipient NAION may also occur in patients with metastatic cancer and is possibly related to their hypercoagulable state. Although there is no treatment once vision loss develops, the optimization of risk factors may prevent the progression of incipient NAION to classic NAION.
This review focuses on the sexual and relationship consequences of treatment for prostate cancer along the disease trajectory from diagnosis to treatment for advanced and metastatic cancer. In ...addition to describing what we know about the sexual effects of treatment on the heterosexual couple, issues specific to gay men will be included. Finally, the review will end with a discussion of strategies that may be used to assist these men and their partners negotiate a new way of being sexual in the aftermath of treatment.
Connections exist between inflammation and cancer, for example with regard to disease progression and prognosis. Therefore, we investigated whether systemic inflammatory processes indicated by ...increased serum C-reactive protein (CRP) provide prognostic information for physicians prescribing palliative radiotherapy.
We analyzed data from 781 patients and evaluated prognostic factors for survival.
Only 277 patients (35%) had CRP <8 mg/l before radiotherapy. No significant association was observed between CRP level and steroid treatment. In patients with the highest CRP level (>60 mg/l, 20% of patients), intravenous therapy with antibiotics was more common. CRP significantly influenced survival and contributed prognostic information together with established parameters, such as performance status (PS). In the multivariate model, white blood cell count did not provide relevant additional information. A simple four-tiered prognostic score solely based on CRP showed promising results.
Most patients treated with palliative radiotherapy had increased CRP. This widely available biomarker might improve decision-making and should be further validated.
Patients with advanced cancer experience significant symptoms, ineffective treatments, and hospice underutilization. Home-based palliative care (HBPC) may fill a service gap for patients who require ...intensive home management, but are not enrolled in hospice. Even as data emerge on the utilization impacts of HBPC, other impacts are not as well known.
We describe findings of a pilot project in HBPC, Community Bridges (CB), for patients with advanced cancer. We assessed baseline symptom severity, caregiver burden, patient and caregiver program satisfaction, and CB team experience.
Seventeen patients were seen. Baseline patient symptom burden and caregiver burden were high. Half of patients died within six months of enrollment. Patients and caregivers reported high program satisfaction and that CBs filled a gap in care. CB providers often served in the role as crisis managers and as trusted reporters for treating oncologists.
CBs filled an unmet need for patients with advanced, metastatic cancer who desired ongoing cancer treatment, but were also in need of intensive end-of-life home services.
No abstract available. Article truncated at 150 words. History of Present IllnessA 39 year old woman is seen with a history of cough intermittently productive of small amounts of blood or ...blood-tinged sputum for 4 months. She reports no other respiratory symptoms and has otherwise felt well. PMH, FH and SHThere was no significant PMH and no prior history of lung disease. Her father has a history of Parkinson’s disease and osteosarcoma. She is a nonsmoker, does not drink alcohol, and has never abused drugs. She has 2 children and is engaged to be remarried. Physical ExaminationHer physical examination is normal. Chest X-rayHer chest x-ray is below (Figure 1). Figure 1. Panel A: Frontal chest radiography. Panel B: Lateral chest radiography.Laboratory EvaluationHemoglobin was 13.2 g/dL and WBC was 8400 cells/μL with a normal differential. Urinanalysis was unremarkable. Which of the following statements regarding hemoptysis is or are true?1.A normal chest …
