Archive for April, 2013

New cancer guidelines to help adolescents and young adults

UNMC oncologist chairs panel that develops new guidelines to help guide adolescents, young adults through cancer

A University of Nebraska Medical Center pediatric oncologist, Peter Coccia, M.D., served as chairman of a national panel that developed patient guidelines to help guide adolescents and young adults with cancer through diagnosis, treatment and after therapy.

These guidelines answer patients and their family’s most common questions related to how to prepare for treatment, what to ask the doctor, and explain the most common medical terms.

“The adolescent and young adult (AYA) group includes individuals between the ages of 15 to 39 and represents a challenging age group for oncologists to treat successfully,” Dr. Coccia said.

The American Cancer Society’s Cancer Journal for Clinicians notes that remarkable progress has been made in the treatment of children under the age of 15 and in adults over 40 years of age in the last 35 years, but there has been minimal improvement in the survival rate in the 70,000 new AYA patients with invasive cancer diagnosed yearly.

The guidelines were developed through the National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 21 of the world’s leading cancer centers dedicated to improving the quality and effectiveness of care provided to patients with cancer. The UNMC Eppley Cancer Center at The Nebraska Medical Center is a charter member of the NCCN.

The NCCN Guidelines are developed and updated through an evidence-based process in which the expert panel integrates comprehensive clinical and scientific data with the judgment of the multidisciplinary panel members and other experts drawn from NCCN member institutions. Access to the NCCN Guidelines for Patients or any of the NCCN Guidelines is available free of charge at NCCN.com.

About the National Comprehensive Cancer Network

The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 21 of the world’s leading cancer centers, is dedicated to improving the quality and effectiveness of care provided to patients with cancer. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers. The primary goal of all NCCN initiatives is to improve the quality, effectiveness, and efficiency of oncology practice so patients can live better lives.

The NCCN member institutions are: City of Hope Comprehensive Cancer Center, Los Angeles, CA; Dana-Farber/Brigham and Women’s Cancer Center | Massachusetts General Hospital Cancer Center, Boston, MA; Duke Cancer Institute, Durham, NC; Fox Chase Cancer Center, Philadelphia, PA; Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT; Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, WA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Memorial Sloan-Kettering Cancer Center, New York, NY; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; The Ohio State University Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute, Columbus, OH; Roswell Park Cancer Institute, Buffalo, NY; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO; St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute, Memphis, TN; Stanford Cancer Institute, Stanford, CA; University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; UNMC Eppley Cancer Center at The Nebraska Medical Center, Omaha, NE; The University of Texas MD Anderson Cancer Center, Houston, TX; and Vanderbilt-Ingram Cancer Center, Nashville, TN.


Study Reveals Two Effective Surgical Options for Stroke Prevention

Patients who have experienced stroke or a transient ischemic attach (TIA) are at significant risk for another stroke. In many cases, a TIA is a warning sign that a true stroke may happen in the future if something is not done to prevent it.

“Preventive surgery can reduce the risk of a future stroke 9 to 26 percent a year,” says William Thorell, MD, neurosurgeon at The Nebraska Medical Center.

“Now physicians have two safe and effective options for treating carotid artery disease, the traditional carotid revascularization endarterectomy or carotid stenting,” says Dr. Thorell. “In the past, endarterectomy was thought to be the preferred procedure. However, recent evidence produced by the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) revealed similar results in patients for the treatment of carotid stenosis.” Results were published in the July 2010 issue of the New England Journal of Medicine.

“The morbidity and mortality are about equivalent for both at approximately 5 percent,” says Dr. Thorell. Complications include stroke, heart attack and death. In this particular trial, the death rate was extremely low, at just .3 to .7 percent.

A patient who presents with symptoms of a stroke or TIA, should undergo imaging in the cerebral vessels. This can be done with ultrasound, MRA or CTA.

If the scan reveals narrowing of the carotid arteries by 50 percent or more, the patient should be seen by a specialist to determine if he or she is a candidate for surgery. “We work as a team with our vascular surgery colleagues to determine which procedure is most appropriate for the patient,” says Dr. Thorell. “In certain situations, stenting is preferable to endarterectomy. This includes patients who have had previous radiation surgery to the head and neck, patients who have had a previous endarterectomy with recurring narrowing and patients with difficult anatomy for surgery.”

While many patients are prescribed drugs like statins, blood pressure medications and anti-platelet agents such as Aggrenox to reduce their risk of stroke, surgical treatment of severe blockages in the carotid artery has been shown to be more effective than medical therapy alone in preventing ischemic strokes caused by plaque buildup.

Stroke is the third leading cause of death and the number one cause of disability in adults, with 750,000 new strokes occurring each year.


Rise in Some Head and Neck Cancers Linked to HPV

A rise in the incidence of certain head and neck cancers among middle-aged Americans and their link to the human papilloma virus (HPV) is leading some medical experts to begin recommending the HPV vaccine for both men and women.

“The last decade has seen a 5 to 6 percent increase per year in the incidence of cancers of the tonsils and base of the tongue,” says William Lydiatt, MD, a head and neck cancer specialist at The Nebraska Medical Center, “and it is primarily due to the human papilloma virus (HPV). Sixty to 70 percent of all tonsil cancers in the U.S. are HPV-related.”

