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Saturday, September 24, 2016

what you have been reading (past 24 hrs) top 10: Ovarian Cancer and Us (blog)


Common cancers share familial susceptibility: implications for cancer genetics and counselling

Background It has been proposed that cancer is more common in some families than in others, but the hypothesis lacks population level support. We use a novel approach by studying any cancers in large three-generation families and thus are able to find risks even though penetrance is low.
Methods Individuals in the nation-wide Swedish Family-Cancer Database were organised in three generations and the relative risk (RR) of cancer was calculated to the persons in the third generation by the numbers of patients with cancer in generations 1, 2 and 3.
Results The RRs for any cancer in generation 3 increased by the numbers of affected relatives, reaching 1.61 when at least seven relatives were diagnosed. The median patient had two affected relatives, and 7.0% had five or more affected relatives with an RR of 1.46, which translated to an absolute risk of 21.5% compared with 14.7% in population by age 65 years. For prostate cancer, the RR was 2.85 with four or more affected family members with any cancer, and it increased to 14.42 with four or more concordant cancers in family members. RRs for prostate cancer were approximately equal (2.70 vs 2.85) if a man had one relative with prostate cancer or four or more relatives diagnosed with any cancer.
Conclusions A strong family history of cancer, regardless of tumour type, increases cancer risk of family members and calls for mechanistic explanations. Our data provide tools for counselling of patients with cancer with both low and high familiar risks.

Paradox of Prescribing Late Chemotherapy: Oncologists Explain

Purpose: The value of chemotherapy for patients with cancer in the last weeks of life warrants examination. Late chemotherapy may not improve survival or quality of life but typically precludes hospice enrollment and may result in additional symptoms, increased use of other aggressive treatments, and worsening quality of life. Few studies have explored oncologists’ rationales for administering chemotherapy near death. This study examines the self-reported factors that influence oncologists’ decisions about late chemotherapy.
Methods: In-depth individual interviews were conducted with 17 oncologists through a semistructured interview guide. Interviews were audio recorded and transcribed verbatim. Transcripts were coded and analyzed using conventional content analysis, a qualitative method that allows the detection and analysis of patterns in the data.
Results: Clinical factors take priority in determining late chemotherapy decisions when clear treatment choices exist. When clinical factors are ambiguous, emotion becomes a highly salient influence. Oncologists view late chemotherapy to be patient driven and use it to palliate emotional distress and maintain patient hope even when physical benefit is unexpected. Oncologists experience unique and difficult challenges when caring for dying patients, including emotionally draining communication, overwhelming responsibility for life/death, limitations of oncology to heal, and prognostic uncertainty. These challenges are also eased by offering late chemotherapy.
Conclusion: The findings reveal a nuanced understanding of why oncologists find it difficult to refuse chemotherapy treatment for patients near death. Optimal end-of-life treatment decisions require supportive interventions and system change, both of which must take into account the challenges oncologists face.

Genetic Test Results Spur Ethical Dilemmas


Urologist Use of Cystoscopy for Patients Presenting with Hematuria in the United States



Despite guidelines emphasizing the importance of cystoscopy in hematuria evaluations, just over one-third of patients diagnosed with hematuria by urologists undergo this procedure. There also appears to be considerable misallocation of cystoscopy for hematuria patients, with excessive use among low-risk patients and significant potential for missed cancer cases among those at higher risk of malignancy.

New survey for people with Lynch Syndrome in the UK (2016)

The Family History of Bowel Cancer Clinic

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bowelcancerukBowel Cancer UK is campaigning to improve the identification and management of people with Lynch syndrome.
They’ve put together a 15 minute survey to give people the chance, anonymously, to share their experience of being diagnosed, and managed for Lynch syndrome.

Your experiences will help Bowel Cancer UK to continue to campaign to improve the diagnosis and management of Lynch syndrome.
Please share the survey with your family and friends who also have Lynch syndrome.

