Noncurative Intent Research Articles

Maximum Diameter and Number of Tumors as a New Prognostic Indicator of Colorectal Liver Metastases.

Surgical resection is currently considered the only potentially curative option as a treatment strategy of colorectal liver metastases (CRLM). However, the criteria for selection of resectable CRLM are not clear. The aim of this study was to confirm a new prognostic indicator of CRLM after hepatic resection. One hundred thirty nine patients who underwent initial surgical resection from 1994 to 2015 were investigated retrospectively. Prognostic factors of overall survival including the product of maximum diameter and number of metastases (MDN) were analyzed. Primary tumor differentiation, vessel invasion, lymph node (LN) metastasis, non-optimally resectable metastases, H score, grade of liver metastases, resection with non-curative intent and MDN were found to be prognostic factors of overall survival (OS). In multivariate analyses of clinicopathological features associated with OS, MDN and non-curative intent were independent prognostic factors. Patients with MDN ≥30 had shown significantly poorer prognosis than patients with MDN <30 in OS and relapse-free survival (RFS). MDN ≥30 is an independent prognostic factor of survival in patients with CRLM and optimal surgical criterion of hepatectomy for CRLM.

Are patients with cancer concerned about burdening their families?

86 Background: A diagnosis of advanced cancer frequently thrusts family members into the role of caregiver. Although caregiver burdens have been well documented, less is known about the level of concern borne by the patient (pt) with cancer in placing a family member in this role, known as self-perceived burden (SPB). Methods: As part of the larger “Living with Cancer” project we prospectively surveyed 1307 pts with advanced malignancies receiving treatment with non-curative intent at 17 New Jersey cancer programs within the Regional Cancer Care Associates network between Sept 2015 and Apr 2016. Pts were asked one question about SPB on family members (5-level Likert scale). Results: Pts felt that “Living with Cancer burdens my family” all day every day 68 pts (5%), part of each day 109 pts (8%), most days 136 pts (10%), occasionally 571 pts (44%) or not at all 423 pts (32%). Twenty-four percent of responses were flagged as concerned (rated most days or greater by 313 pts). In a logistic regression model, SPB was correlated with marital status (married and divorced more concerned than single) and younger age (both p &lt; 0.05). Patients living in lower median income neighborhoods also appeared to have a higher frequency of concern (p &lt; 0.1) Factors not correlating with the level of SPB included gender, race, solid vs liquid tumor type, and length of cancer diagnosis. SPB was also not influenced by DNR status, having developed a Living Will, or documentation of power of attorney. Distance from the pt’s home to the cancer center was not associated with SPB on the caregiver. For comparison, on the same LWC project 38% of pts with advanced cancer were concerned about the financial toxicity of their care and 33% were concerned about pain (both p &lt; 0.01 compared to SPB). Conclusions: Self-perceived burden on a caregiver was identified in 24% of pts with advanced cancer, less than those concerned about financial toxicity or pain, in this NJ series. Divorced/married pts and younger pts with cancer are more likely to express concern. Developing an EOLC plan (DNR/Living will/POA) does not appear to influence SPB concerns.

Are patients with advanced cancer concerned about financial toxicity?

10065 Background: Cancer patients (pts) are more than twice as likely to enter bankruptcy as the general US population. It is unknown how often pts with metastatic cancer are concerned about the financial toxicities (FTox) of treatment. Methods: As part of the larger “Living with Cancer” project we prospectively surveyed 941 pts with advanced malignancies receiving treatment with non-curative intent at 6 New Jersey cancer programs within the Regional Cancer Care Associates network. Pts were asked 2 questions about the financial burden and pain associated with cancer (5-point Likert scale). Results: Pts felt that “Living with Cancer has impacted the financial well-being of me or my family” severely 44 pts (5%), significantly 124 pts (14%) moderately 193 pts (21%), minimally 250 pts (28%) or not at all 292 pts (32%). For comparison, pts felt “Living with Cancer the pain I experience is” unbearable/constant 12 pts (1%), severe 82 pts (9%), moderate 209 pts (23%), mild 306 pts (34%), non-existent 294 pts (33%). Responses were flagged as concerned if rated severe, significant or moderate. Concern about FTox was more prevalent than about pain (p < 0.005). FTox and pain responses had a weak positive correlation (r = 0.370; p < 0.001). Utilizing median household income per zip code as a surrogate (n = 867), logistic regression demonstrated that as income increases the probability of being concerned about FTox decreases significantly (p < 0.001). A pt with median US income of $51,000 has a 48% chance of being concerned about FTox, whereas a pt with income of $151,000 has a 23% chance. Younger pts also were significantly (p < 0.001) more concerned about FTox; 30 yr 82%, 60 yr 48% and 80 yr 24%. Pts with liquid malignancies had a higher proportion of concerned pts than solid malignancies (liquid 104/218 concerned, solid 241/644 concerned, p < 0.005). Conclusions: Financial toxicity concerns are common among pts with metastatic/advanced cancers, being self-reported in 40% of pts of this NJ series. FTox concerns were more prevalent than concern about pain, and were more common in pts with liquid rather than solid malignancies. Younger pts and those who live in less affluent neighborhoods are more likely to be concerned about the FTox of cancer care.

