Ten Practice Changes I Will Make After Attending ASCO ??

Endobronchial radiation therapy for non-small cell lung cancer. AP view (Photo credit: Wikipedia)

After ASCO someone wrote this last week. Will you change your mind just for a meeting which major sponsor is Big Pharma ? 

 I have looked back and seen which of the changes have become standards of practice. I have adopted most of these changes many months prior to them becoming standards of care.
In the past these have included:

• Avoiding CYP2DP inhibitors in patients taking tamoxifen
• Trying pregabalin for hot flashes in patients with breast cancer
• Adopting the use of pemetrexed maintenance in patients with stable disease after chemotherapy for non-squamous non–small cell lung cancer (NSCLC)
• Adding cisplatin to gemcitabine for patients with advanced biliary cancer
• Recommending no full axillary dissection in breast cancer patients with positive sentinel nodes provided they met the criteria of the ACOSOG Z11 study
• Recommending no radiation therapy for patients ≥ 70 years with estrogen receptor (ER)–positive clinical stage I breast cancer
• Using denosumab instead of zolendronic acid in certain patients with bone metastases
• Offering naproxen as prophylaxis for pegfilgrastim-induced bone pain
• Recommending yoga to cancer patients experiencing insomnia and fatigue
• Using FOLFIRINOX as first-line therapy for patients with advanced pancreatic cancer with good performance status
• Substituting capecitabine for infusional fluorouracil (5-FU), along with radiation for neoadjuvant rectal cancer treatment
• Extending the duration of imatinib as adjuvant treatment for high-risk patients with gastrointestinal stromal tumors (GIST)
• Treating patients with castrate-resistant advanced prostate cancer with abiraterone
• Using ipilimumab for treatment of patients with melanoma
• Using crizotinib for patients with ALK-positive NSCLC
• Using bendamustine/rituximab as first-line therapy for low-grade lymphoma
• Monitoring vitamin D levels in breast cancer patients on aromatase inhibitors
• Using more steroids for patients on palliative care
• Trying duloxetine for chemotherapy-induced peripheral neuropathy

Here is this year’s list from ASCO 2013:

1. Consider continuing adjuvant tamoxifen for 10 rather than 5 years, based on the aTTom study, which was presented at the plenary session (Abstract 5). Results support the data reported from the ATLAS study, and, putting all the data together, there seems to be a several percentage point–improvement in progression-free survival (PFS), with slightly less improvement in overall survival (OS), to date. Additional toxicity was minimal.
2. Decrease the frequency of screening CT in patients in remission from diffuse large B-cell lymphoma and Hodgkin’s disease (Abstracts 8504 and 8505). There seemed to be no improvement in survival in patients who had routine scans ordered as opposed to those patients who were only scanned when they had symptoms or abnormal physical findings.
3. Consider using entecavir rather than lamivudine as prophylaxis for hepatitis B reactivation in lymphoma patients (Abstract 8503). It seems to be more effective, but the higher cost could be an issue.
4. Use more single-fraction XRT for palliation of painful bone metastases in patients with end-stage cancer (Abstract 9502). This study supports the findings of a number of previous studies, which reported equivalent palliation with the easier and shorter course of radiation therapy.
5. Use second-line therapy with docetaxel in appropriate patients with advanced gastroesophageal junction adenocarcinoma (Abstract 4023). As opposed to supportive care without chemotherapy, there was an improvement in survival and quality of life.
6. Stop using “preventive” calcium and magnesium infusions in patients getting oxaliplatin for colorectal cancer. Neither therapy prior to and/or after oxaliplatin infusion prevented neuropathy in a double-blind randomized Alliance trial (Abstract 3501) reported by Loprinzi et al.
7. Reconsider the role of maintenance therapy for metastatic colorectal cancer, based on results of the CAIRO3 (Abstract 3502) and SAKK 41/06 (Abstract 3503) trials. In the CAIRO trial, there was a slight improvement in OS, but, in the SAKK trial, bevacizumab as a single agent did not improve PFS or OS. This is in contrast to retrospective data, previously reported. Putting all the studies together, the case for any type of maintenance during “chemotherapy holidays” is not very compelling.
8. Give patients who are being treated with adjuvant paclitaxel after adjuvant chemotherapy the option of 12 weekly doses, which was equivalent to 6 doses of higher-dose paclitaxel every 2 weeks with pegfilgrastim in the S0221 study (Abstract CRA1008). It was less toxic and, overall, less expensive, although somewhat more inconvenient. One could probably extrapolate and use 8 weekly doses instead of 4 doses every 2 weeks, as well.
9. Consider retreatment with ipilimumab in patients with advanced melanoma who previously responded to that drug and then relapsed, as there are increasing reports of safety and probable efficacy (Abstracts 9041 and 9059). Of note, there are a number of long-term survivors (12%–49%!) after first-line treatment (Abstract 9053), and the drug appears to be safe and effective in elderly patients (Abstract 9063).
10. Reassure patients with stage I seminoma and nonseminoma germ cell tumors that active surveillance is a reasonable and safe option (Abstract 4502 and 4503). Survival was close to 100% in both retrospective reviews.

