Hypofractionated RT in Locally Advanced NSCLC: Phase I Trial Yields M

Dose-escalated hypofractionated radiotherapy yielded a maximum tolerated dose for patients with locally advanced non-small-cell lung cancer (NSCLC) and shed light on dangerous toxicity at higher doses, according to a new study. The toxicity was dominated by late radiation toxicity to the central and perihilar structures including the proximal bronchial tree and surrounding vasculature.

“In most of the randomized concurrent chemotherapy trials, patients were treated to doses of 60 to 66 Gy but nevertheless still experienced local failure rates of approximately 30%,” wrote authors led by Donald M. Cannon, MD, of the Mountain States Tumor Institute in Twin Falls, Idaho. “Given these suboptimal results, strategies of treatment intensification to improve outcomes continue to be explored.”

The new phase I study, published online ahead of print on October 21 in the Journal of Clinical Oncology, enrolled 79 patients with NSCLC at a single institution. After five patients were treated on a pilot study at a dose of 57 Gy of hypofractionated radiotherapy, the study’s dose escalation protocol (without any concurrent chemotherapy) proceeded. Forty-seven of the patients ended up receiving only the 57 Gy base dose; 11 patients received 63.25 Gy, 3 received 69.25 Gy, 12 received 75 Gy, 4 received 80.5 Gy, and 2 received 85.5 Gy. The median dose was 57 Gy in 25 fractions.

After a median follow-up period of 17 months, the median overall survival rate was 16 months; 29% of the cohort survived to 3 years. There was no difference seen in rates of local control between those treated at 69.25 Gy and higher and those treated at the lower 57 and 63.25 Gy doses (P = .81).

The maximum tolerated dose was established at 63.25 Gy. There were no cases of grade 3 or higher radiation pneumonitis, and 12 patients (16%) had grade 2 pneumonitis. There were also no instances of grade 3 or worse acute or late esophageal toxicities, though 48% of the cohort experienced grade 2 esophagitis.

Six grade 4 or 5 toxicities were deemed likely to be related to radiotherapy. One patient treated at 63.25 Gy died from progressive hypoxemia with bilateral lung infiltrates without disease progression 1 month after therapy. Three patients treated at 75 Gy and above died from massive hemoptysis 8 or more months after the therapy. Univariate analysis showed that higher delivered dose was significantly associated with development of any grade 4 to 5 toxicity, with a hazard ratio of 1.13 (95% CI, 1.04-1.23; P = .0036).

While the study suggests this therapy up to 63.25 is well tolerated, the authors noted that “our results are a reminder that the spectrum of toxicities from dose-intensified thoracic radiotherapy can be broad.” The results have implications for design of trials aiming to improve rates of local control. “In addition to controlling for pneumonitis risk, radiation dose-escalation studies in lung cancer should require strict limits to doses received by the proximal bronchial tree,” they concluded.

¿QUE EVIDENCIAS TENEMOS SOBRE EL CIGARRILLO ELECTRÓNICO?.

E-cigarettes and electronic nicotine delivery systems should be better..E-cigarettes and electronic nicotine delivery systems (ENDS) have not been scientifically validated and may be more dangerous than they are often considered, according to the International Union Against Tuberculosis and Lung Disease. The Union issued a new position statement in November on e-cigarettes and ENDS, calling for stricter regulation of these products, which are rapidly growing in popularity.

“Right now, significant numbers of people around the globe are using these products,” said Jose Luis Castro, the interim executive director of the organization, in a press release. “They just don’t know what they are ingesting, what that might mean for their health in the long term or what their use of e-cigarettes and ENDS means for the people around them. It is an echo of the traditional cigarette industry in the 20th century, which created the current global epidemic of tobacco-related harm and mortality. To avoid repeating the same mistakes, we need to act now to regulate e-cigarettes and protect consumers around the world.”Importantly, the Union asserts that the safety of these devices has not been scientifically demonstrated. In general, it is claimed that they release only water vapor, but “adverse health effects for third parties exposed cannot be excluded because the use of electronic cigarettes leads to emission of fine and ultrafine inhalable liquid particles, nicotine, and cancer-causing substances into indoor air,” according to the position statement. An assessment by the German Cancer Research Center found that the aerosol of some liquids in the devices contains substances including formaldehyde, acetaldehyde, acrolein, diethylene glycol, chromium, and lead.And aside from potential third-party health effects, the efficacy of the devices themselves has yet to be conclusively proven. They are intended as smoking cessation aids, but research on their efficacy as such has been somewhat inconclusive. Some people do indeed cut back or quit smoking using e-cigarettes.

