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Michael D. Green and James A. Hayman

The management of Merkel cell carcinoma (MCC) requires multidisciplinary care for optimal patient outcomes. Radiotherapy (RT) is most commonly used as adjuvant therapy to improve locoregional control in patients with MCC who undergo surgery. Additionally, it can sometimes be used as definitive monotherapy for patients who decline or are not candidates for surgery and as palliative treatment in those with metastatic MCC. This article discusses the indications, treatment considerations, and recommended dose prescriptions for RT in the management of early- and advanced-stage disease. Considerable hope exists that immunotherapy advances will synergize with RT to further enhance clinical outcomes.

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Lisa Hazard, Gary Yang, Mary Frances McAleer, James Hayman and Christopher Willett

Radiation therapy serves an integral role in the primary and adjuvant treatment of esophagus cancer. Radiation techniques continue to improve, providing more accurate localization of the tumor while limiting dose to normal structures. This article reviews current practices and recommendations for radiation therapy technique for esophageal and gastroesophageal malignancies.

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Robert E. Glasgow, David H. Ilson, James A. Hayman, Hans Gerdes, Mary F. Mulcahy and Jaffer A. Ajani

The clinical spectrum of esophageal cancer has changed dramatically over the past couple of decades. Most notably, a profound rise in esophageal adenocarcinoma and decrease in the incidence of squamous carcinomas have occurred. An understanding of the factors that influence survival for patients with localized esophageal cancer has evolved concomitantly with these changes in epidemiology. Significant advancement in endoscopic and radiographic staging allows for more selective use of treatment modalities. The treatment of localized esophageal cancer mandates a multidisciplinary approach, with treatment tailored to disease extent, location, histology, and an accurate assessment of pretreatment staging. Despite these improvements in the staging and use of multimodality therapy, only modest improvements in patient survival have been observed. This article summarizes these modern approaches to localized cancer of the esophagus.

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David B. Shultz, John C. Grecula, James Hayman, Maximilian Diehn and Billy W. Loo Jr

Small cell lung cancer is an aggressive malignancy that is highly responsive to radiation therapy (RT), which has an important role in all stages of disease. For locally advanced, limited-stage disease, the standard of care is chemotherapy with concurrent radiation, which should be started early. The optimal radiation dose and field design remain to be determined. Randomized trials are currently being conducted to determine if dose intensification will improve outcomes, whereas consensus on elective nodal irradiation is evolving. Current studies are evaluating the potential benefit of consolidative thoracic RT in the management of patients with extensive-stage disease that has responded favorably to chemotherapy. Finally, prophylactic cranial irradiation improves survival in both limited- and extensive-stage disease that has responded to initial therapy.

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Jennifer L. Schwartz, Sandra L. Wong, Scott A. McLean, James A. Hayman, Christopher D. Lao, Jeffrey H. Kozlow, Kelly M. Malloy, Carol R. Bradford, Marcus L. Frohm, Douglas R. Fullen, Lori Lowe and Christopher K. Bichakjian

Merkel cell carcinoma (MCC) is a rare malignancy of the skin, and prospective randomized clinical studies on management and treatment are very limited. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for MCC provide up-to-date, best evidence-based, and consensus-driven management pathways with the purpose of providing best care and outcomes. Multidisciplinary management with consensus treatment recommendations to individualize patient care within the framework of these guidelines is optimal. The University of Michigan multidisciplinary MCC program uses NCCN Guidelines in the management and treatment of its patients. This article discusses 4 patient presentations to highlight the implementation of the NCCN Guidelines for MCC at the University of Michigan.

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Allison Matthews, Surbhi Sidana, Lauren Seymour, Nancy Pick, James Pringnitz, David Argue, Gina Lange, Eva Brandes, Allison McClanahan, Adrienne Nedved, Suzanne Hayman, Saad Kenderian, Shaji Kumar, David Dingli, Taxiarchis Kourelis, Rahma Warsame, Prashant Kapoor, Mithun Shah, Hassan Alkhateeb, Patrick Johnston, Stephen Ansell, Nabila Bennani, Mustaqeem Siddiqui and Yi Lin

Background: The patient/caregiver experience during CAR-T therapy is stressful, overwhelming, terrifying, and often a patient’s last treatment option. The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Innovation and Design team has worked with the CAR-T therapy clinical team to develop a patient experience that provides patients with a sense of caring, supportive environment, timely knowledge, and realistic expectations. Using a human-centered design approach, the Innovation and Design team worked with patients and caregivers to understand latent and unspoken needs in order to develop an ideal CAR-T therapy patient journey. Methods: With qualitative interviewing techniques, patient observation, and low fidelity experimentation, 21 patients/caregiver pairs were interviewed throughout their CAR-T therapy experience in 2018. Patients were interviewed at several touch points as well as encouraged to reach out to the Innovation and Design team at any point with reflections on their experiences. Patients were recruited as they began their evaluation phase for CAR-T therapy. The interviews were unscripted to allow for a breadth of discovery by not constraining the conversations to previously developed themes. As themes emerged from patient/caregiver interviews, artifacts and interventions were designed to alleviate pain points and improve the patient/caregiver experience. These artifacts and interventions were integrated into the clinical processes in real time and patient/caregivers were interviewed to understand the impact of these activities. Results: Several themes emerged from qualitative interviews with patients and caregivers. From the themes, interventions were developed. We were able to demonstrate a qualitative improvement in patient/caregiver experience through these interventions (Figure 1). Conclusions: Patients/caregivers undergoing CAR-T therapy have unique issues surrounding the logistics of care, emotional burden, and physical effects of treatment. We implemented processes to address these issues and observed a qualitative improvement via patient interviews/feedback. Ongoing work includes optimizing remote monitoring, digital platforms for patient education, and a quantitative study looking at patient reported outcomes (PROs) in such patients. To our knowledge, this is the first report for care delivery optimization in real-world practice for this new therapy.

