Acute Oncology Research Articles

Nurses' Perspectives on the Care Provided to Cancer Patients

Optimal care for patients with cancer involves the provision of effective physical and psychological care. Nurses are key providers of this care; however, the effectiveness of care is dependent on the nurses' training, skills, attitudes, and beliefs. The study reported in this article explored cancer nurses' perceptions of their ability to provide psychosocial care to adults with cancer and their subsequent evaluation of the effectiveness of the care provided. This study was the first part of a larger project that evaluated the effectiveness of Proctor's model of clinical supervision in an acute care oncology environment. An exploratory qualitative design was used for this study. One focus group interview was conducted with 10 randomly selected registered nurses working within the oncology units at a major Melbourne tertiary referral hospital. Analytic themes were developed from the coded data using content analysis. The 4 analytic themes to emerge from the data were frustration, difficult to look after yourself, inadequate communication processes, and anger. The findings from this study indicate that, although informal mechanisms of support are available for oncology nurses, most of these services are not accessed. Leaders in cancer care hospital settings need to urgently develop and implement a model of support for their oncology nurses who are attempting to provide psychosocial support to oncology patients.

Az onkológiai ellátás egészség-gazdaságtani vonatkozásai: a teljesítményvolumen-korlát (TVK) finanszírozási hatása

The aim of our study is to analyze the effect of performance volume limit (PVL) on the performance indicators of acute oncology care, with special respect to the health insurance reimbursement not paid to health care providers. Data were derived from the nationwide administrative dataset of the National Health Insurance Fund Administration (OEP) covering the period of 2006-2008. We analyzed the effect of PVL according to medical specialities. We calculated the average annual reimbursement rate of DRG cost-weight with and without the application of PVL. The loss due to PVL was calculated both by monetary terms and as the % of annual revenue. The loss of medical specialities measured by monetary units (Hungarian forint, HUF) and as a percent of their revenues was the following in 2008: oncology 1327 million HUF (4.7%), cardiology 791 million HUF (3.0%), gynecology and obstetrics 772 million HUF (3.0%), internal medicine 708 million HUF (3.3%), intensive care 661 million HUF (2.5%), surgery 637 million HUF (3.2%), pediatrics 614 million HUF (3.9%), traumatology 545 million HUF (2.5%), radiotherapy 438 million HUF (3.1%). The application of performance volume limit had significantly different effect on the different medical specialities. Oncology care can be considered as one of the largest losers of the application of performance volume limit.

Acute care oncology nursingAcute care oncology nursing Cynthia C Chernecky and Kathleen Murphy-EndeElsevier£41.99624pp97814160373479781416037347

Acute care oncology nursingAcute care oncology nursing Cynthia C Chernecky and Kathleen Murphy-EndeElsevier£41.99624pp97814160373479781416037347

Perfusion computed tomography could be a new tool for single-session imaging of ureteric obstructive pathology: an experimental study in rats

Background/Purpose Perfusion imaging redefines computed tomography (CT) as a technique that can now depict vascular physiology in addition to detailed anatomy. The major clinical applications of perfusion CT are in acute stroke and oncology. Currently, there are very limited data on the application of perfusion CT in urology. The aim of the present study is to investigate the potential value of perfusion CT in anatomic and functional evaluation of obstruction in a single session on experimental hydronephrosis model in rats. Thus, we evaluate the perfusion CT in a new clinical application. Methods Twenty-eight rats were randomly allocated into 4 groups each consisting of 7 rats. At the third week of experimental intervention, postoperative renogram curves and perfusion parameters of the right kidneys' cortex and pelvis were assessed by CT. The right ureter was sutured as proximal complete obstruction in group 1, as distal complete obstruction in group 2, and as proximal partial obstruction in group 3. Group 4 served as the sham control group. Computed tomography was performed with single-slice tomography. Dynamic examination was performed with the help of perfusion software through contrast-enhanced tomography examination. Results In all study groups, the aorta time/density curves showed a rapid increase after a rapid decrease, and the duration to reach peak concentration in the normal kidney cortex was observed to be later than the aorta as expected. In groups 1, 2, and 3, the duration to reach peak concentration lengthened and the peak concentration values decreased. The time/density curves gradually increased as a result of the accumulation of the contrast agent in the pelvis, and a peak was observed at the end of the procedure in all study groups. In groups 1, 2, and 3, a statistically significant decrease ( P = .01, P = .01, and P = .01, respectively) was observed in the peak concentration values of the contrast agent in comparison to group 4. The flow and blood volume values gradually decreased as the grade of the obstruction increased and the localization of the obstruction or grade of obstruction moved closer to the kidney. Conclusion In conclusion, perfusion CT technique, performed in a single session, is a useful method for anatomic visualization, together with functional evaluation, in the diagnosis of ureteric obstructive pathology of experimental hydronephrosis model.

