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Targeted Radiation Might Help Fight Advanced Breast Cancer: Study

MONDAY, March 24, 2014 (HealthDay News) -- A minimally invasive treatment that delivers radiation directly to tumors may slow progression of breast cancer that has spread to the liver, a new study suggests.

The treatment is called yttrium 90 (Y-90) radioembolization. Doctors insert a catheter through a tiny cut in the groin and guide it into the artery that supplies the liver. Radiation-emitting micro beads are then sent through the catheter and float out to kill small blood vessels that feed the tumor.

Researchers led by Dr. Robert Lewandowski, an associate professor of radiology at Northwestern University Feinberg School of Medicine in Chicago, looked at the outcomes of 75 patients. The women ranged in age from 26 to 82, and had chemotherapy-resistant breast cancer that had spread to the liver ("metastatic" disease). Their liver tumors were too large or too numerous to be treated with other methods, the authors noted.

Y-90 radioembolization therapy stabilized 98.5 percent of the treated liver tumors, according to the study, which was to be presented Monday in San Diego at the annual meeting of the Society of Interventional Radiology.

In addition, 24 of the women experienced a more than 30 percent shrinkage in tumor size after treatment, which caused few side effects.

"Although this is not a cure, Y-90 radioembolization can shrink liver tumors, relieve painful symptoms, improve the quality of life and potentially extend survival," Lewandowski said in a society news release.

"While patient selection is important, the therapy is not limited by tumor size, shape, location or number, and it can ease the severity of disease in patients who cannot be treated effectively with other approaches," he added.

Two breast cancer experts were cautiously optimistic about the findings.

According to Dr. Neelima Denduluri, "while these results appear promising, this is a very small retrospective study," meaning that it fell short of the "gold standard" type of prospective trial that tracks patients going forward over time. "Randomized controlled prospective studies addressing this issue are necessary before radioembolization can be incorporated routinely," she believes.

For now, "in women that cannot receive systemic therapy due to toxicities [side effects], are not eligible for clinical trials that utilize new agents, or have exhausted conventional chemotherapy options, radioembolization may be a choice," said Denduluri, a medical oncologist with Virginia Cancer Specialists in Arlington, Va., a US Oncology Network affiliate.

Dr. Stephanie Bernik is chief of surgical oncology at Lenox Hill Hospital in New York City. She said that while this type of therapy has been used to fight liver tumors, "the ability to use this therapy in treatment of metastatic breast cancer to the liver offers some hope to patients with the disease."

Bernik stressed that, right now, the treatment can only extend survival for women with advanced breast cancer, it is not a cure. However, "as the technique is modified and perfected, it is hoped the [treatment] can help achieve remission in women with advanced disease."

Each year in the United States, about 117,000 patients are diagnosed with breast cancer that has spread to the liver. Chemotherapy is the standard treatment in such cases, but is not effective in, or suitable for, all patients.

Experts note that studies presented at medical meetings are typically considered preliminary until published in a peer-reviewed journal.

-- Robert Preidt
Copyright © 2014 HealthDay. All rights reserved. SOURCES: Neelima Denduluri, M.D., medical oncologist, Virginia Cancer Specialists, Arlington, Va., a US Oncology Network affiliate; Stephanie Bernik, M.D., chief of surgical oncology, Lenox Hill Hospital, New York City; Society of Interventional Radiology, news release, March 24, 2014

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New Guidelines Might Limit Need for Lymph Node Removal for Breast Cancer

MONDAY, March 24, 2014 (HealthDay News) -- Biopsies of so-called "sentinel" lymph nodes under the arms should become more widespread among breast cancer patients, according to updated guidelines from the American Society of Clinical Oncology (ASCO).

The group, which represents cancer specialists, said the new recommendations should also restrict the number of women who will require further removal of multiple nodes after biopsy, cutting down on painful side effects.

In sentinel lymph node biopsy, a few lymph nodes are removed and checked for signs of cancer -- hence the name "sentinel." Usually, if these lymph nodes have no cancer, it means the remaining, unchecked lymph nodes should also be cancer-free.