Recent studies also indicate there may be a link between these cancers and having multiple sex partners and oral sex, says Dr. Lydiatt. A 2007 study in the New England Journal of Medicine found that younger people with head and neck cancers who tested positive for oral HPV infection were more likely to have had multiple vaginal and oral sex partners in their lifetime. However, half of these individuals had fewer than five sex partners, he says.

Approximately 80 percent of sexually active women and 75 percent of men harbor the HPV virus. In men, it is usually asymptomatic.

These HPV-related cancers are two times more common in men than women. While still fairly rare among the population as a whole compared to other cancers, the rising incidence is beginning to reach epidemic proportions, says Dr. Lydiatt. Currently, approximately 12,000 Americans will be diagnosed with cancers of the tonsil or base of the tongue each year with 8,000 being men and 4,000 women, he says. “It’s now comparable to the same rate as cervical cancer,” says Dr. Lydiatt.

With numbers on the rise, Dr. Lydiatt recommends that both young men and women receive the HPV vaccine called Gardasil, which has been approved by the Food and Drug Administration (FDA) to prevent cervical and anal cancers.

The good news is that even at stage IV, these individuals have a very high cure rate, says Dr. Lydiatt. The typical patient is a white, non-smoking male in his 50s who presents with a sore in the throat, which will not heal or a painless neck mass just below the jaw line. The patient may complain of difficulty eating, swallowing and talking. Other symptoms include ear pain, change in voice, sore throat, bleeding gums, bad breath and an altered sense of taste. An early symptom that may be detected during a clinical exam is an asymmetry of the tonsil, notes Dr. Lydiatt.

Tonsil cancer can spread very quickly and metastasize to other parts near the throat. A neck mass should be evaluated if it does not go away in one week. Based on clinical suspicion, a CAT scan should be considered followed by a biopsy of the tonsil, tongue or neck mass, says Dr. Lydiatt.

If a positive diagnosis is found, patients with these types of cancers have the best outcomes with a comprehensive, multi-disciplinary approach to treatment because of the nature of the disease and the substantial affects treatment can have on a person’s basic aspects of living including their ability to eat, drink, swallow, taste and talk, says Dr. Lydiatt. The Nebraska Medical Center uses a multi-disciplinary approach that includes a combination of oncologists, radiation oncologists, dental oncologists, head and neck surgeons, speech and swallowing specialists, nutritionists, nurses and social workers. Some patients may also need psychosocial counseling to prevent depression because of the physical changes they may experience to the facial and neck areas.


Intestinal Rehabilitation Helps Restore Gastrointestinal Function to Patients

Intestinal failure, whether occurring as a sudden catastrophe or more insidiously over years of symptoms and surgeries, can be devastating for patients and difficult to manage for physicians. “For both adults and children with the diagnosis, treatment can be complex, often requiring intensive nutritional support, management of wounds and central lines, surgical intervention and assistance with psychological and addiction issues,” says David Mercer, MD, PhD, an intestinal transplant surgeon and director of the Intestinal Rehabilitation Program at The University of Nebraska Medical Center (UNMC).

Broadly defined, intestinal failure (IF) is the inability to maintain a reasonable state of nutrition and hydration using the gut alone. In children, this is often the result of a problem at birth such as gastroschisis, necrotizing enterocolitis or intestinal atresia. In adults, IF can develop suddenly from problem such as intestinal volvulus or ischemia or more insidiously after multiple operations for inflammatory bowel disease or adhesive obstructions. “In some cases, while the intestinal appears intact, there is significant functional impairment, either from pain or poor motility, which prevents normal intake or digestion,” says Dr. Mercer.

Patients with IF may require nutritional supplements or even parenteral nutrition. “Symptoms such as pain, diarrhea or constipation, vomiting or bloating can be incapacitating for IF patients and often prevents them from working, going to school or enjoying life,” says Dr. Mercer. “These patients can be very difficult and time-consuming to manage, especially with complex surgical problems such as enterocutaneous fistulas. Many patients develop significant pain issues and narcotic tolerance.”

The Intestinal Rehabilitation Program at UNMC is a multidisciplinary team that collaborates to treat patients with symptoms ranging from chronic abdominal pain and malnourishment to complete loss of the small intestine. “We can see any patient who is not receiving 100 percent of their calories and hydration by mouth,” says Dr. Mercer. “In serious cases, the earlier patients are referred, the better they do.”

Treatment for each patient is strictly individualized using advanced medical and surgical techniques to restore gastrointestinal function and encourage intestinal adaptation. “It is our goal to have every patient, adult or child to be able to take 100 percent of their food and water by mouth,” says Dr. Mercer. “While this is not always achievable in every patient, we believe our experience and resources allow us to provide the best overall care for this population.”

Patients seen by the Intestinal Rehabilitation Program will receive a thorough anatomic, functional and nutritional assessment. Based on these results, a comprehensive treatment and care management plan will be developed and shared with the primary care physician. Some patients may require surgical correction of anatomic problems, lengthening procedures, home TPN management and management of IF-related symptoms. “The majority of basic care issues can continue to be managed by the primary care doctor,” says Dr. Mercer. “However, patients with complex nutritional issues may need closer management by our Intestinal Rehabilitation team.”