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Targeted agents differ from cytotoxic chemotherapy in their mechanism of action and clinical outcomes. Similarly, drug development for targeted agents may also differ. Targeted agents are generally better tolerated than chemotherapeutic agents and may have activity at doses lower than maximum tolerated dose (MTD). Optimum drug dosing needs to be based not only on toxicities but also on pharmacokinetic and pharmacodynamic parameters. As cytostatic-targeted agents may induce disease stabilization, time to progression and survival may be a more appropriate outcome of interest than disease regression. Translational research becomes an indispensable part of trials with targeted agents to identify optimum dosing and to identify predictive biomarkers. This includes advances in technology, better understanding of tumor biology, and validation of research techniques. Clinical trials with novel randomization designs have been developed in recent years to optimize identification of drug activity in a targeted population. [ABSTRACT FROM AUTHOR]

Colon and rectal cancers (CRC) are among the most common adult malignancies worldwide, and for a variety of reasons, the numbers of survivors of colorectal cancer are likely to increase in coming years. The incidence of these cancers doubles with each successive decade of life beyond 50 years, and with the expansion of the older population in the coming years, the absolute numbers of CRC patients in the United States will grow substantially.1 It is estimated that by the year 2030 the number of persons over the age of 65 years will have doubled and the number of persons over the age of 85 years will have quadrupled.2 Given this expanding and aging population, projections suggest that the numbers of CRC patients may increase by as much as 30%.3 Thus, with these profound demographic changes, it will be imperative to have a better understanding of the late effects and health care needs of longterm CRC survivors. [ABSTRACT FROM AUTHOR]

Lung cancer emerged during the 20th century as an epidemic of enormous proportions.1 A rare disease at the beginning of the past century, lung cancer continues to be one of the most common cancers in the world, affecting 173,700 Americans (93,110 men and 80,660 women) in 2004.2 Mirroring changes in smoking patterns, the incidence of lung cancer among men continues to decline. Large-scale smoking among women occurred almost 20 years after men in the United States, with a subsequent delay in increased cases, peaking in the 1990s. Encouragingly, the most recent evidence demonstrates that lung cancer incidence among women is declining, as are death rates.3 In 2000, approximately 13% of men and 17% of women (age-adjusted, 15% overall) diagnosed with lung cancer were expected to survive at least 5 years (an estimated 26,065 Americans each year). [ABSTRACT FROM AUTHOR]

Cancer survivors have been shown to have an increased risk for second malignant neoplasms (SMN). These increased risks result from genetic predisposition, harmful environmental exposures, or cancer treatment therapies. Regardless of their cause, SMNs now comprise the sixth most common group of malignancies after skin, prostate, breast, lung, and colorectal cancers.1 It is important to emphasize that the fear of SMN related to the treatment of the first cancer diagnosis should not outweigh the positive effects of curative therapy for the first cancer. Both physicians and patients should, however, be aware of the consequences of the cancer treatment regimens, specifically radiation therapy (RT) and chemotherapy, and consider them while devising follow-up plans. [ABSTRACT FROM AUTHOR]

Malignancies most often produce symptoms by local tumor growth and invasion, or by metastatic spread. However, there are remote effects of the primary cancer termed paraneoplastic that can result in significant symptomatology and organ dysfunction.1 It is postulated that these syndromes result from the production of substances, such as hormones or their precursors, steroid metabolites, enzymes, and various cytokines.2 Neurologic syndromes associated with neoplasms may be the result of antibody production related to immunoaccessible antigens produced by the neoplasm. [ABSTRACT FROM AUTHOR]

Cancer cachexia is a complex syndrome clinically manifest by progressive involuntary weight loss and diminished food intake and characterized by a variety of biochemical alterations. Importantly, cancer cachexia has been associated with increased morbidity and mortality and decreased response to therapy. The impact of cancer cachexia on patient outcome and healthcare resources continues to be significant. It is therefore important to identify those cancer patients who are malnourished in an attempt to reverse or at least abate the progression of malnutrition. The goal of nutritional supplementation is to translate repletion into clinical benefit, thereby decreasing morbidity or mortality and increasing the response rate to treatment. The focus of this chapter is to review the etiology of cancer cachexia, summarize the biologic and clinical effects of nutrition, define specific indications for nutrition in the cancer patient population, and explore new therapies available to reverse cancer cachexia. [ABSTRACT FROM AUTHOR]

