This document discusses adjuvant chemotherapy for colorectal cancer. It finds that for stage III cancer, 6 months of FU-FA + oxaliplatin is the standard treatment, based on evidence from trials like MOSAIC showing a 5-6% improvement in disease-free and overall survival rates. For stage II cancer, evidence is less clear but trials like QUASAR showed a small (~3%) overall survival benefit from chemotherapy. The document questions whether shorter treatment durations could be equally effective.
1) Adjuvant chemotherapy is recommended for stage III colon cancer and high-risk stage II cancer to reduce the risk of recurrence. 2) For stage III, 5-FU plus folinic acid or capecitabine are standard options, while adding oxaliplatin to these regimens may provide additional benefit. 3) The value of adjuvant therapies like bevacizumab, cetuximab, and irinotecan is still unclear, with studies showing mixed results.
This document discusses adjuvant chemotherapy for stage III colon cancer. It summarizes several key studies showing improved disease-free and overall survival when oxaliplatin is added to 5-fluorouracil (5FU) chemotherapy. While all prognostic subgroups appear to benefit, the benefit may be less for older patients. Currently, there are no definitive clinical markers that can identify which stage III colon cancer patients do not benefit from oxaliplatin-based adjuvant therapy. The decision to use oxaliplatin should be individualized based on risk factors and patient preferences.
1) The document discusses several studies evaluating different adjuvant chemotherapy regimens for stage III colon cancer.
2) The X-ACT trial found that capecitabine (Xeloda) resulted in superior disease-free survival and a trend towards improved overall survival compared to bolus 5-FU/LV, with a better safety profile.
3) The MOSAIC trial showed that adding oxaliplatin (FOLFOX) to 5-FU/LV improved overall survival compared to 5-FU/LV alone in stage III colon cancer patients.
4) The XELOXA trial found that capecitabine plus oxaliplatin (XELOX) resulted in
This document summarizes information about radiotherapy for non-small cell lung cancer (NSCLC). It discusses the role of radiotherapy for early, locally advanced, and metastatic NSCLC. It describes stereotactic body radiotherapy (SBRT) for early-stage disease and concurrent chemoradiotherapy (CTRT) for locally advanced stages. It also reviews evidence on optimal radiotherapy techniques and dosing, as well as trials investigating induction, consolidation, and adjuvant chemotherapy combined with radiotherapy.
Treating Human Cancers with Medicinal Mushroom Preparations (Croatian Experie...Neven Jakopovic
This scientific presentation details the results of a 3 year human cohort study of 51 cases of colorectal adenocarcinoma and 105 cases of breast cancer, where medicinal mushroom extracts from Myko San company have been used in conjunction with the usual oncological therapy.
The regimen showed clear, dose-dependent benefits to including appropriate medicinal mushroom extracts for improved cancer status, survival and reduction of therapy side effects.
This work was presented by Dr. Ivan Jakopovic at the 4th International Medicinal Mushroom Conference in Ljubljana, Slovenia, in 2007.
This document summarizes evidence for adjuvant and neoadjuvant chemotherapy in non-small cell lung cancer (NSCLC). Meta-analyses show adjuvant cisplatin-based chemotherapy improves 5-year survival by 4-5% after surgery for stages II-III NSCLC. Individual trials also found benefits, though some only for certain stages. Neoadjuvant chemotherapy may improve survival by 5% at 5 years for resectable stage IIIA NSCLC. Ongoing trials aim to personalize chemotherapy based on biomarkers and add targeted therapies.
This is an overview of the adjuvant Tx of pancreatic CA. A Lecture that was given in the annual conference of NCI Egypt: 45 years against cancer in Egypt. Cairo, April, 2013
This document provides information on a case presentation of anal squamous cell carcinoma, including staging, diagnostic workup, management, prognostic factors, and follow up. Key points include:
- The mean age of diagnosis is 62 years and most common symptom is rectal bleeding. Imaging includes CT, MRI, and PET scans to stage disease.
- Treatment depends on disease stage but typically involves chemoradiation with concurrent 5-FU and mitomycin C or cisplatin. Several trials have shown improved outcomes with chemoradiation compared to radiation alone.
- Follow up involves examination and imaging to monitor for recurrence or metastasis. Prognostic factors include tumor size, response to initial treatment, and presence of late
1) Adjuvant chemotherapy is recommended for stage III colon cancer and high-risk stage II cancer to reduce the risk of recurrence. 2) For stage III, 5-FU plus folinic acid or capecitabine are standard options, while adding oxaliplatin to these regimens may provide additional benefit. 3) The value of adjuvant therapies like bevacizumab, cetuximab, and irinotecan is still unclear, with studies showing mixed results.
This document discusses adjuvant chemotherapy for stage III colon cancer. It summarizes several key studies showing improved disease-free and overall survival when oxaliplatin is added to 5-fluorouracil (5FU) chemotherapy. While all prognostic subgroups appear to benefit, the benefit may be less for older patients. Currently, there are no definitive clinical markers that can identify which stage III colon cancer patients do not benefit from oxaliplatin-based adjuvant therapy. The decision to use oxaliplatin should be individualized based on risk factors and patient preferences.
1) The document discusses several studies evaluating different adjuvant chemotherapy regimens for stage III colon cancer.
2) The X-ACT trial found that capecitabine (Xeloda) resulted in superior disease-free survival and a trend towards improved overall survival compared to bolus 5-FU/LV, with a better safety profile.
3) The MOSAIC trial showed that adding oxaliplatin (FOLFOX) to 5-FU/LV improved overall survival compared to 5-FU/LV alone in stage III colon cancer patients.
4) The XELOXA trial found that capecitabine plus oxaliplatin (XELOX) resulted in
This document summarizes information about radiotherapy for non-small cell lung cancer (NSCLC). It discusses the role of radiotherapy for early, locally advanced, and metastatic NSCLC. It describes stereotactic body radiotherapy (SBRT) for early-stage disease and concurrent chemoradiotherapy (CTRT) for locally advanced stages. It also reviews evidence on optimal radiotherapy techniques and dosing, as well as trials investigating induction, consolidation, and adjuvant chemotherapy combined with radiotherapy.
Treating Human Cancers with Medicinal Mushroom Preparations (Croatian Experie...Neven Jakopovic
This scientific presentation details the results of a 3 year human cohort study of 51 cases of colorectal adenocarcinoma and 105 cases of breast cancer, where medicinal mushroom extracts from Myko San company have been used in conjunction with the usual oncological therapy.
The regimen showed clear, dose-dependent benefits to including appropriate medicinal mushroom extracts for improved cancer status, survival and reduction of therapy side effects.
This work was presented by Dr. Ivan Jakopovic at the 4th International Medicinal Mushroom Conference in Ljubljana, Slovenia, in 2007.
This document summarizes evidence for adjuvant and neoadjuvant chemotherapy in non-small cell lung cancer (NSCLC). Meta-analyses show adjuvant cisplatin-based chemotherapy improves 5-year survival by 4-5% after surgery for stages II-III NSCLC. Individual trials also found benefits, though some only for certain stages. Neoadjuvant chemotherapy may improve survival by 5% at 5 years for resectable stage IIIA NSCLC. Ongoing trials aim to personalize chemotherapy based on biomarkers and add targeted therapies.
This is an overview of the adjuvant Tx of pancreatic CA. A Lecture that was given in the annual conference of NCI Egypt: 45 years against cancer in Egypt. Cairo, April, 2013
This document provides information on a case presentation of anal squamous cell carcinoma, including staging, diagnostic workup, management, prognostic factors, and follow up. Key points include:
- The mean age of diagnosis is 62 years and most common symptom is rectal bleeding. Imaging includes CT, MRI, and PET scans to stage disease.
