CA-A Cancer Journal For Clinicians

2016 US lymphoid malignancy statistics by World Health Organization subtypes

Collectively, lymphoid neoplasms are the fourth most common cancer and the sixth leading cause of cancer death in the United States. The authors provide contemporary lymphoid neoplasm statistics by subtype based on the 2008 World Health Organization classifications, including the most current US incidence and survival data. Presented for the first time are estimates of the total numbers of US lymphoid neoplasm cases by subtype as well as a detailed evaluation of incidence and survival statistics. In 2016, 136,960 new lymphoid neoplasms are expected. Overall lymphoma incidence rates have declined in recent years, but trends vary by subtype. Precursor lymphoid neoplasm incidence rates increased from 2001 to 2012, particularly for B‐cell neoplasms. Among the mature lymphoid neoplasms, the fastest increase was for plasma cell neoplasms. Rates also increased for mantle cell lymphoma (males), marginal zone lymphoma, hairy cell leukemia, and mycosis fungoides. Like incidence, survival for both mature T‐cell lymphomas and mature B‐cell lymphomas varied by subtype and by race. Patients with peripheral T‐cell lymphomas had among the worst 5‐year relative survival (36%‐56%, depending on race/sex), while those with mycosis fungoides had among the best survival (79%‐92%). For B‐cell lymphomas, 5‐year survival ranged from 83% to 91% for patients with marginal zone lymphoma and from 78% to 92% for those with hairy cell leukemia; but the rates were as low as 47% to 63% for patients with Burkitt lymphoma and 44% to 48% for those with plasma cell neoplasms. In general, black men had the lowest survival across lymphoid malignancy subtypes. These contemporary incidence and survival statistics are useful for developing management strategies for these cancers and can offer clues regarding their etiology. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Study suggests it is safe to ease neutropenic restrictions

Evidence is lacking that the commonly placed restrictions on diet, social contacts, and pets decrease infection rates in patients undergoing intense chemotherapy. The current study supports the relaxation of neutropenic restrictions. More research is needed to study social contact and pet restrictions, but major centers have relaxed dietary restrictions and emphasize a common sense approach.


Disparities found in perception of symptoms between patients and oncology team

The prevalence and importance of pain and fatigue in patients with cancer continue to be underestimated by oncology physicians and nurses. Clinicians need to assess symptoms of fatigue and pain carefully at each encounter. An increased awareness of patient‐reported outcomes and education for HCPs is needed to improve patients' QOL.


Radiotherapy combination opportunities leveraging immunity for the next oncology practice

Approximately one‐half of patients with newly diagnosed cancer and many patients with persistent or recurrent tumors receive radiotherapy (RT), with the explicit goal of eliminating tumors through direct killing. The current RT dose and schedule regimens have been empirically developed. Although early clinical studies revealed that RT could provoke important responses not only at the site of treatment but also on remote, nonirradiated tumor deposits—the so‐called “abscopal effect”— the underlying mechanisms were poorly understood and were not therapeutically exploited. Recent work has elucidated the immune mechanisms underlying these effects and has paved the way for developing combinations of RT with immune therapy. In the wake of recent therapeutic breakthroughs in the field of immunotherapy, rational combinations of immunotherapy with RT could profoundly change the standard of care for many tumor types in the next decade. Thus, a deep understanding of the immunologic effects of RT is urgently needed to design the next generation of therapeutic combinations. Here, the authors review the immune mechanisms of tumor radiation and summarize the preclinical and clinical evidence on immunotherapy‐RT combinations. Furthermore, a framework is provided for the practicing clinician and the clinician investigator to guide the development of novel combinations to more rapidly advance this important field. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Human papillomavirus vaccination guideline update: American Cancer Society guideline endorsement

Answer questions and earn CME/CNE The American Cancer Society (ACS) reviewed and updated its guideline on human papillomavirus (HPV) vaccination based on a methodologic and content review of the Advisory Committee on Immunization Practices (ACIP) HPV vaccination recommendations. A literature review was performed to supplement the evidence considered by the ACIP and to address new vaccine formulations and recommendations as well as new data on population outcomes since publication of the 2007 ACS guideline. The ACS Guideline Development Group determined that the evidence supports ACS endorsement of the ACIP recommendations, with one qualifying statement related to late vaccination. The ACS recommends vaccination of all children at ages 11 and 12 years to protect against HPV infections that lead to several cancers and precancers. Late vaccination for those not vaccinated at the recommended ages should be completed as soon as possible, and individuals should be informed that vaccination may not be effective at older ages. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Ovarian function suppression is beneficial in some premenopausal women with early breast cancer

Premenopausal women with HR‐positive early breast cancer benefit from exemestane plus OFS versus tamoxifen with or without OFS. Results of SOFT and TEXT support the addition of OFS to exemestane or tamoxifen in premenopausal women whose risk of recurrence warrants (neo)adjuvant chemotherapy. Women with low‐risk early breast cancer derive minimal benefit from the addition of OFS.