Thousands of individual citations using the expression cancer advocacy can be found in contemporary medical and scientific literature as well as in the popular press and on Internet websites. For purposes of this chapter, the term cancer advocacy is used to describe a skill set that has been documented in previously published work by Clark and Stovall. This chapter also includes specific examples of how self-described advocacy organizations are involved with research organizations and how they influence cancer research and related health policy. [ABSTRACT FROM AUTHOR]

Prevalence data on psychosocial morbidity indicate that from 30% to 50% of cancer patients may experience distress significant enough to warrant professional intervention at some time during survivorship. These patients may require professional attention to manage the debilitating effects of diagnosis, treatment, and morbidity that can wax and wane over time depending upon a host of other variables. It is in this group that some form of psychosocial rehabilitation may be useful. [ABSTRACT FROM AUTHOR]

Survival rates for hematopoietic cell transplantation (HCT) have improved with advances in supportive care that have reduced acute, transplant-related mortality. More than 40,000 transplants were performed worldwide in 2002, mostly for the treatment of leukemia, lymphoma, or multiple myeloma1 (see Chapters 63 through 69 for discussions of specific diseases). The probability of successful transplantation is generally greater for patients transplanted early in their disease course, for younger patients, and for patients who receive stem cells from donors whose human leukocyte antigens (HLA) match the patient's. For survivors who receive HCT for acute leukemia or chronic myeloid leukemia and who remain free of disease after 2 years, the probability of living 5 or more years is 89%. [ABSTRACT FROM AUTHOR]

Anxiety and depression can be viewed as part of a broader construct of psychologic distress. We chose to focus on anxiety and depression rather than on psychologic distress for several reasons. First, the literature on anxiety and depression can be more readily identified than the literature on the broader and less well defined construct of psychologic distress. Second, as described in the following, criteria have been established for the diagnosis of clinical syndromes of anxiety and depression; no similar criteria exist for the diagnosis of clinical syndromes of psychologic distress. Third, as described here, this approach allows us to build upon the findings of several previous systematic reviews and meta-analyses that also have focused on psychosocial and pharmacologic approaches to the management of anxiety and depression in adult cancer patients. [ABSTRACT FROM AUTHOR]

Of the more than 200,000 men diagnosed each year with prostate cancer in the United States,1 most live with their disease or the effects of treatment for many years.2 Although many men remain asymptomatic throughout their lives, others face a multitude of physical and psychosocial challenges. Because the duration of survival is typically long, patients and their families are particularly interested in optimizing their quality of life. At the generic level, health-related quality of life (HRQOL) encompasses an individual's perceptions of his or her own health and ability to function in the physical, emotional, and social domains.3,4 In prostate cancer survivors, the medical outcomes of urinary, bowel, and sexual impairments that result from treatment will influence the rest of the patient's life. The psychosocial aspects of HRQOL are impacted by the intimate nature of these medical side effects. Urinary leakage and erectile dysfunction may cause both private and public social embarrassment. In addition, such treatment-related complications may be compounded by the additional stressors associated with aging, such as retirement or death of peers.5 Nearly onethird of men diagnosed with prostate cancer in a genitourinary clinic had levels of psychologic distress that met criteria for anxiety disorder. [ABSTRACT FROM AUTHOR]

Testicular cancer (TC) is the most frequent malignancy in men between 20 and 40 years of age, and the annual incidence rates are continuously increasing in the Western world.1 Since the introduction of cisplatin-based chemotherapy, at least 90% of the patients are cured,2 and testicular cancer survivors (TCSs) currently have a life expectancy similar to that of age-matched normal men, with posttreatment life spans of 30 to 50 years. Thus, an increasing number of TCSs experience survivorship problems related to the malignancy, its treatment, or both. [ABSTRACT FROM AUTHOR]