Reirradiation of Head and Neck Cancers With Intensity Modulated Radiation Therapy: Outcomes and Analyses

Toreview our 15-year institutional experience using intensity modulated radiation therapy (IMRT) to reirradiate patients with head and neck squamous cell carcinomas (HNSCC) and identify predictors of outcomes and toxicity. We retrospectively reviewed the records of 227 patients who received head and neck reirradiation using IMRT from 1999 to 2014. Patients treated with noncurative intent were excluded. Radiation-related acute and late toxicities were recorded. Prognostic variables included performance status, disease site, disease-free interval, chemotherapy, and RT dose and volume. Correlative analyses were performed separately for surgery and nonsurgery patients. Two hundred six patients (91%) were retreated with curative intent, and 173 had HNSCC histology; 104 (50%) underwent salvage resection, and 135 (66%) received chemotherapy. Median follow-up after reirradiation was 24.7months. Clinical outcomes were worse for HNSCC patients, with 5-year locoregional control, progression-free survival, and overall survival rates of 53%, 22%, and 32%, respectively, compared with 74%, 59%, and 79%, respectively, for non-HNSCC patients. On multivariate analysis, concurrent chemotherapy and retreatment site were associated with tumor control, whereas performance status was associated with survival. Favorable prognostic factors specific to surgery patients were neck retreatment and lack of extracapsular extension, whereas for nonsurgery patients, these were a nasopharynx subsite and complete response to induction chemotherapy. Actuarial rates of grade ≥3 toxicity were 32% at 2years and 48% at 5years, with dysphagia or odynophagia being most common. Increased grade ≥3 toxicity was associated with retreatment volume >50cm(3) and concurrent chemotherapy. Reirradiation with IMRT either definitively or after salvage surgery can produce promising local control and survival in selected patients with head and neck cancers. Treatment-related toxicity remains significant. Prognostic factors are emerging to guide multidisciplinary treatment approaches and clinical trial design.

Advanced Cancer and End-of-Life Preferences: Curative Intent Surgery Versus Noncurative Intent Treatment.

People with cancer face complex medical decisions, including whether to receive life-sustaining treatments at the end of life. It is not unusual for clinicians to make assumptions about patients' wishes based on whether they had previously chosen to pursue curative treatment. We hypothesized that cancer patients who initially underwent curative intent surgery (CIS) would prefer more aggressive end-of-life treatments compared to patients whose treatment was noncurative intent (non-CIT). This study was a retrospective review of data from a large, randomized controlled trial examining the use of an online decision aid for advance care planning, "Making Your Wishes Known" (MYWK), with patients who had advanced cancer. We reviewed patients' medical records to determine which patients underwent CIS versus non-CIT. In the parent trial, conducted at an academic medical center (2007-2012), 200 patients were enrolled with stage IV malignancy or other poor prognosis cancer. Patients' preferences for aggressive treatment were measured in two ways: using patient-selected General Wishes statements generated by the decision aid and patient-selected wishes for specific treatments under various hypothetical clinical scenarios (Specific Wishes). We evaluated 79 patients. Of these, 48 had undergone initial CIS and 31 had non-CIT. Cancer patients who initially underwent CIS did not prefer more aggressive end-of-life treatments compared to patients whose treatment was non-CIT. Clinicians should avoid assumptions about patients' preferences for life-sustaining treatment based on their prior choices for aggressive treatment.