Perspectives on palliative care in Lebanon: Knowledge, attitudes, and practices of medical and nursing specialties

Our objective was to determine the knowledge, attitudes, and practices of physicians and nurses on Palliative Care (PC) in Lebanon, across specialties. We performed a cross-sectional descriptive survey using a self-administered questionnaire; the total number of completed and returned questionnaires was 868, giving a 23% response rate, including 74.31% nurses (645) and 25.69% physicians (223). Significant differences were found between medical and surgical nurses and physicians concerning their perceptions of patients' and families' outbursts, concerns, and questions. Knowledge scores were statistically associated with practice scores and degree. Practice scores were positively associated with continuing education in PC, exposure to terminally ill patients, and knowledge and attitude scores. Acute critical care and oncology were found to have lower practice scores than other specialties. Formal education in palliative care and development of palliative care services are very much needed in Lebanon to provide holistic care to terminally ill patients.

Acute Care Oncology Nursing – Second editionAcute Care Oncology Nursing – Second edition

This useful book is succinct and to the point. It does what it suggests in the title, which is to address the nursing aspects of acute cancer problems.

A cross-Canada survey of clinical programs for the care of survivors of cancer in childhood and adolescence

More than 80% of children who have been recently diagnosed with cancer will survive for five years or more. A majority of these survivors are at risk for developing one or more long-term sequelae of their therapy. Thus, they all require specialized medical care that is focused on their specific risks. A survey of informants from all 17 paediatric cancer programs in Canada was conducted to determine the care offered to survivors of childhood cancer, both during their paediatric and adolescent years, as well as after they transition to adulthood. Sixteen informants representing all 17 centres responded to the survey by telephone or e-mail. Twelve of the 17 centres (71%) had a formal program or clinic dedicated to the care of survivors during their paediatric and adolescent years, while the remaining centres cared for survivors in their acute care oncology clinics. However, only six of 17 centres (35%) had access to a formal program for survivors once they reach adulthood. Fifteen of the 17 centres (88%) adhered to published long-term follow-up guidelines, and 13 of 17 centres (76%) provided a treatment summary and/or a survivorship care plan to each survivor before their transfer out of paediatric care. Despite the centralization of paediatric oncology care within 17 specialist centres and the availability of universal health care, many Canadian survivors of childhood cancer do not have access to clinics specializing in long-term risk-based survivor care, and this access further decreases once they reach adulthood.

