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doi: 10.1097/01.COT.0000287935.47884.0a
Journal Scan

“Laparoscopic Transgastric Esophageal Mucosal Resection for High-Grade Dysplasia” by Constantine T. Frantzides, MD, PhD; Atul K. Madan, MD; Ronald E. Moore, MD; and others.

This article describes a first-of-its-kind surgical technique—laparoscopic transgastric esophageal mucosal resection—which tackles a potentially cancerous esophageal condition from a new angle—the inside.

The operation, intended for patients with precancerous Barrett's esophagus with high-grade dysplasia, begins with an abdominal incision through which the surgeon approaches the inside esophageal layer, where cancer typically starts, and removes abnormal segments.

Currently, one physician is performing this surgical technique: Constatine Frantzides, MD, PhD, Director of Minimally Invasive Surgery at Evanston Northwestern Healthcare.

“This is the first report of this type of procedure to treat this condition,” he said in a news release. “The minimally invasive technique is a major advancement because it offers patients an alternative to traditional surgery that removes the esophagus entirely or to endoscopic procedures that examine and remove abnormal segments of the esophagus but may miss an underlying malignancy.”

The article describes the first two patients who had successful surgery. Segments of high-grade dysplasia were removed from each patient using the technique; neither patient had carcinoma in situ or invasive esophageal cancer, however.

The patients have been followed for 20 and 10 months, respectively, and are healing without complications or recurrence.

Dr. Frantzides and colleagues are currently developing protocols to test the effectiveness and long-term benefit of the surgical technique.

J Laparoendosc Adv Surg Tech A 2004;14(5):261–265.

“Forgoing Treatment at the End of Life in 6 European Countries” by Georg Bosshard, MD, MAE; Tore Nilstun, PhD; Johan Bilsen, RN, MSc; and others for the European End-of-Life (EURELD) Consortium.

European countries have diverse trends on whether to withhold or withdraw life-prolonging treatment at the end of life, as shown in this study of six European nations. The authors note that, while similar studies have been done for single countries or specific patient groups, like cancer patients, this is the most comprehensive one to date.

The data come from questionnaires sent to physicians in six countries—Switzerland, the Netherlands, Belgium, Denmark, Italy, and Sweden—asking about the physicians' decision-making process for end-of-life care.

Of the 20,480 deaths, 5,575 involved a decision not to treat. The incidence of decisions not to treat ranged from in 41% of deaths in Switzerland to in only 6% in Italy.

Medication was the treatment most frequently foregone, in 44% of deaths, followed by hydration and nutrition, 22%.

Oncotherapy was much less likely to be foregone, in only 6% of total deaths, ranging from 10% in Belgium to 2% in Denmark.

In instances where oncotherapy was foregone, however, malignancy was the ultimate cause of death in 93% of cases.

Malignancy was also a notable cause of death when other treatments were withheld: 26% of deaths when medication was foregone and 31% when hydration or nutrition were withheld, for example.

The researchers also looked at a few end-of-life decision factors that have not been explored in studies of this type. For example, they examined the relationship of treatments withheld (or never started) to treatments started and later withdrawn.

A decision to withhold treatment occurred in 49% of cases, with the remainder being decisions to withdraw or to withhold and withdraw treatment.

Decisions to withhold treatment were more common in patients older than 79 (54%), in patients dying outside of the hospital (53%), and when the withheld treatment would shorten life by more than one month (62%).

Arch Intern Med 2005;165(4):401–407.

“Profile of Patients with Kaposi's Sarcoma in the Era of Highly Active Antiretroviral Therapy” by James H. Gallafent, Susan E. Buskin, Peter B. De Turk, and David M. Aboulafia.

The changing profile of AIDS patients who develop Kaposi's sarcoma (KS) may outline a subpopulation who have barriers to obtaining care and following highly active antiretroviral therapy (HAART) regimens, this study found.

Treating AIDS with HAART, which became widely used in King County, Washington, in 1997, has decreased the incidence of KS in AIDS patients there, and has also altered the profile and prognosis of these patients.

The authors compare KS patients in the pre-HAART era (1990 to 1996) and the HAART era (1997 to 2003). Both diagnoses of AIDS and KS fell after HAART became widely prescribed—KS diagnoses dropped from an average of 53 a year to an average of six a year.

Additionally, the time from HIV diagnosis to KS diagnosis rose from four years pre-HAART to seven years in the HAART era, and one-year survival rates for KS increased from 59% to 79%.

Even though median CD4+ counts and median HIV-1 viral loads in KS patients did not change significantly with the use of HAART, the incidence of opportunistic illnesses decreased from 50% pre-HAART to 25% in the HAART era.

