Controversies in Multimodality Treatment

Phase III clinical trials have demonstrated the superiority of combined modality treatment over surgery, chemotherapy, or radiotherapy alone for several types and stages of cancer. However, the emergence of new data with potential relevance to treatment decisions is a dynamic process. Just as one issue is addressed by clinical research, the next question is asked by investigators involved in the design of future trials. In addition, clinical trials may produce confusing or contradictory data. Accordingly, if one attempts to define "state-of-the-art" multimodality cancer therapy, there may be disagreement among treating physicians in many clinical situations. Several examples are presented next.

Lung cancer is the most common cause of cancer deaths among men and women in the United States. Patients with this disease are common in the practices of medical and radiation oncologists as well as thoracic surgeons. The importance of surgical resection in the treatment of stage I and II non-small cell lung cancer is well established, as is the role of chemotherapy for patients with symptomatic metasta-tic disease. The efficacy of postoperative adjuvant chemotherapy following lung cancer resection has recently been demonstrated.65,66 However, it is unclear which chemotherapy regimen is optimal, and whether patients should be treated if they have a small stage IA cancer, if more than 6 weeks have elapsed since surgery, or if patients are advanced in age. Postoperative radiotherapy has been shown to reduce local recurrence without a clear prolongation of survival for patients with stage II and III disease. The decision to use this treatment in the immediate postoperative period versus at the time of tumor recurrence must be individualized.

There are strong data to indicate that patients with clinical stage III lung cancer should undergo careful mediastinal staging before surgery. If multistation nodal involvement is evident, based on radiographic procedures or surgical nodal evaluation, tumor resection should not be carried out. This practice is not followed by many physicians across the United States. The role of preoperative chemotherapy for patients with clearly resectable stage IIIA lung cancer is not well defined, nor is the optimal combination of chemotherapy, radiotherapy, and surgery for patients with advanced IIIA disease.

Breast cancer is the second most common cause of cancer death among women in the United States. The efficacy of hormonal and radiation therapy following resection of in situ cancer has been established, although the use of one or both modalities must be considered for each patient.67 Adjuvant chemotherapy following resection of node-positive disease for pre- and postmenopausal women is well established, although the optimal combination of chemotherapy drugs and the role of consolidation therapy are unclear.68 Radiotherapy to the chest wall following resection of breast cancer with multiple positive nodes can prolong survival. However, the utilization of this treatment is highly variable.69

Patients with locally advanced breast cancer are generally treated with induction chemotherapy. The optimal role and sequence of radiation and surgical resection are not clear.70,71 Finally, although a multitude of chemotherapy drugs have been shown to be effective in the treatment of metastatic breast cancer, there is disagreement concerning the use of sequential single agents versus combination chemotherapy.72

Esophageal cancer that invades at least into the muscu-laris propria is often treated with concurrent chemoradio-therapy followed by surgery. If one examines the results of Phase III clinical trials, the efficacy of this combined modality therapy is questionable.73,74 In the management of rectal cancer, the use of a mesorectal excision has been shown to be superior to conventional resection.75 It is not clear how to determine which surgeons are properly trained to perform this procedure.76 Induction chemoradiotherapy is used in selected patients in an effort to minimize the extent of resection and, in some cases, to permit a sphincter-sparing approach.

For patients with muscle-invasive bladder cancer, chemoradiotherapy can be used selectively to achieve bladder preservation.77 However, the application of limited surgery, chemoradiotherapy, and radical cystectomy remains highly variable.78 The management of prostate cancer is complex, as options often include observation, hormonal therapy, surgery, or radiation (external beam or brachytherapy).79 Clinically node-negative nonseminomatous testicular cancer can be managed with initial chemotherapy or with observation; treatment varies with the preference of the treating physician and the details of the patient's disease.80

Cigarette Crusher

Cigarette Crusher

Get All The Support And Guidance You Need To Permanently STOP Being A Slave To Nicotine And Cigarettes. This Book Is One Of The Most Valuable Resources In The World When It Comes To Easy Ways To Eliminate Smoking Addiction And Revitalize Your Body.

Get My Free Ebook


Post a comment