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Saturday, December 20, 2014

A multicenter, non-randomized, phase II study of docetaxel and carboplatin administered every 3 weeks as 2nd line chemotherapy in patients with first relapse of platinum sensitive epithelial ovarian, peritoneal or fallopian tube



open access

Conclusions

The three-weekly regimen of docetaxel in combination with carboplatin was feasible and active as second-line treatment of platinum-sensitive ovarian, peritoneal and Fallopian tube cancer. The major toxicity was neutropenia, while the frequency of peripheral neuropathy was low.

Metronomic oral cyclophosphamide (MOC) in the salvage therapy of heavily treated recurrent ovarian cancer patients



open access

Incidence of breast and gynaecological cancers by ethnic group in England, 2001-2007



open access

 Conclusions
Our study provides evidence that the risk of breast and gynaecological cancers varies by ethnic group and that those groups typically grouped together are not homogenous with regards to their cancer risk. Furthermore, several of our findings cannot be readily explained by known risk factors and therefore warrant further investigation.

Skin Cancer Risk in BRCA1/2 Mutation Carriers



abstract

 Women with BRCA1/2 mutations have an elevated risk of breast and ovarian cancer. These patients and their clinicians are often concerned about their risk for other cancers, including skin cancer. Research evaluating the association between BRCA1/2 mutations and skin cancer is limited and has produced inconsistent results. Herein, we review the current literature on the risk of melanoma and non-melanoma skin cancers in BRCA1/2 mutation carriers. No studies have shown a statistically significant risk of melanoma in BRCA1 families. BRCA2 mutations have been linked to melanoma in large breast and ovarian cancer families, though a statistically significant elevated risk was reported in only one study. Five additional studies have shown some association between BRCA2 mutations and melanoma, while four studies did not find any association. With respect to non-melanoma skin cancers, studies have produced conflicting results. Given the current state of medical knowledge, there is insufficient evidence to warrant increased skin cancer surveillance of patients with a confirmed BRCA1/2 mutation or a family history of a BRCA1/2 mutation, in the absence of standard risk factors. Nonetheless, suspected BRCA1/2 mutation carriers should be counseled about skin cancer risks and may benefit from yearly full skin exams.

Very late recurrence (after more than 20 years) of epithelial ovarian carcinoma: case report and literature review



  "Lifelong follow-up is critically important for ovarian cancer patients."
  (Opinion - and clinical/research reporting)


abstract

PURPOSE:

To present a case of very late (more than 20 years) recurrence of epithelial ovarian carcinoma and to review the pertinent literature. We encountered a 50-year-old patient who, at the age of 22, underwent cytoreductive surgery and adjuvant chemotherapy for stage III serous ovarian carcinoma. She recurred after 28 years and underwent secondary surgery and chemotherapy.

METHOD:

A PubMed search of the English literature containing the following key words: ovarian cancer, late recurrence, late relapse, late metastasis was performed.

RESULTS:

Only five cases (including the present one) with recurrence after more than 20 years are so far on record. Of these, four patients were 33 years old or younger and had advanced stage at diagnosis. Time to recurrence ranged from 21 to 28 years. All patients had serous carcinoma and three had recurrence in lymph nodes.

CONCLUSIONS:

Very late recurrence is an extremely rare event and may result from either regrowth of dormant tumor cells or from development of a new cancer. Lifelong follow-up is critically important for ovarian cancer patients.

Music therapy in cancer patients: fact or fiction?



open access

Future Oncology - Index: Themed Content: Minimizing morbidity in radiation oncology



Index


 Best of the Radiosurgery Society® Scientific Meeting 2014: stereotactic radiosurgery/stereotactic body radiotherapy treatment of extracranial and intracranial lesions

Research Article


Chest wall and rib irradiation and toxicities of early-stage lung cancer patients treated with CyberKnife stereotactic body radiotherapy

Special Report


The promise of combining radiation therapy and immunotherapy: morbidity and toxicity

Review


Radiation oncology: physics advances that minimize morbidity

Radioprotective agents for radiation therapy: future trends

Radiobiological modifiers in clinical radiation oncology: current reality and future potential

The use of angiotensin II receptor antagonists to increase the efficacy of radiotherapy in cancer treatment

Radiogenomics: the search for genetic predictors of radiotherapy response

Minimizing morbidity in radiation oncology: a special issue from Future Oncology



Future Medicine

New ways to successfully target tumor vasculature in ovarian cancer



abstract


Purpose of review: The aim of this article was to review the recent literature on potential therapeutic strategies for overcoming resistance to antivascular endothelial growth factor drugs in ovarian cancer.

Recent findings: Although clinical benefits of antivascular endothelial growth factor therapy were observed in ovarian cancer treatment trials, this use yielded only modest improvement in progression-free survival and, with the exception of cediranib, no effect on overall survival. Adaptive resistance and escape from antiangiogenesis therapy is likely a multifactorial process, including induction of hypoxia, vascular modulators, and immune response. New drugs targeting the tumor vasculature or other components of the surrounding microenvironment have shown promising results.

Summary: When to start and end antiangiogenesis therapy and the choice of optimal treatment combinations remain controversial. Further evaluation of personalized novel angiogenesis-based therapy is warranted. Defining the critical interaction of these agents and pathways and the appropriate predictive markers will become an increasingly important objective for effective treatment.

Friday, December 19, 2014

Combining images and genetic data proves gene loss behind aggressive ovarian cancers - PTEN



media

 Cancer Research UK scientists have shown that loss of a gene called PTEN triggers some cases of an aggressive form of ovarian cancer, called high-grade serous ovarian cancer, according to a study published in Genome Biology today.....

FDA Approves Olaparib (Lynparza) for BRCA Ovarian Cancer



medscape

Olaparib Approved in Europe for BRCA Ovarian Cancer (2015 in U.S.?)



medscape

Preclinical Efficacy for AKT Targeting in Clear Cell Carcinoma of the Ovary



abstract

The aim of this study was to determine the role of AKT as a therapeutic target in ovarian clear cell carcinoma (CCC), an aggressive, chemoresistant histological subtype of ovarian cancer. AKT activation was assessed by immunohistochemistry (IHC) using human tissue microarrays of primary ovarian cancers, comprised of both CCC and serous adenocarcinoma (SAC). The growth-inhibitory effect of AKT-specific targeting by, the small molecule inhibitor, perifosine was examined using ovarian CCC cell lines in vitro and in vivo. Finally, the activity of perifosine was examined using in CCC-derived tumors that had acquired resistance to anti-VEGF or chemotherapeutics like bevacizumab or cisplatin, respectively. Interestingly, AKT was frequently activated both in early-stage and advanced-stage CCCs.

