Surgery News - December 2007 - (Page 7)

DECEMBER 2007 • SURGERY NEWS ONCOLOGY Margins, Other Risks Assessed Radiation • from page 1 however, recurrence rates fell from 13% to 4% (P = .0001) in women with invasive tumors, and from 15% to 6% in those with DCIS (P = .0001). For women with high-grade tumors, local recurrence rates dropped from 19% to 7% (P = .002) in those with high-grade invasive disease and from 17% to 5% (P less than .0001) in those with high-grade DCIS, Dr. Jones reported. Margin involvement predicted greater risk of recurrence in a univariate analysis of the data, but dropped out when the investigators did a multivariate Cox regression analysis. Dr. Jones identified two positive prognostic factors favoring freedom from recurrence: age greater than 50 years (hazard ratio 0.41, P less than .0001) and receiving the boost (HR 0.56, P = .002). Only two factors predicted increased risk of recurrence: high-grade DCIS (HR 1.51, P = .03) and high-grade invasive tumor (HR 1.86, P = .003). “Age was the most striking risk factor for local recurrence,” Dr. Jones said. “Having a high grade of invasive tumor seems to be a more important prognostic factor than margin involvement. The boost dose reduces the effects of margin involvement, and substantially reduces the risk of local recurrence in our high-risk patients.” ■ Gy boost to the tumor bed, while the remainder had no further radiation. Trial investigators reported that the boost reduced cumulative local recurrence from 12% to 7% overall at a medium follow-up of 10.8 years, with the greatest reduction in absolute risk observed in women 40 years of age or less: 23.9% to 13.5%. Severe fibrosis did increase from 1.6% to 4.4% with the boost. Ten-year survival was the same, 82%, in both groups ( J. Clin. Oncol. 2007;25:3259-65). To assess the impact of margins and other risk factors, investigators conducted a subgroup analysis of 1,724 patients. A central pathology review reported by Dr. Heather A. Jones at ASTRO showed that 78% (1,345 women) had negative margins, 12% (207) had close margins, and 7% (120) had positive margins (the remaining 3% were not classified). The boost did not make a significant impact in patients without margin involvement, according to Dr. Jones, who did the analysis while a visiting clinician in the Netherlands and is now at the University of Pittsburgh. Radiating the tumor bed reduced the local recurrence rate from 6% to 5% if these patients had invasive disease and from 7% to 6% if they had DCIS. For patients with margin involvement, Preop Radiation Stretches Pancreatic Cancer Survival BY JANE SALODOF MACNEIL Else vier Global Medical Ne ws L O S A N G E L E S — Preoperative radiation was associated with longer median survival for patients with resectable pancreatic cancer in a retrospective study of 3,885 cases in the National Cancer Institute’s Surveillance, Epidemiology, and End Results registry. Only 85 patients received neoadjuvant radiation, a controversial treatment, but their median survival was 23 months vs. 17 months for 1,628 patients given postoperative radiation. Both radiation treatment groups fared far better than the 2,172 patients who received no radiotherapy and had a median survival of only 2 months. The survival advantage with neoadjuvant radiation was significant whether compared with both alternatives (postoperative radiation and no radiation; hazard ratio 0.55, P = .001) or to postoperative radiation alone (HR 0.63, P = .03). Alexander M. Stessin, a student in the Tri-Institutional MD/PhD Program in New York, reported the data at the annual meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO). His coinvestigators were Dr. Joshua E. Meyer of New York–Presbyterian Hospital and Dr. David L. Scherr of that hospital and Cornell University, both in New York. Mr. Stessin and his coauthors selected pancreatic cancer patients in the SEER database who underwent complete resection from 1988 to 2003. The study excluded patients with stage III or IV disease, multiple primary malignancies, and missing observations. The authors also reported that analysis showed patients lived longer if they were white, under age 60, had a well- or moderately differentiated grade of tumor or earlier stage disease, and/or were diagnosed in a more recent year. The poster drew praise from Dr. Theodore M. Lawrence, chair of radiation oncology at the University of Michigan, Ann Arbor, and a former president of ASTRO. Most of the radiotherapy patients probably had chemoradiation, he suggested, because postoperative chemoradiation is the standard of care in the U.S. and chemotherapy data are not available from the SEER registry. ■ Incidence of VTE Rises 28% in Hospitalized Cancer Patients of a perception that oncologists were see- counter anemia also might play a role, he national patient registries with relevant clinical data.” ing more thrombosis in their patients. speculated. Thrombosis was associated with greater Dr. Kaasa referred to a published study They wanted to know if this were true, C H I C A G O — The incidence of