An audit of levels of psychological support referrals for cancer patients

There is a wealth of literature concerning the psychological care of patients with cancer but little regarding its delivery and implementation. This retrospective audit reviewed the care of cancer patients (n=50) admitted to a 65-bed inpatient acute oncology unit who were referred to the liaison psychiatry team for mental health assessment. The audit covered a five-year time span and focused on ‘Key recommendation 9’ of National Institute for Health and Clinical Excellence (NICE 2004) guidance that proposed a four-level model of professional psychological assessment and intervention. The audit highlighted underprovision of and too few adequately trained professionals providing level three psychological care interventions at the inpatient unit as well as poor documentation of psychological assessments. Areas of good practice included prompt referrals to supportive care services, consistent follow-up and safe discharge systems. a bs tr ac t

Predictive Factors for Acute and Late Urinary Toxicity After Permanent Prostate Brachytherapy: Long-Term Outcome in 712 Consecutive Patients

To describe the frequency of acute and late Radiation Therapy Oncology Group (RTOG) urinary toxicity, associated predictive factors, and resolution of International Prostate Symptom Score (IPSS) in 712 consecutive prostate brachytherapy patients. Patients underwent implantation between 1998 and 2003 (median follow-up, 57 months). The IPSS and RTOG toxicity data were prospectively collected. The patient, treatment, and implant factors were examined for an association with urinary toxicity. The time to IPSS resolution was examined using Kaplan-Meier curves, and multivariate modeling of IPSS resolution was done using Cox proportional hazards regression analysis. Logistic regression analysis was used to examine the factors associated with urinary toxicity. The IPSS returned to baseline at a median of 12.6 months. On multivariate analysis, patients with a high baseline IPSS had a quicker resolution of their IPSS. Higher prostate D90 (dose covering 90% of the prostate), maximal postimplant IPSS, and urinary retention slowed the IPSS resolution time. The rate of the actuarial 5-year late urinary (>12 months) RTOG Grade 0, 1, 2, 3, and 4 was 32%, 36%, 24%, 6.2%, and 0.1%, respectively. At 7 years, the prevalence of RTOG Grade 0-1 was 92.5%. Patients with a larger prostate volume, greater number of needles, greater baseline IPSS, and use of hormonal therapy had more acute toxicity. On multivariate analysis, the significant predictors for late greater than or equal to RTOG toxicity 2 were a greater baseline IPSS, maximal postimplant IPSS, presence of acute toxicity, and higher prostate V150 (volume of the prostate covered by 150% of the dose). More recently implanted patients had less acute urinary toxicity and patients given hormonal therapy had less late urinary toxicity (all p < 0.02). Most urinary symptoms resolved within 12 months after prostate brachytherapy, and significant long-term urinary toxicity was very low. Refined patient selection and greater technical experience in prostate brachytherapy were associated with less urinary toxicity.

The silent risks of blood transfusion

Clinical research has identified blood transfusion as an independent risk factor for immediate and long-term adverse outcomes, including an increased risk of death, myocardial infarction, stroke, renal failure, infection and malignancy. New findings have called into question the traditional assumptions clinicians utilize in evaluating the risks and benefits of blood transfusion. Appreciation of newly recognized risks is important for conserving scarce resources and optimizing patient outcomes. Recent clinical outcomes research has examined the impact of blood transfusion on critically ill patients, trauma patients, patients undergoing cardiac surgery, patients experiencing acute coronary syndromes, oncology patients and others. These studies provide additional evidence of adverse outcomes associated with blood transfusion in a wide variety of clinical contexts. The benefits of blood transfusion have never been conclusively demonstrated, but evidence of transfusion-related harm continues to accumulate. Given the transfusion triggers that currently predominate in clinical practice it appears that clinical outcomes could improve significantly with more widespread adoption of restrictive transfusion strategies.

Incidence of and Risk Factors for Transferring Cancer Patients from Rehabilitation to Acute Care Units