Treatment of CCC cells with perifosine attenuated the activity of AKT targeted therapy for ovarian clear cell carcinoma. AKT-mTORC1 signaling, inhibited proliferation, and induced apoptosis. The effect of perifosine was more profound under conditions of high AKT activity compared to low AKT activity. Increased AKT activation and enhanced sensitivity to perifosine were observed in the context of cisplatin-resistant CCC. Treatment with perifosine concurrently with cisplatin significantly enhanced the anti-tumor effect of cisplatin. Moreover, perifosine showed significant anti-tumor activity in CCC-derived tumors that had acquired resistance to bevacizumab or cisplatin. Collectively, these data reveal that AKT is frequently activated in ovarian CCCs and is a promising therapeutic target in aggressive forms of ovarian cancer.

Implications: AKT-targeted therapy has value in a front-line setting as well as a second-line treatment for recurrent disease developing after platinum-based chemotherapy or bevacizumab treatment.

Interactions of Multitargeted Kinase Inhibitors and Nucleoside Drugs: Achilles Heel of Combination Therapy?



abstract (technical)



Multitargeted tyrosine kinase inhibitors (TKI) axitinib, pazopanib, and sunitinib are used to treat many solid tumors. Combination trials of TKIs with gemcitabine, a nucleoside anticancer drug, in pancreas, renal, lung, ovarian, and other malignancies resulted in little benefit to patients. ........An additional unwanted interaction may be reduced FLT uptake in tumor tissues that could lead to aberrant conclusions regarding tumor response.

 fluorothymidine (FLT)

Targeting those with decreased meaning and peace: a supportive care opportunity



abstract


PURPOSE:

To evaluate if an individual's level of meaning/peace (M/P) predicts various quality of life (QOL) and mental well-being measures. To identify targets that might enhance the overall spiritual well-being and QOL of ovarian cancer patients.

METHODS:

Multi-site analysis of women with newly diagnosed stages II-IV ovarian, primary peritoneal, or fallopian tube cancer. Patients completed the following surveys: Functional Assessment of Chronic Illness Therapy-Ovarian (FACT-O), Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp), Edmonton Symptom Assessment System (ESAS), Hospital Anxiety and Depression Scale (HADS), Templer's Death Anxiety Scale (DAS), Herth Hope Index (HHI), and Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS). Linear regression models were created to examine the effect of M/P (FACIT-Sp) upon QOL, symptoms, and other measures of mental well-being. These models adjusted for the effect of site, race, age, stage, anaphylaxis to chemotherapy, and partner status as potential confounders.

RESULTS:

This study enrolled 104 patients from three separate sites. After adjusting for potential confounders, it was found that higher M/P predicted better QOL (FACT-O) (p < 0.0001). Higher M/P also predicted decreased death anxiety, depression, and anxiety (p ≤ 0.005). Finally, higher M/P predicted increased hope and coping scores (p ≤ 0.0005).

CONCLUSIONS:

Level of M/P is associated with several important mental and physical health states. This information may allow providers to identify patients at increased risk for mental/physical distress and may facilitate early referral to targeted psychotherapy interventions focused on improving patient QOL and decreasing anxiety and depression.

Predictive factors for the presence of malignant transformation of pelvic endometriosis



abstract


OBJECTIVES:

To determine predictive factors for the presence of malignant transformation in ovarian endometriotic cysts.

STUDY DESIGN:

This was an IRB approved, case control study analyzing patient data from 2004 to 2013. Pathology database records were searched to identify patients with benign endometrioma and ovarian carcinoma arising in the background of endometriosis. Inclusion criteria required each patient to have a preoperative diagnosis of adnexal mass and no other findings concerning for malignancy. Patient clinical records were queried for preoperative symptoms, serum CA125 levels and radiologic findings. Pathologic data were collected including histology, tumor grade and stage.

RESULTS:

A total of 138 patients met inclusion criteria; 42 women with ovarian cancer arising in the background of endometriosis and 96 women with benign endometrioma. Women diagnosed with ovarian cancer were significantly older than women with endometriosis (53.6 vs. 39.2 years). There was no difference in presence of symptoms between the two groups. Women with malignant tumors were found to have significantly larger cysts (14cm vs. 7.5cm; p<0.0001) that were more often multilocular (45.7% vs. 12.2%; p<0.0001), and contained solid components (77.1% vs. 14.5%; p<0.0001). Among patients that were observed prior to surgery there was a significant difference in the change in size of the mass over time with 4.2cm increase for cases vs. 1.0cm increase for controls (p=0.02). Multiple logistic regression analysis indicated that for every 5 years increase in age there was an adjusted OR of 2.17 (p=0.003). An age of 49 years or greater had an 80.6% sensitivity (95% CI: 62.5-92.5%) and an 82.9% specificity (95% CI: 67.9-92.8%) for malignancy, and solid component on imaging had an adjusted OR of 23.7 (p<0.0001). Serum CA125 levels tended to be higher in patients with malignant tumors but did not reach statistical significance with a mean of 204.9 vs. 66.9 (p=0.1).

CONCLUSIONS:

Significant predictors for malignant transformation of endometriosis include cyst characteristics and age. Women above the age of 49 with multilocular cysts and solid components are at high risk for malignant transformation of endometriosis. Serum CA125 level is not a significant predictor of malignant transformation.

Wednesday, December 17, 2014

Medscape Ethics Report 2014, Part 1: Life, Death, and Pain (slideshow)



Medscape includes country comparisons

http://img.medscapestatic.com/pi/features/slideshow-slide/ethics2014-part1/fig1.jpg

Life-and-Death Decisions That Keep Doctors Up at Night



Medscape

NIH complementary and integrative health agency gets new name (U.S.)



NCCIH

The National Institutes of Health agency with primary responsibility for research on promising health approaches that already are in use by the American public has a new name — the National Center for Complementary and Integrative Health (NCCIH).....

Searching for metastases in ovarian tissue before autotransplantation: a tailor-made approach



abstract

OBJECTIVE:

To exclude minimal residual disease in remaining ovarian tissue after harvesting the ovarian cortex for cryopreservation, by means of a tailor-made approach.

