Oncology Perspective Research Articles

The clinical-care focused psychological interview (CLiC): a structured tool for the assessment of cancer patients' needs.

Integrating the psychosocial perspective in oncology is warranted. Here, we introduce a structured psychological intervention, the clinical-care focused psychological interview (CLiC), to address patients’ needs in the relationship with health professionals, clinical pathway and decision-making process. The perceived utility and feasibility of the CLiC were evaluated in a preliminary sample of 30 patients who were candidates to undergo a radical cystectomy at the European Institute of Oncology, Milan, Italy. Patients reported a very high satisfaction with the interview, because it prepared them for their upcoming surgery by gathering more information about their clinical pathway and allowed them to discover the information they still needed. 30% stated that CLiC helped them to reorganise their thoughts and 36.7% understood the role of psychological intervention in the clinical pathway. Only 20% considered the CLiC useful in helping to build their relationship with the clinical staff. Before an invasive surgery such as radical cystectomy, patients’ need for information regarding the upcoming surgery seems to prevail. Knowing the future consequences and adjusting toward the disease could be paramount for patients in facing uncertainty and they might feel that creating a relationship with physicians could be a secondary issue. However, our data show that a structured psychological intervention such as the CLiC interview can collect important information for patients and healthcare professionals to develop real patient-centred care.

Translational considerations in nanomedicine: The oncology perspective.

Nanoparticles can provide effective control of the release rate and tissue distribution of their drug payload, leading to major pharmacokinetic and pharmacodynamic changes vis-à-vis the conventional administration of free drugs. In the last two decades, we have witnessed major progress in the synthesis and characterization of engineered nanoparticles for imaging and treatment of cancers, resulting in the approval for clinical use of several products and in new and promising approaches. Despite these advances, clinical applications of nanoparticle-based therapeutic and imaging agents remain limited due to biological, immunological, and translational barriers. There is a need to make high impact advances toward translation. In this review, we address biological, toxicological, immunological, and translational aspects of nanomedicine and discuss approaches to move the field forward productively. Overcoming these barriers may dramatically improve the development potential and role of nanomedicines in the oncology field and help meet the high expectations.

The Advantages of Robotic Gastrectomy over Laparoscopic Surgery for Gastric Cancer.

We compared short- and long-term clinical outcomes including inflammatory marker levels between robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) to define the advantages of RG over LG. We enrolled 209 patients with gastric cancer who underwent curative distal gastrectomy. We compared short- and long-term clinical outcomes including inflammatory marker levels between RG and LG to define the advantages of RG over LG. C-reactive protein (CRP) levels; the CRP-to-albumin, neutrophil-to-lymphocyte, and platelet-to-lymphocyte ratios; and the prognostic nutritional index were compared as systemic inflammatory markers. RG was associated with a longer operative time. The incidence of postoperative infectious complications of grade II or higher according to the Clavien-Dindo classification was not significantly different between the two groups. Amylase levels in drainage fluid on postoperative days 1 and 3 were significantly lower in the RG group than in the LG group. The incidence of pancreatic fistula in the RG group (4.3%) was lower than that in the LG group (7.5%), albeit without significance. There were no significant differences in inflammatory marker levels either before or after surgery between the two groups. The 3-year overall survival rate did not significantly differ between the RG and LG groups (91.1% vs. 91.1%). Similar results were observed regarding the 3-year disease-specific survival rate (100% vs. 97.1%). RG might be feasible and safe for treating gastric cancer from both surgical and oncological perspectives. The use of robotic assistance is associated with decreased amylase levels in drainage fluid, which may reduce the risk of pancreatic fistula and prevent pancreatic injury.

Radiobiology of stereotactic ablative radiotherapy (SABR): perspectives of clinical oncologists.

