1/12. The management of non-small-cell lung cancer: a case history.Accurate assessment and treatment of the patient with lung cancer requires a team approach involving respiratory physicians, cardiothoracic surgeons, oncologists and the palliative care team. Adequate staging and assessment of prognostic factors are essential before deciding what treatment is appropriate for an individual patient. Surgery is the mainstay of treatment for early disease. patients with medically inoperable stage 1 (T1, T2, N0) tumours should be considered for radical radiotherapy; additional chemotherapy in early stage disease may offer an additional survival advantage, but its overall role can only be assessed by further clinical trials. In more locally advanced tumours radical radiotherapy has never been formally tested. It is however, often used in patients where the tumour can be encompassed safely within a radiation field. This will depend on total dose and fractionation schedule as well as the volume of tissue irradiated. Neo-adjuvant chemotherapy prolongs survival in these patients. As only a few patients are cured, symptom control and quality of life are usually the most important goals of management and can be achieved by a variety of interventions. It is disappointing that in such a common disease less than 5% of patients are entered into clinical trials. Without such evidence the therapeutic outcomes in NSCLC cannot be improved.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/12. Ethical decision-making on communication in palliative cancer care: a personalist approach.Perhaps one of the main ethical dilemmas physicians face in cancer medicine is the question of truthfulness with terminally ill cancer patients. Reluctance to share the truth with the patient about his or her diagnosis and/or prognosis is frequently associated with cultural pressures. Based on two cases, the authors illustrate how ethical analysis can help in solving dilemmas related to truth disclosure to terminally ill cancer patients and their families. A personalist approach reveals that the often-adduced conflict between nonmaleficence/beneficence and autonomy with regard to truth telling originates from a narrow understanding of the concept of autonomy. This confrontation is, therefore, more apparent than real. A brief review of the main ethical systems and the results of their application to clinical decision-making follow the discussion of the cases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/12. Gastrointestinal toxicity associated with weekly docetaxel treatment.Previous studies have demonstrated a marked reduction of haematological and non-haematological toxicity if weekly doses of docetaxel <40 mg/m2 were used. Reviewing the literature, neutropenic enterocolitis is uncommon but not unknown in patients treated with taxane-based chemotherapy. Although this complication occurs rarely, here we report on two patients, one with metastatic breast cancer and one with non-small-cell lung cancer, treated on a weekly schedule with single-agent docetaxel. Both patients developed excessive and fatal haemorrhragic gastroduodenitis and enterocolitis associated with grade 2 and 3 neutropenia. We would like to stress the importance of symptoms such as abdominal pain and tenderness, fever, diarrhoea and mucositis, with or without neutropenic fever, in patients treated with docetaxel-based chemotherapy. These symptoms should alert the physician and supportive care management should be started aggressively and immediately.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/12. Living as a cancer surpriser: a doctor tells his story.Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at massachusetts General Hospital (MGH), founded the Kenneth B. Schwartz Center. The Schwartz Center is a non-profit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient, support to the caregivers, and sustenance to the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers and gain insight and support from fellow staff members. We tell the story of one physician with incurable non-small cell lung cancer (NSCLC) who had an unexpectedly favorable response to an experimental treatment while receiving it as a part of his palliative care. His unique insight provides an opportunity to elucidate some of the issues that arise from living both as a patient-caregiver and as a cancer "surpriser." When caregivers face their own cancer, their reflections as patient-caregivers offer an internal perspective on the illness experience and help us as fellow caregivers to better understand and support all patients who face serious illnesses, both those who are colleagues and those who are not. Just like any patient with cancer, patient-caregivers experience the dramatic changes in health, daily life, and perspective that come with serious illness. Within the context of a life-threatening illness, caregiver-patients and their families search for