ISSN 1751-4975

Oncology News
Volume 5 Issue 3 : July/August 2010 • www.oncologynews.biz

In this Issue

High Grade Glioma Through the Ages

2010 Top Priorities for Cancer Nurses
The Use of Imaging in Breast Cancer Diagnosis
and Triple Assessment
Developments in the Radiological Management
of Rectal Cancer
Prescribing Information Tarceva® (erlotinib)
25, 100 and 150 mg tablets. Full prescribing information should be viewed prior
to prescription. Indication: Maintenance treatment in patients with locally
A lifeline after
advanced or metastatic non-small cell lung cancer with stable disease after 4 cycles
of standard platinum-based first-line chemotherapy. Also for treatment of patients
with locally advanced or metastatic non-small cell lung cancer after failure of at
first-line chemotherapy
least one prior chemotherapy regimen. When prescribing, factors associated with
prolonged survival should be taken into account. No survival benefit or other
clinically relevant effects of the treatment have been demonstrated in patients with
in advanced NSCLC
EGFR-negative tumours. Dosage and administration: The daily dose is 150 mg
taken orally at least one hour before or two hours after the ingestion of food. When
dose adjustment is necessary, reduce in 50 mg steps. Safety and efficacy of Tarceva
in children has not been established. Contra-indications: Known hypersensitivity
to erlotinib or any of the excipients. Precautions: Smoking has been shown to
reduce Tarceva exposure by 50-60%, so smokers should be advised to stop.
Interstitial lung disease (ILD), including fatalities, has been reported (incidence
0.6%). In patients who develop acute onset of new and/or progressive unexplained
pulmonary symptoms such as dyspnoea, cough and fever, interrupt therapy
pending diagnostic evaluation. If ILD is diagnosed, discontinue therapy and initiate
appropriate treatment. Diarrhoea should be treated with loperamide. Tarceva dose
reduction or interruption may be necessary in patients with severe or persistent
diarrhoea. It may be necessary to intensively rehydrate the patient intravenously,
monitor renal function and serum electrolytes including potassium. In patients with
pre-existing liver disease or on concomitant hepatotoxic medications, consider
periodic liver function testing. Interrupt if changes in liver function are severe.
Not recommended in severe hepatic impairment. Increased risk of gastrointestinal
(GI) perforation in patients receiving concomitant anti-angiogenic agents,
corticosteroids, NSAIDs, and/or taxane-based chemotherapy, or who have a history
of peptic ulceration, or diverticular disease. Permanently discontinue Tarceva in
patients with GI perforation. Bullous, blistering and exfoliative skin conditions have
been reported, including very rare cases suggestive of Stevens-Johnson
syndrome/toxic epidermal necrolysis, some of which were fatal. Tarceva should be
interrupted/discontinued if bullous, blistering or exfoliative skin conditions
develop. Very rare cases of corneal perforation or ulceration have been reported.
Other ocular disorders (see Adverse reactions below) have been reported
which are risk factors for corneal perforation/ulceration. Tarceva should be
interrupted/discontinued if acute/worsening ocular disorders develop. As tablets
contain lactose do not administer to patients with galactose intolerance, Lapp
lactase deficiency or glucose-galactose malabsorption. Drug Interactions:
Plasma concentrations increase when combined with potent CYP3A4 inhibitors e.g.
ketoconazole. It may therefore be necessary to reduce the dose of Tarceva. Potent
CYP3A4 inducers e.g. rifampicin will decrease Tarceva plasma concentrations.
Concomitant treatment should be avoided. If the combination is necessary consider
an increase in Tarceva dose to 300 mg, provided safety is closely monitored
(renal/liver function and serum electrolytes). If well tolerated, after 2 weeks
consider a further increase to 450 mg with continued monitoring. Caution should
be observed during concomitant treatment with other CYP3A4 inducers. Caution