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Incidence and mortality rates in breast, corpus uteri, and ovarian cancers in Poland (1980–2013)

open access:

Incidence and mortality rates in breast, corpus uteri, and ovarian cancers in Poland (1980–2013): an analysis of population-based data in relation to socio-economic changes

 Objectives: This study aimed to analyze incidence and mortality trends in breast cancer (BC), corpus uteri cancer (CUC), and ovarian cancer (OC) in Poland in the context of sociodemographic changes.
Materials and methods: Incidence and mortality data (1980–2013) were retrieved from the Polish National Cancer Registry, while socioeconomic data (1960–2013) were obtained from the World Bank. Age-standardized incidence and mortality rates were calculated by direct standardization, and join-point regression was performed to describe trends using the average annual percentage change (AAPC).
Results: A significant decrease in birth and fertility rates and a large increase in gross domestic product were observed together with a decrease in the total mortality rate among women, as well as an increase in life expectancy for women.....
Conclusion: After 1994, a decrease in OC incidence was found, while the incidence of BC and CUC continued to increase. A reduction in mortality rate was observed for BC and OC predominantly at the end of the study period, while for CUC, after a long decreasing mortality trend, a significant increase was observed.

Vesical (bladder) clear cell adenocarcinoma arising from endometriosis: A mullerian tumor, indistinguishable from ovarian clear cell adenocarcinoma

ˈvesəkəl/adjective AnatomyMedicine
adjective: vesical of, relating to, or affecting the urinary bladder.
open access:
Vesical clear cell adenocarcinoma arising from endometriosis: A mullerian tumor, indistinguishable from ovarian clear cell adenocarcinoma

Case Report.
A 44-year-old para 0, with a history of urge urinary incontinence and recurrent urinary tract infections, presented with urinary frequency, incontinence, and hematuria. In 2008, she was diagnosed with urge incontinence and treated with tolterodine with improvement in symptoms. Multiple urinalyses at that time were positive for blood. The patient was lost to follow up until 2015, when she re-presented with recurrent symptoms. A urinalysis revealed many red blood cells and multiple urine cultures were negative.....The immunoprofile itself could not distinguish primary bladder clear cell adenocarcinoma from metastatic clear cell adenocarcinoma from the gynecologic tract.

  • Malignant transformation of extra-ovarian endometriosis is rare
  • Histology and immunohistochemistry support mullerian origin of this malignancy
  • Consideration can be given to extrapolating treatment from gynecologic literature


Endometriosis is associated with increased rates of ovarian, particularly clear cell, adenocarcinomas. Malignant transformation of ovarian endometriosis is most common but rare cases have been reported in the bladder, abdominal wall, diaphragm, and rectum. We present the case of a 44-year-old female with vesical clear cell adenocarcinoma arising in a background of endometriosis in the absence of other pelvic endometriosis. The malignancy was diagnosed on transurethral resection of bladder tumor and managed with radical surgery. Histology and immunohistochemical findings were consistent mullerian origin and indistinguishable from similar tumors arising in the female genital tract. Extrapolating from the gynecologic literature, the recommendation was made for adjuvant chemotherapy. Further studies are needed to clarify the optimal treatment paradigm for ovarian and bladder clear cell adenocarcinomas.

Endometriosis, the presence of endometrial glands and stroma at extra-uterine sites, is common among reproductive age women, prevalence ranging 3–15% (Kim et al., 2014). The etiology of endometriosis is unknown but proposed mechanisms include retrograde menstruation, hematogenous or lymphatic dissemination, and coelomic metaplasia. Endometriosis is most frequently identified on the ovaries, rectovaginal septum, and broad and uterosacral ligaments (Loizzi et al., 2015). Endometriosis may also involve extra-pelvic organs including the small and large intestine, abdominal scars, the urinary system, and the lung/diaphragm. The bladder is the most common site of occurrence within the urinary system, though it is involved in less than 1% of extra-ovarian cases (Dadhania et al., 2015, Mann et al., 2012)....

2016 European Assoc Urology: Upper Urinary Tract Urothelial Cell Carcinoma (note: Lynch syndrome)



2.3.Future goals

The results on ongoing and new systematic reviews will be included in the 2017 update of the UTUC Guidelines. These reviews are performed using standard Cochrane systematic review methodology; http://www.cochranelibrary.com/about/about-cochrane-systematic-reviews.html.


