Sunday, February 26, 2006
Saturday, February 25, 2006
Prophylactic Surgery to Reduce the Risk of Gynecologic Cancers in the Lynch Syndrome - January 19, 2006 NEJM
Prophylactic Surgery to Reduce the Risk of Gynecologic Cancers in the Lynch Syndrome
Kathleen M. Schmeler, M.D., Henry T. Lynch, M.D., Lee-may Chen, M.D., Mark F. Munsell, M.S., Pamela T. Soliman, M.D., Mary Beth Clark, M.S.W., Molly S. Daniels, M.S., Kristin G. White, B.S., Stephanie G. Boyd-Rogers, R.N., Peggy G. Conrad, M.S., Kathleen Y. Yang, M.D., Mary M. Rubin, Ph.D., Charlotte C. Sun, Dr.P.H., Brian M. Slomovitz, M.D., David M. Gershenson, M.D., and Karen H. Lu, M.D.
ABSTRACT
Background Women with the Lynch syndrome (hereditary nonpolyposis colorectal cancer) have a 40 to 60 percent lifetime risk of endometrial cancer and a 10 to 12 percent lifetime risk of ovarian cancer. The benefit of prophylactic gynecologic surgery for women with this syndrome has been uncertain. We designed this study to determine the reduction in the risk of gynecologic cancers associated with prophylactic hysterectomy and bilateral salpingo-oophorectomy in women with the Lynch syndrome......
Monday, February 20, 2006
2005 Survey of HNPCC Management Analysis of Responses from 18 International Cancer Centres
Survey of HNPCC Management Analysis of Responses from 18 International Cancer Centres
Hereditary Cancer in Clinical Practice 4/2005
Survey of HNPCC Management Analysis of Responses from 18 International Cancer Centres
Hereditary Cancer in Clinical Practice 2005; 3(4) pp. 137-146
authors: Elizabeth Chow, Finlay Macrae, John Burn,
Introduction
HNPCC is an autosomal dominant condition with high penetrance for colorectal and certain other cancers. A mutation in one of the several mismatch repair genes is responsible. Mutational analysis is widely available to guide risk assessment and screening strategies in families with HNPCC. However, there are many management decisions that need to be made where the level of evidence supporting those decisions is low. In September 2003, participants at the International Collaborative Group for Hereditary Non-Polyposis Colorectal Cancer were invited to complete a questionnaire relating to their clinic practices, so as to inform the cancer genetics community about variations and levels of consensus.
Methods
Eighteen centres (three from Australia, nine from the UK, two from the USA, two from Denmark, one from Canada, one from Israel) responded to the questionnaire. The questionnaire covered clinical definitions of HNPCC and high and moderate risk, thresholds for referral to clinics, positioning and funding of pre-genetic testing in clinical management, indications and funding for mutational analysis, consent protocols, counselling relating to variants of uncertain significance, disclosure of genetic testing information across families, surveillance planning for colorectal, gynaecological and other malignancies, and surgical decision making. Responses were generally in the multiple choice format, and where appropriate one or more “correct” answers were allowed. Free text provision (“other”) was liberally provided throughout. The questionnaire was not anonymous. However, as there was no universal agreement from the contributors to identify their own familial clinic's response, the results are presented anonymously.
Results
Results are displayed with reference to the question and the multiple choice response alternatives.
A. Definition
1. In your familial bowel cancer practice, for the purposes of initiating direct mutational analysis (without necessarily requiring evidence of MSI/IHC MMR protein loss), which definition of HNPCC do you accept? (tick any)
a) Amsterdam I
b) Amsterdam II
c) Amsterdam II plus ovarian cancer
d) Amsterdam II plus stomach cancer
e) Amsterdam II plus biliary tract cancer
f) Amsterdam II plus brain cancer
g) Amsterdam II plus breast cancer in hMLH1
h) Amsterdam II plus clear cell cancer of kidney
i) Other---please specify any variation
Saturday, February 18, 2006
2006 Review: Cochrane Collaboration - Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer
Review]
Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer
K Jaaback and N Johnson
The Cochrane Database of Systematic Reviews 2006 Issue 1 (Status: New)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD005340.pub2 This version first published online: 25 January 2006 in Issue 1, 2006
Date of Most Recent Substantive Amendment: 15 November 2005
This record should be cited as: Jaaback K, Johnson N. Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer. The Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005340. DOI: 10.1002/14651858.CD005340.pub2.