The new ASCO recommendations expand eligibility for sentinel node biopsy and will reduce the number of patients who undergo a more invasive procedure called axillary -- underarm -- lymph node dissection, which carries a higher risk of complications, the group said.

In axillary lymph node dissection, most lymph nodes under the arm on the same side as the breast tumor are removed and examined for cancer. This procedure can cause long-term side effects such as pain and numbness in the arm and swelling due to a build-up of lymph fluid.

The new guidelines state that for women whose sentinel lymph nodes show no signs of cancer, removal of more underarm lymph nodes is not recommended.

The guidelines also addressed the case of women who undergo lumpectomy instead of full mastectomy and are also scheduled for whole-breast radiation therapy to help "mop up" residual cancer. If these patients have signs of cancer in only one or two sentinel lymph nodes upon biopsy, they too may opt to avoid further node removal, the ASCO experts said.

Women who have undergone mastectomy but show signs of cancer's spread in sentinel lymph nodes should be offered further node removal, the guidelines reaffirmed.

The ASCO also said women who are diagnosed with certain breast cancers while pregnant can skip sentinel node biopsy.

The ASCO issued initial guidelines on sentinel node biopsy in 2005. The new guidelines, published March 24 in the Journal of Clinical Oncology, are based on the findings of a panel of experts who reviewed studies published between 2004 and 2013.

"The updated guideline incorporates new evidence from more recent studies -- nine randomized controlled trials and 13 cohort studies since 2005," panel co-chairman Dr. Armando Giuliano said in an ASCO news release.

"Based on these studies, we're saying more patients can safely get sentinel node biopsy without axillary lymph node [removal]," he said. "These guidelines help determine for whom sentinel node biopsy is appropriate."

Panel co-chairman Dr. Gary Lyman said, "We strongly encourage patients to talk with their surgeon and other members of their multidisciplinary team to understand their options and make sure everybody is on the same page."

"The most critical determinant of breast cancer prognosis is still the presence and extent of lymph node involvement," he said. "Therefore, the lymph nodes need to be evaluated so we can understand the extent of the disease."

Two breast cancer specialists welcomed the new guidelines.

"Over the past few years, there has been a movement to limit the amount of axillary [lymph node] surgery in patients undergoing breast conservation," said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City.

Bernik said the new guidelines are important because some doctors have been reluctant to move away from further underarm node removal when a patient has even one affected sentinel node. "This update will give surgeons the confidence to tell patients that a sentinel lymph node biopsy may be enough, even if there is evidence of spread, in patients undergoing [lumpectomy]," Bernik said.

"However, it is still important for surgeons to discuss the pros and cons with a patient, as not all [real-world] patients fit the study criteria," she said. "Furthermore, it needs to be stressed that the more limited surgery does not apply to women undergoing mastectomies."

Dr. Debra Patt is the medical director of an expert panel that assesses cancer care guidelines for the US Oncology Network. She said she was "thrilled" at the new ASCO guidelines because they seem to echo the results of recent studies.

"In 2010, a study presented at the ASCO annual meeting showed that women undergoing breast-conservation surgery with clinically node-negative small breast cancers could safely avoid removing all the lymph nodes from under the arm in most cases," Patt said. "There has been greater variance in treatment patterns in my community practice, and I believe these updated guidelines will direct practitioners to evidence-based patient care."

-- Robert Preidt
Copyright © 2014 HealthDay. All rights reserved. SOURCES: Stephanie Bernik, M.D., chief, surgical oncology, Lenox Hill Hospital, New York City; Debra Patt, M.D., medical director, Pathways Task Force and Healthcare Informatics, US Oncology Network; American Society of Clinical Oncology, news release, March 24, 2014

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Genetics Home Reference: hereditary diffuse gastric cancer

Hereditary diffuse gastric cancer (HDGC) is an inherited disorder that greatly increases the chance of developing a form of stomach (gastric) cancer. In this form, known as diffuse gastric cancer, there is no solid tumor. Instead cancerous (malignant) cells multiply underneath the stomach lining, making the lining thick and rigid. The invasive nature of this type of cancer makes it highly likely that these cancer cells will spread (metastasize) to other tissues, such as the liver or nearby bones.