- Treatment depends on disease stage but typically involves chemoradiation with concurrent 5-FU and mitomycin C or cisplatin. Several trials have shown improved outcomes with chemoradiation compared to radiation alone.
- Follow up involves examination and imaging to monitor for recurrence or metastasis. Prognostic factors include tumor size, response to initial treatment, and presence of late
This document summarizes a presentation on rare central nervous system (CNS) cancers. It discusses molecular markers in gliomas, treatment with antiangiogenic drugs like bevacizumab, and management of low-grade tumors. It also reviews studies on chemotherapy for recurrent and newly diagnosed low-grade gliomas, ongoing clinical trials, and risks of distant spread with bevacizumab treatment.
This document summarizes the debate around providing adjuvant chemotherapy following neoadjuvant chemoradiotherapy for rectal cancer. It outlines the current treatment approaches and evidence for and against adjuvant chemotherapy. Studies have shown conflicting results as to whether adding oxaliplatin to adjuvant chemotherapy improves outcomes. Large trials comparing adjuvant chemotherapy to observation alone did not find significant differences in survival or recurrence, though a meta-analysis found a small improvement in disease-free survival with chemotherapy. The author concludes that for locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy, adjuvant chemotherapy is indicated for high-risk pathologic stage II/III tumors but the benefits are less clear for lower-risk cases.
This document discusses treatment approaches for locally advanced non-small cell lung cancer (NSCLC). It presents a case of stage IIIB NSCLC and reviews the history and evolution of combined modality therapy using chemotherapy and radiotherapy. Concurrent chemoradiotherapy is now the standard of care and research focuses on optimizing radiotherapy dose/fractionation and integrating targeted therapies and prophylactic cranial irradiation to further improve outcomes.
Multimodality Treatment Of Stage Iii Nsclcfondas vakalis
1) Multimodality treatment including chemotherapy and radiotherapy has improved outcomes for stage III non-small cell lung cancer (NSCLC) over the past decade, increasing median survival by 5 months and 1-2 year survival by 10%.
2) Induction chemotherapy with a platinum agent and third-generation drug for 2-3 cycles followed by radiotherapy remains a good standard treatment for fit patients.
3) Concurrent chemoradiotherapy and combined modality approaches may offer further benefits but require more evidence, as they present increased toxicity risks that need to be weighed against uncertain survival gains.
Concurrent Chemoradiation in Postoperative Setting In LAHNC. A comparision of...Santam Chakraborty
A journal club presentation comparing and contrasting the EORTC and RTOG trials of concurrent chemoradiation in Head Neck Cancers in the post operative setting.
Long Term Effects of Using Medicinal Mushroom Preparations in Human Colorecta...Neven Jakopovic
52 patients with bowel cancer and 89 with breast cancer used medicinal mushroom extracts from Myko San company with standard oncological treatments. In this cohort study, lasting from 2005-2010, we analysed the long term effects of using medicinal mushroom products in cancer patients.
While medicinal mushrooms are not 'magic bullets', this study provides unquestionable evidence of the benefits of their use as supportive therapy in cancer patients, leading to significantly improved outcomes.
This work was presented by Neven Jakopovic at the 6th International Medicinal Mushroom Conference in Zagreb, Croatia, in 2011.
1. Resection offers the only chance of cure for pancreatic cancer, but adjuvant therapy after surgery may improve outcomes. Studies have shown benefits from chemoradiation over chemotherapy alone.
2. For borderline resectable or locally advanced unresectable disease, neoadjuvant therapy or chemoradiation may help make initially unresectable tumors operable or improve survival compared to chemotherapy alone.
3. Intensity modulated radiation therapy (IMRT) allows safer dose escalation and better sparing of nearby organs compared to 3D conformal radiation, potentially improving local control and survival. Proper motion management and image guidance are needed to fully realize the benefits of IMRT.
Treatment Of Stage Iii Nsclc The Role Of Radiation Therapyfondas vakalis
1. Chemo-radiotherapy is the standard of care for stage III non-small cell lung cancer (NSCLC) based on randomized clinical trial outcomes, though local control and toxicity remain issues.
2. Advances in radiation therapy techniques like 3D conformal radiation therapy and intensity modulated radiation therapy may help improve local control and reduce toxicity by better sparing healthy tissues.
3. Patient-specific factors like tumor volume, nodal disease extent, co-morbidities, and dosimetry parameters should be considered to select optimal combined modality treatments and minimize risks.
The document discusses treatment options for a 66-year-old man from Nigeria diagnosed with locally advanced head and neck squamous cell carcinoma. The man was treated initially with induction chemotherapy consisting of a PF regimen, followed by concurrent chemoradiation with gemcitabine and radiotherapy, achieving a partial response. The document then outlines general treatment modalities and strategies for locoregionally advanced head and neck cancer.
Five years treatment outcomes of postoperative radiotherapy inBasalama Ali
This study evaluated treatment outcomes of 89 Saudi women with uterine cancers who received postoperative radiotherapy between 2007-2012. It found:
1. Five-year locoregional control rates were 80.9% for endometrial cancer, 87.1% for carcinosarcoma, and 100% for leiomyosarcoma.
2. Distant metastases control at 5 years was 69.3% for endometrial cancer, 16.3% for carcinosarcoma, and 45% for leiomyosarcoma.
3. Overall survival at 5 years was 71.1% for endometrial cancer, 16.3% for carcinosarcoma, and 60%
Chemoradiation therapy followed by local excision may be comparable to radical surgery for selected rectal cancer patients under certain circumstances. Studies have shown chemoradiation followed by local excision results in a pathological complete response rate of around 40-50% for cT2 tumors. For patients who achieve a complete response, the risk of local recurrence after local excision alone is very low at 0-2%. For non-responders, salvage radical surgery results in good outcomes with local recurrence rates of 50-70% after salvage surgery. This organ preservation approach offers advantages of reduced treatment related toxicity compared to radical surgery. However, long term follow up data is still needed and patient selection is important for success.
*Based on retrospective analysis of 2018 patients from the First BEAT trial
Okines A, et al. Br J Cancer. 2009;101:1033-1038.
*Clinical practice refers to outcomes seen in a large clinical trial, not necessarily guidelines.
Treating the Patient With Newly Diagnosed Metastatic Colorectal Cancer
clinicaloptions.com/oncology
Recommended Treatment Plan
FOLFOXIRI + bevacizumab for 6 months as neoadjuvant
therapy
Re-evaluate for resection after 3 months of therapy
If resection possible after 6 months, proceed with
resection
This document summarizes research on using CyberKnife and TomoTherapy for treating liver cancer. It discusses studies from Korea, Taiwan, China, Belgium, and the US on using these technologies for inoperable primary or recurrent hepatocellular carcinoma and liver metastases. Key findings included high response rates and local control. Current research interests discussed standardizing treatment protocols and criteria across countries through guidelines. Future directions may involve regional collaboration on studies to further optimize these radiotherapy approaches for liver cancer.
This document summarizes key findings from a clinical trial comparing the combination of nivolumab and ipilimumab to nivolumab or ipilimumab alone as treatment for previously untreated unresectable or metastatic melanoma. The combination of nivolumab and ipilimumab showed improved progression-free and overall survival compared to either agent alone. The combination also demonstrated a higher objective response rate, particularly in patients with PD-L1 expression levels of 5% or higher. Treatment-related adverse events were more common with the combination but most were manageable.