Surgical palliation for malignant disease requiring locoregional control.

Surgical palliation of cancer is best defined as procedures performed with non-curative intent to improve quality of life or control symptoms of advanced malignancy. Soft tissue involvement of advanced malignancies may produce symptoms such as pain, bleeding, or odor that significantly reduce quality of life. Literature on outcomes of palliative resection of soft tissue malignancy for local or regional control is lacking. Soft tissue resections performed with palliative intent for locoregional control were identified from a prospectively maintained palliative surgery database at a tertiary care center from January 2004 to July 2013. Tumor type, presenting symptom, procedure performed, and symptom recurrence were recorded. Patients were followed for at least 60 days or until death. Thirty-one patients who underwent palliative soft tissue resection for local control were identified. Primary tumor types included melanoma (n=9, 29.0%), squamous cell carcinoma (n=9, 29.0%), sarcoma (n=5, 16.1%), breast (n=3, 9.7%), and other (n=5, 16.1%). Eighteen of 31 patients (58.1%) underwent resection for pain, two (6.5%) for bleeding, and eleven (35.5%) for local control or other symptoms. Procedures were performed on the trunk (n=17, 54.8%), extremities (n=7, 22.6%), head/neck (n=5, 16.1%), or multiple areas (n=2, 6.5%). Eleven of 31 patients (35.5%) underwent axillary, inguinal, or neck lymph node dissection, seventeen (54.8%) radical resection, and three (9.7%) wound excision. Split-thickness skin graft was performed in 6 of 17 radical resections (35.3%). Five patients (16.1%) had symptom recurrence at the site of the initial palliative procedure, of whom four (12.9%) underwent a second palliative procedure. Seven patients (22.6%) had new disease-related symptoms develop during follow-up. Thirty-day morbidity was 29.0%; mortality was 3.2%, which was associated with progression of disease. Palliative surgery for local control of advanced soft tissue malignancy can provide durable symptom relief and improved quality of life. These procedures positively impact patients regardless of primary tumor type or tumor extent. Careful patient selection is important in order to maximize benefit of surgical palliation and minimize morbidity and mortality.

Modern imaging techniques for preoperative detection of distant metastases in gastric cancer.

A substantial portion of patients with newly diagnosed gastric cancer has distant metastases (M1 disease). These patients have a very poor prognosis and it is generally accepted that they should be treated with noncurative intent. Because it dramatically changes prognosis and treatment plans, it is very important to diagnose distant metastases. In this article, the definition, pathways, incidence and sites of distant metastases in gastric cancer are described. Subsequently, the current performance of imaging in detecting distant metastases in newly diagnosed gastric cancer is outlined and future prospects are discussed.

Clinical features and outcome of primary pancreatic lymphoma.

Primary pancreatic lymphoma (PPL) is a rare tumor that is often misdiagnosed. Clinicopathologic features, optimal therapy, and outcomes are not well defined. We reviewed our institutional experience with PPL. Search of our institutional database identified that between 1987-2012, 21,760 patients with lymphoma and 11,286 patients with a primary pancreatic tumor were evaluated. There were 44 patients with pathologically confirmed PPL. Clinical data were obtained by chart review and survival distributions were estimated using the Kaplan-Meier method and compared using the log-rank test. At baseline, LDH was elevated in 55 % of the patients, CA 19-9 in 25 %, and CEA in 20 %. Imaging characteristics included large, unresectable tumors (67 %), and lymphadenopathy inferior to the renal vein (50 %). Twenty-three patients underwent surgery for resection (5), diagnosis (13), or palliation (5). Chemotherapy alone achieved a 75 % complete response rate. Eight patients experienced relapse, 88 % of which occurred at distant sites. Median overall survival was 6.1 years and 10-year disease-specific survival (DSS) was 69 %. Patients with a low risk International Prognostic Index (IPI) and those with a follicular histologic subtype demonstrated 5-year DSS of 100 %. Chemotherapy for PPL results in a high complete response rate and long DSS, which is similar to nodal non-Hodgkin's lymphoma (NHL). A favorable outcome is expected for IPI low risk patients and follicular histologic subtype. Systemic therapy should generally be the initial therapy when the diagnosis is known. Prolonged follow up is recommended to detect relapses. Surgery alone should be reserved for non-curative intent (i.e. diagnostic or palliative).