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Despite Low-Risk Prostate Cancer, High-Tech Treatment Rises

Source: IMNG Medical Media

The use of the most advanced technologies for treating prostate cancer, such as intensity-modulated radiotherapy and robotic prostatectomy, is common and increasing among the very men least likely to benefit from treatment, according to a report published June 26 in JAMA.
In a retrospective cohort study involving nearly 56,000 men newly diagnosed with prostate cancer during a recent 5-year period, advanced treatment technologies steadily supplanted more conservative approaches in older men who had low-risk disease, a high risk of dying from some other cause, or both, said Dr. Bruce L. Jacobs of the University of Michigan, Ann Arbor, and his associates (JAMA 2013;309:2587-95).
Paradoxically, this increase occurred against a backdrop of “increasing awareness about the indolent nature of some prostate cancers and of growing dialogue about limiting treatment in these patients,” the researchers noted.
“Our findings suggest that, even during this period of enhanced stewardship, incentives favoring the diffusion of these technologies outweighed those related to implementing a more conservative management strategy,” they said.
Dr. Jacobs and his colleagues examined this issue using data from the Surveillance, Epidemiology, and End Results (SEER) Medicare database after noting the rapid growth in the use of advanced treatment technologies, as well as the aggressive direct-to-consumer marketing and other “incentives” propelling that growth. They identified men aged 66 years and older whose prostate cancer was diagnosed during a 5-year period and who were followed for 1-6 years afterward.
The study population comprised 23,633 men who underwent intensity-modulated radiotherapy (IMRT) and 5,881 who had robotic prostatectomy, who were compared with 3,926 men who underwent traditional external-beam radiation therapy, 6,123 who had open radical prostatectomy, and 16,384 who opted for watchful waiting (observation).
The investigators estimated the study subjects’ probability of dying within 10 years based on age, race, comorbidity, socioeconomic class, type of residence (urban or rural), and the region of the country in which they lived.
As expected, the use of the advanced technologies increased over time in the entire study population. But it also increased among the men who “stood to gain the least in terms of survival.”
During the 5-year study period, the use of both IMRT and robotic prostatectomy increased from 32% to 44% of men who had low-risk disease based on the clinical stage of their tumor, Gleason score, and prostate-specific antigen (PSA) level. The use of both also increased from 36% to 57% of men who were at high risk of dying from another cause. And it rose from 25% to 34% of men who had both low-risk disease and a high risk of noncancer mortality.
At the same time, the use of more conservative approaches declined to a similar degree in these low-risk patients.
In a further analysis of the data, the use of advanced treatment technologies in men who were the most unlikely to die of prostate cancer increased from 13% at the start of the 5-year period to 24% at the end, a relative increase of 85%, Dr. Jacobs and his associates said.
These trends are particularly concerning because both IMRT and robotic prostatectomy are considerably more expensive than the less aggressive approaches they are displacing, the researchers added.
Some clinicians and patients may believe that the more advanced technologies yield better outcomes, but “comparative studies have shown that the advantages of these newer treatments are marginal at best,” Dr. Jacobs and his colleagues said.
“More diligence is needed to reduce the potentially unnecessary treatment of men with a low risk of dying from prostate cancer,” they said.
The study was supported by the American Cancer Society, the National Institutes of Health, Blue Cross Blue Shield of Michigan, and the National Cancer Institute. Dr. Jacobs reported no financial conflicts of interest, and two of his associates reported ties to ArborMetrix and HistoSonics.

Influence of Study Features and Methods on Overdiagnosis Estimates in Breast and Prostate Cancer Screening

Ruth Etzioni, PhD; Roman Gulati, MS; Leslie Mallinger, MPH; and Jeanne Mandelblatt, MD, MPH

Source: Ann Intern Med. 2013;158(11):831-838. doi:10.7326/0003-4819-158-11-201306040-00008

Knowledge of the likelihood that a screening-detected case of cancer has been overdiagnosed is vitally important to make treatment decisions and develop screening policy. An overdiagnosed case is an excess case detected by screening. Estimates of the frequency of overdiagnosis in breast and prostate cancer screening vary greatly across studies. This article identifies features of overdiagnosis studies that influence results and shows their effect by using published research. First, different ways to define and measure overdiagnosis are considered. Second, contextual features and how they affect overdiagnosis estimates are examined. Third, the effect of estimation approach is discussed. Many studies use excess incidence under screening as a proxy for overdiagnosis. Others use statistical models to make inferences about lead time or natural history and then derive the corresponding fraction of cases that are overdiagnosed. This article concludes with questions that readers of overdiagnosis studies can use to evaluate the validity and relevance of published estimates and recommends that authors of studies quantifying overdiagnosis provide information about these features.