Stereotactic ablative radiotherapy (SABR) is a novel radiation treatment method that delivers an intense dose of radiation to the treatment targets with high accuracy. The excellent local control and tolerance profile of SABR have made it become an important modality in cancer treatment. The radiobiology of SABR is a key factor in understanding and further optimizing the benefits of SABR. In this review, we have addressed several issues in the radiobiology of SABR from the perspective of clinical oncologists. The appropriateness of the linear-quadratic (LQ) model for SABR is controversial based on preclinical data, but it is a reliable tool from the perspective of clinical application because the biological effective dose (BED) calculated with it can represent the tumor control probability (TCP). Hypoxia is a common phenomenon in SABR in spite of the relatively small tumor size and has a negative effect on the efficacy of SABR. Preliminary studies indicate that a hypoxic radiosensitizer combined with SABR may be a feasible strategy, but so far there is not adequate evidence to support its application in routine practice. The vascular change of endothelial apoptosis and blood perfusion reduction in SABR may enhance the response of tumor cells to radiation. Combination of SABR with anti-angiogenesis therapy has shown promising efficacy and good tolerance in advanced cancers. SABR is more powerful in enhancing antitumor immunity and works better with immune checkpoint inhibitors (ICIs) than conventional fractionation radiotherapy. Combination of SABR with ICIs has become a practical option for cancer patients with metastases.

Atrial Fibrillation, Cancer and Echocardiography.

Nonvalvular atrial fibrillation (AF) is a relatively frequent arrhythmia in cancer patients; it is possibly due to direct effect of cancer or consequence of cancer therapies. AF creates important problems for both therapeutic management and prognosis in cancer patients. The anticoagulation of cancer patients presenting AF is a main issue because of the difficult balance between thromboembolic and bleeding risks, both elevated in this clinical setting. A comprehensive echo Doppler examination is mandatory to identify the eventual sources of emboli in left atrial (LA) cavity, mainly the transesophageal echocardiography (TEE), but also to predict the subsequent development of heart failure. This evaluation is particularly important to graduate anticoagulation and to prevent and manage symptoms/signs of heart failure. The performance of a TEE precardioversion is highly encouraged to detect possible thrombi in LA appendage. A careful assessment of LA size (LA volume index) and function (LA emptying fraction and/or LA strain) should always be planned to predict the possible recurrence of AF paroxysmal episodes. This is in fact a key action, not only from the cardiologic point of view but also for the oncologic perspectives in individual situations. Patients with larger left atrium and more impaired LA function should be addressed toward a less aggressive cancer treatment, with drugs which are not associated or are poorly related with the risk of AF development. A correct and comprehensive echocardiographic assessment could even induce the oncologist to change the cancer management balancing the oncologic and the cardiac risk.

Management of advanced melanoma in the current era: A medical oncology perspective for the Indian scenario.

Malignant melanoma is an aggressive malignancy with high recurrence rates after curative surgery and in advanced stages is characterized by resistance to conventional chemotherapy. With better understanding of the genomic landscape and mutational signature of these tumours over the past decade, there has been a paradigm shift in management of melanoma using immunotherapy (anti-PD-1 and anti-CTLA-4 antibodies) and targeted drugs against BRAF and MEK. These drugs have shown survival benefits in both adjuvant and metastatic setting with patients being eligible for immunotherapy irrespective of any biomarker. However, these drugs have varying toxicity profiles and there are no studies comparing these two classes of drugs in either the adjuvant or metastatic setting leaving the question of sequencing open to clinical judgement. Moreover, availability and cost are issues that need to be considered before use of these drugs in the Indian setting.

Management of rheumatic complications of immune checkpoint inhibitor therapy - an oncological perspective.

Immune checkpoint inhibitors (CPIs) are an effective treatment for many cancers but cause diverse immune-related adverse events (IrAEs). Rheumatological IrAEs include arthralgia, arthritis, tenosynovitis, myositis, polymyalgia rheumatica and sicca syndrome. CPI use can unmask RA as well as causing flares of prior autoimmune or connective tissue disease. Oncologists categorize and grade IrAEs using the Common Terminology Criteria for Adverse Events and manage them according to international guidelines. However, rheumatological events are unfamiliar territory: oncologists need to work with rheumatologists to elicit and assess symptoms, signs, results of imaging and autoantibody testing and to determine the use of steroids and DMARDs. Myositis may overlap with myasthenic crisis and myocarditis and can be life-threatening. Treatment should be offered on balance of risk and benefit, including whether to continue CPI treatment and recognizing the uncertainty over whether glucocorticoids and DMARDs might compromise cancer control.