Abstract
Background
Ovarian cancer tends to be chemosensitive and confine itself to the surface of the peritoneal cavity for much of its natural history. These features have made it an obvious target for intraperitoneal chemotherapy. Chemotherapy for ovarian cancer is usually given as an intravenous infusion repeatedly over 5 to 8 cycles. Intraperitoneal chemotherapy (IP) is given by infusion of the chemotherapeutic agent directly into the peritoneal cavity. This may increase the anticancer effect with fewer systemic adverse effects in comparison to intravenous therapy.
Objectives
To determine if adding a component of the chemotherapy regime into the peritoneal cavity affects overall survival, progression free survival, quality of life (QOL) and toxicity for women receiving primary treatment of epithelial ovarian cancer.
Search strategy
The reviewers searched the UK Cochrane trials register, Gynaecological Cancer Group Specialised Register, computer databases and handsearched and cascade searched the major gynaecological oncology journals.
Selection criteria
The analysis was restricted to randomised controlled trials assessing women with a new diagnosis of primary epithelial ovarian cancer, of any FIGO stage, following primary cytoreductive surgery. Standard intravenous chemotherapy was compared with chemotherapy that included a component of intraperitoneal administration.
Data collection and analysis
Two reviewers conducted data extraction independently. The reviewers retrieved data on overall and disease free survival as well as adverse events and QOL and then performed a meta-analysis of outcomes, using hazard ratios for time-to-event variables and relative risks for dichotomous outcomes.
Main results
Eight randomised trials studied 1819 women receiving primary treatment for ovarian cancer. Women were less likely to die if they received an intraperitoneal (IP) component to the chemotherapy (hazard ratio (HR) =0.79; 95% confidence interval (CI): 0.70 to 0.90)and the disease free interval (HR =0.79; 95%CI: 0.69 to 0.90) was also significantly prolonged. There may be greater serious toxicity with regard to gastrointestinal effects, pain and fever but less ototoxicity with the intraperitoneal than the intravenous route.
Authors' conclusions
This analysis establishes the benefit of IP chemotherapy. It increases overall survival and progression free survival from advanced ovarian cancer. The results of this meta-analysis provide the most reliable estimates of the relative survival benefits of IP over IV therapy and should be used as part of this decision making process. However, the potential for catheter related complications and toxicity needs to be considered when deciding on the most appropriate treatment for each individual woman. The optimal dose, timing and mechanism of administration cannot be addressed from this meta-analysis. This needs to be addressed in the next phase of clinical trials.
Plain language summary
Intraperitoneal (IP) chemotherapy for advanced ovarian cancer improves both overall and disease free survival.
Ovarian cancer commonly spreads through the peritoneal cavity and usually responds to intravenous chemotherapy. This review compared the effectiveness of this intravenous chemotherapy to chemotherapy administered directly into the peritoneal cavity. The evidence suggests an improvement in survival if some of the chemotherapy is administered via the intraperitoneal route. The disadvantage is an increase in adverse effects principally relating to the presence of a peritoneal catheter, including pain, catheter blockage, gastrointestinal effects and infection.
Sunday, January 22, 2006
Published Jan 2006: Journal of Gynecologic Oncology - "Not Qualified - A Patient's Perspective" author: Sandi Pniauskas
DOI information: 10.1016/j.ygyno.2005.11.045
http://dx.doi.org/10.1016/j.ygyno.2005.11.045
http://www.sciencedirect.com/science?_ob=ArticleURL&_rdoc=1&_fmt=full&_udi=B6WG6-4J2M1JK-3&_coverDate=01%2F18%2F2006&_cdi=6814&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=1169252&md5=1ceff77e8809e6d057af5644208ab8e4
Letter to the Editor
Published: The Journal of Gynecologic Oncology January 18th, 2006
Not qualified—a patient's perspective
Sandi PniauskasCorresponding Author Contact Information, E-mail sandipn@sympatico.ca
117 Glen Hill Drive, Whitby, Ontario, Canada L1N 6Z8
Received 31 August 2005. Available online 18 January 2006.