Women with breast cancer account for the largest group of female cancer survivors. It is estimated that there are currently 8.9 million cancer survivors in the United States; 41% of the female subjects are breast cancer survivors.1 The growing number of breast cancer survivors reflects increasing incidence of the disease, diagnosis at earlier stages when outcome is better, and widespread adoption of effective adjuvant treatment (see Chapter 28 and Chapter 54). [ABSTRACT FROM AUTHOR]

An emerging body of research has documented the quality of life of women with gynecologic cancer around the time of diagnosis and during treatment. However, we know much less about the quality of life and psychosocial and medical needs of gynecologic cancer survivors after treatment.1,2 In particular, there are very few studies documenting the risk of possible late medical effects of gynecologic cancer treatment such as osteoporosis and second primary cancers. More is known about self-reported symptoms and psychosocial sequelae, such as sexual functioning and psychologic distress, but even these studies rarely focus on survivors more than 5 years after diagnosis. Additionally, much of the extant research has limitations such as small sample sizes, nonstandardized measures, and crosssectional designs, often without appropriate comparison groups. Finally, there is a dearth of research testing interventions to ameliorate problems experienced by gynecologic cancer survivors. While in some areas additional research is needed to better describe the sequelae and determine who is at risk for adverse late effects, in others areas (e.g., sexual functioning), adequate data describing the problem are available, and a stronger focus on treatment interventions is needed. (See also Chapter 90, Reproductive Complications and Sexual Dysfunction in the Cancer Patient.) [ABSTRACT FROM AUTHOR]

The first attempts to treat Hodgkin's disease by radiotherapy were conducted at the beginning of the last century. The prognosis for survival was poor but slowly improved by the use of radiotherapy and some chemotherapy until 1960. For example, in 1939 a 20-year survival rate of 17% was reported. [ABSTRACT FROM AUTHOR]

More than 12,000 children and adolescents younger than 20 years are diagnosed with cancer each year in the United States.1 With the use of risk-based therapies, the overall 5-year survival rate is approaching 80%, resulting in a growing population of childhood cancer survivors. In 1997, there were an estimated 270,000 survivors of childhood cancer; over two-thirds of these were older than 20 years of age.2 This figure translates into 1 in 810 individuals under the age of 20 and 1 in 640 individuals between the ages of 20 and 39 years having successfully survived childhood cancer (see Chapter 62). [ABSTRACT FROM AUTHOR]

With continued advances in strategies to detect cancer early and treat it effectively, along with the aging of the population, the number of individuals living years beyond a cancer diagnosis can be expected to continue to increase. Statistical trends show that, in the absence of other competing causes of death, 64% of adults diagnosed with cancer today can expect to be alive in 5 years. Relative 5-year survival rates for those diagnosed as children (age less than 19 years) are even higher, with almost 79% of childhood cancer survivors estimated to be alive at 5 years and 75% at 10 years. [ABSTRACT FROM AUTHOR]

In 1884, an official ceremony was held and the cornerstone laid for an ornate and turreted building in New York City that would for many years house the first cancer treatment center in the country. The site, located on the upper west side of Central Park, then a virtual wilderness area on the larger island of Manhattan, was selected because the belief at the time was that cancer was contagious. The rounded design of the towers, where patient beds were to be located, was intended to discourage the risk of germs, which were thought to lurk in corners. Named The New York Cancer Hospital, this institution would later be moved in 1948 to its current east side location where it was, until 1960, called the Memorial Hospital for Cancer and Allied Diseases. The history of this leading center for cancer care and research, known today as the Memorial Sloan-Kettering Cancer Center, a sprawling multisite enterprise, is illustrative of where we have come in viewing cancer. [ABSTRACT FROM AUTHOR]