This document discusses recent data on radiation therapy for prostate cancer. It begins by outlining the risk of prostate cancer development and mortality rates over time. It then examines risk stratification systems and treatment options for low, intermediate, and high risk disease. The document focuses on the benefits of dose escalation in radiation therapy, noting several studies that found higher radiation doses improved outcomes with acceptable toxicity when using newer techniques like IMRT. It also discusses hypofractionated regimens and image-guided radiation as ways to further improve the therapeutic ratio. In summary, this document reviews evidence that higher and more precisely delivered radiation doses can improve prostate cancer control while maintaining reasonable side effects.
This document summarizes key points from a presentation on watch and wait strategies after chemoradiotherapy for rectal cancer. It discusses principles of adjuvant therapy, indications for neoadjuvant therapy, assessment of treatment response, and outcomes data supporting watch and wait for patients who achieve a clinical complete response. The take home message emphasizes that watch and wait offers an alternative to surgery for some patients and should be discussed, but is best carried out in specialized cancer centers.
Current Practice with Helical Tomotherapy in Yonsei Universityaccurayexchange
Helical tomotherapy has been used at Yonsei University since 2006, with 6 machines total across various hospitals. It provides superior dosimetric results compared to 3D-CRT and IMRT for liver cancer patients. Analysis of 12 patients' treatment plans found helical tomotherapy achieved better conformity and homogeneity. It also reduced the mean dose to the stomach and lowered the percentage of the remaining liver receiving high doses. While helical tomotherapy improves survival for HCC larger than 5 cm and SBRT is safe and effective for small HCC, further follow up is still needed. RTOG 1112 is a randomized phase III study comparing SBRT followed by sorafenib versus sorafenib alone in patients
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Adjuvant chemotherapy in resectable colon cancer with liver metastasisseayat1103
This document discusses adjuvant chemotherapy for resectable liver-limited colorectal cancer metastases. Several studies show adjuvant chemotherapy improves disease-free survival and marginally improves overall survival compared to surgery alone. Perioperative FOLFOX chemotherapy reduces risk of progression-free survival events. Ongoing trials evaluate adjuvant CAPOX with or without bevacizumab to determine optimal regimen.
The document summarizes guidelines for treating idiopathic thrombocytopenic purpura (ITP) in adults. It recommends treating newly diagnosed patients with platelet counts <30x10^9/L and preferring longer steroid courses over short steroid or IVIG courses as first-line treatment. It recommends splenectomy for patients failing steroid and against further treatment for asymptomatic patients after splenectomy with platelet counts >30x10^9/L. It also recommends TPO agonists for patients at risk of bleeding who relapse after splenectomy or have contraindications to splenectomy after failing at least one other therapy, and rituximab for patients at risk of bleeding who failed one line of steroid
This document summarizes a presentation on rare central nervous system (CNS) cancers. It discusses molecular markers in gliomas, treatment with antiangiogenic drugs like bevacizumab, and management of low-grade tumors. It also reviews studies on chemotherapy for recurrent and newly diagnosed low-grade gliomas, ongoing clinical trials, and risks of distant spread with bevacizumab treatment.
This document summarizes the debate around providing adjuvant chemotherapy following neoadjuvant chemoradiotherapy for rectal cancer. It outlines the current treatment approaches and evidence for and against adjuvant chemotherapy. Studies have shown conflicting results as to whether adding oxaliplatin to adjuvant chemotherapy improves outcomes. Large trials comparing adjuvant chemotherapy to observation alone did not find significant differences in survival or recurrence, though a meta-analysis found a small improvement in disease-free survival with chemotherapy. The author concludes that for locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy, adjuvant chemotherapy is indicated for high-risk pathologic stage II/III tumors but the benefits are less clear for lower-risk cases.
This document discusses treatment approaches for locally advanced non-small cell lung cancer (NSCLC). It presents a case of stage IIIB NSCLC and reviews the history and evolution of combined modality therapy using chemotherapy and radiotherapy. Concurrent chemoradiotherapy is now the standard of care and research focuses on optimizing radiotherapy dose/fractionation and integrating targeted therapies and prophylactic cranial irradiation to further improve outcomes.
Multimodality Treatment Of Stage Iii Nsclcfondas vakalis
1) Multimodality treatment including chemotherapy and radiotherapy has improved outcomes for stage III non-small cell lung cancer (NSCLC) over the past decade, increasing median survival by 5 months and 1-2 year survival by 10%.
2) Induction chemotherapy with a platinum agent and third-generation drug for 2-3 cycles followed by radiotherapy remains a good standard treatment for fit patients.
3) Concurrent chemoradiotherapy and combined modality approaches may offer further benefits but require more evidence, as they present increased toxicity risks that need to be weighed against uncertain survival gains.
Concurrent Chemoradiation in Postoperative Setting In LAHNC. A comparision of...Santam Chakraborty
A journal club presentation comparing and contrasting the EORTC and RTOG trials of concurrent chemoradiation in Head Neck Cancers in the post operative setting.
Long Term Effects of Using Medicinal Mushroom Preparations in Human Colorecta...Neven Jakopovic
52 patients with bowel cancer and 89 with breast cancer used medicinal mushroom extracts from Myko San company with standard oncological treatments. In this cohort study, lasting from 2005-2010, we analysed the long term effects of using medicinal mushroom products in cancer patients.
While medicinal mushrooms are not 'magic bullets', this study provides unquestionable evidence of the benefits of their use as supportive therapy in cancer patients, leading to significantly improved outcomes.
This work was presented by Neven Jakopovic at the 6th International Medicinal Mushroom Conference in Zagreb, Croatia, in 2011.
1. Resection offers the only chance of cure for pancreatic cancer, but adjuvant therapy after surgery may improve outcomes. Studies have shown benefits from chemoradiation over chemotherapy alone.
2. For borderline resectable or locally advanced unresectable disease, neoadjuvant therapy or chemoradiation may help make initially unresectable tumors operable or improve survival compared to chemotherapy alone.
3. Intensity modulated radiation therapy (IMRT) allows safer dose escalation and better sparing of nearby organs compared to 3D conformal radiation, potentially improving local control and survival. Proper motion management and image guidance are needed to fully realize the benefits of IMRT.
Treatment Of Stage Iii Nsclc The Role Of Radiation Therapyfondas vakalis
1. Chemo-radiotherapy is the standard of care for stage III non-small cell lung cancer (NSCLC) based on randomized clinical trial outcomes, though local control and toxicity remain issues.
2. Advances in radiation therapy techniques like 3D conformal radiation therapy and intensity modulated radiation therapy may help improve local control and reduce toxicity by better sparing healthy tissues.
3. Patient-specific factors like tumor volume, nodal disease extent, co-morbidities, and dosimetry parameters should be considered to select optimal combined modality treatments and minimize risks.
The document discusses treatment options for a 66-year-old man from Nigeria diagnosed with locally advanced head and neck squamous cell carcinoma. The man was treated initially with induction chemotherapy consisting of a PF regimen, followed by concurrent chemoradiation with gemcitabine and radiotherapy, achieving a partial response. The document then outlines general treatment modalities and strategies for locoregionally advanced head and neck cancer.
Five years treatment outcomes of postoperative radiotherapy inBasalama Ali
This study evaluated treatment outcomes of 89 Saudi women with uterine cancers who received postoperative radiotherapy between 2007-2012. It found:
1. Five-year locoregional control rates were 80.9% for endometrial cancer, 87.1% for carcinosarcoma, and 100% for leiomyosarcoma.