Among the only randomized trials on their efficacy was conducted in New Zealand. The study randomized 657 smokers who wanted to quit to either nicotine e-cigarettes, nicotine patches, or placebo e-cigarettes. After 6 months, verified abstinence from smoking was found in 7.3% of nicotine e-cigarette patients, 5.8% of patch patients, and 4.1% of placebo patients; they concluded that there was thus insufficient statistical power to determine any differences, and that more research is “urgently needed” to establish benefits of the devices.

The Union also points out that regulation of e-cigarettes and ENDS varies widely around the world, and they advocate regulating them as medicines. Some countries, including Brazil, Norway, and Singapore, have simply banned the devices.

“E-cigarette and ENDS manufacturers and vendors have been vocal about the supposed benefits of their products and quick to shout down calls for regulation or questions about their contents,” Castro said. “Based on our review of the available evidence, we strongly support the regulation of the manufacture, marketing, and sale of electronic cigarettes or electronic nicotine delivery systems; and our preferred option is to regulate these products as medicines.”

Feliz Navidad a todos y mejor entrada de Año 2014

TARGETS LUNG CANCER WITH PROTONS: Proton Therapy for Lung Cancer

Tomado de MDAnderson Cancer Center.

Pioneers in the Fight Against ‘the Big One’: Proton Therapy for Lung Cancer

Released: 11/12/2013 12:00 PM EST
Source Newsroom: University of Texas M. D. Anderson Cancer Center

more news from this source

Lung cancer is the number one cancer killer in the U.S., causing more deaths than the next three most common cancers – colon, breast and prostate – combined. Worldwide, lung cancer accounts for 1.3 million deaths annually. An estimated $10.3 billion per year is spent in the U.S. on lung cancer treatment alone, yet those diagnosed with the disease have just a 15 percent survival rate.1

Physicians at The University of Texas MD Anderson Proton Therapy Center are leaders in the research and treatment of lung cancer and pioneers in developing proton therapy for lung cancer patients. With its advanced image guidance and ability to precisely target tumors in the lungs, the powerful radiation of protons can be delivered with optimal accuracy – sparing critical nearby structures, such as the esophagus, heart and spinal cord. Because the tumor can be treated with a higher dose of radiation, benefits may include better local control of the disease, higher survival rates and improved quality of life.

“MD Anderson is at the forefront of the most advanced lung cancer treatments available. It is part of our mission to raise awareness of proton therapy as a potential option for people fighting for their lives,” says James D. Cox, M.D., former head of Radiation Oncology at MD Anderson. “When the Proton Therapy Center was established in 2006, for example, it was the first to treat lung cancer with protons and chemotherapy.”

Proton Therapy at MD Anderson
Roughly 15 to 20 percent of lung cancer patients have tumors that can be treated with surgery combined with other therapies such as radiation. Another 30 to 50 percent of patients have locally advanced tumors that require a combined treatment regimen that includes chemo or targeted therapy in addition to radiation therapy. However, it is challenging to deliver an adequate dose of radiation to a cancerous tumor while sparing nearby normal tissues.

Proton therapy’s advantage for many lung cancer patients is based on this feature. Further, by minimizing the exposure of normal tissues, proton treatment may also reduce some of the side effects of traditional radiation and help patients maintain good quality of life.