One in every 1,000 pregnant women will be diagnosed with cancer.1 Despite this fact, the level of evidencebased medicine available in the field of cancer during pregnancy is low. Randomized controlled trials in this area do not exist. Instead, retrospective collections of patients treated with varying treatment regimens and strategies, collected case reports, studies based on events, such as the Japanese atomic bomb experience, and, for rare malignancies, isolated case reports generally constitute the medical literature on pregnancy and cancer. Nonetheless, this chapter may guide oncologists facing patients in this relatively uncommon, but serious position. We discuss the use of the major diagnostic and treatment modalities in oncology during pregnancy: surgery, diagnostic imaging and therapeutic radiation, and antineoplastic agents. Therapeutic strategies for malignancies seen most frequently during pregnancy are addressed: these include breast cancer, cancer of the uterine cervix, Hodgkin's disease, and non-Hodgkin's lymphoma. Medical management of symptoms of malignancy and its treatment that are unique to the pregnant patient are discussed. [ABSTRACT FROM AUTHOR]

Clinical studies of chemotherapy, or other antineoplastic therapies, are usually conducted in physiologically otherwise normal patients with cancer. As a result, limited information is typically available about the optimal dosage and schedule of chemotherapy for patients with organ dysfunction and the impact of chemotherapy in such patients. This is a potentially important problem, because most chemotherapies, as with other pharmacologic agents, are metabolized by the liver or kidney. Over the past decade, a concerted effort has been made to focus on chemotherapy in this patient population. The new generation of biologic therapies may not possess this difficulty, as the monoclonal antibodies that, to date, comprise the most successful of these agents are metabolized by the reticuloendothelial system and may not require these modifications. However, these concerns regarding the appropriate administration of antineoplastic agents will persist with the new small molecule inhibitors, including tyrosine kinase inhibitors, which also may require individual evaluation in patients with organ dysfunction. [ABSTRACT FROM AUTHOR]

Advancing age comes bundled with increased cancer incidence and mortality. Indeed, the median age at diagnosis of all cancers combined is 69 years for men and 67 for women.3 Age-adjusted cancer incidence is 10 times higher in the 65+ population compared to their younger counterparts (2,151.2 versus 208.8/100,000 persons).2 Similarly, age-adjusted cancer mortality is 15-fold higher in the 65+ population (1,068.2 versus 67.3/100,000 persons). Figure 97.1 illustrates the proportions of the commonest cancers incidence and mortality in the 65+ population. As a result, although the total U.S. population is expected to grow by 9% between 1990 and 2010, the incidence of cancer is expected to increase by a disproportionate 32% in the same time frame. These trends are mirrored in countries across the globe. [ABSTRACT FROM AUTHOR]

During the 1960s, as oncology research was rapidly expanding, MacFarlane Burnett's idea that cancer resulted from a failure of tumor surveillance by the aging immune system was broadly acknowledged. The development of cancer genetics focused the field on mutational causes of tumorigenesis. However, a new appreciation for the role that a well-functioning immune system plays in protecting against virally induced tumors was brought to light in the 1980s with the acquired immunodeficiency syndrome (AIDS) epidemic. The phenomenon of the human immunodeficiency virus (HIV)-associated cancer epidemic within defined populations, particularly due to the recent dramatic responses to treatment of the underlying immunodeficiency, has given insight into other etiologic factors for a variety of tumors. [ABSTRACT FROM AUTHOR]

Metastatic disease to bone is the most common malignancy of bone. The American Cancer Society estimated that in 2004 there will have been 1,368,030 new cases of cancer in the United States.1 Of these, they estimated that approximately 2,400 will be new cases of primary bone malignancy; that is, compared with over 230,000 new cases of prostate carcinoma, 217,000 cases of breast carcinoma, and 173,000 cases of lung carcinoma. Those three diagnoses, along with kidney cancer and thyroid carcinoma, represent 80% of metastases to the skeleton.2 Autopsy studies have shown that 50% to 70% of patients with prostate cancer develop metastases and 85% of patients with breast cancer develop skeletal metastases. The skeleton is surpassed only by the lungs and liver for incidence of metastatic disease. Any bone of the skeleton can be involved; however, the axial skeleton is most commonly involved. Involvement of the appendicular skeleton most commonly involves the proximal portion of the lower extremities. Within the spine, it is primarily the anterior and middle columns that are involved. [ABSTRACT FROM AUTHOR]