Toward Improving Practices for Submission of Diagnostic Tissue Blocks for National Cancer Institute Clinical Trials.

The National Cancer Institute (NCI) National Clinical Trials Network performs phase II and III clinical trials, which increasingly rely on the submission of diagnostic formalin-fixed, paraffin-embedded tissue blocks for biomarker assessment. Simultaneously, advances in precision oncology require that clinical centers maintain diagnostic specimens for ancillary, standard-of-care diagnostics. This has caused tissue blocks to become a limited resource for advancing the NCI clinical trial enterprise and the practice of modern molecular pathology. The NCI convened a 1-day workshop of multidisciplined experts to discuss barriers and strategic solutions to facilitate diagnostic block submission for clinical trial science, from the perspective of patient advocates, legal experts, pathologists, and clinical oncologists. The expert views and opinions were carefully noted and reported. Recommendations were proposed to reduce institutional barriers and to assist organizations in developing clear policies regarding diagnostic block submission for clinical trials.

Improvement of the anti-proliferative activity of the peptide ERα17p in MCF-7 breast cancer cells using nanodiamonds

Nanodiamonds (NDs) are emerging delivery systems with biomedical applications and interesting perspectives in oncology. Their use has been proposed to assist the internalization of anticancer drugs and to decrease administered drug doses. The pro-apoptotic peptide ERα17p, which is issued from the hinge/N-terminus parts of the AF2 region of the human estrogen receptor α (ERα), is active at a concentration of 10μM on breast cancer cells and particularly on those cancer cells that are ERα-positive. We have synthesized ND@ERα17p conjugates by physisorption of the cationic peptide ERα17p on the surface of anionic NDs. Resulting ND@ERα17p suspensions were characterized by far-UV electronic circular dichroism (ECD), dynamic light scattering (DLS) and zetametry. We then tested the anti-proliferative action of ND@ERα17p on ERα-positive MCF-7 breast carcinoma cells. ND@ERα17p allowed a decrease of the active concentration to 0.1nM (ND@ERα17p), revealing unambiguously that NDs could be used to improve the anti-proliferative action of this peptide. This preliminary study proposes a novel approach for enhancing the apoptotic action displayed by ERα17p, in the context of breast cancer.

Development of an MCDA framework for evaluation and positioning of oncological treatments in clinical practice.

95 Background: Ensuring that effective innovations are accessible in a timely and affordable manner to all cancer patients is a challenge that stakeholders face today. Several oncology frameworks (ASCO, ESMO, ICER, NCCN) have been developed to define and quantify the value of oncological therapies to support clinicians and patients at the time of selection and as a basis for decision-making. However, current frameworks only define treatment value in terms of clinical benefit, creating a need for one that allows holistic evaluation of treatments and supports decision-making in clinical practice. The ECO Foundation led this study to develop a reflective multi-criteria decision analysis (MCDA) based framework for evaluation and positioning of new oncological drugs from the clinical oncology perspective. Methods: The framework was developed following EVIDEM methodology. Systematic literature review was performed to identify most relevant criteria used for evaluation of innovative treatments to complement the EVIDEM V4.0 framework. The criteria compendium was presented to a group of clinical oncologists from ECO. The Expert Group assessed each criterion for its inclusion in the framework and suggested modifications in their definition and/or response scale. This framework was then tested with two case studies (Abemaciclib for metastatic HER-/HR+ breast cancer and TAS for metastatic colorectal cancer). The objective was to validate the criteria selected alongside their definitions and response scale with practical examples. A reflective discussion based on the score assigned to each criterion was also carried out. Results: Out of 15 criteria presented to the Expert Group, 8 were included in the final framework, and definition and/or response scale of 7 of these criteria were modified: Disease severity, Unmet needs, Efficacy comparison, Safety/tolerability comparison, Treatment intention, Treatment cost comparison, Comparison of other medical costs and Quality of evidence. Conclusions: A reflective MCDA framework has been developed and validated, based on the value of the treatment, for assessment and positioning of oncological therapies in the context of clinical practice in Spain.

