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Jana Portnow, Christine Lim and Stuart A. Grossman

Invasive procedures are commonly required in the diagnosis and management of cancer in adults. However, little is known regarding the prevalence and severity of procedure-related pain in this patient population. This prospective study was conducted to determine the frequency and types of invasive procedures performed in a large comprehensive cancer center, the intensity of pain associated with these procedures, the types of periprocedural analgesics administered, and how these patients would like their procedural pain to be managed in the future. During a 6-week period, 102 cancer patients were interviewed immediately after undergoing an invasive procedure. They were asked to rate the pain they experienced before, during, and after their procedure using a verbal descriptor scale (VDS) ranging from 0 to 10. They also were asked if they would want more, less, or the same amount of pain medication if they were to undergo the same procedure again. The most frequently performed procedures were bone marrow aspirates and biopsies (68%), lumbar punctures (14%), and placements of central venous catheters (10%). The average pain rating during these procedures was 4.2 (standard deviation [SD], 3.0). However, 26% of patients experienced severe pain (VDS score [threesuperoir]7) during the procedures. Twenty-four percent of patients surveyed received conscious sedation for their procedure. There was no statistical relationship between patients' pain ratings and their satisfaction with the pain control they received during the procedures. This study represents the largest descriptive study of procedural pain in adult cancer patients. As more than 50% of these patients experienced moderate to severe pain during procedures, further studies are needed to improve the control of procedure-related pain in patients with cancer.

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Karisa C. Schreck, Andrew Guajardo, Doris D.M. Lin, Charles G. Eberhart and Stuart A. Grossman

BRAF V600 mutations are being identified in patients with primary brain tumors more often as molecular testing becomes widely available. Targeted treatment with BRAF inhibitors has been attempted in individual cases with some responses, whereas others showed no response or developed resistance. Preclinical work suggests that gliomas could be more responsive to the concurrent use of BRAF and MEK inhibition for MAP kinase pathway suppression. This report presents 2 cases of malignant brain tumors with BRAF V600E mutations that were resistant to radiation and temozolomide, and reports on their response to targeted treatment with the BRAF and MEK inhibitors dabrafenib and trametinib. One patient with an anaplastic pleomorphic xanthoastrocytoma experienced a partial response for 14 months, demonstrated by progressive tumor shrinkage and clinical improvement; however, this was followed by clinical and radiographic progression. The patient with glioblastoma continued to have stable disease after 16 months of treatment. These cases are encouraging in a disease that urgently needs new treatments. Further work is necessary to understand response rates, duration, and survival in primary brain tumors.

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Stuart A. Grossman, Susannah Ellsworth, Jian Campian, Aaron T. Wild, Joseph M. Herman, Dan Laheru, Malcolm Brock, Ani Balmanoukian and Xiaobu Ye

Background: The immune system plays an important role in cancer surveillance and therapy. Chemoradiation can cause severe treatment-related lymphopenia (TRL) (<500 cells/mm3) that is associated with reduced survival. Materials and Methods: Data from 4 independent solid tumor studies on serial lymphocyte counts, prognostic factors, treatment, and survival were collected and analyzed. The data set included 297 patients with newly diagnosed malignant glioma (N=96), resected pancreatic cancer (N=53), unresectable pancreatic cancer (N=101), and non–small cell lung cancer (N=47). Results: Pretreatment lymphocyte counts were normal in 83% of the patient population, and no patient had severe baseline lymphopenia. Two months after initiating chemoradiation, 43% developed severe and persistent lymphopenia (P=.001). An increased risk for death was attributable to TRL in each cancer cohort (gliomas: hazard rate [HR], 1.8; 95% CI, 1.13–2.87; resected pancreas: HR, 2.2; 95% CI, 1.17–4.12; unresected pancreas: HR, 2.9; 95% CI, 1.53–5.42; and lung: HR, 1.7; 95% CI, 0.8–3.61) and in the entire study population regardless of pathologic findings (HR, 2.1; 95% CI, 1.54–2.78; P<.0001). Severe TRL was observed in more than 40% of patients 2 months after initiating chemoradiation, regardless of histology or chemotherapy regimen, and was independently associated with shorter survival from tumor progression. Conclusions: Increased attention and research should be focused on the cause, prevention, and reversal of this unintended consequence of cancer treatment that seems to be related to survival in patients with solid tumors.