should be observed when ciprofloxacin or potent CYP1A2 inhibitors (e.g.
fluvoxamine) are combined with Tarceva. Dose reduction may be required if an
adverse event occurs. Monitor patients taking warfarin or other coumarin-derivative
anticoagulants for changes in prothrombin time or international normalised
ratio (INR). Concomitant administration of inhibitors of the P-glycoprotein active
substance transporter e.g. cyclosporin and verapamil may lead to altered
distribution and/or elimination of Tarceva. Solubility of Tarceva decreases at pH
above 5. Drugs that alter the pH of the upper GI tract e.g. omeprazole (PPI) and
ranitidine (H2 antagonist) have been shown to decrease Tarceva exposure.
Increasing the dose of Tarceva when co-administered with such agents is unlikely
to compensate for the loss of exposure. The effects of antacids on Tarceva exposure
have not been investigated. Avoid use of PPIs. If use of antacids is necessary take
at least 4 hours before or 2 hours after Tarceva. If use of ranitidine is necessary take
Tarceva 2 hours before or 10 hours after ranitidine dose. Pregnancy and
lactation: There is no adequate experience in human pregnancy and lactation
therefore Tarceva should only be used if the potential benefit justifies the potential
risks. Women of childbearing potential must be advised to avoid pregnancy while
on Tarceva and adequate contraceptive methods should be used during therapy,
and for at least 2 weeks after completing therapy. Adverse reactions: See SmPC
for full listing. Serious adverse reactions: Gastrointestinal: Cases of gastrointestinal
bleeds (common) and GI perforation (uncommon) have been reported. Hepato-
biliary disorders: Rare cases of hepatic failure (including fatalities) have been
reported. Respiratory, thoracic and mediastinal disorders: Uncommon reports of
serious interstitial lung disease (ILD), including fatalities. Infections and infestations:
Severe infections, with or without neutropenia, have included pneumonia, sepsis
Now licensed for
and cellulitis. Common adverse reactions: Rash (75%), diarrhoea (54%), fatigue (52%)
and anorexia (52%) were the most commonly reported adverse events in relapsed
disease (BR.21 study). Most were grade 1/2 in severity and manageable without
first-line maintenance in
intervention. Diarrhoea can rarely lead to dehydration, hypokalemia and renal
failure. Adverse events which occurred at a frequency ≥3% over placebo included
pruritus, dry skin, nausea, vomiting, stomatitis, abdominal pain, dyspnoea, cough,
patients with stable disease*
infection, conjunctivitis and keratoconjunctivitis sicca. Rash (49%) and diarrhoea
(20%) were also the most frequent adverse drug reactions seen during maintenance
(SATURN study). Other reported events include: Skin and subcutaneous disorders:
Alopecia, paronychia, hirsutism, eyebrow changes, brittle and loose nails,
hyperpigmentation, very rare cases suggestive of Stevens-Johnson syndrome/toxic
epidermal necrolysis, some of which were fatal. Hepato-biliary disorders: Liver *Tarceva is indicated as monotherapy for maintenance treatment in
function test abnormalities have been commonly observed. Most cases were mild
or moderate in severity, transient in nature or associated with liver metastases. Eye patients with locally advanced or metastatic NSCLC with stable disease
disorders: Keratitis and very rare cases of corneal ulcerations and perforations. after 4 cycles of standard platinum-based first-line chemotherapy 1
Respiratory, thoracic and mediastinal disorders: Epistaxis. Legal category: POM
Presentations, Basic NHS Costs, and Marketing authorisation numbers:
Tarceva (erlotinib) tablets 25 mg x 30: pack £378.33. EU/1/05/311/001. Tarceva
(erlotinib) tablets 100 mg x 30: pack £1,324.14. EU/1/05/311/002. Tarceva
(erlotinib) tablets 150 mg x 30: pack £1,631.53. EU/1/05/311/003 Marketing
authorisation holder: Roche Registration Ltd, 6 Falcon Way, Shire Park, Welwyn
Garden City, AL7 1TW, United Kingdom. Tarceva is a registered trade mark.
MEDI00121. Date of preparation: May 2010.
Reference: 1. Tarceva® Summary of Product Characteristics, April 2010.