Proton therapy is currently available at only 11 centers in North America (13 centers are in development). MD Anderson has one of the largest and most technically advanced centers in the world. The 96,000-square foot Proton Therapy Center – the first proton center in the world within a comprehensive cancer center – offers a range of proton treatment options. These include pencil beam proton therapy, a highly precise form of proton radiation also known as scanning beam, and intensity-modulated proton therapy (IMPT) – the most advanced form of proton radiation. For patients with recurrent lung cancer, who have already received full doses of traditional radiation, pencil beam and intensity-modulated therapies may further limit or eliminate radiation to sensitive areas.

The Proton Therapy Center treats as many as 900 patients annually. Nearly 5,000 patients have been treated to date, accounting for 15 percent of the total number of patients who have received proton treatment nationally. Approximately 1,000 of these patients have been treated for lung cancer. The best lung cancer candidates for proton radiation are those whose cancer is localized in the chest and can’t be removed surgically, notes Cox.

“We’re just beginning to see the potential benefits of proton therapy and as we move forward it looks more and more like an excellent treatment modality,” says Anne S. Tsao, M.D., associate professor in Thoracic/Head and Neck Medical Oncology. “As we learn more and gather evidence of these benefits, proton therapy will likely be extended to a broader patient population.”

“We’re just beginning to see the potential benefits of proton therapy and as we move forward it looks more and more like an excellent treatment modality,” says Anne S. Tsao, M.D., associate professor in Thoracic/Head and Neck Medical Oncology. “As we learn more and gather evidence of these benefits, proton therapy will likely be extended to a broader patient population.”

Research

Cox explains the outcomes of proton therapy with concurrent chemotherapy, how lung cancer patients typically tolerate treatment and what the future holds for lung cancer patients being treated with proton therapy at MD Anderson.

The Proton Therapy Center is advancing the science of proton therapy by providing answers to critical knowledge gaps, confirming the effectiveness of proton therapy and evaluating its use in combination with chemotherapy, targeted molecular therapies and conventional radiation therapy.

Every patient treated at the Proton Therapy Center is offered the opportunity to participate in one of more than 25 clinical protocols, which allow for the capture, analysis and reporting on treatment results related to tissue toxicity, dose optimization, and quality of life.

Lung cancer patients, for example, may take part in a phase II randomized clinical trial comparing high-dose traditional intensity-modulated radiation therapy (IMRT) with high-dose proton therapy. MD Anderson researchers are also investigating such areas as long-term outcomes for patients with locally advanced lung cancer treated with proton therapy and survival rates among proton lung patients versus those treated with traditional radiation and chemotherapy.

Since 2005, MD Anderson has published more than 175 studies focused on proton therapy for lung cancer. Recent findings include:

• Concurrent chemoradiation therapy, the standard of care for locally advanced non-small-cell lung cancer (NSCLC), can cause esophagitis and pneumonia, and X-ray-based radiation often cannot be given at doses high enough to destroy tumor cells without toxicity to nearby normal tissues. In a study published in thejournal Cancer, researchers showed that higher doses of proton radiation can be delivered to lung tumors with lower risk of these life-threatening conditions.
• Comparing toxicity and tumor coverage delivered to stage 1 NSCLC patients via traditional stereotactic body radiation therapy, passively scattered proton therapy and intensity-modulated proton therapy, researchers found that: the proton radiation approaches were better in terms of target volume coverage; significantly reduced the mean total lung dose; and reduced mean maximal dose to other nearby critical structures, including the aorta, heart, pulmonary vessels and spinal cord. The study was published in theInternational Journal of Radiation Oncology, Biology, Physics.
• Proton Therapy Center researchers have completed phase I of a study, published in the International Journal of Radiation Oncology, Biology, Physics, examining the effect of shorter courses of proton beam therapy in patients that have locally advanced NSCLC but that cannot receive chemotherapy with radiation. Using higher doses of proton beam therapy, treatment was typically completed in approximately three weeks.

“Advances are rapidly occurring in the field of proton therapy for lung cancer. Consider the ability to precisely target a tumor that moves with every breath or radiating a recurrent cancer that previously we wouldn’t have because of the toxic effects of earlier treatments,” says Daniel Gomez, M.D., assistant professor in Radiation Oncology. “Evidence-based innovations in proton therapy are making it possible to treat complicated tumors that traditional forms of radiation can’t target as effectively. As more patients are treated, the technology will continue to improve.”