Article Outline
References
Wednesday, August 31, 2005
Let me take this proactive approach in once again advocating on behalf of women with ovarian cancer, their families and caretakers. Furthermore, please allow me to emphasize that, as a consumer, I appreciate and understand the wider ‘picture’. however, I do not accept the status quo. As a short recap, I offer my observations as an ‘informed’ (as opposed to expert) ovarian cancer survivor of 6 years. Prior to the publication of Who should operate on patients with ovarian cancer? An evidence-based review [1], I was in discussion with a number of agencies bringing attention to the lack of current information within certain Canadian databases. I was advised that only MDs could request a review, which prompted my correspondence, as follows:
Ovarian cancer has the highest mortality rate of not only all gynecologic cancers, but all female-specific cancers. There is no screening test, and prophylactic surgery is the recommendation for those at high risk (breast/salpingo-oophorectomy). Ignorance of the facts regarding ovarian cancer, including relative risk factors, is due to our lack of comprehensive up-to-date data collection and transparency in its education/publication.
In the past two decades, there has been no improvement in overall survival rates in ovarian cancer. Improvement has been noted only in the area of median survival rates and to some degree a lessening of treatment related side effects. Emphasis on QOL is a new phenomenon in research, but, in my opinion, results are understated. So, having said this, the paper as below was published August 26, 2005 with a specific focus on the surgical management of ovarian cancer. Surgical management is one of the key factors, albeit not the only one, in improved survival rates in patients with advanced stage ovarian cancer as well as reduced recurrence rates in early stages.
In May 2005 and relevant to the discussion at hand is the published paper Development of ovarian cancer surgery quality indications using a modified Delphi approach [2] authored in part by the Surgical Oncology Program, Cancer Care Ontario. The follow-up management is a key and important factor that has not been addressed. This refers to follow-up management of pre/peri/post-menopausal women with ovarian cancer. To date, there are no guidelines. The question is, who should operate on ovarian cancer patients? The study presents no absolute recommendations, and, therefore, we wait. However, as published May 17, 2005, SEER database was used to analyze follow-up times specific to a number of cancers and should also be an obvious important criteria based, in part, on the study published below.
The threshold year of statistical cure for ovarian cancer was 10.4 years. [3].
So, a number of observations if you will, indicating some interesting and poignant comments:
“Our review followed the methodology established by the 2001 U.S. Preventative Services Task Force (USPSTF) and Canadian Task Force (CTF) guidelines [14,15]. (reference 15 refers to Canadian Task Force on Periodic Health Exam; Ottawa, Canada Communication Group; 1994).”
“No evidenced-based guidelines linking surgical specialty with ovarian cancer outcomes were found within the Cochrane database.”
“The results of Eisenkop et al. (1992) demonstrated the greatest influence of surgical specialty on median survival; 35 months for those operated on by GO (gynecologic oncologist) compared to 17 months for those operated on by ‘other’ surgeons.”
“Mayer et al., which was graded as fair (e.g. level of evidence), found that patients (early-stage) operated on by GO had a 24% improvement in 5-year overall survival (P < 0.05).
In conclusion, with the exception of Cochrane, I am unable to request a comprehensive analysis on ovarian cancer. I would however advise that there is an urgency to do so.
References
[1] K.C. Giede, K. Kieser, J. Dodge and B. Rosen, Who should operate on patients with ovarian cancer? An evidence-based review, Gynecol Oncol, University of Toronto, Canada (2005 (Aug 26)).
[2] A. Gagliardi, M. Fung Kee Fung, B. Langer, H. Stern and A.D. Brown, Development of ovarian cancer surgery quality indicators using a modified Delphi approach, Gynecol. Oncol. 97 (2005), pp. 446–456. Abstract | Full Text + Links | PDF (210 K)
[3] P. Tai, E. Yu, G. Cserni, G. Vlastos, M. Royce, I. Kunkler and V. Vinh-Hung, Minimum follow-up time required for the estimation of statistical cure of cancer patients: verification using data from 42 cancer sites in the SEER database, BMC Cancer 5 (2005), p. 48.
Corresponding Author Contact InformationFax: +1 905 666 0188.
Gynecologic Oncology
Article in Press, Corrected Proof
Copyright © 2006 Elsevier B.V. All rights reserved. ScienceDirect® is a registered trademark of Elsevier B.V.
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