2. Distant metastases control at 5 years was 69.3% for endometrial cancer, 16.3% for carcinosarcoma, and 45% for leiomyosarcoma.
3. Overall survival at 5 years was 71.1% for endometrial cancer, 16.3% for carcinosarcoma, and 60%
Chemoradiation therapy followed by local excision may be comparable to radical surgery for selected rectal cancer patients under certain circumstances. Studies have shown chemoradiation followed by local excision results in a pathological complete response rate of around 40-50% for cT2 tumors. For patients who achieve a complete response, the risk of local recurrence after local excision alone is very low at 0-2%. For non-responders, salvage radical surgery results in good outcomes with local recurrence rates of 50-70% after salvage surgery. This organ preservation approach offers advantages of reduced treatment related toxicity compared to radical surgery. However, long term follow up data is still needed and patient selection is important for success.
*Based on retrospective analysis of 2018 patients from the First BEAT trial
Okines A, et al. Br J Cancer. 2009;101:1033-1038.
*Clinical practice refers to outcomes seen in a large clinical trial, not necessarily guidelines.
Treating the Patient With Newly Diagnosed Metastatic Colorectal Cancer
clinicaloptions.com/oncology
Recommended Treatment Plan
FOLFOXIRI + bevacizumab for 6 months as neoadjuvant
therapy
Re-evaluate for resection after 3 months of therapy
If resection possible after 6 months, proceed with
resection
This document summarizes research on using CyberKnife and TomoTherapy for treating liver cancer. It discusses studies from Korea, Taiwan, China, Belgium, and the US on using these technologies for inoperable primary or recurrent hepatocellular carcinoma and liver metastases. Key findings included high response rates and local control. Current research interests discussed standardizing treatment protocols and criteria across countries through guidelines. Future directions may involve regional collaboration on studies to further optimize these radiotherapy approaches for liver cancer.
This document summarizes key findings from a clinical trial comparing the combination of nivolumab and ipilimumab to nivolumab or ipilimumab alone as treatment for previously untreated unresectable or metastatic melanoma. The combination of nivolumab and ipilimumab showed improved progression-free and overall survival compared to either agent alone. The combination also demonstrated a higher objective response rate, particularly in patients with PD-L1 expression levels of 5% or higher. Treatment-related adverse events were more common with the combination but most were manageable.
This document discusses recent data on radiation therapy for prostate cancer. It begins by outlining the risk of prostate cancer development and mortality rates over time. It then examines risk stratification systems and treatment options for low, intermediate, and high risk disease. The document focuses on the benefits of dose escalation in radiation therapy, noting several studies that found higher radiation doses improved outcomes with acceptable toxicity when using newer techniques like IMRT. It also discusses hypofractionated regimens and image-guided radiation as ways to further improve the therapeutic ratio. In summary, this document reviews evidence that higher and more precisely delivered radiation doses can improve prostate cancer control while maintaining reasonable side effects.
This document summarizes key points from a presentation on watch and wait strategies after chemoradiotherapy for rectal cancer. It discusses principles of adjuvant therapy, indications for neoadjuvant therapy, assessment of treatment response, and outcomes data supporting watch and wait for patients who achieve a clinical complete response. The take home message emphasizes that watch and wait offers an alternative to surgery for some patients and should be discussed, but is best carried out in specialized cancer centers.
Current Practice with Helical Tomotherapy in Yonsei Universityaccurayexchange
Helical tomotherapy has been used at Yonsei University since 2006, with 6 machines total across various hospitals. It provides superior dosimetric results compared to 3D-CRT and IMRT for liver cancer patients. Analysis of 12 patients' treatment plans found helical tomotherapy achieved better conformity and homogeneity. It also reduced the mean dose to the stomach and lowered the percentage of the remaining liver receiving high doses. While helical tomotherapy improves survival for HCC larger than 5 cm and SBRT is safe and effective for small HCC, further follow up is still needed. RTOG 1112 is a randomized phase III study comparing SBRT followed by sorafenib versus sorafenib alone in patients
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Adjuvant chemotherapy in resectable colon cancer with liver metastasisseayat1103
This document discusses adjuvant chemotherapy for resectable liver-limited colorectal cancer metastases. Several studies show adjuvant chemotherapy improves disease-free survival and marginally improves overall survival compared to surgery alone. Perioperative FOLFOX chemotherapy reduces risk of progression-free survival events. Ongoing trials evaluate adjuvant CAPOX with or without bevacizumab to determine optimal regimen.
The document summarizes guidelines for treating idiopathic thrombocytopenic purpura (ITP) in adults. It recommends treating newly diagnosed patients with platelet counts <30x10^9/L and preferring longer steroid courses over short steroid or IVIG courses as first-line treatment. It recommends splenectomy for patients failing steroid and against further treatment for asymptomatic patients after splenectomy with platelet counts >30x10^9/L. It also recommends TPO agonists for patients at risk of bleeding who relapse after splenectomy or have contraindications to splenectomy after failing at least one other therapy, and rituximab for patients at risk of bleeding who failed one line of steroid
This study evaluated everolimus in combination with exemestane versus placebo plus exemestane for postmenopausal women with hormone receptor-positive, HER2-negative advanced breast cancer progressing on previous non-steroidal aromatase inhibitor therapy. The study found that progression-free survival was significantly improved with everolimus and exemestane compared to exemestane and placebo. However, everolimus also resulted in more adverse events and discontinuations. Overall survival data were immature at the interim analysis. The addition of everolimus to endocrine therapy improved outcomes but needs to be weighed against increased side effects.
Follicular dendritic cell sarcoma is a rare cancer that arises from follicular dendritic cells in lymph nodes or extranodal sites. It is classified as a dendritic cell neoplasm. Most cases occur in cervical or axillary lymph nodes, but extranodal cases can arise in organs like the spleen, gastrointestinal tract, liver, or lungs. Complete surgical resection is the primary treatment, but recurrence rates are high without adjuvant therapy. Prognosis is related to factors like tumor size and location, with intra-abdominal and larger tumors associated with poorer outcomes.
Temozolomide and thalidomide for treatment of neuroendocrine tumorseayat1103
This study evaluated the combination of temozolomide and thalidomide in patients with metastatic neuroendocrine tumors. 29 patients received the oral regimen of temozolomide 150 mg/m2 days 1-7 and 15-21 plus thalidomide, with dose adjustments allowed. The objective response rate was 25% and the 2-year survival rate was 61%. However, toxicity led to discontinuation in 55% of patients, with neuropathy and lymphopenia being significant issues. The combination showed activity against pancreatic and pheochromocytoma neuroendocrine tumors but less against carcinoid tumors. Further study of this oral regimen is still needed.
Phase ii study of temozolomide and thalidomideseayat1103
This study evaluated the combination of temozolomide and thalidomide in patients with metastatic neuroendocrine tumors. The results showed an objective response rate of 25% and a biochemical response rate of 40%. However, over half of patients discontinued treatment early due to toxicities such as neuropathy and infection. Further study is needed to better understand the efficacy and safety profile of this drug combination.
The document summarizes current standards and next steps in treating gastric cancer. It discusses how adjuvant chemotherapy and neoadjuvant/perioperative chemotherapy have been shown to improve survival rates compared to surgery alone, increasing 5-year survival by 5-10% and 18% risk reduction respectively. However, tolerance of adjuvant treatments is often poor with high rates of delays, reductions and early termination. Neoadjuvant chemotherapy is better tolerated and may improve R0 resection rates and survival, as supported by several randomized clinical trials.