new meaning as they face an uncertain future and address the issues of life and death. In addition to such processes, patient-caregivers with cancer also find that their own medical knowledge and their colleagues' reactions shape their experiences and to an extent separate them from those of other patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/12. Interstitial densities following radiotherapy.After admission on June 30, R.D. remained intubated, and he continued on i.v. steroids, heparin, and warfarin. Nutritional needs were met with a nasointestinal feeding tube and nutritional preparations. He was alert and oriented and communicated appropriately with family and staff via written notes. The patient and his wife wanted to try a ventilator for a period of time before considering a "No CPR" order. His chest wound continued to be open but was healing slowly. Over the next few days, R.D. became more hypoxic with increased respiratory effort and required sedation and assist-control ventilator settings. On July 1, he required more sedation to keep him comfortable, but remained alert and oriented and continued to communicate with his family. On July 3, he sat in a chair for 1.5 hours. On July 4, he developed a large right pneumothorax and a chest tube was placed. He continued to indicate that he was short of breath. The patient remained very anxious and was started on a propofol drip. Later that day, his wife had a discussion with the healthcare team; the decision was made not to resuscitate the patient. On July 5, R.D.'s agitation increased and he was started on additional propofol for sedation, vecuronium bromide to facilitate breathing, and lorazepam i.v. push for relaxation. R.D.'s oxygenation-ventilation status declined through the night. After a discussion between the family and the physician on July 6, life support was withdrawn, and R.D. died later that day. Some of the factors that may have led to R.D.'s radiation-induced pneumonitis include his prior history of smoking as well as his former occupation as a coal miner. He received 15 radiation treatments to his chest area. He also received chemotherapy, including the drug paclitaxel; this combination may have contributed to his radiation-induced pneumonitis. The pneumonitis led to his immunosuppressed condition. R.D.'s superior vena cava syndrome led to the formation of clots for which he received heparin and coumadin. He received steroids to reduce the inflammation from the mediastinoscopy site and in his lung tissues. All of these factors contributed to R.D.'s outcome.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/12. Neutropenic enterocolitis (typhilitis) associated with docetaxel therapy in a patient with non-small-cell lung cancer: case report and review of literature.Neutropenic enterocolitis (NE) is an unusual acute complication of neutropenia, most often associated with leukemia and lymphoma which is characterized by segmental cecal and ascending colon ulceration that may progress to necrosis, perforation, and septicemia. We present a case of neutropenic enterocolitis in a patient with non-small-cell lung cancer who received docetaxel and flavopiridol as part of a phase I clinical trial and review cases in the literature where docetaxel was involved. Given the increased use of docetaxel and other taxanes in the treatment of advanced lung cancer, physicians should be aware of this potential toxicity of therapy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/12. lung cancer treatment in new zealand: physician's attitudes.AIMS: To determine treatment practices of new zealand physicians who manage non-small cell lung cancer (NSCLC). methods: A questionnaire on the treatment of NSCLC was emailed to all respiratory physicians, medical oncologists, and radiation oncologists in new zealand. Respondents were asked to select the treatment they would offer in six lung cancer case scenarios. RESULTS: Thirty-one (81%) respiratory physicians, 15 (71%) medical oncologists, and 8 (30%) radiation oncologists responded to the questionnaire. Surgery was selected (by all groups) as the best option for early-stage disease NSCLC. radiotherapy or combination chemo/radiotherapy (for locally advanced disease) was favoured by 37% of respiratory physicians for stage IIIa and 28% for stage IIIb--compared with medical oncologists (100% and 80%) and radiation oncologists (86% and 28%). Chemotherapy for 'fit' patients with advanced disease was favoured by only 11% of respiratory physicians, compared with 67% of medical oncologists and 33% of radiation oncologists. Best supportive care (BSC) was the favoured treatment for patients with advanced disease with poor performance patients. CONCLUSION: This study demonstrates considerable heterogeneity in the choice of treatment for NSCLC between specialities, particularly for locally advanced and advanced disease. These findings suggest international guidelines are not being adhered to, and variations in treatment may potentially have outcome implications for patients.- - - - - - - - - - ranking = 9keywords = physician (Clic here for more details about this article) |