Adverse events should be reported. Reporting forms

and information can be found at www.yellowcard.gov.uk.
Adverse events should also be reported to Roche
Products Limited. Please contact Roche Drug Safety
Centre on 01707 367554.

Date of preparation of item: June 2010. TARC00587.

 Editorial
Cancer risk; Confusing Comments Dietary Components
ancer is undoubtedly caused by exposure to
C noxious compounds, from asbestos to the
synthetic dye, Kipper Brown B. What we need to
have is a way of life and a diet which not only steers us
away from obvious harmful carcinogens (e.g. smoking
tobacco), but tries to stave off the risk of developing
cancer in general. If cancer is unpredictable in its origin
(leaving aside those of a clearly inherited nature), can
regimes of diet and life style significantly reduce the
risk? What we need to dwell on here is the word
“significantly” because confusion seems to be rife as to Denys Wheatley, Editor
whether dietary components or supplements do or do
not reduce risk. Can we really be as sure about cancer
risks as knowing that eating spinach can reduce the risk of becoming
anaemic? Does drinking pomegranate juice really reduce the
incidence of prostate cancer, and how? And how much needs to be
drunk to significantly reduce risk? A year or two back, it was
suggested by investigators at Harvard Medical School that eating
cooked tomatoes three times a week reduced the risk of prostate
cancer by 30-50%. This seems even more promising, but society was
unmoved, unlike the present cult of drinking pomegranate juice.
In cancer news, we constantly hear of dietary regimes that mollify
the potential development of certain types of cancer. Apart from
blockers of uv light and anti-oxidants that mop of potentially
dangerous free radical (e.g. vitamin C), many claims are made about
substances that can subvert or defer the onset of cancer. In some
cases, claims have been made that “cancer cells are stopped in their
tracks” (cell cycle arrest) while the rest of the body goes on as normal.
What I find difficult to swallow is the selectivity in some such
molecule that would not also disturb my intestinal crypt cells.
[Reputedly, researchers in Georgetown University found some
ingredient of chocolate that had this effect, which worked even better
along with red wine!] So who is fooling who in such cases, and why
can we not prevent these unguarded blanket statements from being
promulgated by the media that can impact so hugely on the general
public?
Although resveratrol (plus some specifics saponins) in red wine can
help in cardiovascular and other systems, the alcohol and its tannins
can also have detrimental effects; so we are always dealing with
compromises. Widespread publication on the beneficial effects of
dietary components reducing risk seldom deal adequately with their
obverse effects, and what is written about risk reduction is so often
reported in isolation. I cannot but harp back to a point I repeatedly
make that each tumour is unique and each patient is unique. And so
the unpredictability of what happens at the individual level cannot be
Oncology News Welcomes New Reviewers
Mr Richard Novell (pictured) a Consultant
Coloproctologist at the Royal Free Hospital
in London will review the journal: Clinical
Colorectal Cancer (CIG). He qualified in
1981 from the Middlesex Hospital and
undertook his higher surgical training and
research at the Royal Free Hospital; in
1992 he was awarded the degree of Master
of Surgery. In 1994 he was appointed
Consultant Colorectal Surgeon to the
Luton & Dunstable Hospital, and returned to The Royal Free
Hospital in 2006, where he works in a multidisciplinary team
treating 120 new colorectal cancers per year. Richard’s other main
interest is inflammatory bowel disease, and he has published and
Volume 5 Issue 3 • July/August 2010
read off from what the population studies show or seem
to predict. [I would recommend those of other
persuasions read the extraordinarily perceptive writing
of Nassim Nicholas Taleb in his “Black Swan” (ISBN-
978-0-1410-3459-1) in this regard, dealing with the
unpredictability of nature and how in general this fact is
simply ignored.]
This lack of a holistic viewpoint lets these reports be
promulgated and their “simple” messages are absorbed
by so many non-sceptical readers in the general public
bent on improving their lot by following fads and
fashions. How a single substance impacts on the body
depends on the metabolism of individual, and cannot be
assumed to act across the board in the same way. A more holistic
approach is needed in trying to reduce the risk of cancer. In some
respects things have improved, but ironically at the other end of the
problem, i.e. in the treatment management of a cancer sufferer, with
the input of surgeons, psychiatrists, dieticians etc.
Just taking a quick look at a couple recent news items about other
dietary substances, reports suggest that salicylate is of potential
benefit in reducing the risk of a range of childhood cancers [1]. Do
childen get enough salicylate in their diet, or should they be given a
supplement each day to keep cancer at bay? I would suggest that very
few parents would act accordingly. Anyway, exactly how much
salicylate does the average child consume in the diet, and how do we
know that the risk for those with an adequate intake is reduced
compared with those who do not; i.e. who set the “norm” against
which risk is seen as being reduced? Based on the same kind of
thinking, tea now seems to be important in reducing the incidence of
rheumatoid arthritis and death from cardiovascular disease in the
elderly. “Regular” coffee drinking reputedly reduces breast cancer in
elderly women, and the risk of head and neck cancer. But we also
learn that acrylamide in coffee preparations increases the risk of
pancreatic cancer. Confused? I am. But perhaps many oncologists will
have views on this issue, and that is why ON will in future have
sections devoted to hearing your comments on matters raised by the
many questions in this editorial and other articles in future issues -
your feedback is appreciated. n
Reference
[Many substances mentioned can be tracked through most search engines online,
with sources not only in scientific journals, but in a plethora of press releases.
Hence only one reference to the salicylate matter is given here.]
1. G. Morgan and Johnsen JI. Might salicylate exert benefits against childhood
cancer? Ecancermedicalscience 2010;4:156.
presented internationally on a wide variety of surgical conditions
including Crohn’s disease, colorectal and liver tumours and rectal
prolapse.
Mr Mriganka De a Consultant ENT Head & Neck/Thyroid Surgeon at
Derby Royal Hospitals NHS Trust undertook his Basic surgical training
in South Wales and Higher surgical training in the West Midlands
region. He was a Head & Neck Fellow in Amsterdam & Glasgow and
Research Fellow in University of Birmingham. His research program
focuses on Epigenetic of Head & Neck cancer and metastases, from the
basic underlying biology to new potential treatments. Mriganka
specialises in Head & Neck Oncology and Thyroid & Parathyroid
surgery and will review the journal: Head & Neck (Wiley).
71
 Contents Oncology
ISSN 1751 4975