Postoperative nonalcoholic fatty liver disease is correlated with malnutrition leading to an unpreferable clinical course for pancreatic cancer patients undergoing pancreaticoduodenectomy.

This study aimed to clarify the impact of postoperative nonalcoholic fatty liver disease (NAFLD) on the clinical course of patients with pancreatic ductal adenocarcinoma (PDAC). One hundred and eight patients with pancreatic cancer undergoing pancreaticoduodenectomy (PD) with curative intent in between 2005 and 2016 were enrolled in this study. Post-PD NAFLD was assessed by computed tomography (CT), which was routinely performed at 3months, 6months, and 1year after surgery. The clinical impact of post-PD NAFLD was examined from an oncological perspective. There were 50 (46.2%) post-PD NAFLD patients. The NAFLD group showed significantly lower CT values at 3months, 6months, and 1year after surgery than those without NAFLD. Patients with NAFLD showed significant body weight loss and a decrease in serum albumin level after surgery compared with those without NAFLD. Consequently, the 70% completion rate of adjuvant chemotherapy with gemcitabine, but not S1, was significantly lower in the NAFLD group than in the non-NAFLD group. The 5-year overall survival and disease-free survival rates were comparable between the two groups. Post-PD NAFLD was associated with malnutrition in patients with PDAC, reducing their tolerance to gemcitabine-based adjuvant chemotherapy. Post-PD NAFLD needs to be emphasized and requires special nutritional intervention in patients with PDAC.

The PERSONS score: A new tool for cancer patients' symptom assessment in simultaneous care and home care settings.

Scientific societies recommend early interaction between oncologic and supportive care, but there is still a lack of systematic evaluations regarding symptoms from the perspective of oncologists. The aim of this prospective study was to evaluate the PERSONS score, in both "simultaneous care" and "supportive care" settings using the Edmonton Symptom Assessment Scale (ESAS) as a comparator. From November 2017 to April 2018, 67 and 110 consecutive patients were enrolled in outpatient and home care cohorts, respectively. The final study population comprised 163 patients. There were no significant changes over time in the total PERSONS scores and total ESAS scale. The intra-interviewer reliability (ICC2,1) and inter-interviewer reliability (ICC2,k) showed good reproducibility (test-retest) in each group of patients: 0.60 (0.49-0.70) and 0.82 (0.75-0.87), respectively, for the home care patients and 0.73 (0.62-0.81) and 0.89 (0.83-0.93), respectively, for the outpatient cohort. There were high correlations between PERSONS and ESAS, both at the baseline and final assessments. The mean PERSONS and ESAS scores between the home care patients and outpatients were not different at the baseline and final assessments. Receiver operating characteristics (ROC) curve for the PERSONS total score revealed good diagnostic ability. Area under the curve (AUC) was 0.825 and 0.805 for improvement and deterioration, respectively. The PERSONS score is an easy to apply tool for symptom assessment. Importantly, the PERSONS score showed high concordance with the established ESAS scale and, therefore, provides an alternative for everyday use in supportive care assessment.

Where Do We See Alpha Emitters in Clinical Practice? A Radiation Oncology Perspective

Alpha emitters have always promised to deliver potential benefit in cancer therapy. Using the example of radium-223 (Xofigo) and the paradigm of ionising radiation, this review looks at targeted alpha therapy from the perspective of a radiation oncologist.

The Role of Standard and Advanced Imaging for the Management of Brain Malignancies From a Radiation Oncology Standpoint.

Radiation therapy (RT) plays a critical role in the overall management of many central nervous system (CNS) tumors. Advances in RT treatment planning, with techniques such as intensity modulated radiation therapy, volumetric modulated arc therapy, and stereotactic radiosurgery, now allow the delivery of highly conformal dose with great precision. These techniques rely on high-resolution 3-dimensional anatomical imaging modalities such as computed tomography or magnetic resonance imaging (MRI) scans to accurately and reliably define CNS targets and normal tissue avoidance structures. The integration of cross-sectional imaging into radiation oncology has directly translated into improvements in the therapeutic window of RT, and the union between radiation oncology and imaging is only expected to grow stronger. In addition, advanced imaging modalities including diffusion, perfusion, and spectroscopic MRIs as well as positron emission tomography (PET) scans with novel tracers are being utilized to provide additional insight into tumor biology and behavior beyond anatomy. Together, these standard and advanced imaging modalities hold significant potential to improve future RT delivery and response assessment. In this review, we will discuss the current utilization of standard/advanced imaging for CNS tumors from a radiation oncology perspective as well as the implications of novel MRI and PET modalities currently under investigation.