The aim of this study was to examine the clinical factors associated with transfer from an acute inpatient rehabilitation service to an inpatient oncology service. Retrospective chart review in an inpatient rehabilitation unit within a tertiary cancer center. Participants included consecutive patients admitted to an acute inpatient rehabilitation unit (n = 98). The average age of these patients was 60 yrs old (range from 18 to 86). Main outcomes measures included the frequency of transfer and reason for transfer. Thirty-five percent (34/98) of patients were transferred back to the oncology service during acute rehabilitation, among them, 12% was for planned cancer treatment and 88% for worsening medical conditions. Age, sex, tumor diagnosis, presence of metastatic lesion, and most abnormal laboratory values at rehabilitation admission were not significant factors for transferring. Significant factors for transfers were low albumin (P = 0.04), elevated creatinine levels (P = 0.01), tube feeding (P = 0.03), and a Foley catheter (P = 0.02). Those patients who were transferred back to the oncology service were more likely to die during hospitalization (15%, 5/33) and less likely to be discharged to home (52%, 17/33) compared with patients who were not transferred (2% death, 1/62; 90% home, 56/62, P < 0.0001). Transferring back to the acute oncology service is 35% among patients undergoing acute cancer rehabilitation.

Does Image-Guided Radiotherapy Improve Toxicity Profile in Whole Pelvic-Treated High-Risk Prostate Cancer? Comparison Between IG-IMRT and IMRT

To evaluate the impact of adding image-guided (IG) technique to intensity-modulated radiotherapy (IMRT) on dosimetric avoidance of organs at risk (OAR) and acute toxicities. A total of 25 consecutively treated patients (10 from National University Hospital and 15 from University of California San Francisco) with high-risk prostate cancer formed the study cohort. All received definitive IMRT with prophylactic nodal RT. Similar IMRT contouring and planning techniques were used at both centers. At the University of California, San Francisco, intraprostatic fiducial markers were used for daily pretreatment on-line corrections (IG-IMRT). In contrast, at the National University Hospital, no fiducial markers were used (IMRT). At the University of California, San Francisco, the planning target volume margins to the prostate were 2-3 mm. At the National University Hospital, they were 1 cm circumferentially, except for 0.5 cm posteriorly. The acute rectal and bladder toxicities and dosimetric endpoints to the planning target volume and organs at risk were compared. The planning target volume dose coverage was not significantly different between IMRT and IG-IMRT for the prostate, seminal vesicles, and lymph nodes. The volume of rectum and bladder receiving >/=40, >/=60, and >/=70 Gy were all significantly less using IG-IMRT (p <0.001). IG-IMRT yielded lower acute Radiation Therapy Oncology Group Grade 2 rectal (80% vs. 13%, p = 0.004) and bladder (60% vs. 13%, p = 0.014) toxicities. IG-IMRT, using daily target localization with fiducial markers, permits the use of smaller margins and correspondingly lower doses to the organs at risk, such as the rectum and bladder. These tangible gains appear to translate into lower clinically significant toxicities.

Development of a Set of Nomograms to Predict Acute Lower Gastrointestinal Toxicity for Prostate Cancer 3D-CRT

To predict acute Radiation Therapy Oncology Group (RTOG)/European Organization for Research and Treatment of Cancer (EORTC) and Subjective Objective Signs Management and Analysis/Late Effect of Normal Tissue (SOMA/LENT) toxicities of the lower gastrointestinal (LGI) syndrome in patients with prostate cancer undergoing three-dimensional conformal radiotherapy using a tool (nomogram) that takes into account clinical and dosimetric variables that proved to be significant in the Italian Association for Radiation Oncology (AIRO) Group on Prostate Cancer (AIROPROS) 0102 trial. Acute rectal toxicity was scored in 1,132 patients by using both the RTOG/EORTC scoring system and a 10-item self-assessed questionnaire. Correlation between clinical variables/dose-volume histogram constraints and rectal toxicity was investigated by means of multivariate logistic analyses. Multivariate logistic analyses results were used to create nomograms predicting the symptoms of acute LGI syndrome. Mean rectal dose was a strong predictor of Grade 2-3 RTOG/EORTC acute LGI toxicity (p = 0.0004; odds ratio (OR) = 1.035), together with hemorrhoids (p = 0.02; OR = 1.51), use of anticoagulants/antiaggregants (p = 0.02; OR = 0.63), and androgen deprivation (AD) (p = 0.04; OR = 0.65). Diabetes (p = 0.34; OR = 1.28) and pelvic node irradiation (p = 0.11; OR = 1.56) were significant variables to adjust toxicity prediction. Bleeding was related to hemorrhoids (p = 0.02; OR = 173), AD (p = 0.17; OR = 0.67), and mean rectal dose (p = 0.009; OR = 1.024). Stool frequency was related to seminal vesicle irradiation (p = 0.07; OR = 6.46), AD administered for more than 3 months (p = 0.002; OR = 0.32), and the percent volume of rectum receiving more than 60 Gy (V60Gy) V60 (p = 0.02; OR = 1.02). Severe fecal incontinence depended on seminal vesicle irradiation (p = 0.14; OR = 4.5) and V70 (p = 0.033; OR = 1.029). To the best of our knowledge, this work presents the first set of nomograms available in the literature specific to symptoms of LGI syndrome and provides clinicians with a tailored probability of the specific outcome. Validation of the tool is in progress.