Urothelial carcinomas (UCs) are the fifth most common tumours [4]. They can be located in the lower (bladder and urethra) or upper (pyelocaliceal cavities and ureter) urinary tract. Bladder tumours account for 90-95% of UCs and are the most common malignancy of the urinary tract [5]. In contrast, UTUCs are uncommon and account for only 5-10% of UCs [4,6]. Pyelocaliceal tumours are about twice as common as ureteral tumours. In 17% of cases, concurrent bladder cancer is present [7]. Recurrence in the bladder occurs in 22-47% of UTUC patients [8], compared with 2-6% in the contralateral upper tract [9,10].
Approximately 60% of UTUCs are invasive at diagnosis compared with 15-25% of bladder tumours [11,12]. UTUCs have a peak incidence in people aged 70-90 years and are three times more common in men [13,14].
Familial/hereditary UTUCs are linked to (Lynch syndrome) hereditary non-polyposis colorectal carcinoma (HNPCC) [15], which can be screened for during interview (Figure 3.1) [16]. Patients should undergo DNA sequencing to identify hereditary cancers misclassified as sporadic if they fulfil the criteria for HNPCC [15,17].


5.2.1.Imaging tomography urography

Computed tomography urography (CTU) has the highest diagnostic accuracy for the diagnosis of UTUC [41]. The sensitivity of CTU for UTUC is 0.67-1.0 and the specificity is 0.93-0.99 [42-49].....

Friday, September 23, 2016

A Different Kind of Opioid Crisis in Cancer Patients - limits = "unintentional consequences"

  The (UK) study was published online September 15 in Pain.
The undertreatment of cancer pain is also a problem in the United States, said Judith A. Paice, PhD, RN, research professor in medicine-hematology/oncology at Northwestern University in Chicago, Illinois. Dr Paice is an expert who was not involved in the current study.
"The problem in the United States may be worsening through the unintentional consequences associated with measures to limit the opioid abuse epidemic," Dr Paice told Medscape Medical News.

Local Birmingham Women Cancer Survivors Cast In Stage Show Production Heading To TV

press release

NCCN Imaging Appropriate Use Criteria (includes ovarian cancer)

NCCN Imaging Appropriate Use Criteria 

 Search the NCCN Imaging AUC™ - FREE ACCESS

About NCCN Imaging AUC™
NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) include information designed to support clinical decision-making around the use of imaging in patients with cancer and are based directly on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). NCCN Imaging AUC™ are available free of charge to registered users of NCCN.org
NCCN Imaging AUC™ include recommendations pertaining to cancer screening, diagnosis, staging, treatment response assessment, follow-up, and surveillance. Additional information includes the indication, imaging modality, and frequency of use, as well as clinical notes related to the specific recommendation. NCCN Imaging AUC™ also document information on disease stage and histology. All imaging procedures recommended in the NCCN Guidelines®, including radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), functional nuclear medicine imaging (PET, SPECT) and ultrasound, are included within NCCN Imaging AUC™.
NCCN Imaging AUC™ are accessible through an easy to use web-based user interface. The NCCN Imaging AUC™ include a full complement of imaging AUC in oncology care. NCCN, a CMS-approved Provider Led Entity (PLE), is committed to assuring that the most up-to-date recommendations are available and reviews and updates NCCN Imaging AUC™ on a continual basis to ensure that the recommendations take into account the most current evidence.

ESMO: Prevention and screening in BRCA mutation carriers and other breast/ovarian hereditary cancer syndromes

ESMO Clinical Practice Guidelines for cancer prevention and screening

eUpdate Sept 21st, 2016: Ovarian Cancer Treatment Recommendations | ESMO


Published: 21 September 2016. Authors: J.A. Ledermann1, C. Sessa2 & N. Colombo3 on behalf of the ESMO Guidelines Committee
1UCL Cancer Institute, University College London, London; 2Oncology Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland; 3European Institute of Oncology, University of Milan Bicocca, Milan, Italy.