Symptoms of diffuse gastric cancer occur late in the disease and can include stomach pain, nausea, vomiting, difficulty swallowing (dysphagia), decreased appetite, and weight loss. If the cancer metastasizes to other tissues, it may lead to an enlarged liver, yellowing of the eyes and skin (jaundice), an abnormal buildup of fluid in the abdominal cavity (ascites), firm lumps under the skin, or broken bones.

In HDGC, gastric cancer usually occurs in a person's late thirties or early forties, although it can develop anytime during adulthood. If diffuse gastric cancer is detected early, the survival rate is high; however, because this type of cancer is hidden underneath the stomach lining, it is usually not diagnosed until the cancer has become widely invasive. At that stage of the disease, the survival rate is approximately 20 percent.

Some people with HDGC have an increased risk of developing other types of cancer, such as a form of breast cancer in women that begins in the milk-producing glands (lobular breast cancer); prostate cancer; and cancers of the colon (large intestine) and rectum, which are collectively referred to as colorectal cancer. Most people with HDGC have family members who have had one of the types of cancer associated with HDGC. In some families, all the affected members have diffuse gastric cancer. In other families, some affected members have diffuse gastric cancer and others have another associated form of cancer, such as lobular breast cancer. Frequently, HDGC-related cancers develop in individuals before the age of 50.

Gastric cancer is the fourth most common form of cancer worldwide, affecting 900,000 people per year. HDGC probably accounts for less than 1 percent of these cases.

It is likely that 30 to 40 percent of individuals with HDGC have a mutation in the CDH1 gene. The CDH1 gene provides instructions for making a protein called epithelial cadherin or E-cadherin. This protein is found within the membrane that surrounds epithelial cells, which are the cells that line the surfaces and cavities of the body. E-cadherin helps neighboring cells stick to one another (cell adhesion) to form organized tissues. E-cadherin has many other functions including acting as a tumor suppressor protein, which means it prevents cells from growing and dividing too rapidly or in an uncontrolled way.

People with HDGC caused by CDH1 gene mutations are born with one mutated copy of the gene in each cell. These mutations cause the production of an abnormally short, nonfunctional version of E-cadherin or alter the protein's structure. For diffuse gastric cancer to develop, a second mutation involving the other copy of the CDH1 gene must occur in the cells of the stomach lining during a person's lifetime. People who are born with one mutated copy of the CDH1 gene have a 70 percent chance of acquiring a second mutation in the other copy of the gene and developing gastric cancer in their lifetimes.

When both copies of the CDH1 gene are mutated in a particular cell, that cell cannot produce any functional E-cadherin. The loss of this protein prevents it from acting as a tumor suppressor, contributing to the uncontrollable growth and division of cells. A lack of E-cadherin also impairs cell adhesion, increasing the likelihood that cancer cells will not come together to form a tumor but will invade the stomach wall and metastasize as small clusters of cancer cells into nearby tissues.

These CDH1 gene mutations also lead to a 60 percent chance of lobular breast cancer, a slightly increased risk of prostate cancer in men, and a slightly increased risk of colorectal cancer. It is unclear why CDH1 gene mutations primarily occur in the stomach lining and these other tissues.

About 60 to 70 percent of individuals with HDGC do not have an identified mutation in the CDH1 gene. The cancer-causing mechanism in these individuals is unknown.

Read more about the CDH1 gene.

HDGC is inherited in an autosomal dominant pattern, which means one copy of the altered CDH1 gene in each cell is sufficient to increase the risk of developing cancer.

In most cases, an affected person has one parent with the condition.

These resources address the diagnosis or management of hereditary diffuse gastric cancer and may include treatment providers.

You might also find information on the diagnosis or management of hereditary diffuse gastric cancer in Educational resources and Patient support.

General information about the diagnosis and management of genetic conditions is available in the Handbook. Read more about genetic testing, particularly the difference between clinical tests and research tests.

To locate a healthcare provider, see How can I find a genetics professional in my area? in the Handbook.