DESIGN:

Retrospective case series.

SETTING:

Hospital laboratory.

PATIENT(S):

We evaluated the ovarian and tubal tissue from 47 cancer patients (breast cancer, [non-]Hodgkin lymphoma; osteo-, Ewing, myxoid lipo-, and oropharyngeal synovial sarcoma; cervical, rectal, and esophageal cancer), who had stored ovarian tissue for fertility preservation.

INTERVENTION(S):

Immunohistochemistry (IHC) with tumor-related antibodies and genetic mutation analysis were performed to detect micrometastases by multiple sectioning at three levels of the paraffin-embedded formalin-fixed material. Molecular assays were performed with the use of tissue between these three levels of sectioning.

MAIN OUTCOME MEASURE(S):

Detection of micrometastases in ovaries.

RESULT(S):

We analyzed 847 ovarian slides to detect isolated tumor cells (ITCs) or micrometastases by IHC. In only one case (1/47) were ITCs detected in the fallopian tube. That patient had an intra-abdominal metastatic esophageal carcinoma. Additional DNA analyses of breast and rectal cancer, Ewing sarcoma, and human papilloma virus in cervical patients did not show evidence of micrometastases in the ovarian tissue.

CONCLUSION(S):

The tailor-made approach consisted of patient-specific tumor markers which were used to search for ovarian micrometastases. We found evidence of metastatic disease within the fallopian tube of a patient with intraperitoneal metastatic esophageal adenocarcinoma.

Survival outcome of stage I ovarian clear cell carcinoma with lympho-vascular space invasion



abstract

BACKGROUND:

The clinical impact of lympho-vascular space invasion (LVSI) in early-stage ovarian clear cell carcinoma (OCCC) is not well understood. Given the distinct tumor biology and survival patterns of OCCC, the significance of LVSI on survival outcome and treatment response was examined in OCCC.

METHODS:

A multicenter study was conducted to examine stage IA-IC3 OCCC cases that underwent primary surgical staging including lymphadenectomy. LVSI status was determined from archived histopathology slides, correlated with clinico-pathological results, chemotherapy patterns, and survival outcomes.

RESULTS:

LVSI was observed in 47 (20.3%) among 232 cases. In univariate analysis, LVSI was associated with older age (p=0.042), large tumor size (p=0.048), and stage IC (p=0.035). In survival analysis, LVSI was associated with decreased disease-free survival (DFS, 5-year rate, 70.6% versus 92.1%, p=0.0004) and overall survival (OS, 78.8% versus 93.3%, p=0.008) on univariate analysis. After controlling for age, tumor size, stage, and chemotherapy use, LVSI remained an independent prognostic factor for decreased survival outcomes (DFS, hazard ratio [HR] 4.35, 95% confidence interval [CI] 1.73-10.9, p=0.002; and OS, HR 4.73, 95%CI 1.60-14.0, p=0.015). Among 210 cases who received postoperative chemotherapy, while regimen type did not impact survival outcome regardless of LVSI status (DFS, p=0.63), the number of administered cycles showed a survival benefit towards ≥6cycles for patients with LVSI-positive tumors (DFS p=0.009, and OS p=0.016).

CONCLUSION:

LVSI is an important marker to predict survival outcome of stage I OCCC. Regardless of chemotherapy type, patients with stage I OCCC showing LVSI may benefit from receiving postoperative chemotherapy.

Surgical site infection after primary surgery for epithelial ovarian cancer: predictors and impact on survival



abstract


OBJECTIVE::

Surgical site infection (SSI) following epithelial ovarian cancer (EOC) primary surgery (PS) occurs in 10-15% of women. Perioperative factors associated with SSI and impact of SSI on survival were determined.

METHODS::

EOC cases that underwent PS from 1/2/2003-12/30/2011 were retrospectively reviewed. SSIs were defined according to ACS NSQIP. Logistic regression models were fit to identify factors associated with SSI. Cox proportional hazards models were utilized to evaluate the association of patient and perioperative characteristics with overall survival (OS) and disease-free survival (DFS).

RESULTS::

Among 888 cases, 96 (10.8%) developed SSI: 32 superficial, 2 deep, and 62 organ/space. Factors independently associated with superficial SSI were increasing BMI (odds ratio 1.41 [95% confidence interval, 1.12, 1.76] per 5kg/m2), increasing operative time (1.24 [1.02, 1.50] per hour), and advanced stage (III/IV) (10.22 [1.37, 76.20]). Factors independently associated with organ/space SSI were history of gastroesophageal reflux disease (2.13 [1.23, 3.71]), surgical complexity (intermediate 3.11 [1.02, 9.49]; high 8.07 [2.60, 25.09]; referent: low), and residual disease (RD) (measureable ≤1cm 1.77 [0.96, 3.27]; suboptimal >1cm (3.36 [1.48, 7.61]; referent: microscopic). Occurrence of superficial (hazard ratio 1.69 [1.12, 2.57]) or organ/space (1.46 [1.07, 2.00]) SSI was independently associated with worse OS. SSI occurrence was not independently associated with DFS.

CONCLUSIONS::

SSI after PS is associated with decreased OS. Most risk factors for SSI are not modifiable. Alternative measures to lower rates of SSIs are needed as this may improve OS. Preoperative identification of SSI risk factors may assist in risk-assessment and operative planning.

Challenges in managing genetic cancer risk: a long-term qualitative study of unaffected women carrying BRCA1/BRCA2 mutations



abstract


Purpose:
Women carrying BRCA1/BRCA2 germ-line mutations have an increased risk of developing breast/ovarian cancer. To minimize this risk, international guidelines recommend lifelong surveillance and preventive measures. This study explores the challenges that unaffected women genetically predisposed to breast/ovarian cancer face in managing their risk over time and the psychosocial processes behind these challenges

Methods:
 Between 2011 and 2013, biographical qualitative interviews were conducted in Switzerland with 32 unaffected French- and Italian-speaking women carrying BRCA1/BRCA2 mutations. Their mutation status had been known for at least 3 years (mean, 6 years). Data were analyzed through constant comparative analysis using software for qualitative analysis.

Results:
From the time these women received their positive genetic test results, they were encouraged to follow medical guidelines. Meanwhile, their adherence to these guidelines was constantly questioned by their social and medical environments. As a result of these contradictory pressures, BRCA1/BRCA2 mutation carriers experienced a sense of disorientation about the most appropriate way of dealing with genetic risk.