Diagnosis and management of brain metastases: an updated review from a radiation oncology perspective

Journal of Cancer Metastasis and Treatment is an open access journal, focusing on basic and clinical studies related to cancer cell, cell biology, oncology, radiation therapy and radiology, obstetrics and gynecology, pediatrics, surgery, hematology, neuro-oncology, etc.

A skin tumor from an orthopedic oncology perspective: Pilomatrixoma in extremities (11 years experience with 108 cases).

Pilomatrixoma, also known as calcifying epithelioma of Malherbe, is a benign skin neoplasm originating from hair follicle matrix cells. Pilomatrixoma is a common skin neoplasm that is often misdiagnosed as another type of skin condition. The aim of our study is to review 11 years' worth of experience in examining clinical and histopathological presentations, imaging findings, management approaches, and treatment outcomes of pilomatrixoma at a tertiary hospital. A review of the pathology database revealed that 108 extremity pilomatrixomas were excised between 2007 and 2018. Hospital charts, and pathology and orthopedic clinic records, were reviewed for patient data such as age, gender, clinical and histopathological presentations, preoperative diagnosis and imaging results, management approach, recurrence, and treatment outcomes. The main presenting symptom was a hard, subcutaneous, slowly growing mass. The preoperative diagnosis was accurate and consistent with the pathological diagnosis of pilomatrixoma in only 35 cases (32%). The optimal diagnostic tool for pilomatrixoma seems to be ultrasound imaging of superficial tissue, and the optimal first-line treatment might be surgical excision with clear margins. However, pilomatrixoma is a benign tumor, with atypical forms, and there no tumor-specific diagnostic tool is available other than careful histopathological examination.

Rhenium-188 Labeled Radiopharmaceuticals: Current Clinical Applications in Oncology and Promising Perspectives.

Rhenium-188 (188Re) is a high energy beta-emitting radioisotope with a short 16.9 h physical half-life, which has been shown to be a very attractive candidate for use in therapeutic nuclear medicine. The high beta emission has an average energy of 784 keV and a maximum energy of 2.12 MeV, sufficient to penetrate and destroy targeted abnormal tissues. In addition, the low-abundant gamma emission of 155 keV (15%) is efficient for imaging and for dosimetric calculations. These key characteristics identify 188Re as an important therapeutic radioisotope for routine clinical use. Moreover, the highly reproducible on-demand availability of 188Re from the 188W/188Re generator system is an important feature and permits installation in hospital-based or central radiopharmacies for cost-effective availability of no-carrier-added (NCA) 188Re. Rhenium-188 and technetium-99 m exhibit similar chemical properties and represent a “theranostic pair.” Thus, preparation and targeting of 188Re agents for therapy is similar to imaging agents prepared with 99mTc, the most commonly used diagnostic radionuclide. Over the last three decades, radiopharmaceuticals based on 188Re-labeled small molecules, including peptides, antibodies, Lipiodol and particulates have been reported. The successful application of these 188Re-labeled therapeutic radiopharmaceuticals has been reported in multiple early phase clinical trials for the management of various primary tumors, bone metastasis, rheumatoid arthritis, and endocoronary interventions. This article reviews the use of 188Re-radiopharmaceuticals which have been investigated in patients for cancer treatment, demonstrating that 188Re represents a cost effective alternative for routine clinical use in comparison to more expensive and/or less readily available therapeutic radioisotopes.

