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Presenter : Eileen M. O’Reilly
Outcomes in pancreatic cancer are improving. The beneficial effects being achieved with adjuvant and neoadjuvant therapies, and the recent application of molecular profiling, both germline and somatic, are collectively impacting survival. The NCCN Guidelines for Pancreatic Cancer urge clinicians to undertake “agnostic” germline testing for all persons with pancreatic cancer. Fit patients should also be considered for adjuvant therapy with modified FOLFIRINOX (leucovorin, 5-FU, irinotecan, oxaliplatin). Novel therapies that focus on DNA damage repair strategies are proving to be important, but notably several late-stage trials of several other approaches, reported in the last year, proved disappointing.
Presenter : Javid J. Moslehi
Cardio-oncology is a growing field, due to several factors. These include the recognition that similar risk factors predispose people to both cardiovascular disease and cancer. In addition, certain cancers affect the heart, and cancer treatments can have short-term and long-lasting deleterious effects on the cardiovascular system. More than 40 years ago, it became evident that anthracyclines and radiation cause heart damage, and since then the list of cancer treatments that can harm the cardiovascular system has grown to include more modern treatments, such as anti-HER2 agents and angiogenesis inhibitors. Most recently, immune checkpoint inhibitors (ICIs) have been added to the list of cancer treatments that cause cardiovascular damage. ICI-associated myocarditis is a relatively rare but fatal complication that develops rapidly after initiating immunotherapy. Oncologists should be aware of the potential cardiovascular complications of cancer treatments, and should assess the cardiovascular health of all patients about to undergo therapy. Cancer survivors should be assessed and advised about prevention and treatment that may be needed to address cardiovascular disease.
Presenters : Robert Pilarski, Jennifer M. Weiss, Susan M. Domchek and Moderated by Tuya Pal
With the introduction of panel and direct-to-consumer testing, genetic testing has become commonplace in recent years, paving the way for both increased awareness around prevalent genetic cancer risks, and also an onslaught of misinformation. At the NCCN 2020 Virtual Annual Conference, Dr. Tuya Pal led a panel of experts in discussing the utility and difficulties associated with multigene testing, the emerging role of moderate-penetrance genes in defining risks for hereditary cancer, and the controversies associated with direct-to-consumer genetic testing services.
Presenter : Philippe E. Spiess
The current NCCN Guidelines for Bladder Cancer reflect the most up-to-date, evidence-based data relating to the evaluation and management of non–muscle-invasive bladder cancer (NMIBC). The most notable revision to the guidelines this year is the addition of pembrolizumab for a high-risk subset of patients not responding to bacillus Calmette-Guérin (BCG). It is anticipated that current BCG shortages will offer unique opportunities to promote and enhance clinical trials for patients with bladder cancer. Recent efforts to more precisely define BCG-unresponsive disease (adopted by the FDA) have been critical to standardizing definitions and evaluating the efficacy of clinical trials in bladder cancer.
Presenters : Mazyar Shadman and Deborah M. Stephens
In the era of newer, highly effective targeted therapies for chronic lymphocytic leukemia (CLL), experts debated whether there is still a role for chemoimmunotherapy in the first-line setting for the treatment of this disease. In general, targeted therapies are preferred as first-line treatment for all patients, with the exception of low-risk patients [younger, fit patients with mutated IGHV who are candidates for fludarabine/cyclophosphamide/rituximab (FCR)]. About 37% of low-risk patients experience long-term durable remissions and remain stable after treatment with FCR for many years. Advantages of FCR over small molecule inhibitors include cost, fixed duration treatment, and long-term survival benefit. Disadvantages are an etimated 5% risk of developing myelodysplastic syndrome or acute myeloid leukemia. Advantages of small molecule inhibitors are improvements in progression-free and overall survival and quality of life when compared with chemoimmunotherapy. Disadvantages of small molecule inhibitors are high cost and the need for continuous treatment. However, studies are underway to develop fixed duration regimens with combinations of small molecule inhibitors that aim to deepen remissions.
Presenter : Dustin A. Deming
An improved understanding of the molecular landscape of metastatic colorectal cancer (CRC) has opened the door for new treatment options. Clinicians should test for molecular alterations that predict resistance to epidermal growth factor receptor (EGFR) inhibitors, such as KRAS and NRAS, and additionally clinically actionable alterations, including BRAF V600 mutations, HER2 amplification, NTRK fusions, and mismatch repair deficiency. Improved outcomes can be achieved with precision treatment strategies for the various CRC subtypes, although clinical features, such as tumor bulk and patient performance status, still help to guide treatment choice. Immune therapies have also produced impressive results in patients with mismatch repair–deficient/microsatellite instability–high tumors. These newer approaches were recently incorporated into the NCCN Guidelines for Colon and Rectal Cancers. In the future, these newer approaches may be used in earlier treatment settings.
Presenters : Benjamin O. Anderson and Janice A. Lyons
Locoregional management of early-stage breast cancer has been trending toward less-extensive axillary resections, based on increasing evidence showing that patients with 1 or 2 positive sentinel nodes and/or micrometastases can safely be managed with sentinel node biopsy alone, thereby avoiding complete axillary lymph node dissection (cALND) in the significant majority of patients. Because of the 15% to 20% lymphedema risk associated with cALND, increasing efforts are being made to avoid the procedure when evidence suggests that more limited procedures are safe, as reflected by acceptable locoregional recurrence rates. Axillary radiotherapy (RT) has been shown to be an effective alternative to ALND for patients fitting criteria from the pivotal AMAROS trial: patients with T1/T2 disease and are clinically node-negative, who undergo either breast-conserving therapy or mastectomy. Considerations for RT begin with the question of nodal involvement, with treatment planned accordingly. With more neoadjuvant therapy being used, there are nuances in locoregional management that clinicians must now appreciate, both in terms of ALND and axillary RT.
Presenter : Louis Burt Nabors
Optimizing treatment for patients with low-grade gliomas should focus on the role of radiation and chemotherapy, as well as the prognostic impact of molecular diagnostics (1p/19q and IDH status). For anaplastic oligodendroglioma, focus should be placed on molecular markers (particularly 1p/19q status) and combination treatment with chemotherapy (temozolomide or PCV [procarbazine, lomustine, and vincristine]) and radiation. For patients with malignant glioblastomas, the role of methylguanine methyl-transferase (MGMT) methylation status has become increasingly important to treatment decisions. MGMT methylation status should be considered in elderly patients and/or those with low performance status (methylated patients benefit from temozolomide) and a hypofractionated radiation schedule should be used.
Presenters : Chad A. LaGrange, M. Dror Michaelson and Colleen H. Tetzlaff
A number of therapeutic options are available for the treatment of advanced kidney cancer, including targeted therapy, immunotherapy, and nephrectomy. Choice of therapy for advanced kidney cancer is guided by risk stratification. Immunotherapy combinations are generally superior to vascular endothelial growth factor -based monotherapy, and overall survival rates continue to increase substantially. With new systemic therapy options, additional improvements have been noted in durable responses to treatment and in quality of life. Nephrectomy remains an important consideration in selected patients, particularly those with minimal burden of metastatic disease. Managing the adverse events of treatment of advanced kidney cancer requires close attention and multidisciplinary collaboration.