Conclusion:
Given the contradictory attitudes of health-care professionals in caring for unaffected BRCA1/BRCA2 mutation carriers, there is an urgent need to educate physicians in dealing with genetically at-risk women and to promote a shared representation of this condition among them.

Clinical characteristics and outcomes of patients with stage I epithelial ovarian cancer compared to fallopian tube cancer



abstract

OBJECTIVE:

Compare clinical characteristics and survival between patients with stage I epithelial ovarian cancer and fallopian tube cancer.

STUDY DESIGN:

We identified women with stage I epithelial ovarian cancer and fallopian tube cancer that underwent treatment between 2000 and 2010......

RESULTS:

The study group consisted of 385 women with epithelial ovarian cancer and 43 with fallopian tube cancer. Patients with fallopian tube cancer had a higher rate of stage IA disease (65% vs. 48%; P = 0.02) and grade 3 tumors (60.4% vs. 30.9%; P < 0.001). Patients with fallopian tube cancer had a significantly higher rate of breast cancer (25.6% vs. 5.7%; P < 0.001) and BRCA 1 mutations (45.8% vs. 9.1% P < 0.001). There was no difference in the rates of platinum-based and paclitaxel chemotherapy between the groups. Women with fallopian tube cancer were more likely to have received six or more cycles of chemotherapy (58.1% vs. 44.1%; P = 0.02). The 5-year disease-free survival rates were 100% in women with fallopian tube cancer and 93% in patients with epithelial ovarian cancer (P = 0.04). The 5-year overall survival rates were 100% and 95% for fallopian tube cancer and epithelial ovarian cancer, respectively (P = 0.7).

CONCLUSIONS:

We found a higher rate of stage IA, grade 3, and serous carcinoma in fallopian tube cancer. Women with fallopian tube cancer had a higher rate of breast cancer. There was no difference in overall survival between the groups.

Positron Emission Tomography (PET) in Oncology



Free Full-Text 




1.8.1. Ovarian Cancer

There is mounting evidence that FDG-PET/CT has an increasing role in the management of ovarian cancer, with its main indication to detect tumor recurrence in presence of rising CA-125 serum values and negative conventional imaging studies [93]. The benefits of the use of FDG-PET/CT in these settings has been reported several times in the literature [94,95], with a sensitivity of more than 90% in detecting occult metastases. In the study of Zimny et al., FDG-PET/CT preceded the conventional diagnosis by a median of 6 months in patients judged clinically free of disease. Menzel et al. suggest that a PET indication is worthwhile at CA 125 levels of approximately 30 U/mL [96]. A more recent prospective multi-center, cohort study (90 patients) confirmed the impact of FDG-PET/CT in suspected recurrent ovarian cancer, which affected disease management decisions in 60% of the cases (in 49% with a high, in 11% with a medium clinical impact) with a much higher detection rate compared to conventional imaging [97].
For the characterization of asymptomatic adnexal findings, FDG-PET/CT has no place due to lack of sensitivity [98], and MRI remains the best imaging modality choice.
For the initial staging of ovarian cancer, FDG-PET/CT is not routinely used. Nevertheless, some publications noticed that it could be interesting in advanced epithelial ovarian cancer, in particular for the detection of supradiaphragmatic lymph node metastases like parasternal lymph nodes, with better accuracy than conventional CT (detection rate: 67% vs. 33%) [99]. However, increased mediastinal FDG uptake was not shown to play a significant prognostic role, while complete cytoreduction did [100]. For the initial preoperative staging of ovarian cancer, FDG-PET/CT may be superior compared to CT alone [101,102], but some publications also observed limits, as De Iaco et al., who reported a sensitivity and specificity of 78 and 68% respectively, with a high rate of false negative results in lesions <5 mm such as found in presence of peritoneal carcinomatosis [103].
However, conflicting results have been reported on the sensitivity of FDG-PET/CT scan in detecting peritoneal carcinomatosis; Turlakow, Suzuki and Kim reported higher diagnostic accuracy of FDG-PET/CT than CeCT in this settings, with a sensitivity and specificity for FDG-PET/CT of 67%–92.2% and 90%–94% respectively, as compared to 22%–88.5% and 65%–77% respectively for CeCT [104,105,106]. The sensitivity of FDG-PET/CT proved also similar to that of conventional MRI, and even better for detecting small peritoneal lesions (<2 cm) in patients with recurrent ovarian cancer [107]. However, FDG-PET/CT has limits, in particular for the detection of small peritoneal implants (<5 mm) because of the limited PET resolution, and surgical staging remains the gold standard [108]. The good performances of FDG-PET/CT in detecting peritoneal carcinomatosis lead to interesting information for optimizing patient selection for cytoreductive surgery in recurrent ovarian cancer; recently, Ebina et al. observed that FDG-PET/CT led to a change in management plan in 58.4% in that case, with a total number of patients in whom cytoreductive surgery was selected as the treatment of choice increased from 12 to 35 according to FDG-PET-CT results [109]. In the preoperative management, FDG-PET/CT is also able to detect distant metastases (25/95 patients upstaged from FIGO stage III to stage IV by FDG-PET/CT in a recent study [110]. However, upward stage migration did not worsen the prognosis of stage III patients, and in advanced ovarian cancer, the only prognostic factor that retained a significant prognostic value is the quality of response to cytoreductive therapy. Another study proposed FDG-PET/CT criteria such as FDG-PET/CT stage IV, pleural exudates, and PET-positive large bowel mesentery implants, which were statistically significant in the prognosis univariate analysis to guide the administration of neo-adjuvant chemotherapy in advanced ovarian cancer, but, once again, incomplete tumor debulking was the only statistically significant independent prognostic variable using multivariate analysis (p = 0.0001) [111]. Other prognostic factors like MTV or TGL may be interesting, but more data are needed at this time to confirm that [112].
- See more at: http://www.mdpi.com/2072-6694/6/4/1821/htm#sthash.MzNWUkeA.dpuf

Dynamic Changes in Numbers and Properties of Circulating Tumor Cells and Their Potential Applications | HTML