Transplantation versus liver resection in patients with hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is one of the most common solid cancers in the world. Its treatment strategies have evolved significantly over the past few decades but the best treatment outcomes remain in the surgical arena. Especially for early HCCs, the options are abundant. However, surgical resection and liver transplantation provide the best long-term survival. In addition, there are evidence the ablative therapy such as radiofrequency ablation, could provide equivalent outcome as compared to resection. However, HCC is a unique malignancy as the majority of patients develop this cancer in the background of cirrhotic livers. As such, the treatment consideration should not only look at the oncological perspective but also the functional status of the liver parenchyma, i.e., the state of cirrhosis and presence of portal hypertension. Even with the most widely adopted staging systems for HCC such as the Barcelona Clinic Liver Cancer (BCLC) staging system and many other staging systems, none of them are ideal in including the various considerations for patients with HCCs. In this article, the key issues between choosing surgical resection and liver transplantation are discussed. A comprehensive review of the current surgical options are outlined in order to explore the pros and cons of each option.

Responses to a cancer diagnosis: a qualitative patient-centred interview study.

A cancer diagnosis is an emotive and challenging time for patients. This study aimed to systematically explore patients' accounts of experiencing their cancer diagnosis. The purpose of this article is to offer a typology of patient responses to receiving a cancer diagnosis as a means through which to affirm the range of patients' experiences and to guide clinicians' practice. Qualitative semi-structured interviews were conducted between 2015 and 2017 with 80 patients living with cancer: 34 females and 46 males, aged between 31 and 85, diagnosed with a range of cancer types, stages and treatment trajectories, from two metropolitan hospitals on the east coast of Australia. Interview data were analysed thematically, using the framework approach. A typology of responses to the cancer diagnosis was derived from the analysis and included (1) the incongruent diagnosis, unexpected because it did not 'fit' with the patient's 'healthy' identity; (2) the incidental diagnosis, arising from seemingly unrelated or minor medical investigations; (3) the validating diagnosis, as explanation and confirmation of previously unexplained symptoms, pain or feelings; (4) the life context diagnosis, where the cancer diagnosis was positioned relative to other challenging life events, or as relatively inconsequential compared with the hardship of others. A diagnosis of cancer is not always (or only) experienced by patients with shock and despair. Diagnosis is perceived and experienced in diverse ways, shaped by broader social or life contexts, and with important implications for the clinical encounter and communication from an oncology perspective.

BPI19-021: Medical Oncologist Perspectives of the Veterans Affairs National Precision Oncology Program

Background: Genomic sequencing of tumor samples is often considered for patients diagnosed with metastatic malignancies. In July 2016, the Veterans Health Administration (VHA) created the VA National Precision Oncology Program (NPOP) to offer next generation sequencing (NGS) multigene panels for veterans with advanced solid tumors. We sought to assess the perceptions of NPOP among medical oncologists across VHA. Methods: Semi-structured interviews were designed to evaluate the following concepts: expectations for NGS testing, required workflow to conduct testing, applicability of testing results, and summative views of genomic sequencing. VHA medical oncologists who had previously sent at least one sample for testing through NPOP were solicited to participate for an in-person or telephonic conversation. Interviews were analyzed by an inductive narrative approach to code responses, which was then followed by thematic analysis for key findings that emerged. Results: 17 medical oncologists were interviewed from 16 different VA medical centers (VAMCs) in 12 states. 16 (94.1%) oncologists reported sending at least 5 samples for NGS testing; 4 (23.5%) oncologists practiced at VAMCs that sent over 100 samples. Clinicians collectively expected that testing would determine all clinically relevant genomic alterations in a reasonable time. Testing was expedited for oncologists who maintained a collaborative relationship with their local pathologists and proceduralists. 8 (47.1%) oncologists felt that testing reports should provide greater insight into the clinical significance of uncommon gene variants. 6 (35.3%) respondents expressed that educational efforts are warranted to describe optimal sample processing, indications for testing, and/or relevance of rare mutations. Twelve (70.6%) respondents felt strongly that NGS testing would improve outcomes for their patients, while 3 (17.6%) oncologists were wary that the current number of actionable mutations is too limited to offer widespread benefit. Conclusions: VHA medical oncologists opined that NGS testing through VA NPOP improved outcomes. The testing process is expedited with multidisciplinary involvement. Designed approaches to semi-algorithmically report testing results may improve efficiency of clinical decision-making. More education is warranted to detail the procedural requirements to conduct testing, indications for test ordering, and interpretation of results.