News
Volume 5 Number 3 July/August 2010
Volume 5 Issue 3 uly/August 2010 • www oncologynews b z

71 Editorial – Denys Wheatley

73 Conference Digest
76 High Grade Glioma Through the Ages
Chris Jones, Surrey, UK

80 Nursing Section -
2010 Top Priorities for Cancer Nurses In his ssue

High Grade Gl oma Through he Ages

Maureen Morris, New Zealand 2010 Top Prior ties for Cancer Nurses
The Use of Imaging in Breast Cancer Diagnosis
and Tr ple Assessment
Developments in the Radiolog cal Management

82 Imaging Section – of Rectal Cancer

The Use of Imaging in Breast Cancer Diagnosis and Triple Front cover shows the new Novalis Tx
radiosurgery platform by BrainLAB and
Assessment Varian Medical Systems
Melvyn Ang, Gavin Briggs, Tom Lynch, Colin R James, Belfast, UK

86 Colorectal Section –
Oncology News is published by
Developments in the Radiological Management of Rectal McDonnell Mackie, 88 Camderry Road,
Cancer Dromore, Co Tyrone, BT78 3AT, N Ireland.
Andrew Riddell, Richard Novell, London, UK Publisher: Patricia McDonnell
Web: www.oncologynews.biz
88 Sponsored Featured – Advertising and Editorial Manager:
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Bladder Cancer – Poor Understanding Jeopardises Care
Alison Birtle, Preston, UK
Copyright: All rights reserved; no part of this publication
94 Book Review may be reproduced, stored in a retrieval system or trans-
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the prior written permission of the publisher or a license
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96 Conference News Copyright Licensing Authority. Disclaimer: The publisher,
Previews and reports from the conference scene. the authors and editors accept no responsibility for loss
incurred by any person acting or refraining from action as
99 Awards & Appointments a result of material in or omitted from this magazine. Any
new methods and techniques described involving drug
usage should be followed only in conjunction with drug
100 Diary manufacturers' own published literature. This is an inde-
Listing of meetings, courses and conferences, both UK and international. pendent publication - none of those contributing are in
any way supported or remunerated by any of the compa-
nies advertising in it, unless otherwise clearly stated.
102 Courses & Conferences Comments expressed in editorial are those of the
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104 News Update and no correspondence will be entered into.
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72 Volume 5 Issue 3 • July/August 2010