Delivery of neoadjuvant chemoradiation for patients with stage II and III rectal cancer is suboptimal

The use of guideline‐recommended therapy of neoadjuvant chemoradiation and surgery for patients with rectal cancer has increased over the past decade, but nevertheless only 55% of patients received such treatment. Being of nonwhite race or Hispanic ethnicity, lacking private insurance, and living in an area with low aggregate educational levels were associated with a lower probability of receiving trimodality therapy.


Critical care of patients with cancer

Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state‐of‐the‐art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Pathophysiological basis of human papillomavirus in penile cancer: Key to prevention and delivery of more effective therapies

Answer questions and earn CME/CNE Squamous cell carcinoma (SCC) of the penis is a rare malignancy in the United States, with a significantly higher incidence—up to 20 to 30 times greater—in areas of Africa and South America. This can be explained in part by the significantly greater prevalence of sexually transmitted diseases among high‐risk males often having unprotected sex with multiple sexual partners. Human papillomavirus (HPV) has been implicated as the infectious pathway by which several these penile neoplasms originate from precursor lesions. In this regard, a fundamental understanding of HPV in penile carcinogenesis can have meaningful implications in understanding 1) the diagnosis of HPV‐related precursor penile lesions, 2) targeting HPV‐specific molecular pathways, and 3) cancer prevention. Using vaccination programs not only may improve patient outcomes but also may minimize the need for highly aggressive and often debilitating surgical resection. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Current concepts in the diagnosis and pathobiology of intraepithelial neoplasia: A review by organ system

Answer questions and earn CME/CNE In this report, a team of surgical pathologists has provided a review of intraepithelial neoplasia in a host of (but not all) anatomic sites of interest to colleagues in various medical specialties, namely, uterine cervix, ovary, breast, lung, head and neck, skin, prostate, bladder, pancreas, and esophagus. There is more experience with more readily accessible sites (such as the uterine cervix and skin) than with other anatomic sites, and the lack of uniform terminology, together with divergent biology in various sites, makes it difficult to paint a unifying, relevant portrait. The authors' aim was to provide a framework from which to move forward as we care for patients with such precancerous lesions. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Cancer treatment and survivorship statistics, 2016

The number of cancer survivors continues to increase because of both advances in early detection and treatment and the aging and growth of the population. For the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborate to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results cancer registries. In addition, current treatment patterns for the most prevalent cancer types are presented based on information in the National Cancer Data Base and treatment‐related side effects are briefly described. More than 15.5 million Americans with a history of cancer were alive on January 1, 2016, and this number is projected to reach more than 20 million by January 1, 2026. The 3 most prevalent cancers are prostate (3,306,760), colon and rectum (724,690), and melanoma (614,460) among males and breast (3,560,570), uterine corpus (757,190), and colon and rectum (727,350) among females. More than one‐half (56%) of survivors were diagnosed within the past 10 years, and almost one‐half (47%) are aged 70 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by primary care providers. Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence‐based resources are needed to optimize care. CA Cancer J Clin 2016. © 2016 American Cancer Society.


State of the science on prevention and screening to reduce melanoma incidence and mortality: The time is now

Answer questions and earn CME/CNE Although overall cancer incidence rates are decreasing, melanoma incidence rates continue to increase about 3% annually. Melanoma is a significant public health problem that exacts a substantial financial burden. Years of potential life lost from melanoma deaths contribute to the social, economic, and human toll of this disease. However, most cases are potentially preventable. Research has clearly established that exposure to ultraviolet radiation increases melanoma risk. Unprecedented antitumor activity and evolving survival benefit from novel targeted therapies and immunotherapies are now available for patients with unresectable and/or metastatic melanoma. Still, prevention (minimizing sun exposure that may result in tanned or sunburned skin and avoiding indoor tanning) and early detection (identifying lesions before they become invasive or at an earlier stage) have significant potential to reduce melanoma incidence and melanoma‐associated deaths. This article reviews the state of the science on prevention and early detection of melanoma and current areas of scientific uncertainty and ongoing debate. The US Surgeon General's Call to Action to Prevent Skin Cancer and US Preventive Services Task Force reviews on skin cancer have propelled a national discussion on melanoma prevention and screening that makes this an extraordinary and exciting time for diverse disciplines in multiple sectors—health care, government, education, business, advocacy, and community—to coordinate efforts and leverage existing knowledge to make major strides in reducing the public health burden of melanoma in the United States. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Rates of testing for BRCA mutations in young women are on the rise

Genetic testing for BRCA mutations is increasing for young women, which is in keeping with current guidelines, and frequently affects treatment decisions. Adequate genetic counseling must be widely available for young women with breast cancer.