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Screening for prostate cancer

English: Prostate and bladder, sagittal section. 中文: 前列腺與膀胱，矢狀切面。 (Photo credit: Wikipedia)

Several places when you can find more about screening, in special for prostate cancer. We are going to attempt to share all this article in this post, and updating as new evidence's articles ( more and more every day ), and then you can decide for yourself.

Expanding the evidence on cancer screening: the value of scientific, social and ethical perspectives: Lucie Rychetnik, Stacy M Carter, Alexandra Barratt and Les Irwig. Med J Aust 2013; 198 (10): 536-539. doi: 10.5694/mja12.11275

United State American Task Force for Preventive Guidelines

Canadian Task Force on Preventive Health Care ( CTFPHC )

American Urological Association 

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Information for primary care: PSA testing in asymptomatic men (evidence document

A light blue ribbon is the symbol for prostate cancer (Photo credit: Wikipedia)

Source: http://www.cancerscreening.nhs.uk

Public Health UK

Information for primary care: PSA testing in asymptomatic men (evidence document)

Published January 2010

PDF Format (670Kb)

The information booklet PSA Testing in Asymptomatic Men was designed to help primary care teams to provide asymptomatic men with information on the prostate-specific antigen (PSA) test for prostate cancer.

This version of the booklet has been produced to provide exactly the same information, but also gives primary care teams details of the evidence on which that information is based.

How to order a printed version.

Download Document

prostate cancer.pdf (654 KB)

https://mega.co.nz/#!xs0kFLaC!Jh3zai8JY_Ekn5h2txPsL3Aq1ddkJS3PMYNHFrINBcg

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Before Prostate Cancer Screening, Men Should Know Harm Is More Likely Than Benefit

By Bridget M. Kuehn on April 8, 2013

Men should know that they are more likely to be harmed than to benefit from prostate cancer screening and should only be screened if they have a strong preference for screening, a new guideline states. Image: scibak/iStockphoto.com

Men should be fully informed that they’re unlikely to benefit from prostate cancer screening and may face a substantial risk of various harms, such as complications from biopsy or treatment that may include infection, incontinence, or impotency, according to a new guideline from the American College of Physicians (ACP) published today in the Annals of Internal Medicine.
One in 6 men will be diagnosed as having prostate cancer in his lifetime, but only 3 of 100 men who are diagnosed as having the disease will die of it, according to the guideline. In other words, 97 of 100 men with prostate cancer will die of some other cause. In addition, most men who die of prostate cancer are older than 75 years. Yet despite the low risk of death from prostate cancer, especially among younger men, screening—using either the prostate-specific antigen (PSA) tests or a digital rectal examination—continues to be commonplace.
Thus, the likelihood of a man benefiting from prostate cancer screening is quite limited; about 1000 men would have to be screened to save 1 life, the guideline notes. Harm resulting from testing, however, is far more common. The false-positive rate for these tests is high and men who receive a positive result may undergo further invasive tests, such as a prostate biopsy, which can lead to infection, bleeding, or hospitalization. In addition, men who are diagnosed as having prostate cancer are likely to undergo radiation or surgery. Prostate cancer surgery is associated with a small increased risk of death, a 37% increased risk of sexual dysfunction, and an 11% increased risk of urinary incontinence.
Based on these risks and the fact that few men are likely to benefit, the US Preventive Services Task Force has recommended against prostate cancer screening with the PSA test. Other guidelines reviewed by the ACP as part of their own guideline-producing process recommend that physicians talk with patients about the risks and the patient’s preferences.
The ACP recommends that physicians fully inform patients aged 50 to 69 years that they are unlikely to benefit and face a substantial risk of harm from prostate cancer screening. The group also says that screening with the PSA test should be carried out only after such disclosure has occurred and the patient has expressed a clear preference for screening.
The authors conclude that “each man should have the opportunity to decide for himself whether to have the PSA screening test.”
Moreover, the ACP advises against prostate cancer screening with a PSA test for men younger than 50 years, older than 69 years, or with a remaining life expectancy of less than 10 to 15 years.

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