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Genetic Testing in Men With Metastatic Prostate Cancer
Multiple cancer predisposition genes have been associated with prostate cancer. Guidelines from the National Comprehensive Cancer Network (NCCN) recommend that genetic counseling be considered for men with metastatic prostate cancer because approximately 10 percent of these men have a pathogenic germline mutation in a DNA repair gene. Decisions regarding genetic testing are complex, and the potential benefits should be weighed against the potential negative aspects, including psychosocial consequences, disclosure to family members, and genetic discrimination.
Heated Intraperitoneal Chemotherapy for Treatment of Unresectable Ovarian Cancer
Neoadjuvant chemotherapy (NACT) followed by interval cytoreduction and postoperative chemotherapy is an option in ovarian, fallopian tube, or peritoneal cancer (EOC) cases when optimal cytoreduction is not feasible. In a randomized trial of interval cytoreduction with or without the addition of heated intraperitoneal cisplatin therapy (HIPEC) in over 200 women with stage III EOC, HIPEC lowered mortality (50 versus 62 percent) at a median follow-up of 4.7 years, increased median recurrence-free survival (14 versus 11 months) and overall survival (46 versus 34 months), with similar rates of serious adverse events. It is unclear whether the favorable effects of HIPEC were due to the additional dose of chemotherapy, the intraperitoneal route, or heated therapy. A limitation of HIPEC is that it requires specialized technical expertise.
Bevacizumab Plus Lomustine Does Not Improve Survival in Recurrent Glioblastoma
In a previous noncomparative phase II trial in patients with recurrent glioblastoma, the combination of lomustine and bevacizumab appeared to improve survival compared with either therapy alone. However, these results could not be confirmed in a larger phase III trial of lomustine plus bevacizumab versus lomustine alone in over 400 patients with a first recurrence of glioblastoma after standard therapy. Although response rates and progression-free survival were improved by the addition of bevacizumab, adverse event rates were also higher, and overall survival was similar between the two arms (9.1 versus 8.6 months). Outside of a clinical trial, we suggest single-agent therapy with bevacizumab, lomustine, or temozolomide in most patients selected for systemic therapy. Treatment should be individualized based on multiple factors including prior therapies, performance status, steroid requirements, and side effect profiles.
Edoxaban Versus Low Molecular Weight Heparin for Venous Thromboembolism in Cancer Patients
Direct oral anticoagulants (DOACs) are often used for first-line therapy for the treatment of venous thromboembolism (VTE) in patients without cancer, but their efficacy in patients with cancer is unknown. An open-label randomized trial in patients with cancer and VTE reported that anticoagulation with the DOAC edoxaban was as effective as with the low molecular weight heparin (LMWH) dalteparin in preventing VTE recurrence; however, the rate of major bleeding was increased for patients receiving edoxaban. Further trials are warranted before DOACs can be routinely recommended over LMWH as first-line therapy for the treatment of VTE in patients with cancer.
Bevacizumab Not Indicated as Part of Adjuvant Treatment for Non-Small Cell Lung Cancer
A cisplatin-based chemotherapy doublet is indicated as adjuvant chemotherapy for patients who have undergone definitive surgical resection of high-risk non-small cell lung cancer (NSCLC). A randomized trial found no improvement in overall survival or progression-free survival when bevacizumab was added to cisplatin-based chemotherapy compared with chemotherapy alone in the adjuvant setting. Although bevacizumab, when added to chemotherapy, is associated with improved overall survival in patients with metastatic NSCLC, bevacizumab is not indicated as part of adjuvant treatment for patients who have undergone definitive resection.
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