The liver is a frequent site of metastases from solid tumors and the most common site of distant metastases from colon and rectal cancer. Death from colon and rectal cancer is usually a result of metastatic disease. In one study, more than one-half of patients who died of colon and rectal cancer had liver metastases at autopsy, and the majority of these patients died as a result of their metastatic liver disease.1 Unlike many types of cancer, however, the presence of distant metastases from colon and rectal cancer does not necessarily preclude curative treatment. Nearly 40% of patients with colon and rectal cancer and hematogenous metastases have disease that is predominantly in the liver. Moreover, in a subpopulation of patients, the number of lesions is limited. Accordingly, there exists a strong rationale for regional therapies directed specifically against colon and rectal cancer liver metastases. This pattern of metastases is rarely observed in other cancers. [ABSTRACT FROM AUTHOR]

Metastasis is the major cause of death in cancer patients. The lungs are the second most frequent site of metastatic disease for all histologies and the sole site of metastasis in 20% of autopsy cases.1 The presence of pulmonary metastasis implies systemic dissemination of disease and was once considered beyond the realm of surgical cure. It was widely accepted that surgery could provide nothing beyond palliation. We now recognize that metastases that are isolated to the lungs are not consistently associated with the same dismal survival as metastases to multiple sites.2 During the past 40 years, surgical resection has become a standard approach for the treatment of pulmonary metastasis in selected histologies. A multitude of series have documented the survival benefits of pulmonary metastasectomy in selected patients. [ABSTRACT FROM AUTHOR]

Brain metastases are the most common intracranial solid tumors identified in adults, with 150,000 to 170,000 newly diagnosed cases of brain metastases per year in the United States. Ten percent to 30% of adult cancer patients develop brain metastases in their lifetime with an incidence of up to 25% to 40% at time of autopsy. The mean age of patients diagnosed with brain metastases is 60 years.4 Brain metastases are much less frequent in children, affecting approximately 3% of children with localized solid tumors and 7% of those with known metastatic disease. The most common primary tumor giving rise to brain metastases is non-small cell lung cancer, followed by small cell lung cancer and breast cancer (Figure 92.1). The median time from diagnosis of the primary tumor to development of brain metastases is approximately 8 months. [ABSTRACT FROM AUTHOR]

According to the Institute of Medicine, "at the beginning of the 21st century, half of all patients diagnosed with cancer will die of their disease within a few years." This statistic does not fully explain the reality of the illness and its repercussions for the individuals living with cancer and their families and friends. Many patients live through a final period of life when health professionals, in concert with the patient, must acknowledge that there are no reasonable treatments that remain untried. The patient will most probably die of complications of the cancer. This is a stressful period when health professionals must continue their efforts to treat the patient's suffering and alleviate onerous symptoms. [ABSTRACT FROM AUTHOR]

This chapter will review risk factors and management for three types of reproductive complications of cancer treatment: infertility, menopausal symptoms, and sexual dysfunction. Each problem area affects unique, albeit overlapping, populations of cancer patients and survivors. [ABSTRACT FROM AUTHOR]

Enormous advances have occurred in the past two decades in our understanding of cancer pain and in our capacity to relieve it in most cases. Progress has been made in our understanding of the pathogenesis of nociception, the epidemiology of cancer pain, the validation of effective treatment algorithms, and the evaluation of novel pharmacologic and nonpharmacologic approaches to ameliorate pain. Paralleling these developments in research, pain management has emerged as a priority in healthcare policy and medical education. [ABSTRACT FROM AUTHOR]