Development and introduction of a pain score documentation chart in the acute oncology setting

AbstractBackground: Recommendations to improve cancer pain management include the introduction of routine and clearly visible documentation of pain scores. Whilst this practise has been adopted in many cancer and palliative care units, longitudinal evidence to support the view that the practise has provided improved analgesic outcomes for patients is limited. The aims of this study were threefold; (i) to collaboratively develop a locally acceptable pain documentation chart; (ii) to test this chart by comparing patient‐reported and nurse‐documented scores with pain scores collected by researchers using validated measures; and (iii) to examine whether or not pain scores and analgesia scores longitudinally improved over the study period.Methods: Using a multidisciplinary approach, a pain score documentation chart was developed for use on an acute hospital's oncology ward. Prior to the chart's introduction, the brief pain inventory (BPI) was administered to 45 in‐patients. The patients were then asked to report on a regular basis their numeric pain scores, which were documented on the chart. At the time of discharge or after 7 days, the BPI was repeated. The pain chart scores and the BPI item, ‘average pain experienced in the preceding 24 h’ were correlated.Results: The initial chart scores significantly correlated with the first BPI score (P = 0.001), and a similar relationship was found between scores collected at the end of the study period (P = 0.020). Analgesic scores improved, patients were satisfied with the approach taken to their analgesic management and the pain scores were charted with a similar frequency to vital signs (pulse, temperature, blood pressure).Conclusions: Pain score charting is feasible and acceptable to patients and nursing staff in an acute hospital. Most importantly, this process has the potential to improve the analgesic outcomes of cancer patients.

Gamma Knife Radiosurgery for Malignant Melanoma Brain Metastases

To evaluate the efficacy and toxicity of gamma knife radiosurgery in the treatment of melanoma metastases to the brain.We retrospectively reviewed 55 patients with single or multiple intracranial melanoma metastases treated at the University of California, San Francisco, with gamma knife radiosurgery from 1991 through 1995. Sixteen patients were treated with gamma knife radiosurgery for recurrence following previous radiation therapy, 11 received radiosurgery as a boost to whole-brain radiation therapy, and 28 had radiosurgery alone for initial management of brain metastases. The median minimum radiosurgery tumor dose for 140 treated lesions was 19 Gy (range, 10-22 Gy) prescribed at the 35% to 90% isodose contour (median, 50%). The median total target volume per patient was 6.1 cc (range, 0.25-28.3 cc).With a median follow-up of 75 weeks in living patients, the median survival times were 35 weeks overall: 35 weeks for patients with solitary metastases versus 33 weeks for those with multiple metastases. A factor that was significant in univariate analysis of survival was total target volume treated. This parameter remained significant on multivariate analysis. The actuarial median freedom from progression analyzed by lesion for 113 lesions in 46 patients with imaging follow-up was 89 weeks with 6-month and 1-year actuarial freedom from progression rates of 89% (95% confidence interval, 80%-95%) and 77% (95% confidence interval, 62%-87%). In univariate analysis, improved freedom from progression was associated with smaller target volume treated, smaller maximum diameter, or higher prescribed dose. Four patients (7%) developed acute Radiation Therapy Oncology Group grade > or = 2 morbidity, and five patients (9%) developed late grade > or = 2 morbidity.Median survival and freedom from progression in patients treated with radiosurgery for melanoma metastatic to the brain are comparable to results in published radiosurgery series of grouped histologies. For melanoma patients, total intracranial tumor volume appears to be of greater prognostic significance than the absolute number of metastases treated. We conclude that gamma knife radiosurgery is effective and should be considered among various management strategies.