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Jaffer A. Ajani, James S. Barthel, David J. Bentrem, Thomas A. D'Amico, Prajnan Das, Crystal S. Denlinger, Charles S. Fuchs, Hans Gerdes, Robert E. Glasgow, James A. Hayman, Wayne L. Hofstetter, David H. Ilson, Rajesh N. Keswani, Lawrence R. Kleinberg, W. Michael Korn, A. Craig Lockhart, Mary F. Mulcahy, Mark B. Orringer, Raymond U. Osarogiagbon, James A. Posey, Aaron R. Sasson, Walter J. Scott, Stephen Shibata, Vivian E. M. Strong, Thomas K. Varghese Jr., Graham Warren, Mary Kay Washington, Christopher Willett and Cameron D. Wright

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Jaffer A. Ajani, James S. Barthel, Tanios Bekaii-Saab, David J. Bentrem, Thomas A. D'Amico, Prajnan Das, Crystal Denlinger, Charles S. Fuchs, Hans Gerdes, James A. Hayman, Lisa Hazard, Wayne L. Hofstetter, David H. Ilson, Rajesh N. Keswani, Lawrence R. Kleinberg, Michael Korn, Kenneth Meredith, Mary F. Mulcahy, Mark B. Orringer, Raymond U. Osarogiagbon, James A. Posey, Aaron R. Sasson, Walter J. Scott, Stephen Shibata, Vivian E. M. Strong, Mary Kay Washington, Christopher Willett, Douglas E. Wood, Cameron D. Wright and Gary Yang

Overview Cancers originating in the esophagus, gastroesophageal junctions, and stomach constitute a major health problem worldwide. In the United States, 37,600 new diagnoses of and 25,150 deaths from upper gastrointestinal cancers were estimated in 2009. 1 A dramatic shift in the location of upper gastrointestinal tumors has occurred in the United States, 2 and changes in histology and location of them were observed in some parts of Europe. 3,4 In countries in the Western Hemisphere, the most common sites of gastric cancer are the proximal lesser curvature, cardia, and gastroesophageal junction. 2 These changing trends may also begin to occur in South America and Asia. Epidemiology Gastric cancer is rampant in many countries around the world. In Japan, it remains the most common type of cancer among men; in China, more new cases are diagnosed each year than in any other country. The incidence of gastric cancer, however, has been declining globally since World War II and it is one of the least common cancers in North America. By some estimates, it is the fourth most common cancer worldwide. 5 In 2009, 21,130 new diagnoses of gastric cancer were estimated in the United States and 10,620 deaths expected. 1 In developed countries, the incidence of gastric cancer originating from the cardia follows the distribution of esophageal cancer. 6–8 Noncardia gastric adenocarcinoma has marked geographic variation, with countries such as Japan, Korea, China, Taiwan, Costa Rica, Peru, Brazil, Chile, and the former Soviet Union showing a high incidence. 9 In contrast to the incidence trends in the West, nonproximal...
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Gregory P. Kalemkerian, Wallace Akerley, Paul Bogner, Hossein Borghaei, Laura QM Chow, Robert J. Downey, Leena Gandhi, Apar Kishor P. Ganti, Ramaswamy Govindan, John C. Grecula, James Hayman, Rebecca Suk Heist, Leora Horn, Thierry Jahan, Marianna Koczywas, Billy W. Loo Jr, Robert E. Merritt, Cesar A. Moran, Harvey B. Niell, Janis O’Malley, Jyoti D. Patel, Neal Ready, Charles M. Rudin, Charles C. Williams Jr, Kristina Gregory and Miranda Hughes

Neuroendocrine tumors account for approximately 20% of lung cancers; most (≈15%) are small cell lung cancer (SCLC). These NCCN Clinical Practice Guidelines in Oncology for SCLC focus on extensive-stage SCLC because it occurs more frequently than limited-stage disease. SCLC is highly sensitive to initial therapy; however, most patients eventually die of recurrent disease. In patients with extensive-stage disease, chemotherapy alone can palliate symptoms and prolong survival in most patients; however, long-term survival is rare. Most cases of SCLC are attributable to cigarette smoking; therefore, smoking cessation should be strongly promoted.

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Gregory P. Kalemkerian, Wallace Akerley, Paul Bogner, Hossein Borghaei, Laura Chow, Robert J. Downey, Leena Gandhi, Apar Kishor P. Ganti, Ramaswamy Govindan, John C. Grecula, James Hayman, Rebecca Suk Heist, Leora Horn, Thierry M. Jahan, Marianna Koczywas, Cesar A. Moran, Harvey B. Niell, Janis O'Malley, Jyoti D. Patel, Neal Ready, Charles M. Rudin and Charles C. Williams Jr.