The document summarizes current standards and next steps in treating gastric cancer. It discusses trends showing falling incidence of distal gastric cancer but rising incidence of proximal gastric cancer. It reviews primary staging procedures and treatments for gastric cancer including surgery, adjuvant treatments, and treatments for advanced cases. It provides evidence that adjuvant chemotherapy and perioperative chemotherapy can increase overall survival rates compared to surgery alone.
The document summarizes clinical updates and advances in the treatment of non-small cell lung cancer (NSCLC). It discusses the incidence, subtypes and staging of NSCLC and recommendations for adjuvant therapy, targeted therapy and treatment of metastatic disease. It also reviews results from randomized trials of adjuvant chemotherapy showing improved survival compared to observation alone.
This document discusses adjuvant and neoadjuvant therapy for colon cancer. It presents two case studies of patients with colon cancer and discusses their prognosis and treatment options based on their postoperative biopsy results and stage. It then compares prognosis and treatment for stage II versus stage III colon cancer. The document also discusses international clinical trials evaluating different adjuvant chemotherapy regimens and their benefits and toxicities. It addresses recommendations for adjuvant chemotherapy in elderly patients with stage III colon cancer.
This document summarizes evidence for adjuvant and neoadjuvant chemotherapy in non-small cell lung cancer (NSCLC). Meta-analyses show adjuvant cisplatin-based chemotherapy improves 5-year survival by 4-5% after surgery for stages II-III NSCLC. Individual trials also found benefits, though some only for certain stages. Neoadjuvant chemotherapy may improve survival by 5% at 5 years for resectable stage IIIA NSCLC. Ongoing trials aim to personalize chemotherapy based on biomarkers and add targeted therapies.
This document summarizes adjuvant chemotherapy for resectable non-small cell lung cancer (NSCLC). It discusses that patients with stage I-IIIA NSCLC have a risk of recurrence even after surgery. Large clinical trials have found that platinum-based adjuvant chemotherapy can improve outcomes for completely resected NSCLC. Specifically, the IALT trial found that cisplatin-based chemotherapy improved 5-year survival from 40.4% to 44.5% compared to observation alone. The JBR.10 trial found that vinorelbine and cisplatin improved 5-year survival from 54% to 69% compared to observation. The CALGB 9633 trial initially found paclitaxel/carboplatin improved outcomes but
C:\Documents And Settings\User\Desktop\Head And NeckGamal Abdul Hamid
This document summarizes recent advances in the treatment of head and neck cancer. It discusses the incidence, risk factors, staging, and historical treatment approaches including chemotherapy and chemoradiation. Recent randomized trials show improved outcomes with induction taxane-based chemotherapy followed by chemoradiation compared to chemotherapy and radiation alone. Ongoing trials are further exploring the benefits of induction chemotherapy prior to definitive treatment.
The document summarizes a clinical trial comparing FOLFIRINOX (folinic acid, fluorouracil, irinotecan, and oxaliplatin) to gemcitabine as first-line treatment for metastatic pancreatic cancer. The trial showed FOLFIRINOX resulted in significantly higher response rates, longer progression-free survival and overall survival, though it also had more grade 3/4 adverse events. Based on these results, the document concludes FOLFIRINOX is a new standard first-line treatment for patients with good performance status.
The document summarizes a clinical trial comparing FOLFIRINOX (folinic acid, fluorouracil, irinotecan, and oxaliplatin) chemotherapy to gemcitabine for treatment of metastatic pancreatic cancer. The trial showed that FOLFIRINOX resulted in significantly higher response rates and longer progression-free and overall survival compared to gemcitabine. FOLFIRINOX is now considered a new standard first-line treatment for metastatic pancreatic cancer, despite its greater toxicity requiring careful patient selection and management.
This document summarizes information about radiotherapy for non-small cell lung cancer (NSCLC). It discusses the role of radiotherapy for early, locally advanced, and metastatic NSCLC. It describes stereotactic body radiotherapy (SBRT) for early-stage disease and concurrent chemoradiotherapy (CTRT) for locally advanced stages. It also reviews evidence on optimal radiotherapy techniques and dosing, as well as trials investigating induction, consolidation, and adjuvant chemotherapy combined with radiotherapy.
The document discusses combined chemoradiotherapy for non-small cell lung cancer (NSCLC). It describes the evolution of radiotherapy techniques from older 2D techniques to modern 3D conformal radiation and IMRT. Studies show combined chemoradiotherapy improves survival over radiotherapy alone or sequential chemotherapy and radiotherapy by reducing locoregional recurrence rates. However, concurrent chemoradiotherapy is associated with increased toxicity risks which must be balanced against survival benefits.
This document discusses radiotherapy techniques for early breast cancer, including:
1) Modern techniques like IMRT and 4D radiotherapy allow for better treatment planning and delivery while avoiding nearby organs.
2) Several randomized clinical trials found that a shorter, hypofractionated course of radiotherapy was not inferior to standard radiotherapy in terms of local recurrence or toxicity.
3) Partial breast irradiation techniques are being studied as a way to further reduce treatment volumes and time for selected low-risk patients.
Presentación realizada por la Dra. Pilar Escudero del HCU Lozano Blesa, en el marco de la I Jornada de actualización e innovación en Oncología que tuvo lugar en el CIBA en enero de 2015.
Rare digestive cancers include small bowel adenocarcinoma, anal carcinoma, and biliary tract carcinoma. Small bowel adenocarcinoma has a rising incidence and commonly presents at advanced stages. Anal carcinoma risk factors include HPV and HIV infection. Treatment involves chemoradiation, which achieves high survival rates. Biliary tract carcinomas have a poor prognosis even after surgery due to frequent recurrence. Combination chemotherapy with gemcitabine and platinum agents shows some efficacy in advanced disease.
This document summarizes information on radiosurgery for lung cancer. It discusses stereotactic body radiation therapy (SBRT) as a technique that uses precisely targeted radiation to treat small or moderate lung tumors with a large dose per fraction. Studies show SBRT provides better local control and survival rates than conventional radiation for early stage lung cancer and results similar to surgery with less toxicity. For central tumors, lower SBRT doses are safer to reduce risks of excessive toxicity. SBRT is shown to be effective for tumors over 4 cm and in elderly patients.
1. The document discusses studies comparing adjuvant radiation therapy to salvage radiation therapy for prostate cancer patients with adverse pathological features after radical prostatectomy.
2. The EORTC 22911 trial randomized over 1000 patients to either observation or adjuvant radiation and found significantly improved biochemical progression-free survival with adjuvant radiation.
3. Other large trials including SWOG and ARO 96-02 also found benefits to adjuvant radiation in reducing risks of biochemical recurrence, distant metastases and death from prostate cancer.
1. Colon cancer is the second and third most common cancer in males and females respectively and accounts for 9% of cancer deaths.
2. Screening and lifestyle changes have led to improved outcomes, with a 55% reduction in late-stage colon cancer cases over 3 decades from screening.
3. Adjuvant chemotherapy regimens including FOLFOX, CAPOX and XELOX have improved disease-free and overall survival rates compared to 5-FU/LV alone, particularly for stage III disease.
4. Ongoing research focuses on shortening treatment duration, identifying high-risk patients who may benefit from more intensive regimens, and incorporating molecular markers to optimize adjuvant therapy
While T4 stage, fewer than 12 lymph nodes, and absence of MMR-D are factors considered in deciding adjuvant chemotherapy for Stage II CRC, they are not definitive standards. Currently, there are no established molecular markers that clearly identify patients with high or low risk of recurrence or benefit from chemotherapy for Stage II colon cancer. Researchers are working to develop improved algorithms incorporating clinical, pathological, and emerging molecular markers to better guide treatment decisions.