Clinical Practice Guidelines

This update refers to the  Newly diagnosed and relapsed epithelial ovarian carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up, Ledermann JA, Raja FA, Fotopoulou C et al, Ann Oncol 2013; 24 (Suppl 6): vi24-vi32; and Non-epithelial ovarian carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up, Colombo N, Peiretti M, Garbi A et al, Ann Oncol 2012; 23 (Suppl 7): vii20-vii26.


Personalised medicine

Text update

Maintenance therapy with the oral PARP inhibitor, olaparib has been approved by the European Medicines Agengy in women with high grade serous ovarian cancer and a BRCA mutation who have responded to platinum-based chemotherapy. In the randomised placebo-controlled maintenance trial, study 19, the median progression-free survival was extended from 4.3 to 11.6 months, post randomisation hazard ratio [HR] 0.18; p<0.0001) [1]. An updated survival analysis in patients with either a germline or somatic BRCA mutation showed an improvement in median survival from 30.2 to 34.9 months (HR 0·62 [95% CI 0·41–0·94]). Because of the effect of previous analyses, this difference was not statistically significant. Among the patients with a BRCA mutation, 15% remained on olaparib for at least five years without evidence of any tumour progression [2]. A BRCA mutation is the first genetically defined predictive marker for treatment of ovarian cancer.


  • Patients with recurrent high-grade serous ovarian cancer and a germline or tumour BRCA mutation should be offered maintenance olaparib after a response to platinum-based chemotherapy.

Text update

Testing for a BRCA mutation

BRCA mutations are found in 5%-15% of ovarian cancer population studies [3]. Cohort studies have shown that the absence of a family history of breast/ovarian cancer is a poor negative predictor for a BRCA mutation [4, 5]. It is now recommended that patients with high-grade tumours are tested for germline BRCA mutation. Somatic mutations of BRCA are found in 5%-7% of ovarian cancer cases [6].


  • Patients with high-grade tumours should be tested for a germline BRCA mutation. Consideration should be given to testing tumours for a somatic BRCA mutation.

Thursday, September 22, 2016

Conflicting Interpretation of Cancer Genetic Test Results Common


 The study was published online September 12 in the Journal of Clinical Oncology.

register now - 9 pm Sept 2016 Oncology Opinions Live Broadcast: Platinum-Sensitive Recurrent Ovarian Cancer (Lederman)


Say what? Medical jargon leaves cancer patients feeling lost in translation


 Lost in translation illustration

AstraZeneca provides update on cediranib EU marketing authorisation application

AstraZeneca press release

The decision to withdraw the MAA (Marketing Authorisation Application) was based on outstanding health authority questions that remain at this late stage of the review process. The MAA for cediranib was supported by data from ICON6, a Phase III trial led by the Medical Research Council (MRC) Clinical Trials Unit at UCL. AstraZeneca has not made additional regulatory submissions for cediranib in this indication in any other markets. AstraZeneca is committed to enhancing treatment options for patients with ovarian cancer, including developing chemotherapy-free alternatives to help delay or avoid the use of platinum-based chemotherapies.

Malnutrition Shown Adding Billions to U.S. Health Costs (including cancers)

Science and Enterprise

 Goates and colleagues drew their data from two large-scale national health care surveys, National Health and Nutrition Examination Survey, or Nhanes, and National Health Interview Survey over 6 years. The researchers looked specifically at variables related to nutrition among people with 8 chronic diseases: stroke, chronic obstructive pulmonary disease or COPD, coronary heart failure, breast cancer, dementia, musculoskeletal disorders, depression, and colorectal cancer.
The researchers indicate many patients with these conditions arrive at the hospital with malnutrition, even if obese, or become malnourished at the hospital, which can increase the risk of complications or delay recovery.