Validation of g-8 screening tool for comprehensive geriatric assessment &amp; post-operative delirium in gynecological cancer patients undergoing robotic surgery

those that had received inpatient chemotherapy at St James' Institute of Oncology in Leeds from January 2010 until February 2013. Details regarding cancer diagnosis, treatment, comorbidities and medication use were obtained from the local prospective electronic database Patient Pathway Manager (PPM) and the hospital discharge database Bluespier. Results: A total of 99 patients were identified, with a median age of 78 years. The most common types of cancer observed were colorectal (34%) and upper gastrointestinal (22%). Sixteen patients had no pre-existing comorbidities. Forty four patients had one or two comorbid conditions, and 39 patients had three or more. The intent of treatment was curative in 34% of patients, and non-curative in 65%. At diagnosis, 35% of patients were taking aspirin, 31% were taking a statin and 21% were taking warfarin. Fifty two patients had information regarding medication use at 6 months after diagnosis (53%). Forty seven (90%) of these had no changes made to their medications after diagnosis. Nine patients (17%) were taking warfarin for atrial fibrillation or valve replacement, with only one patient receiving potentially curative treatment. Seven patients (78%) continued to take warfarin, and there was no documentation of discussion with their clinician regarding the appropriateness of anticoagulation. Of the 21 patients taking aspirin at diagnosis, 17 patients (81%) were taking aspirin six months after diagnosis. Thirteen patients (76%) that continued to take aspirin were receiving non-curative treatment. Twenty six patients were taking a statin at diagnosis, and 17 patients (65%) continued to take this after six months. Fifteen of these (88%) were receiving treatment with non-curative intent. No patient had a documented medication review in the oncology clinic. Conclusion: Older cancer patients frequently present with comorbid conditions at the time of diagnosis. A significant proportion of patients in this study were prescribed medications for secondary prevention at the time of cancer diagnosis that were not subsequently reviewed in the oncology clinic. Many of these patients were receiving non-curative treatment. Review of concomitant medications should be carried out by oncologists as part of a comprehensive geriatric assessment prior to treatment decision making. Discontinuation of non-essential medications should be considered in those patients likely to have a short life-expectancy. Disclosure of Interest: None declared.

PC-FACS

PC-FACS

Use and impact of chemotherapy-free intervals in metastatic colorectal cancer in routine practice.

6535 Background: Several randomized trials have shown that chemotherapy-free intervals (CFIs) may reduce toxicity without compromising survival in patients with metastatic colorectal cancer (mCRC) treated with non-curative intent. However, uptake and outcomes of this approach in routine practice are unknown. We performed a population-based study of the patterns of use of CFIs and their impact on survival and toxicity among patients treated with first-line intravenous (IV) chemotherapy in Ontario, Canada. Methods: The Ontario Cancer Registry was linked with several other administrative databases to identify patients with colorectal cancer who started first-line IV chemotherapy between 2007-2009. A patient was considered to have had a CFI if more than 56 days elapsed between two chemotherapy billing claims. Survival of patients who had at least one CFI was compared to those who did not using Cox regression stratified by duration of treatment and adjusted for age, sex and Charlson comorbidity score. Analysis was performed separately for each type of first line treatment: Irinotecan (IRI), Irinotecan plus Bevacizumab (IR+B), and Oxaliplatin (OX). Toxicity was estimated by calculating the rate of emergency department visits and hospitalizations (adjusted for time on treatment) between those who did and did not have chemo breaks. Results: Between 2007-2009, 1,989 patients started first-line chemotherapy for mCRC in Ontario (22.6% IRI, 47.9% IRI+B, 29.5% OX). 489 (24.6%) had at least one CFI (14.9% IRI, 33.2% IRI+B, 18.1% OX). The median duration of first line treatment was 205 days (IQR 107-366 days). The median duration of the first CFI was 127 days (IQR 90-234 days). In multivariate models stratified by duration of treatment, CFIs did not have a negative effect on survival in either of the 3 treatment groups (HR: 0.62 IRI, 0.90 IRI+B, 0.51 O). Toxicity was lower in patients who had at least one CFI (12.6 vs 16.8 ER visits or admissions per person-month, p=0.036). Conclusions: Chemo-free intervals are used in routine practice in Ontario, and are associated with lower toxicity, without any apparent evidence of negative impact on survival.