Free Full-Text 

Abstract

: Circulating tumor cells (CTCs) can be detected in the blood of different types of early or advanced cancer using immunology-based assays or nucleic acid methods. The detection and quantification of CTCs has significant clinical utility in the prognosis of metastatic breast, prostate, and colorectal cancers. CTCs are a heterogeneous population of cells and often different from those of their respective primary tumor. Understanding the biology of CTCs may provide useful predictive information for the selection of the most appropriate treatment. Therefore, CTC detection and characterization could become a valuable tool to refine prognosis and serve as a “real-time biopsy” and has the potential to guide precision cancer therapies, monitor cancer treatment, and investigate the process of metastasis. - See more at: http://www.mdpi.com/2072-6694/6/4/2369/htm#sthash.UvsIAwMW.dpuf

Abstract

: Circulating tumor cells (CTCs) can be detected in the blood of different types of early or advanced cancer using immunology-based assays or nucleic acid methods. The detection and quantification of CTCs has significant clinical utility in the prognosis of metastatic breast, prostate, and colorectal cancers. CTCs are a heterogeneous population of cells and often different from those of their respective primary tumor. Understanding the biology of CTCs may provide useful predictive information for the selection of the most appropriate treatment. Therefore, CTC detection and characterization could become a valuable tool to refine prognosis and serve as a “real-time biopsy” and has the potential to guide precision cancer therapies, monitor cancer treatment, and investigate the process of metastasis. - See more at: http://www.mdpi.com/2072-6694/6/4/2369/htm#sthash.UvsIAwMW.dpuf

Abstract

: Circulating tumor cells (CTCs) can be detected in the blood of different types of early or advanced cancer using immunology-based assays or nucleic acid methods. The detection and quantification of CTCs has significant clinical utility in the prognosis of metastatic breast, prostate, and colorectal cancers. CTCs are a heterogeneous population of cells and often different from those of their respective primary tumor. Understanding the biology of CTCs may provide useful predictive information for the selection of the most appropriate treatment. Therefore, CTC detection and characterization could become a valuable tool to refine prognosis and serve as a “real-time biopsy” and has the potential to guide precision cancer therapies, monitor cancer treatment, and investigate the process of metastasis. - See more at: http://www.mdpi.com/2072-6694/6/4/2369/htm#sthash.UvsIAwMW.dpuf

Abstract

: Circulating tumor cells (CTCs) can be detected in the blood of different types of early or advanced cancer using immunology-based assays or nucleic acid methods. The detection and quantification of CTCs has significant clinical utility in the prognosis of metastatic breast, prostate, and colorectal cancers. CTCs are a heterogeneous population of cells and often different from those of their respective primary tumor. Understanding the biology of CTCs may provide useful predictive information for the selection of the most appropriate treatment. Therefore, CTC detection and characterization could become a valuable tool to refine prognosis and serve as a “real-time biopsy” and has the potential to guide precision cancer therapies, monitor cancer treatment, and investigate the process of metastasis. - See more at: http://www.mdpi.com/2072-6694/6/4/2369/htm#sthash.UvsIAwMW.dpuf

Tuesday, December 16, 2014

Hereditary Cancer-Associated Mutations in Women Diagnosed with Two Primary Cancers: An Opportunity to Identify Hereditary Cancer Syndromes after the First Cancer Diagnosis



FullText    Myriad Genetic Laboratories, Inc., Salt Lake City, Utah, USA 


 Results: Among women with both breast and ovarian cancer, 22.4% (2,237/9,982) had a BRCA1 or BRCA2 mutation. Among women with both colorectal and ovarian cancer, 28.1% (264/941) had a mutation associated with LS. In 66.6% of BRCA1 or BRCA2 mutation carriers and in 58.3% of LS mutation carriers, >5 years passed between the cancer diagnoses.......

 Table 2. Interval between the first and the second cancer diagnosis in patients with HBOC

http://www.karger.com/Article/ShowPic/368836?image=000368836_t02.GIF

 Table 4. Interval between first and second cancer diagnoses in patients with LS

TAB04

Relevance and efficacy of breast cancer screening in BRCA1 and BRCA2 mutation carriers above 60 years



abstract

What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families



open access

 Interpretation: We identified elements of goals-of-care discussions that are most important to older adult patients in hospital with serious illness and their family members. We found that guideline-recommended elements of goals-of-care discussions are not often addressed by health care providers. Our results can inform interventions to improve the determination of goals of care in the hospital setting.

Clouds of Oxygen: Adolescents With Cancer Tell Their Story in Music (rock band)



open access

Lynch Syndrome Caused by Germline PMS2 Mutations: Delineating the Cancer Risk



abstract

 Significant SIRs were observed for cancers of the small bowel, ovaries, breast, and renal pelvis.

Monday, December 15, 2014

ASCO Policy Statement Update: The Critical Role of Phase I Trials in Cancer Research and Treatment



open access

(Lynch Syndrome etc) ASCO CPG Endorsement of the Familial Risk–Colorectal Cancer: ESMO CPG



open access

 Hereditary Colorectal Cancer Syndromes: American Society of Clinical Oncology Clinical Practice Guideline Endorsement of the Familial Risk–Colorectal Cancer: European Society for Medical Oncology Clinical Practice Guidelines

 Lynch syndrome
  • Colon and rectum: Colonoscopy every 1 to 2 years, starting at age 20 to 25 or 5 years before the youngest case in the family. No upper limit is established.
  • Endometrium and ovary: Gynecological examination, pelvic ultrasound (not CA-125), and aspiration biopsy every year, from age 30 to 35 years. Consider prophylactic hysterectomy and salpingoophorectomy when childbearing is completed.
  • Gastric cancer: For gastric cancer, the search for the presence of Helicobacter pylori and subsequent eradication is recommended in mutation carriers. In case of a high incidence of gastric cancer in some populations, some experts recommend upper GI endoscopy every 1 to 3 years.
  • Other Lynch-associated cancers: Surveillance is not recommended due to the low sensitivity and specificity. (Although there are insufficient data supporting surveillance for other target organs, it may be considered in the context of family history.)


    ....... Unlike CRC, data to support the effectiveness of transvaginal ultrasound and endometrial biopsy for gynecologic surveillance are lacking, and only surgical removal of the uterus and ovaries (fallopian tubes???) has been shown to reduce incidence of endometrial and ovarian cancers.10 Individuals with LS also have an elevated risk of developing other cancers, specifically tumors of the urinary tract (lifetime risk, 5% to 12%), small intestine, ovary (lifetime risk, 4% to 12%), stomach (lifetime risk, 8% to 10%), pancreas (lifetime risk, 4%), biliary tract, brain, and skin.11,12 Comparisons of phenotype according to MMR gene mutation have shown that MLH1-mutation carriers tend to develop CRC at younger ages, whereas MSH2 carriers seem to be at higher risk for extracolonic cancers, and for women with MSH6 mutations, the risk for endometrial cancer may surpass the lifetime CRC risk.1315 In contrast, the risks for CRC and endometrial cancer seem to be lower among individuals with mutations in PMS2 (15% to 20%) compared with carriers of other MMR gene mutations.16........