Bankruptcy linked to early mortality in patients with cancer

Financial distress is common in patients with cancer. Filing for bankruptcy is a risk factor for early mortality in patients with cancer. Policy interventions are needed to protect patients, and practitioners need to discuss the financial aspects of care with their patients.


The American Cancer Society challenge goal to reduce US cancer mortality by 50% between 1990 and 2015: Results and reflections

In 1996, the Board of Directors of the American Cancer Society (ACS) challenged the United States to reduce what looked to be possible peak cancer mortality in 1990 by 50% by the year 2015. This analysis examines the trends in cancer mortality across this 25‐year challenge period from 1990 to 2015. In 2015, cancer death rates were 26% lower than in 1990 (32% lower among men and 22% lower among women). The 50% reduction goal was more fully met for the cancer sites for which there was enactment of effective approaches for prevention, early detection, and/or treatment. Among men, mortality rates dropped for lung cancer by 45%, for colorectal cancer by 47%, and for prostate cancer by 53%. Among women, mortality rates dropped for lung cancer by 8%, for colorectal cancer by 44%, and for breast cancer by 39%. Declines in the death rates of all other cancer sites were substantially smaller (13% among men and 17% among women). The major factors that accounted for these favorable trends were progress in tobacco control and improvements in early detection and treatment. As we embark on new national cancer goals, this recent past experience should teach us that curing the cancer problem will require 2 sets of actions: making new discoveries in cancer therapeutics and more completely applying those discoveries in cancer prevention we have already made. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Advancing a comprehensive cancer care agenda for children and their families: Institute of Medicine Workshop highlights and next steps

This article highlights key findings from the “Comprehensive Cancer Care for Children and Their Families” March 2015 joint workshop by the Institute of Medicine (IOM) and the American Cancer Society. This initiative convened more than 100 family members, clinician investigators, advocates, and members of the public to discuss emerging evidence and care models and to determine the next steps for optimizing quality‐of‐life outcomes and well‐being for children and families during pediatric cancer treatment, after treatment completion, and across the life spectrum. Participants affirmed the triple aim of pediatric oncology that strives for every child with cancer to be cured; provides high‐quality palliative and psychosocial supportive, restorative, and rehabilitative care to children and families throughout the illness course and survivorship; and assures receipt of high‐quality end‐of‐life care for patients with advancing disease. Workshop outcomes emphasized the need for new pediatric cancer drug development and identified critical opportunities to prioritize palliative care and psychosocial support as an integral part of pediatric cancer research and treatment, including the necessity for adequately resourcing these supportive services to minimize suffering and distress, effectively address quality‐of‐life needs for children and families at all stages of illness, and mitigate the long‐term health risks associated with childhood cancer and its treatment. Next steps include dismantling existing silos and enhancing collaboration between clinical investigators, disease‐directed specialists, and supportive care services; expanding the use of patient‐reported and parent‐reported outcomes; effectively integrating palliative and psychosocial care; and clinical communication skills development. CA Cancer J Clin 2016. © 2016 American Cancer Society.


American cancer society head and neck cancer survivorship care guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long‐term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech‐language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus‐based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016. © 2016 American Cancer Society.


First‐line low‐dose morphine is better for the control of moderate cancer pain than weaker opioids

Initiating pain control therapy with low‐dose morphine provided better and faster pain relief versus weaker opioids among patients with moderate cancer pain. The frequency and severity of opioid‐related side effects were similar between the patients treated with morphine and those receiving the weaker opioid.


Conversations for Providers Caring for Patients With Rectal Cancer: Comparison of Long‐Term Patient‐Centered Outcomes for Patients With Low Rectal Cancer Facing Ostomy or Sphincter‐Sparing Surgery

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter‐sparing surgery. Sphincter‐sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter‐sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long‐term surgical outcomes. Furthermore, comparison of long‐term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long‐term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision‐making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long‐term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter‐sparing surgery as well as questions to ask during follow‐up examinations to ascertain any long‐term challenges facing the patient. CA Cancer J Clin 2016. © 2016 American Cancer Society.


Use of posttreatment imaging and biomarker testing for survivors of breast cancer

Many clinicians are still using low‐value routine surveillance imaging or biomarker testing in asymptomatic survivors of breast cancer. An imaging test for patients with early‐stage breast cancer after primary treatment was usually performed because of a symptom or clinical finding; however, almost all biomarker testing in this setting was performed as routine surveillance. Quality reporting must include the reasons behind posttreatment testing to avoid categorizing a test done to evaluate a sign or symptom as inappropriate surveillance.