Progressive experience and success in application of blood and marrow transplantation has heightened attention to clinical management of the complications and long-term outcomes of such procedures. More than 20,000 patients yearly undergo transplant therapy and more than 25,000 patients survive beyond 5 years after transplantation. The recognition, prophylaxis, management, and screening for early complications and for late effects following successful transplant have developed by extrapolation of procedures for intensive therapy of hematologic malignancy (e.g., acute leukemia) and by recognition of specific toxicities, immunodeficiencies and problems encountered uniquely by the transplant recipient.1 Similar to other hematology/oncology procedures, most management strategies are supported principally by empirically derived and some experience-supported evidence. Overall, less than one-quarter of transplant decision making is supported by Level 1 evidence. We review the approach to transplant complications through the phases of therapy emphasizing the available evidence, the frequently held consensus opinions, and areas for future study. [ABSTRACT FROM AUTHOR]

Hematopoiesis, the production and maintenance of blood elements, is critical to life. Many of the complications of cancer and anticancer therapies can be clinically damaging to patients as a result of adverse effects on normal hematopoietic mechanisms. Since the early 1990s, it has been possible for physicians to intervene with genetically engineered biotherapies, such as hematopoietic growth factors to mitigate the hematopoietic dysfunction of cancer patients. In this chapter, the evidence is examined upon which physicians and other caregivers may base rational clinical decision making to provide patients with optimal supportive care to improve the hematopoietic problems associated with cancer. [ABSTRACT FROM AUTHOR]

Malignant pleural effusions are a common clinical problem. The estimated annual incidence of malignant pleural effusions in the United States is greater than 150,000 cases per year, with lung cancer accounting for nearly half. Breast cancer, lymphoma, and ovarian cancer round out the top four leading causes of malignant pleural effusions. [ABSTRACT FROM AUTHOR]

Nausea and vomiting are two of the most feared cancer treatment-related side effects for cancer patients and their families. In 1983, Coates et al. found that patients receiving chemotherapy ranked nausea and vomiting as the first and second most severe side effects, respectively. Up to 20% of patients receiving highly emetogenic agents in this era postponed, or even refused, potentially curable treatments. Despite the availability of more than 20 different antiemetics, nausea and vomiting in cancer patients remain problematic and continue to pose tremendous challenges to practicing oncologists. [ABSTRACT FROM AUTHOR]

The management of the cancer patient is often complex and involves multiple disciplines. The complexity of the care that is required often necessitates venous access for the administration of myriad therapies and the acquisition of blood samples. Reliable venous access is critical for the optimal management of the many aspects of care of a patient with cancer. Although the exact number of catheters inserted annually in the United States for care of cancer patients is unknown, it is likely that it represents a significant percentage of the more than 5 million central venous catheters placed. [ABSTRACT FROM AUTHOR]

Acute urologic complications of therapy could arise from any of the three modalities that are used to treat cancers: surgery, radiation and chemotherapy. [ABSTRACT FROM AUTHOR]

The etiology of neurotoxicity following treatment with chemotherapy and/or radiation therapy is not always obvious. Neurologic complications can be difficult to identify, diagnose appropriately, and measure. In addition, neurotoxicity may be delayed and patients may experience tumor-related mortality before the diagnosis of treatmentrelated complications. Furthermore, the signs and symptoms of neurotoxicity may resemble those of disease progression. Finally, underlying diseases, such as diabetes mellitus, infections, hypertension, paraneoplastic syndromes, age-related dementia, seizures, concomitant medications, such as antiepileptic agents, and metabolic disorders can be confounding factors [ABSTRACT FROM AUTHOR]

The treatment of testicular cancer is one of the great success stories of Western medical science. More than 90% of patients are now cured, and essentially all patients, regardless of how advanced their disease is at the time of diagnosis, have a real chance of cure. In contrast, 50 years ago, metastatic testicular cancer was almost always fatal. Testicular cancer represents an example of what can be learned from a systematic and determined clinical trials effort. The current standard chemotherapeutic regimens are based on a long series of randomized controlled trials, despite the fact that this is a relatively rare disease. Because there is almost always the possibility of achieving a cure and because current standard therapies have been based on a solid scientific foundation, mistakes in the management of testicular cancer patients can be particularly costly and difficult to justify. Patients with testicular cancer should be treated by physicians familiar with the disease and with the germ cell tumor literature. [ABSTRACT FROM AUTHOR]

