Read Dr. Craig Hildreth's latest blog on the cancer network website (http://cancernetwork.com/) dated November 21, 2017 - It is Easy to Forget. Click here to read the article.
Significant advances have been made in the treatment of malignant melanoma of the skin. Approximately 87,110 new cases of malignant melanoma will be diagnosed in the US in 2017. The estimated death rate for this year is 9,730 cases. The treatment of malignant melanoma of the skin when it is localized includes a wide local excision with appropriate margins to assure there is no tumor left behind. Depending on the depth of the tumor, consideration should be given to sampling of the lymph nodes (sentinel lymph node biopsy) and occasionally full evaluation of the regional lymph nodes (lymph node dissection). Most recently in an article published in the New England Journal of Medicine on June 8, 2017, the authors demonstrated that immediate complete lymph node dissection did not increase melanoma specific survival among patients with melanoma and sentinel lymph node metastasis. In this study, the three-year rate of melanoma specific survival was similar in the dissection group as compared to the observation group after a sentinel lymph node biopsy. The drawback of this strategy is that fewer nodal recurrences occured in patients who underwent immediate complete lymph node dissection compared to patients who underwent observation. Patients who underwent observation required clinical examination and laboratory testing as well as regular ultrasound imaging of the lymph node basin. In summary, this study showed that active surveillance of the nodal basin is an efficient and safe way to identify patients who may benefit from delayed node-directed treatment. Additionally, with the advent of immunotherapy, which is a strategy that turns the immune system on to detect cancer cells, we have now been able to improve the survival in patients who are at high risk of relapse or recurrence from melanoma. An additional trial published in the New England Journal of Medicine by Eggermont and collaborators demonstrated that patients with high risk malignant melanoma who received postoperative treatment or adjuvant therapy with ipililumab had a significantly higher rate overall survival, and lower recurrence and metastasis compared to the placebo. Furthermore, this therapy was relatively well-tolerated compared to our historical experience with other types of immunotherapy such as interferon.
- Malignant Melanoma
- Sentinel lymph node sampling vs lymph node dissection
- Adjuvant (postoperative immunotherapy with ipililmumab
- Improvement in survival, recurrence and metastasis rates
Read Dr. Craig Hildreth's latest blog on the cancer network website (http://cancernetwork.com/) dated July 4th, 2017 - Speaking the unspoken. Click here to read the article.
Read Dr. Craig Hildreth's latest blog on the cancer network website (http://cancernetwork.com/) dated March 2nd, 2017 - The Rules of the Road. Click here to read the article.
Read Dr. Craig Hildreth's latest blog on the cancer network website (http://cancernetwork.com/) dated December 1st 2016. Click here to read the article.
I and Thou and Cancer
Read Dr. Craig Hildreth's latest blog on the cancer network website (http://cancernetwork.com/) dated August 11th 2016. Click here to read the article.
Attached is Dr. Hildreth's article that he wrote on the www.cancernetwork.com website
Our new cancer centers have opened in both the North (on DePaul campus) and South (on St Anthony's campus) county locations. We've been busy with the new construction of the state of the art cancer centers over the last few months. We'll be posting more often in the months to come now that we've moved in.
In the meantime, I thought I'd share a picture of one of the views in our North county location treatment center (I could only take a picture of one corner of the office to protect the privacy of our patients); it has walls of windows on two sides to let the sunshine in; a nice view and a little sunshine helps to make the day just a little more pleasant for patients getting treatment
During a consultation with an oncologist, one of the most important issues to address is what we call "goals of treatment." Although this may seem like an obvious topic, I see many times where the patient and their physician are not on the same page which leads to frustration for both.
I believe that setting goals with the patient is extraordinarily important- or in the words of Yogi Berra: “If you don't know where you are going, you'll end up someplace else.”
Most times for our cancer patients, we think of goals of therapy in terms of being "curative in intent" or "palliative in intent."
"Curative intent" therapy is where we are trying to cure the patient of the cancer and hopefully return the patient to completely normal function and health afterward; this is our typical goal for most patients with early stage cancers (such as stage I- III breast or colon cancers) or even in cancers that may be more advanced stage but are highly curable regardless of stage (such as certain lymphomas, testicular carcinoma, and others). With "curative intent" given that the goals to permanently eliminate the cancer, we sometimes will ask our patients to tolerate significant side effects since our reward will be cure of the cancer.