8/12. The importance of the interpretation of urine catecholamines is essential for the diagnosis and management of patient with dopamine-secreting paraganglioma.Phaeochromocytoma or paraganglioma that exclusively secretes dopamine is very rare. This case illustrates its atypical presentation and the importance of interpretative reporting for urine catecholamines leading to the diagnosis and subsequent management of a patient with this condition. We report a 71-year-old Chinese woman with a large dopamine-secreting paraganglioma. She presented with low back pain for six months. On examination, a right abdominal mass was palpable incidentally. Her blood pressure was normal throughout. Serial 24-h urine collections for catecholamines showed enormous elevation of urine dopamine excretion to 80.7 micromol/day (normotensive:<2.6 m mol/day). However, the daily excretions of urine adrenaline and noradrenaline, as well as their metabolites were within their respective reference intervals. Good communication between chemical pathologists and physicians prompted the arrangement of the whole body 131I-meta-iodobenzylguanidine (MIBG) scintigraphy, which showed a large signal in the right upper quadrant of the abdomen corresponding to a large extra-adrenal tumour detected by both ultrasonography and computerized tomography (CT) of the abdomen. Histological section of the tumour tissue revealed paraganglioma, which stained positive for chromogranin and neuron-specific enolase. After four months, the patient presented with chest symptoms and CT of the thorax revealed multiple nodules. lung metastases were suspected. However, follow-up urine catechola- mine and dopamine excretions were again within their respective normotensive reference intervals. A second MIBG scintigraphy was performed, but no specific uptake at either the thorax or the abdomen could be demonstrated. Fine-needle aspiration cytology using the thoracoscopic technique was performed and immunochemical staining of the biopsy specimen showed the presence of non- small-cell carcinoma of the lung.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/12. learning to cope: how far is too close?Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at massachusetts General Hospital, founded The Kenneth B. Schwartz Center. The Schwartz Center is a nonprofit organization dedicated to advancing compassionate health care delivery, with the goal of providing hope to patients and support to caregivers. The Schwartz Center Rounds is a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, families, and caregivers, and gain insight and support from fellow staff members.The case is presented of a patient with a precipitous decline in health due to rapidly progressive, metastatic non-small cell lung cancer. The discussion at Schwartz Center Rounds centers on oncologists' feelings of failure and coping mechanisms when dealing with patients' deaths. This discussion is followed by a first-year oncology fellow's reaction to caring for this and other terminally ill patients. Then, to provide a broader framework in which to understand these issues, the emotional cost and measurable benefit of close relationships with patients is investigated. To conclude, further educational initiatives are advocated to assist both physicians-in-training and more senior clinicians in dealing with the difficult issues that arise when caring for very ill and dying patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/12. Chronic myelomonocytic leukaemia after platinum-based therapy for non-small cell lung cancer: case report and review of the literature.Chronic myelomonocytic leukaemia (CMML) is a preleukaemic condition with myeloproliferative features, and classified as a part of myelodysplastic syndrome (MDS). Other than alkylating agents and topoisomerase ii inhibitors, there is less evidence that chemotherapeutic drugs are associated with therapy-related CMML, acute leukaemia or MDS. We present a patient who developed CMML within 2 years of platinum-based chemotherapy for a metastatic non-small cell lung cancer. He received a cumulative dose of 240 mg/m(2) of cisplatin, and 1123 mg/m(2) of carboplatin before developing CMML. The cytogenetic study revealed trisomy 8. This is the first reported case that links platinum-based therapy with development of CMML with trisomy 8. Although the relationship between platinum therapy and the development of CMML is difficult to assess due to combinational nature of therapy in most cases, physicians should consider the possibility of CMML in patients with symptoms or signs suggestive of haematologic malignancy after platinum therapy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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