Cardiac toxicity is a well-recognized serious side effect of chemotherapy. Since early reports of heart failure in children treated with doxorubicin,1 anthracyclines remain the best known chemotherapeutic agents clearly linked to cardiotoxicity. There are, however, a number of other chemotherapeutic agents that cause cardiotoxicity which are still not so well recognized in clinical practice. [ABSTRACT FROM AUTHOR]

Surveillance data indicate that adverse drug reactions result in between 3.5% and 32.9% of hospitalizations. 1-3 Of the more than 350 medications known or suspected of causing pulmonary complications, a substantial number are chemotherapeutic agents. [ABSTRACT FROM AUTHOR]

Advances in the management of cancer, particularly the development of new chemotherapeutic agents, have greatly improved the survival and outcome of patients with hematologic malignancies and solid tumors; overall 5-year survival rates in cancer patients have improved from 39% in the 1960s to 60% in the 1990s.1 However, infection, caused by both the underlying malignancy and cancer chemotherapy, particularly myelosuppressive chemotherapy, remains a persistent challenge. [ABSTRACT FROM AUTHOR]

The hair growth cycle is composed of three well-recognized phases: anagen (growth), catagen (deconstruction), and telogen (resting) phases. At any time, approximately 90% of the 100,000 to 150,000 scalp hairs are in the anagen phase An in-depth discussion of hair cycling is beyond the scope of this chapter, but please refer to the referenced article for an excellent review on the current thinking on the subject. [ABSTRACT FROM AUTHOR]

Many patients receive cytotoxic therapies that result in complications to the oral mucosa. Other patients receive either radiation or surgery as treatment of malignancies involving the head and neck region, with resultant consequences to the normal structures of the oral cavity and pharynx. [ABSTRACT FROM AUTHOR]

Most surgical problems in cancer patients are not urgent. Tumors rarely grow or metastasize rapidly. Surgical evaluation can usually proceed at a measured pace over a number of weeks to accurately assess the patient's underlying cancer, to define associated comorbidities that may modify treatment decisions, to consult various disciplines to devise multimodal therapies, and to work with patients and families to create care plans that account for patient preferences and family needs. In light of this panoply of issues that affect surgical decision making in cancer patients, the presence of a surgical emergency requiring prompt evaluation and intervention is especially problematic. Thorough evaluation of cardiac, pulmonary, and other comorbidities may not be feasible. Discussions with medical and radiation oncologists and other consultants may be constrained by time and availability. Attempts to inform and understand patient and family wishes may be confounded by changes in emotional state and cognitive ability caused by pain, anxiety, fear, and the need to intervene promptly. [ABSTRACT FROM AUTHOR]

Tumor lysis syndrome (TLS) refers to the constellation of electrolyte abnormalities that occur as a result of the rapid and immediate release of intracellular contents into the bloodstream. The syndrome is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia (Table 72.1). Metabolic acidosis and acute renal failure may also occur. The release of intracellular potassium and organic, as well as inorganic, phosphate into the bloodstream from cells undergoing apoptosis, results in the development of hyperkalemia and hyperphosphatemia, respectively. Prolonged and severe hyperphosphatemia may result in a marked decrease of the serum calcium concentration, but symptomatic hypocalcemia rarely develops. It is the rapid breakdown of nucleic acids that leads to hyperuricemia. TLS may develop before the administration of chemotherapy in patients with rapidly proliferating hematologic neoplasms; however, TLS usually occurs after the administration of high doses of chemotherapy, which results in the rapid destruction of tumor cells. [ABSTRACT FROM AUTHOR]