Este Artículo es con fines informativos, se reflejan sus fuentes.

Eloisa Bayo, cuando la investigación y la humanidad se unen para lograr vencer al cáncer, para salvar vidas. Medalla de la Diputación Provincial de Huelva. La Oncologia Radioterápica de Huelva avanza junto a sus pacientes

Therapy for Glioblastoma. Algunas cuestiones sobre el Glioblastoma Multiforme

 ¿Qué  elecciones terapéuticas existen para los pacientes con Glioblastoma Multiforme ?

Las elecciones terapéuticas son claras: la mayor cirugía posible, con o sin Carmustina (quimioterapia intralesional), radioterapia de ultima generación mas la quimioterapia oral con temozolamida. Todo esto asociado a una muy buena atención tanto a nuestro paciente (que suelen ser personas en edad media de su vida), alto nivel de comunicación y empatía, con explicaciones al paciente y su familia de los resultados tras la cirugía, de los posibles tratamientos y por supuesto del pronóstico. No somos nadie para ocultarles la realidad que vamos a vivir juntos durante el devenir de su pronóstico y siempre "TODO EN SU JUSTA MEDIDA".

Una pregunta que me hacen repetidamente es si debe continuar más allá de seis ciclos de temozolomida tras el tratamiento concomitante con radioterapia y quimioterapia. Nosotros finalizamos  después de seis ciclos de Temozolamida de mantenimiento y no realizamos tratamientos  más largos. Los datos de ensayos clínicos aleatorizados han demostrado que los esquemas de temozolomida más intensivos y el tratamiento mas prolongado con temozolomida no mejoran el resultado. Preferimos detener y reiniciar de nuevo más tarde si se produce una recidiva o pasar a una 2ª lineas tras la recidiva.

¿Que hay sobre el nuevo tratamiento valganciclovir? Qué nos aporta? 

Hay una reciente carta al editor de The New England Journal of Medicine sobre valganciclovir y su utilidad en la prolongación de la supervivencia global en pacientes con glioblastoma. Aunque los mismos autores realizaron un pequeño ensayo aleatorio que compara tratamiento estándar ± valganciclovir  no demostraron ninguna evidencia de resultados prolongados en el tiempo, se trataba de  una cohorte retrospectiva no controlada de los pacientes que recibieron terapia antiviral durante   mas de 6 meses y probablemente vivieron más tiempo. No es ninguna sorpresa que los pacientes que lo hacen bien y son capaces de recibir un tratamiento por más tiempo también vivan más tiempo. Esta profecía autocumplida se puede demostrar con cualquier tratamiento. Esperemos informes futuros que avalen o no la hipótesis de una posible génesis vírica del glioblastoma.

¿El ácido valproico aumenta la supervivencia en pacientes con diagnóstico de glioblastoma? . 

Parece ( observaciones no publicadas ) que no podemos confirmar este hallazgo en otros estudios de validación. El ácido valproico no debe ser utilizado con el objetivo de prolongar la supervivencia de los pacientes con diagnóstico de glioblastoma. Sí puede seguir siendo útil para el tratamiento de la epilepsia asociado a tumor.

¿Que podemos decir de la Reintervención en pacientes con diagnostico de Glioblastoma Multiforme?

En ocasiones, surgen las preguntas relativas a si la cirugía de la recidiva tiene valor en pacientes con glioblastoma recurrente. Esto nunca se ha investigado prospectivamente. Sigue siendo una opción para los pacientes con un efecto de masa, en pacientes en los que la resección completa se puede lograr y se prevé además la terapia antitumoral. 

Sería necesario un estudio prospectivo randomizado para establecer el valor de la cirugía de rescate en lugar de ir directamente a la quimioterapia de rescate.

¿Cuáles son los planteamientos actuales sobre el uso de esteroides ?

Cuando los pacientes acuden a mi consulta he observado que un gran porcentaje de ellos están con dosis altas de corticoesteroides sin que tengan razones claras para ello. 

