Targeted and immune therapies have changed the paradigm of treatment for patients with metastatic melanoma. Treatment of patients with symptomatic melanoma brain metastases, however, is complicated by the frequent use of immune suppression for the management of vasogenic edema and the urgency in addressing disease burden. Use of BRAF/MEK inhibitors in patients with a corresponding BRAF V600 mutation often results in rapid response but is hindered by high rates of disease relapse and progression. Immunotherapy has higher durability of response, but the rate of response is slower and responses can be significantly diminished for patients on concurrent steroid therapy. Considering this gap in evidence-based guidance for optimal adjuvant therapy sequence in immunosuppressed patients with BRAF V600–mutant melanoma brain metastases, we report on 4 cases utilizing BRAF/MEK inhibitors as a bridging therapy for brain metastases management before initiation of immune checkpoint inhibitor therapy. Future prospective studies will be required to determine the optimal treatment sequencing for patients in this population with high unmet medical need.
Jacob Strelnikov, Alice Zhou, Omar Butt, Michael Ansstas, and George Ansstas
Loretta Loftus, Christine Laronga, Karen Coyne, and Lynne Hildreth
Analysis of Moffitt Cancer Center data on time from breast biopsy to first definitive surgery showed an average of 6.9 weeks, which concerned the breast program faculty members. Delays in curative surgery may impact mortality, quality of life, and time to adjuvant therapy. The purpose of this study was to analyze steps from breast biopsy to definitive breast cancer surgery and to develop proposals and strategies for improvement. Data were collected from various sources, including the tumor registry, patient appointment system, tumor board lists, and the NCCN Oncology Outcomes Database for Breast Cancer. Three phases of the surgical process were identified with regard to lead time: biopsy to first consult (BX-FC); first consult to tumor board (FC-TB); and tumor board to surgery (TB-SU). Other factors, including operating room capacity and schedules, were also evaluated. The greatest percentage of total lead time occurred in the TB-SU phase (52% vs 35% in BX-FC, and 13% in FC-TB phases). The longest average lead time, 3.6 weeks, was also in the TB-SU phase. The TB-SU time was greatest when surgery was scheduled after tumor board and if surgery required breast reconstruction. Limitation of physician capacity was a major factor in treatment delay. The Opportunity for Improvement project enabled institutional analysis of the need for quality improvement in time for curative surgery for breast cancer. A significant factor that created time delay was physician capacity. As a result, additional faculty and staff have been recruited. A new expanded facility is currently in progress that will provide more physical space and services.
S. Machele Donat
Since the initial report in 2003 of the Intergroup-0080 trial confirming benefit of combined neoadjuvant M-VAC (methotrexate, vinblastine, adriablastine, and cisplatin) chemotherapy and cystectomy in the treatment of muscle-invasive bladder cancer, debate has continued in the literature as to the relative risk/benefits of integrating perioperative chemotherapy into the care of patients, especially in those with organ-confined, muscle-invasive, node-negative disease in whom the benefit may be less. Because of the inaccuracies of clinical staging, the potential morbidity related to M-VAC chemotherapy, a 70% cure rate in pT2No disease with surgery alone, and only a modest (5%) improvement in absolute overall survival with combined therapy, many favor limiting chemotherapy to patients with a pathologic stage of pT3 or greater or node-positive disease. This philosophy was also reflected in the 2008 National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Bladder Cancer, in which neoadjuvant chemotherapy for clinical T2 disease versus adjuvant therapy based on pathologic risks is only “considered.” Additionally, a recent study looking at the perioperative integration of chemotherapy for stage III bladder cancer in the United States using the National Cancer Data Base showed that only 11.6% of patients underwent any perioperative chemotherapy, with most in the adjuvant setting. These findings indicate that despite randomized trial data showing survival benefit for perioperative chemotherapy, and the current guidelines for therapy supporting those findings, chemotherapy is not being integrated well into the care of patients with muscle-invasive bladder cancer, even in those who, experts agree, have the most potential for benefit.
Philip Sobash and Nagla Abdel Karim
atypical disease and metastatic disease. Aim of the study is to explore the benefit of adjuvant therapy for thoracic carcinoid tumors. Methods: A literature review was conducted through PubMed in accordance with PRISMA guidelines to identify studies
Anne Shah, Jon Apple, Andrew J. Belli, Anna Barcellos, Eric Hansen, Laura L. Fernandes, and Ching-Kun Wang
48.5 months for the EGFRm negative group (rwDFS event rate: 46.3%) and unknown EGFRm status (rwDFS event rate: 49.7%), respectively. After adjustment for key patient covariates; disease stage and adjuvant therapy status were significantly associated
Baylee F. Bakkila, Daniel Kerekes, Caroline H. Johnson, and Sajid A. Khan
, adequate lymphadenectomies as per National Comprehensive Cancer Network guidelines and use of adjuvant therapy. Multivariable logistic regressions were fit to determine differences in quality of care by insurance and when controlling for covariates (sex
of capecitabine + oxaliplatin was added as an option in adjuvant therapy with a category 2A designation. Footnote “j” was clarified by adding “exclusive of those cancers that are MSI-H” to grade 3-4. Surveillance Chest
Al B. Benson III, Tanios Bekaii-Saab, Emily Chan, Yi-Jen Chen, Michael A. Choti, Harry S. Cooper, Paul F. Engstrom, Peter C. Enzinger, Marwan G. Fakih, Moon J. Fenton, Charles S. Fuchs, Jean L. Grem, Steven Hunt, Ahmed Kamel, Lucille A. Leong, Edward Lin, Kilian Salerno May, Mary F. Mulcahy, Kate Murphy, Eric Rohren, David P. Ryan, Leonard Saltz, Sunil Sharma, David Shibata, John M. Skibber, William Small Jr, Constantinos T. Sofocleous, Alan P. Venook, Christopher G. Willett, Kristina M. Gregory, and Deborah A. Freedman-Cass
rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Adjuvant Therapy for Stage II Disease The panel discussed the impact of adjuvant chemotherapy on
scientific peer-review process and are overseen by the ORP. An NCCN study funded through the grant mechanism is highlighted below. Randomized Phase II Study Comparing Concise (3 Months) Versus Prolonged (2 Years) Afatinib as Adjuvant Therapy for
Tiffany H. Svahn, Joyce C. Niland, Robert W. Carlson, Melissa E. Hughes, Rebecca A. Ottesen, Richard L. Theriault, Stephen B. Edge, Anne F. Schott, Michael A. Bookman, and Jane C. Weeks
. 5 Coates AS Keshaviah A Thurlimann B . Five years of letrozole compared with tamoxifen as initial adjuvant therapy for postmenopausal women with endocrine-responsive early breast cancer: update of study BIG 1-98 . J Clin Oncol 2007 ; 25 : 486