Search

Malignant hypercalcemia is an excess of calcium in the blood that occurs in 10 to 20 percent of patients with cancer. It is caused by increased bone loss either due to destruction of the bone by metastatic cancer, or through the production of a parathyroid hormone-like protein. (Parathyroid hormone causes the release of calcium from bone.) The usual treatment is hydration (giving the patient fluids), but this is not always effective. Etidronate sodium belongs to a group of chemicals called the diphosphonates, which bind to bone and prevent its breakdown. It has been shown to be effective in lowering calcium levels in patients with malignant hypercalcemia. A total of 157 cancer patients with hypercalcemia were randomly assigned to one of two groups: one group received hydration with saline solution (43 patients), and the other received an infusion of etidronate in saline solution (114 patients). The infusions were given once a day over a two-hour period for three days. Additional hydration was given to both groups as needed to restore fluid levels. Furosemide (Lasix) was also administered, if needed, to prevent fluid overload. By the fourth day, patients in the etidronate group had significantly lower levels of calcium than those in the saline group. Furthermore, 63 percent (72 of 114) of the patients in the etidronate group responded to the treatment, whereas only 33 percent (14 of 43) of the saline group responded to hydration alone. There were few side effects of etidronate treatment; nausea and/or vomiting occurred in 8.8 percent of patients on etidronate compared with 4.5 percent of patients receiving hydration alone. Twelve percent of the etidronate-treated group experienced mild, temporary impairment of kidney function, compared with five percent of the saline group. However, hypercalcemia and dehydration can cause kidney damage, and the adverse effect of etidronate can be minimized by administering the drug slowly over long periods of time. In fact, etidronate treatment may be more effective if the duration of treatment is increased. The most effective treatment for hypercalcemia of malignancy is cancer therapy, etidronate may be useful in the short-term for lowering elevated calcium levels.(Consumer Summary produced by Reliance Medical Information, Inc.)

Etoposide has been repeatedly shown to be active against small cell lung cancer. Since etoposide and cisplatin combine for synergistic activity, this combination is often used in the treatment of small cell lung cancer, where overall response rates of 64 to 88 percent are observed among previously untreated patients and rates of 27 to 58 percent are observed among patients who have failed previous therapy. Research on animals has established that the effectiveness of etoposide is strongly dependent upon the level and schedule of dosage; many current regimens administer the drug over a three- to five-day period. A study was undertaken to determine the effectiveness of an oral regimen of etoposide in the treatment of small cell lung cancer. A total of 83 patients were stratified according to extent of disease, age, sex, and performance status; they were then randomly assigned to groups receiving either cisplatin plus oral etoposide or cisplatin plus intravenous etoposide. The overall response rate for the patients receiving the oral drug was 50 percent while the overall response rate for the intravenous group was 59 percent. This difference was not statistically significant, although it should be mentioned that with the small number of patients in this study, any difference less than 25 percent is unlikely to be truly meaningful. The median duration of the response was 6.1 months and 6.9 months for the oral and the intravenous groups, respectively. The toxic side effects of the chemotherapy were generally comparable between the two groups, although moderate to severe anemia was more common among the patients receiving intravenous treatment, and this group therefore required more transfused blood. The results of the study indicated that until the results of larger studies indicate otherwise, oral etoposide may be used as an effective substitute when intravenous etoposide may not be suitable. (Consumer Summary produced by Reliance Medical Information, Inc.)

To determine the clinical characteristics of patients presenting with malignant ascites, as well as means of evaluating the outcome of patients with the disease, a retrospective review was conducted of all cases of malignant peritoneal effusions diagnosed from 1978 to 1987 at a University Hospital and a Veterans Administration Hospital. Of 65 patients with malignant ascites (40 women; 25 men), the primary site was known in 51 cases (80%). Common sites in women were the ovaries, endometrium, and cervix; in men, common sites were the colon, rectum, and stomach. For five women and nine men the primary site was unknown. Median survival from diagnosis was 7.5 days (mean, 43 days; range, 1-256 days). Chest radiograph and abdominal computed tomography (CT) scan did not disclose the occult primary. An occult primary was detected while the patient was alive in only two cases and at autopsy in two other patients. Due to the poor prognosis for this disease, we do not recommend an aggressive approach to malignant ascites of unknown origin, except perhaps in women, in whom ovarian cancer should be suspected. Cancer 64:753-755, 1989.