La terapia adiuvante e neoadiuvante del cancro gastrico avanzato - Gastrolea...Gastrolearning
This document summarizes research on adjuvant, neoadjuvant, and advanced gastric cancer treatment. It discusses several phase III trials investigating chemoradiotherapy and chemotherapy in the adjuvant setting. It also reviews studies of first-line and second-line chemotherapy regimens for advanced gastric cancer, including combinations containing docetaxel, oxaliplatin, and fluoropyrimidines. Targeted therapies such as trastuzumab, ramucirumab, and lapatinib are also summarized, with some shown to improve outcomes versus chemotherapy alone in biomarker-selected patients.
Colorectal cancer - adjuvant Rx - Nicola Tannerwelshbarbers
This document discusses treatment principles for colorectal cancer including histological staging, chemotherapy, surgery, and trials. It covers adjuvant therapies for colon and rectal cancers including chemotherapy with or without radiotherapy. It also discusses neoadjuvant treatments and timelines for administering adjuvant therapies. Key points covered include Dukes staging, 5-year survival rates by stage, aims of adjuvant therapy, and common surgeries for colon and rectal cancers.
Similar to MCO 2011 - Slide 21 - P. Rougier - Adjuvant treatment (stage 2 and 3) (20)
1) The study examines how and why certain breast cancer cells metastasize to bone through a "seed pre-selection" process.
2) It finds that high Src activity (denoted by a "Src activity signature" or SRS) in primary tumors associates with bone metastasis.
3) In ER-/ERBB2- breast cancers, cytokines CXCL12 and IGF1 in the tumor microenvironment activate Src which promotes cell survival and bone metastasis. Long term exposure to these cytokines in vitro selects for breast cancer cells with higher Src activity and bone metastatic ability.
The document discusses renal cancer (kidney cancer) and advances in its treatment. It describes several targeted drugs that have improved outcomes for metastatic renal cell carcinoma (mRCC) compared to previous immunotherapy options. Drugs include tyrosine kinase inhibitors like sunitinib, sorafenib, pazopanib and axitinib as well as the mTOR inhibitor temsirolimus. Clinical trials have established these as standard first and second line options depending on a patient's risk level and prior treatment history. Ongoing research focuses on optimizing treatment sequencing and identifying biomarkers to guide more personalized therapy selection.
The document summarizes key information about prostate cancer including incidence, mortality rates, clinical stages, risk groups for localized prostate cancer, treatment options for advanced disease including hormone therapy and chemotherapy, and results from clinical trials of chemotherapy agents like docetaxel and cabazitaxel.
The document summarizes highlights from the 11-ICML Lugano conference in 2011, including:
1) Studies showing the impact of the tumor microenvironment in lymphoma prognosis and the predictive value of increased macrophages in Hodgkin's lymphoma biopsies.
2) High response rates to antiviral treatment in patients with indolent B-cell lymphoma associated with HCV infection.
3) A PET-based approach can effectively guide treatment for limited-stage diffuse large B-cell lymphoma.
4) R-CHOP induction followed by rituximab maintenance improves survival over R-FC induction for elderly patients with mantle cell lymphoma.
This document summarizes the management of urinary bladder cancer. It discusses staging, histopathologic types, and treatment options for non-muscle invasive and muscle invasive bladder cancer as well as metastatic disease. Standard first-line chemotherapy for metastatic bladder cancer includes gemcitabine and cisplatin or MVAC. Newer chemotherapy regimens and agents are also discussed.
The document discusses new drugs for the treatment of lymphomas. It outlines several monoclonal antibodies that target antigens on B-cells, including CD20, CD19, CD22 and CD37. Ofatumumab and GA-101 are new anti-CD20 monoclonal antibodies that exhibit enhanced binding and cell-killing properties compared to Rituximab. Inotuzumab Ozogamicin is an antibody-drug conjugate targeting CD22 that is internalized and releases a cytotoxic drug, showing promising activity in early clinical trials.
This document discusses treatment of diffuse large B-cell lymphoma (DLBCL). It notes that DLBCL is a heterogeneous disease with genetic subgroups that have different prognoses and responses to treatment. The addition of the antibody rituximab to chemotherapy improves outcomes for DLBCL compared to chemotherapy alone. Strategies discussed to improve outcomes include increasing chemotherapy dose intensity and the potential role of the drug bortezomib for the activated B-cell subtype.
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- Ovarian cancer is the ninth most common cancer in women and the fifth leading cause of cancer death in women. Risk factors include age over 60, obesity, talcum powder use, fertility drugs, genetic predispositions like BRCA mutations.
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1) Breast cancer is heterogeneous with different subtypes defined by receptor status and gene expression profiles. The subtypes have different biological behaviors and clinical outcomes.
2) Accurate diagnosis requires biopsy (FNA or core) followed by receptor testing before treatment decisions. Surgery options include breast conserving therapy or mastectomy with/without reconstruction.
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The document discusses guidelines for screening, diagnosis, staging, adjuvant therapy, advanced disease treatment, and follow-up for colorectal cancer from both the ESMO and NCCN perspectives. It provides recommendations for screening the general and high-risk populations. It also outlines the diagnostic and staging workup, including endoscopy, biopsy, imaging, and surgical staging. Guidelines are presented for adjuvant therapy based on cancer stage. Recommendations are provided for managing both synchronous and metachronous metastatic disease, as well as rectal cancer treatment.
1) A trial found that adding bevacizumab to chemotherapy for stage III colon cancer extended disease-free survival compared to chemotherapy alone, delaying cancer relapse but not preventing it completely.
2) There was no overall survival benefit observed from adding bevacizumab, suggesting it delays but does not alter the underlying biology of the disease.
3) The interpretation is that relapses were delayed by bevacizumab treatment but then occurred at a steady rate later on, similar to the chemotherapy alone group.
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A. Tfayli - Head and neck - Guidelines and clinical case presentation (2-3 ca...