Transition to noncurative end‐of‐life care in paediatric oncology – a nationwide follow‐up in Sweden

To estimate whether and when children dying from a malignancy are recognized as being beyond cure and to study patterns of care the last weeks of life. A nationwide retrospective medical record review was conducted. Medical records of 95 children (60% of eligible children) who died from a malignancy 2007-2009 in Sweden were studied. Eighty-three children (87%) were treated without curative intent at the time of death. Children with haematological malignancies were less likely to be recognized as being beyond cure than children with brain tumours [relative risks (RR) 0.7; 95% confidence interval (CI) 0.6-0.9] or solid tumours (RR 0.8; 0.6-1.0). The transition to noncurative care varied from the last day of life to over four years prior to death (median 60 days). Children with haematological malignancies were treated with a curative intent closer to death and were also given chemotherapy (RR 5.5; 1.3-22.9), transfusions (RR 2.0; 1.0-4.0) and antibiotics (RR 5.3; 1.8-15.5) more frequently than children with brain tumours the last weeks of life. The majority of children dying from a malignancy were treated with noncurative intent at the time of death. The timing of a transition in care varied with the diagnoses, being closer to death in children with haematological malignancies.

Outcome of children who experience disease relapse following allogeneic hematopoietic SCT for hematologic malignancies

Relapse after allogeneic hematopoietic SCT (HSCT) carries a poor prognosis and is a common cause of death. Outcomes of children who relapse post HSCT are not well known. In this retrospective multicenter study we included 532 patients who underwent allogeneic HSCT and examined the outcomes of 160 patients (30%) who relapsed. Treatment options after relapse included (i) palliative therapy with non-curative intent (n=43), (ii) salvage chemotherapy (without a second HSCT, n=55) or (iii) salvage chemotherapy followed by a second HSCT (n=62). Sixty two patients underwent a second HSCT. The 1-year disease-free survival (DFS) for those given palliative therapy, chemotherapy alone and who underwent a second transplant was <1%, 9% and 50% (P=<0.0001), respectively. The DFS at 1 and 2 year was 50% and 35%, respectively, among the patients who received a second transplant versus 9% and 2% in those who did not (P=<0.0001). In multivariable analysis longer time to relapse (P=0.04) and undergoing a second HSCT (P<0.001) were associated with improved outcome. Withdrawal of immunosuppressive therapy, followed by curative intent chemotherapy should be offered to all patients who relapse after an allogeneic HSCT. A second HSCT should be considered, especially in patients who respond to salvage chemotherapy.

Long-term Outcomes Among Noncuratively Treated Men According to Prostate Cancer Risk Category in a Nationwide, Population-based Study

BackgroundLimited data exist on long-term outcomes among men with prostate cancer (PCa) from population-based cohorts incorporating information on clinical risk category. ObjectiveTo assess 15-yr mortality for men with PCa treated with noncurative intent according to clinical stage, Gleason score (GS), serum levels of prostate specific antigen (PSA), comorbidity, and age. Design, setting, and participantsRegister-based cohort study of 76 437 cases in the National Prostate Cancer Register (NPCR) of Sweden diagnosed from 1991 through 2009 and treated with noncurative intent. Each case was placed in one of five risk categories: (1) low risk: T1–T2 tumor, PSA level <10 ng/ml, and GS ≤6; (2) intermediate risk: T1–T2 tumor and PSA level 10–<20 ng/ml or GS 7; (3) high risk: T3 tumor or PSA level 20–<50 ng/ml or GS ≥8; (4) regional metastases: N1 or T4 tumor or PSA level 50–100 ng/ml; and (5) distant metastases: M1 tumor or PSA ≥100 ng/ml. Outcome measurements and statistical analysisTen- and 15-yr cumulative risk of death after diagnosis from PCa, cardiovascular disease, and other causes. Results and limitationsAmong men with a Charlson Comorbidity Index (CCI) score of 0, no differences were found in observed versus expected all-cause mortality in the low-risk group. Observed mortality was only slightly greater in the intermediate-risk group, but men with high-risk localized PCa or more advanced disease had substantially higher mortality than expected. CCI was strongly associated with cumulative 10-yr mortality from causes other than PCa, especially for men <65 yr. Limitations include potential misclassification in risk category due to GS assignment. ConclusionsPCa mortality rates vary 10-fold according to risk category. The risk of death from causes other than PCa is most strongly related to comorbidity status in younger men.