OBJECT Pathological compression fractures in cancer patients cause significant pain and disability. Spinal metastases affect quality of life near the end of life and may require multiple procedures, ...including medical palliative care and open surgical decompression and fixation. An increasingly popular minimally invasive technique to treat metastatic instabilities is kyphoplasty. Even though it may alleviate pain due to pathological fractures, it may fail. However, delayed kyphoplasty failures with retropulsed cement and neural element compression have not been well reported. Such failures necessitate open surgical decompression and stabilization, and cement inserted during the kyphoplasty complicates salvage surgeries in patients with a disease-burdened spine. The authors sought to examine the incidence of delayed failure of structural kyphoplasty in a series of cement augmentations for pathological compression fractures. The goal was to identify risk predictors by analyzing patient and disease characteristics to reduce kyphoplasty failure and to prevent excessive surgical procedures at the end of life. METHODS The authors retrospectively reviewed the records of all patients with metastatic cancer from 2010 to 2013 who had undergone a procedure involving cement augmentation for a pathological compression fracture at their institution. The authors examined the characteristics of the patients, diseases, and radiographic fractures. RESULTS In total, 37 patients underwent cement augmentation in 75 spinal levels during 45 surgeries. Four patients had delayed structural kyphoplasty failure necessitating surgical decompression and fusion. The mean time to kyphoplasty failure was 2.88 ± 1.24 months. The mean loss of vertebral body height was 16% in the patients in whom kyphoplasty failed and 32% in patients in whom kyphoplasty did not fail. No posterior intraoperative cement extravasation was observed in the patients in whom kyphoplasty had failed. The mean spinal instability neoplastic score was 10.8 in the patients in whom kyphoplasty failed and 10.1 in those in whom kyphoplasty did not fail. Approximately 50% of the kyphoplasty failures occurred at junctional spinal levels. All the patients in whom kyphoplasty failed had fractures in 3 or more cortical walls before treatment, whereas 46% of patients in the nonfailure group had fractures with breaching of 3 or more walls. CONCLUSIONS Although rare, delayed failures of structural augmentation with cement during kyphoplasty do occur and can lead to additional surgeries. A possible predictive index may include wall integrity of the vertebral body, competency of the posterior tension band, and location of the kyphoplasty at a junctional spinal level. Additional studies are required to confirm these findings.
Purpose
The purpose of the study was to identify factors that predict unplanned admission for metastatic cancer patients visiting the emergency department (ED).
Methods
Patients visiting the ED of a ...general hospital from April 2012 to March 2013 were investigated retrospectively. Data including demographics, vital signs, and laboratory measurements were collected from a chart review for each patient. Factors related to emergency admission were identified by univariate and multivariate analyses.
Results
A total of 15,716 individuals visiting the ED during the study period included 1244 (7.9%) patients with cancer. Among the 491 cancer patients with metastasis, univariate analysis revealed that emergency admission was significantly associated with an age of ≥76 years; an altered mental status; fever (≥38 °C); a blood oxygen saturation of <90%; a white blood cell (WBC) count of ≤2000 or ≥10,000/μL; hypoalbuminemia (≤2.5 g/dL); and elevated levels of aspartate aminotransferase (≥100 IU/L), blood urea nitrogen (≥25 mg/dL), and C-reactive protein (CRP, ≥10 mg/dL). Multivariate analysis identified age, an altered mental status, hypoxemia, an abnormal WBC count, and elevated CRP as putative independent predictive factors for emergency admission. The number of these five factors present was also correlated with 30-day mortality (c-statistic = 0.72).
Conclusions
Age, unconsciousness, hypoxemia, an abnormal WBC count, and elevated CRP were found to be associated with emergency admission and 30-day mortality for metastatic cancer patients. Prospective validation of a predictive scoring system based on these findings is warranted.
Emerging evidence suggests that many metastatic cancers arise from cells of the myeloid/macrophage lineage regardless of the primary tissue of origin. A myeloid origin of metastatic cancer stands ...apart from origins involving clonal evolution or epithelial–mesenchymal transitions. Evidence is reviewed demonstrating that numerous human cancers express multiple properties of macrophages including phagocytosis, fusogenicity, and gene/protein expression. It is unlikely that the macrophage properties expressed in metastatic cancers arise from sporadic random mutations in epithelial cells, but rather from damage to an already existing mesenchymal cell, e.g., a myeloid/macrophage-type cell. Such cells would naturally embody the capacity to express the multiple behaviors of metastatic cells. The view of metastasis as a myeloid/macrophage disease will impact future cancer research and anti-metastatic therapies.