Los pacientes que evolucionan con glioma maligno se colocan comúnmente con altas dosis de dexametasona, a pesar de que a menudo es innecesaria porque no nos aporta mas beneficio que dosis menores. Dosis más bajas como 4 mg o 6 mg de dexametasona pueden ser suficiente, y las habituales dosis de 4 x 4 mg de dexametasona no tiene une evidencia formal de su eficacia. Las dosis más altas de dexametasona nunca han demostrado ser mejor que dosis más bajas. 

La forma de administración cada 6 u 8 horas también carece de realidad científica.  La dexametasona tiene una larga vida media de más de 36 horas hace que no haya necesidad de dividir la dosis en cuatro dosis diarias, sino que podría ser administrada en una sola dosis diaria por la mañana y de esta manera evitaremos la estimulación que provoca la dexametasona en la dosis nocturna que condiciona insomnios en nuestros pacientes.

 ¿Cuándo el uso de bevacizumab ?

El bevacizumab es un compuesto interesante, que, por desgracia no se ha desarrollado adecuadamente para pacientes con tumores cerebrales. 

Ensayos aleatorios han demostrado que bevacizumab no prolongará la supervivencia global, sin embargo en pacientes seleccionados con tumores grandes, con efecto de masa y edema peritumoral, es probable que mejore la calidad de vida. Bevacizumab tiene menos efectos secundarios y toxicidad que la dexametasona, y una dosis única puede ser suficiente para controlar el edema peritumoral durante tanto tiempo como 5 a 6 semanas. Por lo tanto, en pacientes seleccionados, puede parecer como un medicamento milagroso y permitir una cierta independencia y autonomía en la calidad de vida de nuestros pacientes, menos dependencia de los esteroides

, y un mejor funcionamiento neurológico, aunque no necesariamente tiene un efecto antitumoral sustancial o prolongar la supervivencia. No sé, habrá que esperar un poco más de tiempo para saber cuales son los verdaderos resultados de Bevacizumab. En nuestro hospital lo usamos asociado a CPT-11 en segunda linea de tratamiento cuando los pacientes progresan con Temozolamida.

En los estudios clínicos, el Bevacizumab se ha administrado cada 2 semanas , sin embargo , la vida media biológica de los anticuerpos monoclonales es más larga. La experiencia práctica de los pacientes que vienen cuando son sintomáticos nos dice que podríamos esperar hasta 6 ó 7 semanas, hasta que los síntomas reaparecen después de una sola dosis de bevacizumab. En la práctica, podría darse cada 3 en vez de cada 2 semanas con las dosis más baja, con excelente tolerancia, menos toxicidad, menor costo y menor número de visitas de pacientes con menos repercusión en la crisis económica que sufre nuestra sanidad. 

Espero os resuelva algunas dudas que a mi siempre me están rondando en la cabeza cuando estudio el Glioblastoma Multiforme.

News September 24, 2013

ASTRO Outlines Five Radiation Oncology Practices That Should Be Curtailed

ATLANTA (IMNG) – Five common radiation therapy practices are not adequately supported by evidence and may not be the best choice for many patients, radiation oncology experts said at the annual meeting of the American Society for Radiation Oncology (ASTRO).

The evidence-based recommendations on radiation therapy for breast cancer, prostate cancer, and bone metastases are part of the national “Choosing Wisely” campaign, which is aimed at improving the quality of care by reducing or eliminating overuse of tests and procedures. This campaign is about “removal of waste to improve quality and safety, and doing no harm to patients,” said Daniel Wolfson, executive vice president and chief operating officer of the American Board of Internal Medicine (ABIM) Foundation, which is leading the Choosing Wisely campaign.

Medical societies in various disciplines have released recommendations geared toward individual clinical disciplines, and now it’s ASTRO’s turn, said Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, in a briefing announcing the guidelines. “The list serves only as a starting point for a detailed conversation between a patient and physician, and to ensure patient-centered care, which is a core principle of ASTRO.”