Family matters in acute oncology

Evidence shows that children of parents with cancer face potential behavioural, cognitive and physical problems (Birmingham 2006; Visser et al 2004). Here, Michele Pengelly describes a nurse-led project aimed at dissipating the negative effects of parental cancer on children and adolescents. The ‘children’s room’ recognises that cancer is a family disease

Multivariate Analysis of Survival, Local Control, and Time to Distant Metastases in Patients with Unresectable Non–Small-Cell Lung Carcinoma Treated with 3-Dimensional Conformal Radiation Therapy with or Without Concurrent Chemotherapy

BACKGROUND: Three-dimensional (3D) conformal radiation therapy (CRT) and chemotherapy have recently improved lung cancer management. PATIENTS AND METHODS: We reviewed outcomes in 68 patients with unresectable stage I-III non–small-cell lung cancer. Treatment consisted of 3D CRT alone or with concurrent chemotherapy (CCR). RESULTS: Concurrent chemotherapy improved survival, to a median of 17 months ± 4.9 months, compared with 8 months ± 4.1 months for the radiation therapy (RT) alone group (P = 0.0347). The 2- and 5-year survival rates were 40.3% ± 7.7% and 14.1% ± 6.4%, repectively, with CCR, compared with 19.6% ± 9.6% and 0, respectively, for RT alone. In a subgroup analysis for age > 65, patients who received CCR (n = 20) had significantly improved survival and local control (P = 0.005 and P = 0.0286, respectively). Acute esophageal toxicity Radiation Therapy Oncology Group grade ≤ 3 was significantly higher in the CCR group and correlated with the RT dose (19% in CCR vs. 0 in RT, P = 0.0234; P = 0.050). The overall incidences of esophageal and pulmonary toxicity grade ≤ 3 were 20.6% and 5.9%, respectively. CONCLUSION: Our study confirms that CCR is associated with improved survival over RT alone, with a tolerable increase in acute toxicity.

Pilot of a Pathway to Improve the Care of Imminently Dying Oncology Inpatients in a Veterans Affairs Medical Center

We report on the implementation of a previously developed clinical pathway for terminally ill patients, Palliative Care for Advanced Disease (PCAD), on a Veterans Administration (VA) acute care oncology unit, comparing processes of care and outcomes for patients on and off the pathway. The PCAD pathway is designed to identify imminently dying patients, review care goals, respect patients' wishes, assess and manage symptoms, address spirituality, and support family members. Retrospective chart reviews from 15 patients who died on PCAD, 14 patients who died on general wards during the same time, and 10 oncology unit patients who died prior to PCAD revealed that PCAD patients were more likely to have documentation of care goals and plans of comfort care ( P = 0.0001), fewer interventions, and more symptoms assessed ( P = 0.004), and more symptoms managed according to PCAD guidelines ( P = 0.02). Implementation of PCAD improved care of dying inpatients by increasing documentation of goals and plans of care, improving symptom assessment and management, and decreasing interventions at the end of life.

