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Outcomes With Neoadjuvant Chemotherapy in Early Breast Cancer
Some women with early breast cancer receive neoadjuvant chemotherapy, based on factors including the stage and receptor status of the cancer. In preliminary results of a patient-level meta-analysis, including 28,000 patients with early breast cancer, a pathologic complete response (pCR) to neoadjuvant chemotherapy was associated with better event-free and overall survival than in those without pCR, irrespective of whether adjuvant chemotherapy was also administered. We continue to advise most women who complete a standard course of neoadjuvant chemotherapy that no further chemotherapy is required. However, for women with triple negative breast cancer who have residual disease, we suggest a course of adjuvant capecitabine, based on previous trial data.
Prostate Cancer and 5-Alpha Reductase Inhibitors
The 5-alpha reductase inhibitors (5-ARIs) finasteride and dutasteride improve lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH), by blocking the conversion of testosterone to the more potent androgen dihydrotestosterone. Although two randomized trials have shown a reduced risk of prostate cancer in men receiving 5-ARIs, concerns were raised about a possible increased risk of high-grade prostate cancers. In a Swedish population-based cohort study of all men over the age of 40 who had at least one prostate-specific antigen (PSA) test in Stockholm County between 2007 and 2015, men who were prescribed a 5-ARI had a decreased risk for prostate cancer, and the effect was larger with longer duration of exposure. The reduction was limited to patients with prostate cancers with Gleason score 6 to 7; there was no impact on the risk of higher-grade disease (Gleason score 8 to 10). These data provide some reassurance that treatment with a 5-ARI for lower urinary tract symptoms is safe with regard to prostate cancer risk, but long-term follow-up data demonstrating improved survival are needed to determine the role of 5-ARIs as chemopreventive agents.
Hybrid Minimally Invasive Versus Open Ivor Lewis Esophagectomy
Ivor Lewis esophagectomy is traditionally an open procedure. In a randomized trial of >200 patients with cancer in the middle or lower third of the esophagus, a hybrid approach of laparoscopic gastric mobilization combined with open right thoracotomy resulted in fewer major intraoperative and postoperative complications (especially pulmonary complications) and similar three-year survival compared with open surgery. This is a reasonable surgical option where appropriate surgical expertise is available.
Adverse Effects With Use of Combination Radium-223 and Abiraterone for Advanced Castration-Resistant Prostate Cancer
Radium-223, a bone-seeking alpha particle emitter, prolongs survival and decreases symptomatic skeletal events in men with prostate cancer and bone metastases; it is being studied in combination with other agents for the treatment of advanced castration-resistant prostate cancer (CRPC). In a phase III trial, combined therapy, compared with abiraterone alone, did not result in a survival benefit but increased the rate of bone fractures. These findings led Health Canada to recommend against the use of radium-223 in combination with abiraterone, and the European Medicines Agency to restrict use of radium-223 to men with at least two previous treatments for bone metastatic CRPC, or to those who could not use any other treatment. We agree with these restrictions and suggest not initiating radium-223 and abiraterone at the same time for most men.
Sequence of Adjuvant Chemotherapy and Radiation in Endometrial Cancer
For patients with high-risk endometrial cancer, components of adjuvant treatment may include chemotherapy and radiation therapy (RT), but the optimal sequence of these interventions is unclear. In an observational cohort including approximately 1500 women with stage III to IV endometrial cancer who received adjuvant chemotherapy and RT, those who received RT after chemotherapy experienced longer five-year overall survival than those who received it before chemotherapy (80 versus 73 percent). For those with endometrial cancer in whom both adjuvant chemotherapy and RT are warranted, we administer RT following the completion of chemotherapy.
Prognosis of Nodular Melanoma
There are four major growth patterns of melanoma: lentigo maligna, nodular, superficial spreading, and acral lentiginous. In an observational study of close to 120,000 patients with melanoma, nodular melanoma was an independent risk factor for death, after controlling for thickness, ulceration, and stage. Nevertheless, the eighth edition of the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging system, which relies upon primary tumor thickness and other features, involvement of regional lymph nodes, and presence or absence of distant metastases, should be used to stage melanomas of any growth pattern.
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