Mortality Among Men with Locally Advanced Prostate Cancer Managed with Noncurative Intent: A Nationwide Study in PCBaSe Sweden

BackgroundThere are limited prognostic data for locally advanced prostate cancer PCa to guide in the choice of treatment. ObjectiveTo assess mortality in different prognostic categories among men with locally advanced PCa managed with noncurative intent. Design, setting, and participantsWe conducted a register-based nationwide cohort study within the Prostate Cancer DataBase Sweden. The entire cohort of locally advanced PCa included 14 908 men. After the exclusion of 2724 (18%) men treated with curative intent, 12 184 men with locally advanced PCa either with local clinical stage T3 or T4 or with T2 with serum levels of prostate-specific antigen (PSA) between 50 and 99 ng/ml and without signs of metastases remained for analysis. MeasurementsWe followed up the patient cohort in the Cause of Death Register for ≤11 yr and assessed cumulative incidence of PCa -specific death stratified by age and clinical characteristics. Results and limitationsThe PCa -specific mortality at 8 yr of follow-up was 28% (95% confidence interval [CI], 25–32%) for Gleason score (GS) 2–6, 41% (95% CI, 38–44%) for GS 7, 52% (95% CI, 47–57%) for GS 8, and 64% (95% CI, 59–69%) for GS 9–10. Even for men aged >85 yr at diagnosis with GS 8–10, PCa was a major cause of death: 42% (95% CI, 37–47%). Men with locally advanced disease and a PSA<4 ng/ml at diagnosis were at particularly increased risk of dying from PCa. One important limitation is the lack of bone scans in 42% of the patient cohort, but results remained after exclusion of patients with unknown metastasis status. ConclusionsThe PCa-specific mortality within 8 yr of diagnosis is high in locally advanced PCa, suggesting undertreatment, particularly among men in older age groups. Our results underscore the need for more studies of treatment with curative intent for locally advanced tumors.

Survival effect of darbepoetin alfa in patients with diffuse large B-cell lymphoma (DLBCL) treated with immunochemotherapy: The LNH03-6B study.

9048 Background: Use of erythropoiesis-stimulating agents (ESAs) in chemotherapy-induced anemia is a major issue. Based on recent studies, FDA has modified labeling for ESAs to include a black box warning that limited prescription to pts receiving chemotherapy for non-curative intent. The GELA has conducted a randomized phase III study to evaluate survival impact of Darbepoetin alfa (DA) in pts with DLBCL treated by chemotherapy. We report results of the second interim analysis, with a median follow-up of 44 months Methods: Pts aged from 60 to 80y with DLBCL and aaIPI≥1 were eligible and randomized between two chemotherapy regimens (R-CHOP14 or R-CHOP21) for 8 cycles and between an investigational arm with DA given to maintain Hb level between 13 and 15 g/dL and a conventional arm with usual management of anemia, including transfusion and ESA. Objective was to evaluate efficacy of DA as measured by PFS, EFS, DFS and OS, and to analyze toxicity Results: 602 pts were included, 600 were evaluable; 238 in DA ...

Survival of patients with oesophago-gastric cancer treated with non-curative intent

Survival of patients with oesophago-gastric cancer treated with non-curative intent

Role of Surgery in High-Risk Localized Prostate Cancer

Men with high-risk localized prostate cancer (PCa) remain a challenge for clinicians. Until recently, surgery was not the preferred approach, in part because risk of subclinical metastatic disease, elevated rates of positive surgical margins, absence of randomized studies, and suboptimal cancer control did not justify the morbidity of surgery. No randomized data comparing surgery with radiation therapy are yet available. Data for and comparisons between treatment options should therefore be analyzed with extreme caution.When selecting the best treatment for patients with clinically localized high-risk PCa, considerations should include the life expectancy of the patient, the natural history of PCa, the curability of the disease, and the morbidity of treatment. High-grade PCa managed with noncurative intent greatly reduces life expectancy, but overall, it must also be remembered that radical prostatectomy (RP) and radiotherapy (RT) appear to have similar effects on quality of life. In this population, RP necessitates an extended pelvic lymph node dissection (PLND), but in selected cases, nerve-sparing is a therapeutic possibility and may offer a significant advantage over rt in terms of local control and-although absolutely not yet proved-maybe even in survival. One clear advantage is the ease of administering adjuvant or salvage external-beam rt (EBRT) after rp; conversely, salvage rp after failed EBRT is an exceedingly difficult surgery, with major complications. Surgery therefore has its place, but must be considered in the context of multimodality treatment and the risk of micrometastatic disease. Awaited trial results will help to further refine management in this group of patients.