Saturday, December 13, 2014

OvCa.net - call for assistance



OvCa.net

Commentary on ‘Performance of ultrasound as a second line test to serum CA125 in ovarian cancer screening’



Commentary - open access

 Conclusions

The last 50 years have seen a sea change in ideas regarding the origins of ovarian cancer, its natural history and the best ways of improving mortality. Despite advances in chemotherapy regimens and targeted therapies there has been little change in the prognosis for women with advanced disease. Hope therefore rests with the ability of ovarian cancer screening strategies to shift the burden of disease to earlier stages, which may translate to better clinical outcomes and reduced mortality. Multimodal screening and ultrasound-based approaches have been shown to be sensitive and specific for detecting ovarian cancer but whether these in themselves will provide sufficient lead time to change the course of the disease remains to be shown. Ultimately success will depend on the continued momentum of the multiple international and multidisciplinary collaborations forged to ensure that research will continue for better biomarkers that can be translated into clinical interventions. It is imperative that clinicians and researchers continue to engage the public and capitalise on the enthusiasm embodied by the high compliance rates seen in the screening studies to work towards reducing mortality from ovarian cancer.

Thursday, December 11, 2014

Enhanced recovery pathways in gynecologic oncology



abstract


Highlights

Enhanced Recovery Pathways (ERP) are safe for patients undergoing complex gynecologic oncology operations, including colonic resection.
Incorporation of a comprehensive ERP is associated with reduced length of stay, excellent patient satisfaction, and lower costs.
Successful implementation of ERP requires standardization and cooperation within the care team.

Abstract

Objective

Many commonplace perioperative practices are lacking in scientific evidence and may interfere with the goal of optimizing patient recovery. Individual components of perioperative care have therefore been scrutinized, resulting in the creation of so-called “enhanced recovery” pathways (ERP), with the goal of hastening surgical recovery through attenuation of the stress response. In this review we examine the evidence for ERP in gynecologic oncology using data from our specialty and general surgery.

Methods

We performed a systematic literature search on ERP in gynecologic oncology in June 2014 using PubMed/MEDLINE, EMBASE, and The Cochrane Library. All study types were included. References were hand reviewed to ensure completeness. The Enhanced Recovery After Surgery (ERAS) Society was contacted to identify any unpublished protocols.

Results

Seven investigations were identified that examined the role of ERP in gynecologic oncology. Common interventions included allowing oral intake of fluids up to 2 hours before induction of anesthesia, solids up to 6 hours before anesthesia, carbohydrate supplementation, intra- and postoperative euvolemia, aggressive nausea/vomiting prophylaxis, and oral nutrition and ambulation the day of surgery. In addition, bowel preparations, the NPO after midnight rule, nasogastric tubes, and intravenous opioids were discontinued. While no randomized data are available in gynecologic oncology, significant improvements in patient satisfaction, length of stay (up to 4 days), and cost (up to $7600 in savings per patient) were observed in ERP cohorts compared to historical controls. Morbidity, mortality, and readmission rates were no different between groups.

Conclusion

Enhanced recovery is a safe perioperative management strategy for patients undergoing surgery for gynecologic malignancies, reduces length of stay and cost, and is considered standard of care at a growing number of institutions. Our specialty would benefit from a formalized ERP such as ERAS which audits compliance to protocol care elements to optimize patient outcomes and value.

Old drug, new trick: Repurposing metformin for gynecologic cancers?



abstract

Highlights

We summarize the molecular mechanisms of action mediating metformin's protective effect in cancer.
Review the preclinical and epidemiological evidences for metformin's potential role in gynecological cancers.
Description of ongoing prospective testing of metformin in gynecologic cancers and future directions.

Abstract

Objective

There is increasing pre-clinical and clinical evidence that metformin, a commonly used diabetes medication, has a protective effect in cancer. The aim of this review is to discuss metformin's anti-cancer molecular mechanisms of action and to summarize the current literature demonstrating metformin's potential in gynecologic cancer prevention and treatment.

Methods

A PubMed search was conducted combining the keywords “metformin” with “neoplasm”, “uterine neoplasms”, “ovarian neoplasms”, and “uterine cervical neoplasms”. Studies published in English between 1994 and 2014 were included.

Results

Pre-clinical studies in endometrial, ovarian, and cervical cancer suggest that metformin inhibits the growth of cancer cells. The primary molecular mechanism mediating this effect appears to be the activation of AMP-activated protein kinase (AMPK) and the subsequent inhibition of mammalian targets of rapamycin (mTOR). The pre-clinical findings are augmented by clinical studies indicating that metformin use is associated with a reduced risk of cancer and improved survival in diabetic women with ovarian and endometrial cancers. No clinical analyses have evaluated metformin use and cervical cancer. Overall, the data showing a favorable effect of metformin is strongest for endometrial and ovarian cancer and prospective clinical testing is ongoing in these two malignancies.

Conclusions

Numerous clinical studies have reported an association between metformin use by diabetic patients and improved outcomes in gynecologic cancers. In addition, pre-clinical reports have identified plausible biological mechanisms to explain the molecular mechanism of action of metformin in cancer. However, the most important question remains unanswered: Will metformin be effective against cancer in patients without diabetes? Until this question is answered with prospective clinical testing, the role of metformin in the treatment or prevention of gynecologic malignancies remains theoretical and the clinical use of metformin as a cancer therapeutic is experimental.

Combining clinical assessment and the Risk of Ovarian Malignancy Algorithm for the prediction of ovarian cancer



abstract

Objectives

ACOG guidelines for the evaluation of women with a pelvic mass employ a combination of physical exam, imaging, and CA125 to guide physicians in the triage of women to gynecologic oncologists. We studied the use of ROMA with clinical assessment for cancer risk assessment in women with a pelvic mass.

Methods

This was a prospective, multicenter trial evaluating women with a pelvic mass who had an initial clinical risk assessment (ICRA) performed by a generalist. ROMA scores were calculated and sensitivity, specificity, PPV and NPV were determined for ICRA and ICRA + ROMA.