The five recommendations are:

• Don’t initiate whole-breast radiotherapy as a part of breast conservation therapy in women aged 50 years and older with early-stage invasive breast cancer without considering shorter treatment schedules.

“We’ve known for years that whole-breast radiation improves local control and improves survival, and has cosmetic advantages over mastectomy,” Dr. Steinberg said. In recent years, however, randomized clinical trials have demonstrated that shorter courses of therapy – less than 4 weeks, compared with 5 weeks for conventionally fractionated radiation – produce equivalent tumor control and cosmetic outcomes.

• Don’t initiate management of patients who have low-risk prostate cancer without discussing active surveillance.

Patients with low-risk prostate cancer should discuss “reasonable management options” with their physicians, including active surveillance. With this recommendation, ASTRO is “reinforcing the shared decision-making model,” Dr. Steinberg said.

• Don’t routinely use extended fractionation schemes (more than 10 fractions) for palliation of bone metastases.

Patients with bone metastases may derive equivalent pain relief from 30 Gy in 10 fractions, 20 Gy over 5 fractions, or even a single 8-Gy fraction, studies suggest. The single-fraction option is more convenient for patients, but it may be associated with a marginally higher need for retreatment of the same site. Patients who are not ambulatory, have transportation problems, or a limited prognosis may be good candidates for the single-fraction option, the guidelines say.

• Don’t routinely recommend proton-beam therapy for prostate cancer outside of a prospective clinical trial or registry.

“There is no clear evidence that proton-beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy,” the Choosing Wisely guidelines state.

At ASTRO 2012, investigators reported that men who receive proton-beam radiotherapy for prostate cancer have modestly better bowel function in the short term than do those who receive conformal or intensity-modulated radiation, but the effect is transient. In addition, proton-beam therapy is estimated to cost about 70% more than external-beam radiotherapy for the treatment of prostate cancer.

• Don’t routinely use intensity-modulated radiation therapy (IMRT) to deliver whole-breast radiotherapy as part of breast conservation therapy.

“Clinical trials have suggested lower rates of skin toxicity after using modern 3D conformal techniques relative to older methods of 2D planning. In these trials, the term ‘IMRT’ has generally been applied to describe methods that are more accurately defined as field-in-field 3D conformal radiotherapy. While IMRT may be of benefit in select cases where the anatomy is unusual, its routine use has not been demonstrated to provide significant clinical advantage,” the guidelines note.

The cost difference between 3D conformal radiotherapy and IMRT for whole-breast radiotherapy is approximately $7,000, according to Dr. Steinberg.

“These are not ‘never do this’ recommendations, these are ‘engage the patient in the shared-decision paradigm’ guidelines, because there may be patients that are better treated with, let’s say, IMRT [for whole-breast radiotherapy],” he said.

Asked whether the Choosing Wisely guidelines in radiation oncology and other disciplines might be used by insurers to justify denying reimbursement for certain procedures, Mr. Wolfson said that “we haven’t seen that, and whether it comes to be will be the question, but we would sharply criticize that [approach].”

Oncología Radioterápica Huelva: ONCOURG® Guía Práctica de Actuación en Urgencias Oncológicas para Especialistas Internos Residentes y Médicos de Atención Primaria

Oncología Radioterápica Huelva: ONCOURG® Guía Práctica de Actuación en Urgencias Oncológicas para Especialistas Internos Residentes y Médicos de Atención Primaria

ONCOURG® Guía Práctica de Actuación en Urgencias Oncológicas para Especialistas Internos Residentes y Médicos de Atención Primaria

Editor Dr. David M Muñoz Carmona

Nueva guía clínica para la actuación en urgencias con enfermos oncológicos.
Muy Interesante tal y como está la Sanidad

La atención del paciente oncológico en urgencias no representa un alto porcentaje de todos los pacientes que acuden a urgencias, pero su atención por médicos no especialistas en oncología hace que a menudo sea bastante compleja.

Algunas series nos hablan que entorno al 5-10% de los pacientes que acuden a urgencias son enfermos oncológicos. Entre los tumores más frecuentes que hacen que el paciente acuda con urgencia podemos encontrar el cáncer de pulmón, el cáncer de mama y el cáncer de colon entre otros.