You may find the following resources about hereditary diffuse gastric cancer helpful. These materials are written for the general public.

You may also be interested in these resources, which are designed for healthcare professionals and researchers.

E-cadherin-associated hereditary gastric cancerfamilial diffuse gastric cancerFDGCHDGChereditary diffuse gastric adenocarcinoma

For more information about naming genetic conditions, see the Genetics Home Reference Condition Naming Guidelines and How are genetic conditions and genes named? in the Handbook.

The Handbook provides basic information about genetics in clear language.

These links provide additional genetics resources that may be useful.

The resources on this site should not be used as a substitute for professional medical care or advice. Users seeking information about a personal genetic disease, syndrome, or condition should consult with a qualified healthcare professional. See How can I find a genetics professional in my area? in the Handbook.

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Lung Cancer: Expanded Alimta Label

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By Cole Petrochko, Staff Writer, MedPage Today

WASHINGTON -- The FDA has expanded the indication for pemetrexed injection (Alimta) to include maintenance therapy in combination with cisplatin for nonsquamous non-small cell lung cancer (NSCLC).

The FDA decision was based on data from a phase III trial of 939 patients with advanced nonsquamous NSCLC reported at the American Society of Clinical Oncology meeting in early June, 2012, which established its efficacy in maintenance therapy.

In that study patients were given 500 mg/m2 of pemetrexed injection on 21-day cycles with 75 mg/m2 of cisplatin, as well as B12 vitamins, folic acid, and dexamethasone. The 539 patients whose disease did not progress during the dual-treatment segment were randomized two-to-one to pemetrexed maintenance or placebo. Both study arms received best supportive care in addition to drug or placebo treatment.

Compared with placebo, pemetrexed treatment benefit was modest -- 44% of pemetrexed-treated patients achieved a complete or partial response to induction therapy versus 42% of patients, while 53% of patients receiving drug therapy and placebo had stable disease after sham or drug treatment.

However, patients receiving drug treatment had a significantly reduced risk of death (HR 0.78, 95% CI 0.64 to 0.96, P=0.02), and median progression-free survival for patients receiving pemetrexed was 4.1 months versus 2.8 months with placebo.

Adverse reactions for pemetrexed as a maintenance therapy during the trials included anemia, neutropenia, fatigue, nausea, vomiting, mucositis, stomatitis, and edema.

The drug was initially approved in 2004 as a combination therapy with cisplatin for malignant pleural mesothelioma where disease was unresectable or curative surgery was not possible and as a second-line treatment for locally advanced metastatic NSCLC after prior chemotherapy treatment.

Pemetrexed was approved as a first-line treatment for locally advanced or metastatic NSCLC in patients with nonsquamous histology in 2008. In 2009, the drug was given approval as a maintenance therapy for locally advanced or metastatic NSCLC in patients with nonsquamous histology following four cycles of platinum-based first-line chemotherapy without disease progression.

Cole Petrochko

Staff Writer

Cole Petrochko started his journalism career at MedPage Today in 2009, after graduating from New York University with B.A.s in Journalism and Psychology. When not writing for MedPage Today, he blogs about nerd culture, designs websites, and buys and sells collectible card game cards. He is based out of MedPage Today's Little Falls, N.J. Headquarters.

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FDA OKs PET Agent for Prostate Cancer

Cole Petrochko

Staff Writer

Cole Petrochko started his journalism career at MedPage Today in 2009, after graduating from New York University with B.A.s in Journalism and Psychology. When not writing for MedPage Today, he blogs about nerd culture, designs websites, and buys and sells collectible card game cards. He is based out of MedPage Today's Little Falls, N.J. Headquarters.

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FDA OKs New Kids' Dose of Cancer Drug

Cole Petrochko

Staff Writer

Cole Petrochko started his journalism career at MedPage Today in 2009, after graduating from New York University with B.A.s in Journalism and Psychology. When not writing for MedPage Today, he blogs about nerd culture, designs websites, and buys and sells collectible card game cards. He is based out of MedPage Today's Little Falls, N.J. Headquarters.

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