There are times when it is unfortunately impossible to cure the patient of the cancer or that cure may not be the goal of the patient. In those cases, we are treating patients with "palliative intent". In other words, and our goal first and foremost is to alleviate symptoms and improve quality of life and in the process hopefully extend the amount of time a patient can live with their cancer. In this case, as I tell my patients : "quality of life is king." The intention of this therapy is to improve quality of life, alleviate symptoms, decrease pain, or avoid symptoms the patient is already feeling well. When pursuing "palliative intent" to treatment, we have to remember that the goal is quality of life more than anything. From my perspective, whatever tool we use to achieve our goal is not as relevant as the improvement in quality of life itself.
With palliative intent therapy, I always remind my patients that the point of chemotherapy is to feel better. It is not necessarily a victory if we make a tumor shrink by 25% on an x-ray but the patient feels miserable every single day. Similarly, there may be some therapies that do not cause a cancer to shrink at all but keep it contained for an extended period of time and the patient can feel quite well.
As always, these are issues that need to be discussed between the patient and their physician. Make sure that you and your doctor both understand and agree on what the goals of therapy are in your case; in that way, you can best work as a team.
Over the last few weeks there has been an intensive discussion regarding the diagnosis of DCIS (Ductal Carcinoma In Situ) which is the earliest form of breast cancer, characterized by the presence of “cancerous” cells located in the milk ducts of the breast. This is called stage 0 breast cancer. Invasive cancer staging starts with stage I to stage IV depending on the tumor size, lymph node involvement, and presence of spread of the cancer to other organs (metastasis).
DCIS is mammographically suspected by the presence of micro calcifications subsequently requiring a biopsy to confirm the diagnosis histologically. The incidence of DCIS has increased over the last few years with the advent of powerful and more sophisticated screening mammography for invasive breast cancer. According to the American Cancer Society statistics, DCIS is diagnosed in 1 of every 4 new breast cancer cases in the US posing a significant public health threat.
The current treatment of breast cancer requires a multidisciplinary approach and DCIS is no exception to this approach. The management of DCIS is personalized and depends on multiple factors such as age, co-morbidities, expectations, and prognostic markers. The current prognostic markers used are Estrogen Receptor (ER) positivity or negativity and grade level (low grade: not so aggressive, high grade: aggressive, intermediate grade: moderately aggressive). Women with DCIS will require surgical excision with negative margins (no cancer left behind), possibly radiation therapy, and possibly anti-estrogen therapy.
So where is the controversy?
The controversy is of excesses. A recent large observational study article in JAMA Oncology by Narod et al showed an extremely low breast cancer specific mortality of 3.3% from DCIS. The investigators demonstrated that radiation therapy after lumpectomy reduced the risk of ipsilateral (same side as the original cancer side) invasive breast cancer recurrence, but did not have any impact on breast cancer specific survival. Prior to the use of mammographic technology the diagnosis of DCIS was rarely made. Studies suggest that up to 60% of DCIS cases will progress to invasive breast cancer. It should be helpful to stratify DCIS into risk categories. Some patients with DCIS will never have their disease progress (low risk), others will have such an aggressive DCIS that extensive treatment should be recommended (high risk), and still other patients will have disease that progresses slowly over many years (intermediate risk).
So what is an oncologist to recommend and a patient to do?
Although the data presented by Narod and colleagues is based on a large number of patients it is an observational study after all. It is indeed provocative and it should spark future investigations on this somewhat neglected non-invasive breast cancer. Mammographic findings and biopsy results should be interpreted cautiously and in the context of the patient. Treatment should be multidisciplinary in nature, consultation with the medical oncologist and radiation oncologist should be seriously considered prior to performing unnecessary mutilating surgery. Radiation treatment should not be routinely offered to low risk patients and molecular profiling should then be considered for more appropriate guidance regarding this modality of treatment. Hormonal or anti-estrogen therapy should be discussed in those patients with ER+ DCIS only and after careful evaluation of the risks and benefits of this therapy.
The most powerful tool that patients, family and caregivers have is information. Bringing a list of pertinent questions and asking for a multidisciplinary approach prior to initiating surgical treatment may allow the patient to have a better understanding of this misunderstood process as is DCIS. Remember, DCIS should be appropriately managed but is not an emergency as some have tried to portray it. Do not be scared, be knowledgeable.
J. Daniel Cuevas, MD
Director Clinical Research
St Louis Cancer Care LLP
JAMA Oncol. Published online August 20, 2015. doi:10.1001/jamaoncol.2015.2510
Stephen Allen, M.D.