Además es muy frecuente que el paciente oncológico sea un gran demandante de atención urgente, estando sus consultas relacionadas tanto por la enfermedad como por cualquier otra patología no relacionada con su proceso oncológico.

Al existir un gran desconocimiento de la patología oncológica en urgencias hace que el índice de ingresos aumente de manera significativa en el hospital.

En primer lugar podríamos llegar a definir el concepto de urgencia oncológica como toda aquella situación que supone un riesgo para la vida del paciente con cáncer o un deterioro de su estado de salud relacionada tanto con su enfermedad como con los tratamientos derivados de su proceso oncológico.

Hoy por hoy cada día más se aumenta tanto la supervivencia como la calidad de vida de los pacientes oncológicos, esto hace que cualquier proceso intercurrente en nuestros pacientes pueda deteriorar la supervivencia de los mismos, por lo que es fundamental el conocimiento de las urgencias oncológicas por los médicos que los van a atender de manera urgente.

La evolución que se ha producido en el campo del tratamiento del paciente oncológico se debe tanto a la importancia que en el sistema de salud supone la patología oncológica, como a que hoy el cáncer es la primera causa de mortalidad nuestro país, por encima de las causas por enfermedades cardíacas o vasculares. En el año 2000 en España fallecieron 91.000 pacientes, lo que representa el 25% de todas las muertes. Por otro lado la supervivencia del paciente diagnosticado de cáncer en España a los cinco años ronda el 57% para los hombres y en el 44% para la mujeres. Todo esto no hace más que resaltar la importancia de la actualización de los conocimientos en la patología urgente oncológica en el entorno de atención primaria y la medicina de urgencias.

No debemos olvidar que los pacientes oncológicos tienen relación directa con su oncólogo médico o su oncólogo radioterápico de manera que cuando son atendidos por los médicos de urgencia demandan la atención de su oncólogo de referencia, lo cual hace incluso más difícil la atención al paciente y a su familia, sin mencionar el probable desconocimiento del proceso de la enfermedad, pronóstico y tratamiento seguidos por el paciente durante su evolución.  Todo esto hace que la toma de decisiones por parte del médico que lo atiende de urgencias sea realmente complicada a la vez que importante.

Nos gustaría resaltar que debido a las circunstancias especiales de la atención en urgencias, y que el paciente que estamos tratando es un enfermo oncológico, hace que la actitud médica de urgencia deba desarrollarse en el entorno de la empatización tanto con el enfermo como con su familia.

Tendremos que ir adquiriendo cada vez más habilidades en el campo de la comunicación con el enfermo oncológico, las técnicas de entrevista clínica, el manejo del control de síntomas, la atención y apoyo a la familia que sin lugar a dudas redundarán en una mejora de la atención del paciente oncológico en urgencias.

Si el paciente llega a urgencias sin diagnóstico o sin filiación de su neoplasia tendremos que estar alerta del síntoma que nos refiera tanto él como su familia realizando una anamnesis y exploración física completa. Tras haber alcanzado una sospecha diagnóstica podremos solicitar estudios complementarios, adquirir una presunción diagnóstica y realizar una derivación al especialista en Oncología de manera adecuada.

Si el paciente llega a urgencias con un diagnóstico y/o tratamiento oncológico establecido, tendremos que orientar nuestra historia clínica hacia el motivo principal de la consulta (efectos secundarios de la quimio-radioterapia, síntomas derivados de la progresión  tumoral, patología intercurrente, etc.)

Para solucionar todas estas situaciones urgentes que entrañan un riesgo vital para el enfermo oncológico o que empeoran su calidad de vida confeccionamos esta GUÍA PRÁCTICA DE ACTUACIÓN EN URGENCIAS ONCOLÓGICAS para médicos especialistas internos residentes y  médicos de atención primaria, al igual que intentamos establecer una pauta de actuación para todos los profesionales sanitarios que atiendan enfermos oncológicos, con todo ello, hemos pretendido que esta guía sea de fácil manejo y útil en la toma de decisiones clínicas urgentes. Pretendemos que sirva para realizar una evaluación integral del paciente oncológico y de su familia, que permita reconocer los problemas tanto físicos, sociales y psicológicos del paciente y por ende que los profesionales que los atienden se sientan capaces de poner en marcha todas sus habilidades y conocimientos a disposición de nuestros pacientes oncológicos.