Nevertheless, the incidence of several comorbid conditions in HAART-era KS patients has risen significantly: alcohol problems (43%, up from 18%); noninjection drug use (45%, up from 18%); injection drug use (25%, up from 10%); psychosis (25%, up from 13%); and hypertension (13%, up from 2%).

The demographics of these patients have also shifted—there are fewer men who have sex with men, but more minorities and people from countries other than the US.

The authors speculate that a combination of mental illness, substance abuse, and minority status might have delayed access to HIV care for these patients until symptoms of KS or an opportunistic illness caused them to seek treatment.

J Clin Oncol 2005;23:1253–1260.

“Communicating with Realism and Hope: Incurable Cancer Patients' Views on the Disclosure of Prognosis” by Rebecca G. Hagerty, Phyllis N. Butow, Peter M. Ellis, and others.

When faced with the diagnosis of incurable cancer, patients want their physicians to have a realistic and individualized approach, as well as detailed information about their prognosis. That is the conclusion of the authors of this study, which is based on a survey to determine how this subset of cancer patients wants to be informed of their prognosis and which delivery features they feel are hopeful.

The authors invited consecutive incurable metastatic cancer patients of 30 Australian oncologists to take a survey about how they want to receive information on their prognosis.

Of 218 patients invited to take the survey, 58% responded. Participants had a mean age of 62.6 and ranged from 34 to 82; 44% were women.

There had been a mean time of 13 weeks since diagnosis of metastases, most patients had estimated survival times of months (42%) or years (42%), and 92% were on radiotherapy or systemic anticancer therapy.

Almost all patients wanted their doctors to be realistic about their future, to give them an opportunity to ask questions, and to acknowledge them as individuals (98% for each).

Offering the most up-to-date treatments, saying that cancer pain will be controlled, and appearing to know everything about a patient's cancer were doctor behaviors that patients identified as most hope giving.

Appearing nervous or uncomfortable and giving the prognosis to the family before the patient gave the least hope, the study found.

The authors point out that some of their findings conflict with current practice guidelines. For example, patients were not very interested in having another medical professional there for the discussion of their prognosis, nor did many want an audiotape of the discussion.

Citing another study that reached similar conclusions, the authors say that published consensus guidelines may need to be modified in light of this feedback.

J Clin Oncol 2005;23(6):1253–1260.

“Palifermin for Oral Mucositis after Intensive Therapy for Hematologic Cancers” by Ricardo Spielberger, MD, Patrick Stiff, MD, William Bensinger, MD, and others.

Palifermin significantly reduced the severity and duration of oral mucositis in patients being treated for hematologic cancers, with minimal side effects, this study found.

Although there is no standard therapy for oral mucositis, it is common in patients with hematologic cancers who have radiation and chemotherapy followed by hematopoietic stem-cell transplants.

As pointed out in an accompanying editorial by Adi A. Garfunkel, DMD, of the Oral Medicine Department of Hadassah University Hospital in Jerusalem, oral mucositis causes severe pain in these patients, reducing quality of life, and the condition can lead to serious complications, such as malnutrition and infection due to a breakdown in the oral mucosal barrier.

For this placebo controlled, double-blind, Phase III study, the authors randomized patients to receive either palifermin (106 patients) or placebo (also 106 patients) for three consecutive days before radiation therapy and three consecutive days after transplant.

The researchers also assessed the severity of oral mucositis for eight days before transplant through 28 days after transplant or until the symptoms resolved.

Also gathered were patient-reported data on mouth and throat soreness and participation in daily activities, as well as information on the amount of opioid analgesics used to control pain.

Oral mucositis with a World Health Organization (WHO) oral-toxicity scale grade of 3 or 4 occurred in 63% of the palifermin group, compared with 98% of the placebo group.

Furthermore, Grade 3 or 4 oral mucositis lasted a median of six days in the palifermin group and nine days in the placebo group.

Patients receiving palifermin also reported less throat and mouth soreness (29.0 vs 46.8 on a Likert scale) and higher levels of daily functionality.

Patients in the palifermin group also took fewer opioid analgesics (212 vs 535 mg), needed less parenteral nutrition (31% of patients vs 55%), and had a low instance of blood-borne infections (15% of patients vs 25%).

Dr. Garfunkel wrote in his editorial: “The work by Spielberger et al, if supported by additional studies to determine the optimal dose and regimen, will fundamentally change targeted therapies for radiochemically induced mucositis.”

N Eng J Med 2004;351(25):2590–2598.

© 2005 Lippincott Williams & Wilkins, Inc.
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