MCO 2011 - Slide 21 - P. Rougier - Adjuvant treatment (stage 2 and 3)
1. Adjuvant chemotherapy in CCR in 2011 Philippe Rougier , Digestive Oncology Hopital Européen Georges Pompidou, APHP 75015 Paris ; France UVSQ ; UFR Paris-ile de France Ouest
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7. Risk of recurrence Risk of death 40% decrease in RR of recurrence 33% decrease in RR of recurrence 20% absolute decrease 20% absolute decrease P < 0.0001 (controle vs 5FU + Levamisole) P < 0.0007 (controle vs 5FU + Levamisole) 5FU + levamisole (n = 304) Levamisole (n = 310) Follow-up only (n = 315) 100 90 80 70 60 50 40 30 20 10 0 0 1 2 3 4 Years from Registration Moertel CG et al. Ann Intern Med. 1995;122:321-326 . Patients free from recurrence (%) Patients surviving (%) A risque 5FU + levamisole (n = 304) Levamisole (n = 310) Follow-up only (n = 315) 100 90 80 70 60 50 40 30 20 10 0 0 1 2 3 4 Years from Registration A 1990: the first step : 5FU + levamisole INT-0035 trial ( Moertel et al, New England Journal of Medicine, 1990)
8. Adjuvant therapy with 5FU increases the chance of survival and Cure patients: evidence in 20,898 CC Stage II CC Stage III CC Sargent D, et al. JCO 2009 1.0 0.8 0.6 0.4 0.2 0 OS estimate p=0.026 0 1 2 3 4 5 6 7 8 Follow-up time (years) Surgery alone 8-year OS rate (95% CI): 66.8% (63.7% to 70.0%) Surgery + FU-based chemotherapy 8-year OS rate (95% CI): 72.2% (69.3% to 75.2%) p<0.0001 Surgery alone 8-year OS rate (95% CI): 42.7% (39.9% to 45.7%) Surgery + FU-based chemotherapy 8-year OS rate (95% CI): 53.0% (50.2% to 55.9%) 0 1 2 3 4 5 6 7 8 Follow-up time (years) CC=colon cancer OS=overall survival OS estimate 1.0 0.8 0.6 0.4 0.2 0
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10. DFS : Stage III (60% of pts) Probability DFS (months) Decrease: 24% RR of recurrence in stage III by FOLFOX4 Hazard ratio: 0.76 [0.62-0.92] FOLFOX4 (n=672) 72.2% 3 years André et al. NEJM 2004, 350; 2343-2351 +6,9 % at LV5FU2 (n=675) : 65.3% FOLFOX4 as adjuvant tt ; Stage II-III CC: MOSAIC FOLFOX4 vs LV5FU2 for 6 m Primary end point : DFS n=2246 Stage :II: 40% III: 60% Colon ADK
11. Years No benefit of chemotherapy Cured by chemotherapy Already Cured by Surgery Adjuvant Therapy for Colon Cancer Stage III What benefit ?? 0 20 40 60 80 100 0 1 2 3 4 5 exposed to toxicit y Surgery alone Surgery plus Chemotherapy 25% % Disease Free Survival 55% 20% 20% 25%
12. Years No benefit of chemotherapy Cured by chemotherapy Already Cured by Surgery Adjuvant Therapy for Colon Cancer Stage III What benefit ?? 0 20 40 60 80 100 0 1 2 3 4 5 exposed to toxicit y Surgery alone Surgery plus Chemotherapy 25% % Disease Free Survival 55% 20% 20% 25% 20% from 5FU & 5% by adding oxaliplatin ?? 1 out of 4 patient Benefit from adjuvant CT and 1 out of 20 from Adding OxaliP
13. 6 Year Overall Survival: Stage II and Stage III Data cut-off: January 2007 FOLFOX4 stage II LV5FU2 stage II FOLFOX4 stage III LV5FU2 stage III 0.1% 4.2% p=0.996 p=0.029 André et al. J Clin Oncol. 2009 MOSAIC 2009 Overall survival (months) Probability 1.0 0.8 0.6 0.4 0.2 0 0.9 0.7 0.5 0.3 0.1 0 6 12 18 24 60 30 36 42 48 54 66 96 72 78 84 90 HR [95% CI] Stage II 1.00 [0.70–1.41] Stage III 0.80 [0.65–0.97]
15. Tolerance : Peripheral sensory neuropathy may be armful in some patients … Proportion of pts treated by FOLFOX4 André et al. J Clin Oncol. 2009 ; 27 :3109 -15 MOSAIC 2009 At 48 months Evaluable patients n=811 Grade 0 84.3% Grade 1 12.0% Grade 2 2.8% Grade 3 0.7%
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19. Gray R et al, Lancet 2007;370:2020−9 5 Year Survival in Stage II Pts: the QUASAR Study Chemo vs Observation OS at 5 Year 80,3 % 77,4 % (+2.9%) Relative Ris 0,83 (IC 95 : 0,71-0,97) 100 80 60 40 20 0 0 2 4 8 Years OS stage II (Dukes B) p = 0,04 6 10 5-FU + AF (Mayo or Roswell Park 6 mth ) ± lévamisole (n = 1 622) Observation (n = 1 617) R patients Characteristics RR of death reduced by 17% + 2.9% Chemotherapy Observation Chimo Observation Stage II (Dukes B2) 92 % 92 % Colon 71 % 71 % Rectum 29 % 29 % FUFOL hebdo 49 % 49 % Médian FU 4,6 Y 4,6 Y
20. Minimal benefit from FOLFOX over LV5FU2 on 5 Year Disease-free S. in Stage II Data cut-off: June 2006 3.8% 7.5% p=0.258 p=0.005 André et al. J Clin Oncol. 2009 ; 27 :3109 -15. MOSAIC 2009 HR [95% CI] p-value Stage II 0.84 [0.62–1.14] 0.258 Stage III 0.80 [0.65–0.93] 0.005 FOLFOX4 stage II LV5FU2 stage II FOLFOX4 stage III LV5FU2 stage III Months Probability 1.0 0.8 0.6 0.4 0.2 0 0.9 0.7 0.5 0.3 0.1 0 6 12 18 24 60 30 36 42 48 54 66 72
21. Absence of benefit from FOLFOX over LV5FU2 on 6 Year Overall Survival: Stage II and Stage III Data cut-off: January 2007 FOLFOX4 stage II LV5FU2 stage II FOLFOX4 stage III LV5FU2 stage III 0.1% 4.2% p=0.996 p=0.029 André et al. J Clin Oncol. 2009 MOSAIC 2009 Overall survival (months) Probability 1.0 0.8 0.6 0.4 0.2 0 0.9 0.7 0.5 0.3 0.1 0 6 12 18 24 60 30 36 42 48 54 66 96 72 78 84 90 HR [95% CI] Stage II 1.00 [0.70–1.41] Stage III 0.80 [0.65–0.97]
22. Years Chemotherapy without benefit Cured by chemotherapy allready cured by surgery Adjuvant chemotherapy for CC Stage II A very small benefit ? => be cautious 0 20 40 60 80 100 0 1 2 3 4 5 T O X I C I T Y Surgery alone Surgery plus chemotherapy 3-5 % 80% 5% 15% Overall Survival
23. Patient Selection +++ => Factors influencing prognosis in stage II ? Lymphatic Venous Perineural invasion Poor Differentiation Tumor invasion (T4) No. of nodes examined Less to 8-10 Perforation Occlusion MSS-MSI T3N0 without unfavorable prognosis factors and or MSI : prognosis close to Stage I T 3-4 N0 with unfavorable prognosis factors : prognosis close to Stage III
24. 0.5 0.7 0.9 1.1 1.3 1.5 Hazard Ratio 1 Stage III High risk Stage II Stage II Stage III High risk Stage II Stage II Overall survival (OS) Disease-free survival (DFS) Hazard ratios for DFS and OS by sub group Favours FOLFOX4 Favours LV5FU2 André et al. J Clin Oncol. 2009 MOSAIC
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28. Gene Expression Profiles in Dukes’B Colon Cancer Wang et al. JCO 2004,22:1564 17616 informative genes 2 dominant clusters (39 resp.14 genes)
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30. p=0.004 QUASAR RESULTS : Colon Cancer Recurrence Score Predicts Recurrence Following Surgery STROMAL FAP INHBA BGN CELL CYCLE Ki-67 c-MYC MYBL2 REFERENCE ATP5E GPX1 PGK1 UBB VDAC2 GADD45B RECURRENCE SCORE Calculated from Tumor Gene Expression Prospectively-Defined Primary Analysis in Stage II Colon Cancer (n=711) D. Kerr et al., ASCO 2009, A 4000 Group Risk (by Kaplan-Meier) 12% 18% 22%