Blood Test Detects Lung Cancer

News | October 22, 2013 | Lung Cancer

By Anna Azvolinsky, PhD

A blood test that detects a combination of proteins can distinguish between early lung cancer and noncancerous lung nodules, according to a study published in Science Translational Medicine. The two types of nodules are currently difficult to distinguish using imaging. The test showed a 90% negative predictive value in a study of 104 patient samples from three clinical sites. Further validation on 37 samples from a single site showed a 94% negative predictive value.

This molecular test may complement the current tools used by clinicians to diagnose early-stage lung cancer.

The early lung cancer detection test is being developed by Seattle-based molecular diagnostic company Integrated Diagnostics (Indi). The test detects the levels of 13 proteins in a patient’s blood sample and could prevent unnecessary biopsies of lung nodules detected by CT scans.

“These studies suggest that Indi’s technology is capable of detecting the molecular signature of lung cancer by measuring the presence of multiple proteins in a patient’s blood,” said senior author Paul Kearney, PhD, president and chief science officer of Integrated Diagnostics, in a released statement.

The researchers used a systems biology approach, screening 371 blood-based proteins on 143 patient samples with either benign or stage 1A lung cancer that were matched for nodule size, age, gender, and clinical site.

Multiple reaction monitoring (MRM) mass spectrometry is used to analyze the relative concentrations on biomarkers. The technology allows simultaneous analysis of many protein levels.

Further analysis to understand the role of these biomarker proteins showed that all 13 are likely regulated by four transcription factors that bind to the regulatory elements of the 13 genes that encode the proteins. All four transcription factors have been associated with lung inflammation and lung cancer, as well as oxidative stress pathways.

The validation using 104 patient samples showed a test sensitivity of 71% and specificity of 44%. The study researchers assumed that the rate of cancer prevalence was 15%. At the same cancer prevalence rate, the sensitivity was 82% and the specificity was 66% in the discovery cohort of 143 samples.

The protein levels were found to be independent of known risk factors for pulmonary nodules: the size of the nodule detected, history of smoking, and age.

According to Kearney and fellow study authors, one-fifth of patients with detectable lung nodules who undergo biopsy or surgery actually have a malignant nodule. Therefore, a reliable test that can discriminate between a benign lung mass and a cancerous lung mass is needed to prevent unnecessary invasive procedures and surgery.

Still, the study cohorts used here are retrospective, and a prospective validation trial is needed to understand the full clinical potential of the blood test. Additionally, the authors note that the test results are not integrated with clinical risk factors, although they also note that “pulmonologists vary broadly in the use of clinical risk factors, and so, it is actually preferable to have a molecular diagnostic test that produces a score independent of clinical risk factors.”

Even if validated, it is likely that such a blood test will be part of the other information used by clinicians to make the best-informed decision for each individual patient.

Stephen Malkoski, MD, PhD, who specializes in pulmonary medicine at the University of Colorado Cancer Center in Aurora and who was not involved in the research, says interpreting the test results would likely depend on the calculated risk clinicians currently use to assess whether a nodule could be cancerous. Factors that go into the risk calculation include size of the nodule, its location, smoking history, age, emphysema, and family lung cancer history. “In a low-risk patient with a 1% to 2% risk of lung cancer, the patient would still likely need a follow-up CT scan since the blood test could not definitely exclude malignancy.”

Malkoski sees the test as potentially being the most helpful in intermediate-risk patients with a calculated risk of malignancy between 10% and 20%. “In this group, a negative test might obviate the need for additional workup, such as a PET scan or biopsy,” he notes. “This may make a clinician more comfortable opting for radiographic follow-up rather than an invasive procedure.”