• Although cancer during pregnancy is Infrequent, its management is difficult for patients, their families, and their physicians. When termination of the pregnancy is unacceptable, decisions regarding the use of Irradiation and chemotherapy are complicated by the well-known high risks of abortion and fetal malformation. This risk is concentrated in the first trimester and varies with the choice of chemotherapeutic agents or combinations of agents. There is only minimal evidence of increased risk of malformation or abortion in the second or third trimester. Recent progress in cancer therapy has made cure a reasonable goal, and for some malignant neoplasms, cure is still possible even when initial therapy is modified or delayed. When cure is a reasonable goal, curative therapy should not be compromised by modification or delay. When treatment for cure or significant palliation is not possible, however, the goal should shift to protection of the fetus from damage by the injudicious use of teratogenic cancer therapy. This report will review the available data that may assist in these difficult decisions.(Arch Intern Med 1988;148:2058-2064)

Natural Obsessions: The Search for the Oncogene, N. Artgier, 394 pp, New York, Houghton Mifflin, 1988. $19.95.Oncogenes: An Introduction to the Concept of Cancer Genes, K. B. Burck, E. T. Liu, and J. W. Larrick, 300 pp, New York; Springer, 1988. $37.75.Understanding Cancer (Third ed). Mark Renneker, 489 pp, Palo Alto, CA, Bull Publishing, 1988. $24.95.

During the third-year medicine clerkship, students were instructed in online computer Physician Data Query (PDQ) searches. Each student completed computer searches in at least one of five tumor topics. Students assigned to selected tumor topics performed significantly better on test questions in their assigned topic as compared to the scores of students who were not assigned that topic. Although students were encouraged to use the PDQ ad libitum, within three months of completing the clerkship, only 22 students (20%) had conducted additional searches. We conclude that PDQ instruction may enhance students' knowledge about cancer. Student instruction can be effectively completed with minimal computer time. The results from our program evaluation and the limited student use following completion of the clerkship suggest that we should identify another user group, such as senior housestaff, to generate greater interest and more frequent use of the PDQ.

Due to shorter hospitalization periods and changes in surgical procedures, breast cancer patients have less inpatient contact with rehabilitation resources. A questionnaire related to educational needs and social support was mailed statewide to 2,000 postmastectomy women who had received a Reach to Recovery visit. The findings are based on quantitative data reported by 933 women and from 27 women in follow-up interviews. Respondents ranked their educational needs in six categories from greatest to least importance as follows: (1) information about breast cancer, (2/3) personal hygiene/exercise and nutrition/weight control (both ranked of equal importance), (4) prosthesis/clothing information, (5) social support, and (6) sexual issues. Performance on the knowledge assessment correlated directly with the amount of educational experience and inversely with age. Respondents who lived in communities of less than 2,500 were less informed than those from other locations. Participation in formalized support groups was infrequent (11%). The major source of information was the media, with 88% indicating they would watch television programs about breast cancer. Thirty-three percent of the respondents indicated they owned a video cassette recorder (VCR); about 93% said VCRs were available for rent in their community. Work associates were identified as a group that encouraged information seeking; health care professionals were the most successful in motivating women to participate in support groups.

Tumor registries provide a valuable source of treatment, survival, and epidemiologic data but have been faulted for incomplete and insufficient collection of data. An eight page, 38-item Cancer Patient Questionnaire (CPQ) was developed to collect more extensive information for the tumor registry. The CPQ identified significantly more patients with a family history of cancer than had previously been detected by chart review by the tumor registrar. The CPQ agreed with data collected by the tumor registry in 96% of cases for place of birth, 84% of cases for occupational history, 91% of cases for tobacco use, and 88% of cases for number of pregnancies or live births. The Cancer Patient Questionnaire is complete and easy to use and may replace the chart review in the collection of these data.

• Certain clinical findings, such as pallor of the conjunctivae, nail beds, lips, oral mucosa, and palmar creases have traditionally been used by physicians in the diagnosis of anemia. We prospectively examined 50 patients to determine whether there was any correlation between these clinical findings and hemoglobin concentration. We noted a statistically significant correlation between hemoglobin concentration and the following: color tint of the lower eyelid conjunctiva, nail-bed rubor, nail-bed blanching, and palmar crease rubor. Results from our study support the contention that the presence and degree of anemia can be estimated clinically by careful physical examination.(Arch Intern Med 1988;148:831-832)