Results

A total of 461 women were entered into the study. There were 375 benign tumors, 48 EOC, 18 LMP tumors and 20 non-ovarian malignancies. For detection of ovarian cancer alone, ICRA had a sensitivity of 85.4%, a specificity of 84.3%, and a NPV of 97.8%. Adding ROMA to ICRA produced a significant improvement of 8.4% in sensitivity, achieving a sensitivity of 93.8% with a specificity of 67.2% and a NPV of 98.8%. Examination of all malignancies (ovarian & non-ovarian) provided a sensitivity of 89.7% for ROMA + ICRA in comparison to 77.9% for ICRA alone, a significant increase in sensitivity of 11.8%. The NPV also significantly increased from 95.5% to 97.3%. Overall, ROMA detected 13 additional malignancies missed by ICRA.

Conclusions

Adjunctive use of ROMA with clinical assessment improves the stratification of women with a pelvic mass into low and high risk groups for ovarian cancer. The combination is particularly effective in ruling out malignant disease.

CA125 kinetic parameters predict optimal cytoreduction in patients with advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy



CA125 

Highlights

This paper aims at determining the optimal CA125 cut-off value to accurately predict complete cytoreduction after NAC.
A CA125 level < 75 UI/ml after the 3rd NAC was an independent predictor factor for complete surgery.

Abstract

Objective

To evaluate the different kinetic parameters of serum CA125 during neoadjuvant chemotherapy (NAC) to predict optimal interval debulking surgery (IDS).

Methods

The present retrospective multicenter study included patients with advanced ovarian cancer treated with neoadjuvant platinum-based chemotherapy followed by IDS between 2002 and 2009. Demographic data, CA125 levels, radiographic data, chemotherapy and surgical-pathologic information were obtained. Univariate and multivariate analyses were performed to evaluate variables associated with complete IDS. ROC analysis was used to determine potential cut-off values to predict the likelihood of complete cytoreduction via IDS.

Results

One hundred and forty-eight patients met the study criteria. Ninety-three patients (62.8%) had optimal cytoreduction with no residual macroscopic disease (CC-0) after IDS. In multivariate analyses, the CA125 level after the 3rd NAC was an independent predictor for optimal cytoreduction (odds ratio: 0.98 [0.97–0.99], p = 0.04). The area under the ROC curve was 0.73. A threshold of 75 UI/ml displayed the most predictive power. The odds ratio to predict complete cytoreduction was 3.29 [1.56–7.10] (p = 0.0008).

Conclusion

Our data indicate that for advanced ovarian cancer, a CA125 level less than 75 UI/ml after the 3rd NAC was an independent predictor factor for complete IDS.

Chemotherapy-induced peripheral neuropathy and its impact on health-related quality of life among ovarian cancer survivors PROFILES registry



abstract

 Highlights
Neuropathy symptoms were experienced by 51% of women with ovarian cancer, especially tingling hands/feet and numbness in fingers/toes.
Even up to 12 years after the end of treatment some women experience neuropathy symptoms.
Neuropathy was associated with worse functioning, overall HRQoL, pain and insomnia.

Abstract

Objective

This study assessed the prevalence and risk factors of chemotherapy-induced peripheral neuropathy, and its impact on health-related quality of life among ovarian cancer survivors, 2–12 years after diagnosis.

Methods

Women (n = 348) diagnosed with ovarian cancer between 2000 and 2010, as registered by the Dutch population-based Eindhoven Cancer Registry, were eligible for participation. A questionnaire, including the EORTC QLQ-C30 and EORTC QLQ-OV28 measures, containing 3 items about neuropathy, was returned by 191 women (55%). Recurrence and chemotherapy data were obtained from medical records.

Results

Of all 191 women, the 129 women who received chemotherapy more often reported having tingling hands/feet and feeling numbness in fingers/toes, specifically 51% reported “a little” to “very much” of these symptoms vs. about 27% who did not receive chemotherapy. Women reporting more neuropathy symptoms reported lower levels of functioning and overall quality of life. They also reported more symptoms of fatigue, nausea/vomiting, pain, dyspnea, insomnia, appetite loss, and financial problems. Moreover, women reporting more neuropathy symptoms had experienced the disease and treatment more often as being a burden and were more worried about their health, had more gastrointestinal and hormonal symptoms, hair loss and more other chemotherapy side effects. Linear regression analyses showed that more cycles of chemotherapy, more recurrences and a shorter period since last treatment were associated with a higher neuropathy score.

Conclusion

Neuropathy symptoms were experienced by 51% of women with ovarian cancer who received chemotherapy even up to 12 years after the end of treatment, and this seriously affected their HRQoL.

Prognostic value of lymph node ratio in patients with advanced epithelial ovarian cancer



abstract

Highlights

Lymph node status is a prognostic factor in ovarian cancer.
Lymph node ratio reflects lymph node spread and surgical extent.
Lymph node ratio predicts overall survival more concisely.

Abstract

Objective

Lymph node status is an established prognostic factor in epithelial ovarian cancer (EOC). Lymph node ratio (number of positive LN/number of resected LN) reflects both qualitative and quantitative lymph node spread as well as surgical effort and extent of disease. We evaluated whether LNR is a more precise prognostic factor than conventional lymph node status in patients with EOC.

Methods

The present retrospective study includes 809 patients with EOC, who underwent primary cytoreductive surgery between 2000–2013. Clinico-pathological parameters and survival data were extracted from a prospectively maintained tumor registry database. The optimal cut-off point for LNR was calculated by using Martingale residuals. Survival analyses were calculated using Kaplan–Meier method and Cox regression models.

Results

Lymphadenectomy was performed in 693 (85.7%) out of 809 patients. Median number of removed LN was 64 (IQR 25–75%: 39–84). LNR of 0.25 was identified as the optimal prognostic cut-off value. The estimated 5-year-OS rates were 69.3% for patients with node-negative EOC compared to 33.1% for patients with any lymph node metastasis (p < 0.001). The estimated 5-year-OS rates were 42.5% for patients with LNR ≤ 0.25, and 18.0% for patients with LNR > 0.25 (p < 0.001). Additionally in multivariate analysis LNR > 0.25 was approved to be an independent prognostic factor for overall survival (adjusted HR 1.44, 95% CI 1.04–2.00; p = 0.028).

Conclusion

LNR more precisely predicts overall survival than conventional lymph node status in EOC patients undergoing primary debulking surgery.