Impact of erythropoiesis-stimulating agent prescribing at an Asian cancer center, after release of safety advisories

Erythropoiesis-stimulating agents (ESAs) provide symptom relief and decrease blood transfusion support among patients with chemotherapy-induced anemia. However, due to increased cardiovascular events associated with off-labeled usage of ESAs, the FDA incorporated black box warnings in 2007 to include the following key points: (a) ESAs should be used only to treat anemia due to concomitant chemotherapy of a noncurative intent and (b) target hemogloblin level should not exceed 12 g/dL. Thus, this study was designed to compare the prescribing of epoetin alfa at National Cancer Centre Singapore before and after FDA black box updates. The secondary objective of this study was to evaluate the appropriateness of efficacy and toxicity monitoring of epoetin alfa. This was a retrospective, single-centered, drug utilization review. Patients who received at least one dose of epoetin alfa were included in this study. Utilization of epoetin alfa was segregated into two time periods: January 1, 2005 to October 15, 2007 (S1, Pre-safety advisories changes) and October 16, 2007 to December 10, 2009 (S2, Post-safety advisories changes). A total of 171 patients were prescribed epoetin alfa at NCCS during the two time periods. However, only 139 patients were eligible for analysis, with 91 and 48 patients in S1 and S2 respectively. After safety advisory changes, there were more (18.2%) metastatic patients and fewer (19.1%) patients with cardiovascular co-morbidities who were prescribed epoetin alfa, the mean hemogloblin level when epoetin alfa was initiated was lowered by 0.46 g/dL, more (43%) dose adjustments were made for 'excessive' responders and more (40.7%) patients had fewer blood transfusions after epoetin alfa therapy (p < 0.05). However, blood pressure control, iron studies, and supplementation did not improve (p > 0.05). This study suggested that oncologists have generally adopted the new ESA safety warnings and adjusted prescribing habits.

Impact of race on survival of prostate cancer patients treated with noncurative intent

5069 Background: We previously reported that African American (AA) men have a higher recurrence rate than Caucasian (CA) men treated with radical prostatectomy at the New York Veteran Administration Medical Center (NY-VAMC), an equal access to care facility (J Urol. 2006). In the current study, we attempted to examine the differences in survival of AA and CA prostate cancer (PC) patients with clinically detected localized disease treated with non curative intent. We hypothesized that comparing patients whose PC was not altered by primary treatment might give a better idea about the difference, if any, of the natural history of PC in AA compared to CA patients. Methods: Men diagnosed with PC at NY-VAMC during 1990–2005 were identified. Inclusion criteria were: 1) biopsy confirmed PC; 2) no evidence of metastatic disease within 6 months after diagnosis; 3) no curative intent treatment. Results: The study included 530 men (288 AA and 242 CA) with median follow-up of 8.1 years (range: 0.6–17.6 years). AA men presented with significantly higher PSA compared to CA patients (median 18.5 versus 11.4 respectively, p = 0.004), however, there were no differences in age at presentation (median 73 versus 74, p = 0.98) or Gleason score (23% of AA and CA had Gleason &gt;7, p = 0.92). Of the 530 patients, 198 (37%) are alive with disease, 67 (13%) died of prostate cancer, 206 (39%) died of other causes, and 59 (11%) died of unknown causes. AA patients had shorter median overall survival compared to CA patients (8 versus 9 years, respectively), however, the difference was not significant (p = 0.29). Factors most predictive of mortality by Cox regression multivariable analysis were PSA at diagnosis (p = 0.001), Gleason score (p = 0.04), and age of patient at diagnosis (p &lt; 0.0001). Race was not an independent predictor of mortality in this model (p = 0.37). Competing risk analysis distinguishing the types of death is underway. Conclusions: The extended follow up available for our study cohort points to non PC related mortality as the major cause of death in patients treated with non-curative intent. No significant financial relationships to disclose.