Emergency management of central nervous system malignancies is an unfortunate reality facing the oncologist. Although expeditious treatment is certainly the cornerstone of management, the astute clinician should carefully weigh a combination of multidisciplinary therapeutic options to ensure optimal outcome for the patient, with an eye toward both treatment sequelae and anticipation of future need for further treatment. [ABSTRACT FROM AUTHOR]

bstruction of the superior vena cava (SVC) is a common complication of thoracic malignancy and of bronchogenic cancer in particular. Although the condition was first described in 1757, little progress had been made in the treatment of these patients until the first report of surgical reconstruction in 1951. However, over the past decade there has been a remarkable evolution in the successful management of this disease, in large measure as a result of the refinement of endovascular techniques, such as stent placement and thrombolysis. [ABSTRACT FROM AUTHOR]

Multiple myeloma (MM) is an incurable plasma cell neoplasm characterized by the accumulation of malignant plasma cells in the bone marrow. In the vast majority of cases, this neoplastic proliferation of plasma cells produces a monoclonal protein or immunoglobulin fragment that can be detected in the blood, urine, or both. Signs and symptoms of MM can be related to the location of these cells as well as the excessive production of irrelevant monoclonal immunoglobulin. As the malignant plasma cells expand in the marrow, normal surrounding bone can dissolve as a result of stimulation of osteoclasts by a variety of cytokines. Damage to the bone can lead to pain, pathologic fractures, and hypercalcemia. Furthermore, normal bone marrow can be suppressed, in particular, erythropoiesis. Impairment of the immune system leads to decreased humoral immunity with increased risk of infection, particularly encapsulated organisms. The paraprotein itself can lead to problems, including hyperviscosity, amyloid, and renal damage. This disease typically occurs in individuals in the sixth or seventh decades, but can also be seen in younger people. Systemic therapy is palliative. For decades, chemotherapy was based on single agents or combinations of alkylating agents and steroids. Despite great enthusiasm, dose intensification is not curative in the majority of cases, but can prolong overall survival (OS) and event-free survival (EFS). Newer drugs, based on antiangiogenesis approaches and targeting cytokine pathways, have generated a great deal of interest. [ABSTRACT FROM AUTHOR]

The non-Hodgkin's lymphomas (NHLs) represent a group of diseases arising from clonal proliferation of lymphocytes. NHL is the most common hematologic malignancy, with an estimated new patient incidence of 54,000 with 14,000 deaths from disease,1 accounting for 4% of the new cancer diagnosed in 2004. The NHLs represent a diverse group of diseases with distinctive natural histories and clinical presentations.2 This diversity arises from the fact that each of the lymphomas is derived from distinct stages of the complex process of lymphocyte ontogeny. Morphology was the mainstay of diagnosis and classification of NHL for many years. In 1994, the authors of the Revised European and American Lymphoma (REAL)3 sought to create a classification system that defined distinct clinical entities. To accomplish this, the morphologic appearance was supplemented by the incorporation of additional information derived from immunophenotyping, genetics, and clinical features. This classification was the basis for the World Health Organization (WHO) classification of the neoplastic diseases of the hematopoietic and lymphoid tissues.4,5 There are 27 entities included in the WHO classification of the non-Hodgkin's lymphoid neoplasms; this number excludes subtypes and subcategories recognized in the WHO classification. The major categories of the WHO classification are shown in Table 68.1. [ABSTRACT FROM AUTHOR]

In attempting to apply evidence-based medicine in the treatment of chronic myeloid leukemia (CML), it must be acknowledged that a randomized study comparing imatinib mesylate therapy and allogeneic stem cell transplantation (SCT) has not been conducted. The question that will remain at the end of this chapter is whether such a study is feasible, or even ethical. The treatment of CML could represent a paradigm in oncology as well as a unique set of challenges. [ABSTRACT FROM AUTHOR]

Thomas Hodgkin reported the initial cases of this distinct malignant lymphoma in 1832. The term Hodgkin's disease (HD) was used because of the uncertainty as to whether this entity was a tumor or an infection. Based on the evidence proving that the Hodgkin Reed-Sternberg cell is a B cell, the term Hodgkin's lymphoma (HL) is the correct term, although physicians are reluctant to change to this terminology [ABSTRACT FROM AUTHOR]