Cancer Care Ontario: Ovarian Cancer Facts Ovarian Cancer Survival Has Increased In Ontario Amongst Most Age Groups

Cancer Care Ontario

Sociodemographic, psychosocial and clinical factors associated with uptake of genetic counseling for hereditary cancer: a systematic review

Sociodemographic, psychosocial and clinical factors associated with uptake of genetic counseling for hereditary cancer: a systematic review 

 Evidence suggests that a significant proportion of individuals referred to cancer genetic counselling (GC) do not attend, and thus may not be engaged in adequate cancer risk management. We aimed to review the literature to better understand barriers to accessing GC and how they may be overcome. We conducted a systematic literature search for articles examining factors influencing cancer GC uptake as well as motivators and barriers to GC attendance. Factors were categorised as sociodemographic, psychosocial or clinical. The literature search identified 1,413 citations, 35 of which met the inclusion criteria. GC uptake ranged from 19% to 88%. With the exceptions of education level, socioeconomic status, cancer-specific distress, personal cancer diagnosis and actual and perceived risk of cancer, support was lacking for most sociodemographic, clinical and psychosocial factors as predictors of GC uptake. Cost and logistical barriers, emotional concerns, family concerns and low perceived personal relevance were reported as important considerations for those declining GC. We conclude that there is poor understanding of GC and a lack of decision support among those referred to GC. Research into ways of providing education and support to referred individuals will be important as the scope and availability of genetic counselling and testing broaden.

When “Actionable” Genomic Sequencing Results Cannot be Acted Upon

JAMA Oncology | JAMA Network

Safety in Numbers: Cancer Surgeries in California Hospitals (ovarian cancer not included)


Some hospitals perform one or two brain cancer surgeries; others do hundreds. Small volumes can mean greater risk of poor patient outcomes. See the numbers for 11 cancers at hospitals across California.

Highlights include:
  • There is an association between low hospital surgery volume and higher mortality and complication rates for the following 11 cancers: bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach.
  • The majority of California's hospitals performed surgery for one or more of these 11 cancers only once or twice in 2014.
  • Of cancer patients who had surgery at a hospital that did a small number of those surgeries in 2014, more than 70% were within 50 miles of a hospital performing higher volumes.*
  • The 249 hospitals that performed only one or two of a particular procedure in 2014 are mostly urban but also rural, and they are in equal numbers small (50%) and large (50%).


OCRFA: Ask Congress to Support Oral Chemotherapy Parity Today!

Join us in asking Congress to pass oral chemotherapy parity legislation today. This legislation will ensure that patients have access to the best chemotherapy drugs available, including many personalized therapies. Send an Action Alert to your Members of Congress Today!

Why do we need this action now?
The last decade has seen an explosion in the number of new chemotherapy drugs, which include many personalized therapies. Unfortunately, insurance coverage of drugs has not kept pace with this innovation.

Traditionally, IV and injected drugs were the primary methods of chemotherapy delivery. These drugs are covered under a health insurance plan's medical benefit, where patients are typically only required to pay a small office visit co-pay.....


(Priscilla Chan/Mark Zuckerberg) Facebook couple commits $3 billion to cure disease : Nature News

Nature News

Canadian Health Coalition: On-line Story Booth (submit your story/experience)

On-line Story Booth
 Stories are a powerful tool to ensure that we do not take our public health care system for granted. That’s why we want you to hear about your experience with the public health care system.
Have you benefited from our universal public health system? Do you have a story about the need for even greater coverage, or a problem with a private care provider?
Take part in our nation-wide on-line story booth to help remind people of the importance of health care, the need to expand it, and why public delivery matters.
Your story may even be featured on our website or turned into a video (we will contact you before this happens).

Public Consultation: deadline Nov 25th - College of Physicians and Health (Emergencies)


(direct link) We want to hear your thoughts on the current policy

 link to online survey (survey monkey)

Feedback Deadline

Physicians and Health Emergencies Nov 25, 2016

The College is currently reviewing the Physicians and Health Emergencies policy, in accordance with our regular policy review cycle. The current policy was developed after the 2003 SARS epidemic and during the 2009 H1N1 pandemic to reaffirm the profession’s commitment to the public and colleagues in times of health emergencies.
We are reviewing the policy to determine how the policy can be improved in order to ensure it reflects current practice issues, embodies the values and duties of medical professionalism, and is consistent with the College’s mandate to protect the public. As part of the review, we are inviting feedback from the profession, the public and other stakeholders on the current policy. Visit the dedicated consultation page to view further information and provide your feedback.