31. QUASAR RESULTS: Recurrence Score, T Stage, and MMR Deficiency are Key Independent Predictors of Recurrence in Stage II Colon Cancer Multivariate Analysis D. Kerr et al., ASCO 2009, A 4000
32. Colorectal Cancer : adjuvant ColoPrint ® : an independent prognostic factor ColoPrint ® : genomic Signature for prognosis prediction in CRC stade II, III RFS 5 y (all stages, n=206) : Low risk 87,6% High risk 67,2% (HR) 2,5 (95%CI : 1,33 – 4,73 ; p<0,005) RFS 5 y (stage II, n=114) : Low risk 90,9% High risk 73,9% (95%CI : 59,2% – 88,6% ; p=0,017) RFS 5 y (stade III, n=62) : Low risk 78,2% high risk 47,2% Salazar R. et al. JCO 2011
36. ACCENT update: 6 trials added † Compared to control arm of intravenous 5-flourouracil (IV 5-FU) and leucovorin (LV) ‡ Remaining patients were stage II or unknown N. Jackson McCleary ASCO 2009 NSABP C-06 1997-99 1557 23 Uracil/tegafur 53 CALGB 89803 1999-01 1263 24 IFL 98 MOSAIC 1998-01 2246 14 FOLFOX4 60 Trial Accrual Period # pts % pts ≥ 70 yrs Experimental treatment arm † % stage III ‡ NSABP C-07 2000-02 2434 16 FLOX 71 PETACC-3 2000-02 3186 13 FOLFIRI 71 X-ACT 1998-01 1983 20 Capecitabine 100
37. ACCENT Forest Plots of Hazard Ratios: Disease-Free Survival N. Jackson McCleary ASCO 2009 No benefit After 70 years
38. ACCENT Forest Plots of Hazard Ratios: Overall Survival N. Jackson McCleary ASCO 2009 No benefit After 70 years
39. b estimated from forest plot c stage III 190 patients a stage III Population > 70 and Hazard-Ratios N>70 % DFS HR OS HR reference ACCENT Oral FP 755 21.3 1.13 1.17 ASCO 2009 X-ACT a 397 20.0 0.93 b 0.93 b Twelves NEJM 2005, ASCO GI 2008 C-06 358 22.3 NA >1.13 NA >1.17 Lembersky JCO 2006 ACCENT Oxaliplatin 703 15.0 1.04 1.19 ASCO 2009 MOSAIC 315 c 14.0 0.91 1.10 unpublished C-07 388 16.9 NA >1.04 NA >1.19 Kuebler JCO 2007 NO16968 a 409 21.7 0.87 0.94 ASCO GI 2010
40. Capecitabine alone, in stage III pts, a reasonable option XELOX / FOLFOX minimal DFS advantage. OS might be improved with a more intensive management of relapse or second-cancer. ? A reduced duration of chemotherapy should be tested and could help ederly patients: IDEA (International Duration Evaluation of Adjt Chemo.) Colon Cancer Prospective Pooled Analysis Which adjuvant treatment in ederly pts? (4)
41. Treatment of Stage III ederly pts according to … Standard Treatment Best Supportive Care Adapted Treatment Geriatric Evaluation Cancer < Live Expentency < Cancer Harmonious Group The Oncologist 2000;5:224-237 Intermediate Group Frail Group FOLFOX ou XELOX LV5FU2, capecitabine, No CT ? No CT
46. Interim OS (ITT Stage III) 955 960 952 914 942 920 899 925 908 884 900 894 863 869 861 844 835 840 573 573 546 FOLFOX4 FOLFOX4 + Bev XELOX + Bev Number at risk 776 763 765 461 449 445 288 269 290 0 1 0 63 70 64 0 0 0 Event-free rate FOLFOX4 FOLFOX4 + Bev XELOX + Bev A de gramont, ASCO GI 2011 No benefit at all ! Bevacizumab has no role in adjuvant FOLFOX (N=955) FOLFOX4 + Bev (N=960) XELOX + Bev (N=952) HR (95% CI) 1.31 (1.03, 1.67) 1.27 (0.99, 1.62) 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 6 18 30 36 42 48 0 12 24 Time (months) 54 60 66 72
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48. Stage III CC FOLFOX4 vs FOLFOX4 + cetuximab 2,450* PETACC-8 Stage III CC mFOLFOX6 vs mFOLFOX6 + cetuximab 2,300 Intergroup 0147 (ECOG/NCCTG) Disease Treatment n Trial *Protocol amended in 2008 for KRAS status Anti-EGFR adjuvant therapy
54. Meta-analysis IV Chemo vs surveillance Colon Rectum Odds ratio 0.81 0.64 95% C.I. 0.69 – 0.94 0.48 – 0.85 29 RCT; 12079 pts; no IDP Dubé S. Dis Colon Rectum 40, 1997 Overall Survival
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56. Gray R et al, Lancet 2007;370:2020−9 5 Year Survival in Stage II Pts: the QUASAR Study Chemo vs Observation OS at 5 Year 80,3 % 77,4 % (+2.9%) Relative Ris 0,83 (IC 95 : 0,71-0,97) 100 80 60 40 20 0 0 2 4 8 Years OS stage II (Dukes B) p = 0,04 6 10 5-FU + AF (Mayo or Roswell Park 6 mth ) ± lévamisole (n = 1 622) Observation (n = 1 617) R patients Characteristics RR of death reduced by 17% + 2.9% Chemotherapy Observation Chimo Observation Stage II (Dukes B2) 92 % 92 % Colon 71 % 71 % Rectum 29 % 29 % FUFOL hebdo 49 % 49 % Médian FU 4,6 Y 4,6 Y
57. Bosset JF et al. NEJM 355, 2006 Non significative amelioration of OS… but only 43% of patients have received the whole planed chemotherapy treatment.
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59. Rectal Cancer Exemple of Recommendations for adjuvant Tt (tncd.org) (Thessaurus de bonne pratique en cancéro digestive) Preop stagging : clinical, NMR, CT, +/- EUS T1-2N0 T3N0 & NMR margin > 1 mm T1-4 N+ T3T4N0 & MRC < 1 mm MRC : circunferential resection margin RT : radiotherapy TME: total mesorectum excision RCT (5FU) : radio-chimiothérapie avec 5FU ou capécitabine Surgery + TME–R0 resection RT 25 Gy or RCT (5FU) RCT (5FU +/- LOHP) pT1-2N0 ypT0-2N0 ypT3-4N0 pT1-2N+ ypT1-4 N+ Follow-up Follow-up ? Adjuvant CT (5FU, X or FOLFOX) « Expert » advise (www.tncd.org)
Editor's Notes
**Pooled analyses in metastatic setting showed improved or similar survival benefit for older pts receiving combination vs IV FU/LV **Suggests older patients derive benefit from adjuvant therapy after surgery **Formed basis of ACCENT data group
† Compared to control arm of intravenous 5-flourouracil (IV 5-FU) and leucovorin (LV) ‡ Remaining patients were stage II or unknown Recently added data from 6 newer studies evaluating the survival benefit of either intravenous (IV) FU combination chemotherapy or oral FU chemotherapy compared to standard IV FU/LV monotherapy in stage II and III CRC Abbreviations: MOSAIC, Multicenter International Study of Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjuvant Treatment of Colon Cancer; XACT, Xeloda in Adjuvant Colon Cancer Therapy; NSABP, National Surgical Adjuvant Breast and Bowel Project; CALGB, Cancer and Leukemia Group B; PETACC, Pan-European Trials in Adjuvant Colon Cancer; FOLFOX, infusional 5-FU/LV + oxaliplatin; FLOX, bolus IV 5-fluorouracil (FU)/ leucovorin (LV) + oxaliplatin; IFL, bolus IV 5-FU/LV + irinotecan; FOLFIRI, infusional 5-FU/LV + irinotecan
To reiterate graphically, these forest plots depict no alteration of treatment effect by age. **These associations are further illustrated by forest plots organized by drug class (Figure 1).