venous and, if so, which patients were most at ( J. Natl. Cancer Inst. 2006;98:708-14) and inpatient mortality throughout the 8 years thromboembolism in hospitalized cancer risk. A grant from the National Cancer In- to European Organization for Research studied by Dr. Khorana and his colleagues. and Treatment of Cancer guidelines that Despite an overall decrease in mortality patients rose by nearly a third from 1995 stitute supported the review. The retrospective cohort study mined warn of an increased risk of thrombosis or over time, mortality was consistently about to 2003, according to a review of more discharge records for 1,824,316 hospital- thrombosis-related complications associ- 10 percentage points higher in patients than a million discharge summaries. izations at 133 academic med- ated with erythropoiesis-stimulating with VTE than in other patients, he said. The overall incidence of veBy tumor site, the incidence of VTE ical centers in the database of agents. He also cited the Food and Drug nous thromboembolism (VTE) the University Health System Administration oncology panel’s recent was highest for pancreatic cancer (8.2%). was 4.1% for all 1,015,598 paConsortium. For patients with call for more studies of, and more restric- Myeloma had the highest rate (5%) among tients in the study, with the hematologic malignancies. (See box.) multiple hospitalizations, the tions on, these agents. rate increasing from 3.6% in Cancer patients with renal disease had “Large epidemiological studies like this investigators only used one 1995-1996 to 4.6% in 2002hospitalization, selected at ran- may give important insight into treatment a VTE rate of 7.6%. In patients with in2003. A near doubling of the indom, to avoid overestimating success, side effects, and even failure,” Dr. fection, the rate was almost as high: 7.4%. cidence of pulmonary emKaasa said. More needs to be done to Other high-risk comorbidities were arterthe frequency of VTE. bolism, from 0.8% to 1.5%, Possible causes for rising VTE identify late, unexpected side effects: ial thromboembolism (6.8%), anemia appeared to drive the increase, as the incidence of deep ve- The chemotherapy rates could be more sensitive “Maybe one solution could be to establish (6.2%), pulmonary disease (5.9%), congestive heart failure (5.7%), screening tools nous thrombosis went up only that is used now and diabetes melitis (4.5%). and changes in slightly. combined with Incidence of Venous Thromboembolism Analysis by ethnicity chemotherapy, Among a subgroup of biologics is showed black patients to be Dr. Khorana 141,845 patients hospitalized partially In Cancer Patients especially vulnerable to VTE; said. “Our feelfor chemotherapy, the inciresponsible. Solid Tumors they had an overall rate of ing is that the dence of VTE increased from DR. KHORANA Pancreatic 8.2% 5.1%. The rate was 4.0% in type of chemo3.9% to 5.7%. Both increasOther noncolorectal 6.6% whites and Hispanics, and es—the overall rise in pulmonary em- therapy that is used now GI cancers Kidney 3.3% in Asians. Other demo5.7% bolism and the comparable surge in VTE combined with biologics is graphic risk factors included among chemotherapy patients—were sta- partially responsible.” 5.6% Ovarian being 65 years of age or oldIn a discussion of the tistically significant (P less than .0001). 5.1% Lung er (4.4% vs. 3.9% of younger “Any patients with cancer who are ad- poster, Dr. Stein Kaasa of Stomach 4.9% patients) or a woman (4.3% mitted to a hospital should be considered St. Olavs University Hospivs. 4.0% of men). at highest risk of VTE,” Dr. Alok A. Kho- tal in Trondheim, Norway, Hematologic Tumors Myeloma The investigators did not 5.0% rana said in an interview at the annual said that contributing fachave access to information on meeting of the American Society of Clin- tors could include type of Non-Hodgkin’s lymphoma 4.8% VTE prophylaxis, but advoical Oncology, where he presented the chemotherapy, combinaHodgkin’s disease 4.6% cated for its use. “Efforts to retions of agents, and treatdata in a poster. duce mortality in hospitalized Dr. Khorana and his colleagues at the ment intensity. The use of Note: Based on a study of discharge records for 1,824,316 hospitalized cancer patients must include James P. Wilmot Cancer Center at the Uni- erythropoietic agents epocancer patients. strategies for thromboproversity of Rochester (N.Y.) Medical Cen- etin alfa (Procrit) and darSource: Dr. Khorana phylaxis,” they concluded. ■ ter undertook the study, he said, because bepoetin alfa (Aranesp) to BY JANE SALODOF MACNEIL Else vier Global Medical Ne ws ELSEVIER GLOBAL MEDICAL NEWS

Table of Contents Feed for the Digital Edition of Surgery News - December 2007

Surgery News - December 2007 Contents Breast Radiation Boost Cuts Cancer Recurrence Mortality Soars in Some Patients With Respiratory Distress New Codes Promote Alcohol Screening New Ideas News From the College: Quality Standards General Surgery: Helping Hand Trauma: Spleen Protocol

Surgery News - December 2007

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