Conference Digest
Conference Reports from the American Society of Clinical Oncology 2010, Chicago 4-8 June
Ipilimumab ‘improves survival in
metastatic melanoma’
novel monoclonal antibody, ipilimumab, the first with a T-
A cell mediated mode of action on the immune system,
increases survival of patients with metastatic melanoma
when used as a monotherapy. Final results from MDX010-20, a
phase IIII randomised, double-blind, multicentre study were pre-
sented in a plenary session. The study compared ipilimumab with
the immune-stimulating gp100 peptide vaccine or a combination
of the two, in patients with previously treated, unresectable stage
III or IV melanoma.
The results, simultaneously published on-line in the New England
Journal of Medicine (www.nejm.org June 5, 2010) showed that
patients who received ipilimumab lived 34% longer than those who
received gp100 peptide vaccine – making this the first randomized
study to demonstrate improved survival in advanced melanoma.
Discussant Dr Vernon Sondak, Department of Cutaneous
Oncology, Moffitt Cancer Center, Tampa, Florida, said that with no
new FDA-approved drugs since IL-2 more than a decade ago:
“Those of us treating melanoma have felt that we have been in a
long dark tunnel, with no documented improvement in survival for
metastatic melanoma patients over the past three decades.”
Results were presented by Dr Steven O’Day, director of the
melanoma program at The Angeles Clinic and Research Institute, Los
Angeles, who said that ipilimumab potentiates T-cell activation by
blocking CTLA-4, an antigen on T-cells that downregulates the T-cell
response. “These results are an exciting advance, both for patients
with advanced melanoma and for the field of cancer immunology.”
In the study, 676 HLA-A*0201-positive patients whose disease
had progressed while they were receiving therapy for metastatic
disease, were randomly assigned, in a 3:1:1 ratio, to receive ipili-
mumab plus gp100, ipilimumab alone, or gp100 alone.
Ipilimumab, at a dose of 3 mg per kilogram of body weight, was
administered with or without gp100 every 3 weeks for up to 4
treatments. The primary end-point was overall survival.
Median overall survival was 10 months among patients receiving
ipilimumab plus gp100, as compared with 6.4 months among
patients receiving gp100 alone (hazard ratio for death, 0.68;
P<0.001). The median overall survival with ipilimumab alone was
10.1 months (hazard ratio for death in the comparison with gp100
alone, 0.66; P=0.003). No difference in overall survival was detect-
ed between the ipilimumab groups. Grade 3 or 4 immune-related
adverse events occurred in 10 to 15% of patients treated with ipili-
mumab, and in 3% treated with gp100 alone. There were 14 deaths
related to the study drugs (2.1%), of which 7 were associated with
immune-related adverse events.
Survival rates in the two ipilimumab
arms were 44 and 46% at one year
and 22 and 24% at two years (com-
pared with 14% two-year survival in
the control arm). Ipilimumab was con-
sistently better for all secondary end-
points, PFS, BORR (best overall
response rate) and DCR (disease con-
trol rate), said Dr O’Day.
Ian Mason. Dr Steven O’Day.
Volume 5 Issue 3 • July/August 2010
MRC study is helping define a new
standard in prostate cancer treatment;
survival benefit shown for adding radiation
to androgen deprivation therapy
O
verall survival in high-risk patients with locally advanced
prostate cancer is significantly increased by combined
treatment of androgen deprivation therapy (ADT) plus
radiotherapy compared to ADT alone, according to a large ran-
domised phase III trial conducted by the UK Medical Research
Council, in collaboration with the National Cancer Institute of
Canada and the South West Oncology Group in the US. This should
now be considered the standard of care, say investigators. Many of
the 1205 high risk patients in the study were recruited from over
60 UK centres. Results of the trial were presented at this year’s
ASCO by Padraig Warde of Princess Margaret Hospital, Canada.
There was a 23% reduction in deaths at seven years in patients
who received combined treatment compared with ADT alone (74
vs 66%; HR 0.77 p=0.03). Substantially more of the 140 deaths
attributable to prostate cancer itself occurred in the ADT arm (89
vs 51%). Disease-specific survival showed a HR of 0.57 (p=0.001),
with 90% surviving on combined therapy compared to 79% on
ADT alone.
Patients with T3/T4 N0/NX, T2 and PSA>40mcg/L or T2 and
PSA>20mcg/L and a Gleason score of 8-10, were randomised to
ADT alone, consisting of either bilateral orchiectomy or LHRH
agonist therapy for a mandatory two weeks with the option of
continuation or to ADT plus radiation therapy involving
45Gy/25F for 5 weeks to the pelvis and 20-24 Gy/10-12F for 2
to 2.5 weeks to the prostate. The protocol also allowed for the
prostate alone to be treated. Adding radiation therapy did not
result in significant toxicity and was well tolerated, said
Professor Warde.
Although the trial was designed in 1993, it is still highly relevant
today, he said, since the latest available CaPSURE data (2004-2007)
show close to half the patients are still being managed with ADT
alone.
“We believe combined therapy should now be considered the
standard of care,” he concluded, “although optimal duration of