OBJECTIVES: To assess the different methodologies utilised to present Health Related Quality of Life (HRQoL) of patients with metastatic cancer, and to compare the impact of such methodologies for an ...immunotherapy in the treatment of second line non-small-cell lung cancer (NSCLC). METHODS: The 10 most recent published technology appraisals in oncology were taken from the National Institute of Health and Care Excellence (NICE) website, and reviewed to determine the approach taken to elicit and present HRQoL data. From this, 4 methodologies were tested on atezolizumab, an anti-programmed death-ligand 1 (PD-L1) antibody for the treatment of NSCLC after prior chemotherapy using data collected from the OAK trial: PFS/PD, time-to-death, on treatment/off treatment, and a combination of on treatment/off treatment and time-to-death. RESULTS: The 10 published NICE technology appraisals spanned a multitude of different indications in oncology, including lung cancer, breast cancer, pancreatic cancer, colorectal cancer, renal cell carcinoma, multiple myeloma and chronic lymphocytic leukaemia. Several appraisals utilised a traditional Progression-Free Survival (PFS)/Stable Disease and Progressed Disease (PD) approach to implement health state utility values (HSUV's). However, others incorporated a time-to-death, "time lived with disease", or an on treatment/off treatment approach. The different methodologies generated different cumulative quality of life gain for atezolizumab versus docetaxel, up to a difference of 0.04 QALYs, or 2 weeks of perfect health: a significant period of time for a patient with a median overall survival of 13.8 months. CONCLUSIONS: The methodologies used to determine total quality of life gain in the appraisal of treatments can impact outcomes considerably. Therefore it's important to ensure methodologies are clinically accepted, validated, and representative of the disease area and treatment under consideration.
OBJECTIVES: This observational study aimed to provide real-world data on denosumab and bisphosphonate use in patients with ST and BM in Germany. METHODS: This is a retrospective analysis of a German ...sick-fund claims database (including ~4 million patients). The study population consisted of ST patients aged >18 years, newly diagnosed with BM with no prior hypercalcemia, initiating denosumab orbisphosphonates. Persistence was defined as continuous prescriptions with <90-days gaps. Compliance was defined as >12 prescriptions in a 12-month period. Switch was defined as change in drug within 90 days. Dying patients were censored on the day of death. RESULTS: 1156 eligible patients with breast BrCa, prostate PrCa and lung cancer LuCa were analyzed (mean age 65 years for BrCa, 74 for PrCa, 65 for LuCa). Of patients with BrCa, PrCa, and LuCa, respectively, 25%, 17% and 20% had prior skeletal related event (SRE) and 8%, 23% and 16% had renal disease. For BrCa, persistence at 1 year % (95% CI) was 78% (70-85) for denosumab and 58% (45-75), 56% (43-72) and 54% (47-61) for ibandronate, pamidronate and zoledronate, respectively. For PrCa, persistence with denosumab and zoledronate were 58% (48-71) and 50% (42-59), respectively. Finally for LuCa persistence for denosumab, pamidronate and zoledronate were 68% (47-99), 34% (15-80) and 60% (50-73), respectively. 1-year compliance % (95% CI) for BrCa was 75% (64-84), 42% (25-61), 48% (31-66) and 48% (40-57) for denosumab, ibandronate, pamidronate and zoledronate, respectively. For PrCa, it was 47% (32-62) and 36% (26-47) for denosumab and zoledronate, and for LuCa was 51% (35-67) for zoledronate. Switch rates in BrCa were 5%, 14%, 14% and 19% for denosumab, ibandronate, pamidronate and zoledronate, respectively, with a similar pattern in PrCa and LuCa. CONCLUSIONS: Denosumab had higher persistence and compliance with lower switch rates.
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