Phase I study of conformal radiotherapy with concurrent gemcitabine in locally advanced bladder cancer

A prospective phase I trial was conducted to determine the maximal tolerated dose of gemcitabine given once weekly during hypofractionated conformal radiotherapy to patients with locally advanced transitional cell carcinoma of the bladder. Eight male patients, median age 69 years, with Stage T2 (n = 4) or T3 (n = 4) N0M0, were enrolled in cohorts of 3. Treatment comprised conformal radiotherapy (52.5 Gy in 20 fractions) within 4 weeks, with concurrent gemcitabine once weekly for four cycles. The weekly gemcitabine dose was escalated from 100 mg/m(2) in increments of 50 mg/m(2) per cohort. Dose-limiting toxicity was defined as any acute Radiation Therapy Oncology Group (RTOG) toxicity Grade 3 or greater arising in >1 of 3 patients in each cohort. Tumor response was assessed cystoscopically and radiologically at 3 months. All 8 patients completed radiotherapy, and 6 of 8 completed chemoradiotherapy. No acute toxicity greater than RTOG Grade 1 was seen with gemcitabine at 100 mg/m(2). Dose-limiting toxicity was observed at 150 mg/m(2) with Grade 3 toxicity seen in 2 of 2 patients (one bladder, one bowel). An additional 3 patients received 100 mg/m(2) with minimal toxicity. No hematologic toxicity was encountered. A complete response was seen in 7 (87.5%) of 8 patients, all of whom were disease free at a median follow-up of 19.5 months (range, 14-23 months). No late toxicity (greater than RTOG Grade 0) has been observed. The maximal tolerated dose for gemcitabine given once weekly with concurrent hypofractionated conformal bladder radiotherapy was 150 mg/m(2), with a maximal recommended dose of 100 mg/m(2). This dose regimen has now entered Phase II clinical trials.

Toxic cure: Hyperfractionated radiotherapy with concurrent cisplatin and fluorouracil for Stage III and IVA head-and-neck cancer in the community

PurposeTo evaluate efficacy and toxicity of the Duke University chemoirradiation regimen for locally advanced head-and-neck cancer in a regional community cancer center. Methods and materialsBetween June 1998 and June 2002, 50 patients with Stage III or IVA squamous cell carcinoma of the head and neck were treated definitively with concurrent combined modality therapy (CMT). Patients received accelerated, hyperfractionated radiotherapy (AFRT), 1.2–1.25 Gy b.i.d., to a median prescribed dose of 70 Gy. Chemotherapy consisted of cisplatin 12 mg and fluorouracil 600 mg/m2 daily for 5 consecutive days during Weeks 1 and 6, followed by two cycles after AFRT. Patients with N2-N3 neck disease (n = 21; 42%) were considered for neck dissection depending on their response to AFRT and chemotherapy. Twenty-nine patients with Stage III and IVA disease treated between 1991 and 1997 with definitive RT alone served as historical controls. ResultsForty-nine patients (98%) in the CMT group completed the prescribed AFRT and 38 (76%) completed four cycles of chemotherapy. Three of 8 patients who underwent neck dissection had a pathologically complete response. The median follow-up for all patients was 23 months. The actuarial progression-free survival rate at 2 years was 75% for the CMT group vs. 40% (p <0.01) for the RT group. The overall survival rate was 80% and 43% (p <0.01), respectively, for the CMT and RT groups. Acute Radiation Therapy Oncology Group Grade 3 toxicities for the CMT group were mucosal (n = 50; 100%), skin (n = 9; 18%), and hematologic (n = 3; 6%). Late Grade 3-4 toxicities consisted of pharyngeal stricture (n = 7; 14%), laryngeal chondritis (n = 3; 6%), osteoradionecrosis (n = 2; 4%), and peripheral neuropathy (n = 1; 2%). ConclusionThis aggressive regimen of AFRT with concurrent cisplatin and fluorouracil with or without neck dissection is feasible in the community setting for patients with Stage III and IVA head-and-neck cancer. Early results indicated excellent survival, albeit with universal acute mucosal, and considerable, although acceptable, late toxicity.