Laparoscopic staging of apparent early stage ovarian cancer: Results of a large, retrospective, multi-institutional series



abstract

Highlights

Stage of disease is still the most important prognostic factor in early ovarian cancer.
Among early ovarian cancer patients there is a non-negligible percentage of upstaged patients.
A complete and accurate surgical staging can be safely achieved through laparoscopic surgery, when performed in referral centers.

Abstract

Objective

The aim of this study is to analyze the safety, adequacy, perioperative and survival figures in a large series of laparoscopic staging of patients with apparent early stage ovarian malignancies (ESOM).

Patients and methods

Retrospective data from seven gynecologic oncology service databases were searched for ESOM patients undergoing immediate laparoscopic staging or delayed laparoscopic staging after an incidental diagnosis of ESOM.
Between May 2000 and February 2014, 300 patients were selected: 150 had been submitted to immediate laparoscopic staging (Group 1), while 150 had undergone delayed laparoscopic staging (Group 2) of ESOM. All surgical, pathologic, and oncologic outcome data were analyzed in each group and a comparison between the two was carried out.

Results

Longer operative time, higher blood loss, more frequently spillage/rupture of ovarian capsule and conversion to laparotomy occurred in Group 1. No significant differences of post-operative complications were observed between the two groups. Histological data revealed more frequently serous tumors (0.06), Grade 3 (p = 0.0007) and final up-staging (p = 0.001) in Group 1. Recurrence and death of disease were documented in 25 (8.3%), and 10 patients (3.3%%), respectively. The 3-year disease free survival (DFS) and overall survival (OS) rates were 85.1%, and 93.6%, respectively in the whole series. There was no difference between Group 1 and Group 2 in terms of DFS (p value = 0.39) and OS (p value = 0.27).

Conclusion

In this very large multi-institutional study, it appears that patients with apparent ESOM can safely undergo laparoscopic surgical management.

Evidence for Ginger in Preventing Chemo-Induced Nausea



Ginger

snopes.com: Kitten Dies Due to Home Depot Christmas Tree



snopes.com

Doctors need patient or family consent before stopping end-of-life treatment: new Ontario draft policy



media

Endometriosis and ovarian cancer - World Journal of Clinical Oncology



open access

..........In addition, we know about the possible links between endometriosis and cancer for almost 100 years. Despite clear evidence revealing that endometriosis increases ovarian cancer risks, it is possible that it may not affect disease progression after the appearance of ovarian cancer. However, despite clear evidence revealing that endometriosis increases ovarian cancer risk, our knowledge of the risk factors is far from established. In our review, we focused on the most recent approaches including possible biomarkers and genetic approaches....

Opioid tramadol can cause potentially fatal blood sugar drop: study



media

Enteroenterostomy - emedicine



emedicine

 Background

Enteroenterostomy is an anastomosis between one part of the small bowel and another part of the small bowel (jejunum or ileum). It is used to restore bowel continuity after resection of a segment of the bowel or after creation of a Roux-en-Y loop of jejunum. When performed as a bypass procedure, enteroenterostomy relieves bowel obstruction.[1, 2].........

Press Releases Blamed for Exaggerated Health News



Health News 

Tuesday, December 09, 2014

New Downloadable Slides: Adding Precision and Power to Progress in Ovarian Cancer Management





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-----Original Message-----

From: "prIME Oncology" <info@primeoncology.org>
Sent: December 9, 2014 10:47 AM
To: sandipn@sympatico.ca
Subject: New Downloadable Slides: Adding Precision and Power to Progress in Ovarian Cancer Management

prIME Oncologyprofessional • independent • medical • education

Adding Precision and Power to Progress in Ovarian Cancer Management

Adding Precision and Power to Progress in Ovarian Cancer Management

prIME Oncology invites you to view downloadable slides from Adding Precision and Power to Progress in Ovarian Cancer Management, a symposium held at IGCS 2014 in Melbourne, Australia.

___________________________________________________________

Activity Features

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Downloadable Slides

» View Activity

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___________________________________________________________

Topics

Know your enemy: The impact of BRCA status on management of ovarian cancer
Clare Scott, MBBS, PhD

Keeping the lid on ovarian cancer: Targeted therapeutic approaches
Jonathan Ledermann, MD, FRCP

Platinum-sensitive relapsed ovarian cancer: New options on the horizon
Amit Oza, MD, FRCPC, MBBS

» View Activity

___________________________________________________________

Target Audience

This activity is intended for medical oncologists, gynecologic oncologists, and other healthcare professionals involved in the treatment of patients with advanced ovarian cancer.

___________________________________________________________

Provider

This activity is provided by prIME Oncology.

ACCME

___________________________________________________________

Support

This educational activity is supported by AstraZeneca.

___________________________________________________________

Other prIME Activities

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Advances and Challenges in the Management of Glioblastoma
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Longwoods eLetter December 9, 2014 | If We Had a Magic Wand



Sundry interesting articles:

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"I apologize because I didn't look hard enough, until now. I didn't look far enough. I didn't review papers from smaller labs in other countries doing some remarkable research, and I was too dismissive of the loud chorus of legitimate patients whose symptoms improved on cannabis." Dr. Sanjay Gupta Why I changed my mind on weed

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If We Had a Magic Wand by Hugh MacLeod and Leslee Thompson
The second essay in the Ghost of Healthcare Hope series

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"If the public had more information on the way doctors are compensated, they might have a more balanced perspective in terms of giving their views to the government during negotiations," says Tom Closson, former president of the Ontario Hospital Association. ...almost all suppliers of plasma products in the UK "have a track record of avoidable quality problems, in many cases resulting in deaths or serious chronic illness such as HIV." Read the essay Tories unlikely to stop Bill prohibiting paid plasma, but why are they even trying? by Rick Janson
While the public, some lawyers and even some politicians, especially in Quebec, are actively involved in the conversation about dying, what are oncologists, primary care and palliative care physicians and other allied health workers – the professionals who are most acutely involved with end-of-life care – doing to mobilize public and private conversations with their patients about PAD and euthanasia? 

...our research suggests that tens of thousands of incidents are slipping under the radar because those who witness poor care and try to report it are being told, in one particular case, to "mind their own business".

Part of the commitment to protect patients and the public should include the identification of risk, as well as the encouragement to voice concerns about the safety and relevance of our practices, policies and procedures in the workplace.

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