ADT remains undefined; it may not be necessary to continue it life-
long”. The benefit of radiotherapy in the modern era may be
greater with dose escalation, he added.
Speaking afterwards, Malcolm Mason, Professor of Clinical
Oncology at Cardiff University and second author of the study, said
the results were likely to be practice-changing. “Of prostate cancer
deaths in the UK, 40% are in high risk patients with localised disease,
and we estimate substantial numbers in
this group are currently being treated
with hormone therapy alone. Probably
no more than 60% of them receive
radiotherapy as well.” A further very
large UK study, STAMPEDE, is randomis-
ing patients receiving combined therapy
to the addition of either chemotherapy,
zoledronic acid or celecoxib or combina-
Professor Padraig Warde.
tions of them, he added.
73
Cilengitide may extend survival for
glioblastoma patients
C
ilengitide, the first of a new class of integrin inhibitors, may
extend survival for patients with recurrent glioblastoma
multiforme, according to results of a randomised phase IIa
study presented at ASCO. The study recruited 81 patients from 15
centres in the US, who were randomised to one of two doses of
cilengitide, 500mg and 2000mg twice weekly, until disease pro-
gression, death or treatment-related adverse events.
From the study, led by Karen Fink of Baylor University, Dallas,
Texas, data showed especially encouraging results for patients
who received the higher dose. Over a third of them were still alive
after one year and 22% after two years. Normally, the median
overall survival of patients with recurrent glioblastoma is a few
months, with only 20% surviving a year. Of 15 patients in Dr
Fink’s study who received cilengitide at the higher dose for 6
months to 4.5 years, none experienced treatment-related severe
adverse events.
Dr Fink said the data were exciting and that 10% of patients
were still alive after four years. “Prognosis for patients with recur-
rent glioblastoma is extremely poor and additional treatment
options have been desperately needed for some time.” Nine in 10
glioblastoma patients experience recurrence after first line surgery,
radiation therapy and chemotherapy.
In the current multicentre study, 66 patients were treated for <6
months, but 15 continued treatment beyond 6 months. Overall
survival in the small numbers still on treatment at 54 months was
doubled for patients receiving the higher dose (5 vs 2.4%). There
was a 34.4% reduction in risk of death with the higher dose (HR
0.65).
Phase III study will focus on newly diagnosed
glioblastoma
A
phase II study of cilengitide -- and temozolimide with con-
comitant radiotherapy followed by cilengitide and temo-
zolomide maintenance therapy in patients with newly diag-
nosed glioblastoma, was published in the Journal of Clinical
Oncology this month. It showed 12 and 24-month overall survival
rates of 68 and 35%, respectively.
Study author, Roger Stupp, of Lausanne, Switzerland, is now
conducting a global phase III trial, CENTRIC, with cilengitide
2000mg in combination with temozolimide and radiotherapy in
patients with newly-diagnosed glioblastoma. A further study is
investigating the agent in patients with newly-diagnosed glioblas-
toma and the unmethylated MGMT promotor in a separate trial
(CORE).
Commenting in Chicago, Dr Stupp said: “CENTRIC is the first
large prospective clinical trial in newly diagnosed gliobllastoma and
will recruit around 500 patients. I believe cilengitide shows promise
for extending survival in patients with newly diagnosed glioblas-
toma and we hope to demonstrate this in CENTRIC.”
Cetuximab achieved disease control in
69% of patients with unresectable
squamous cell skin cancers
M
ore than two-thirds of unresectable squamous cell can-
cers of the skin were controlled by first-line treatment for
six weeks with the EGFR inhibitor cetuximab, according
to results of a phase II study presented in an oral session at ASCO
74
by Dr Eve Maubec of Hopital Bichat, Paris, France.
The study was carried out because the EGF receptor is strongly
expressed in metastatic cutaneous squamous cell cancers.
Cetuximab has shown good results in metastatic squamous cell
cancers of head and neck, where it is a standard first-line therapy,
she explained.
Among the 36 patients in the study, all of whom had an ECOG
performance status below 2 and most of whom were >70 years old
with stage III cancers, the disease control rate was 69%. Two
patients had a complete response and the best overall response rate
was 28%, she said. “Three patients with previously unresectable
tumours were subsequently able to undergo resection following
cetuximab treatment and two of these are now free of disease.”
The median progression-free survival was 121 days and overall
survival 246 days. Duration of response was 194 days and duration
of disease control was 167 days. Over three quarters of the patients
(78%) had an acne-like rash which has been shown to predict cetux-
imab efficacy in studies of other cancers, and this may also be the
case in skin cancer, she said. The safety profile was acceptable and
similar to observations in other studies of cetuximab.
Patients with unresectable squamous cell skin cancers normally
have a poor cure rate. Although conventional chemotherapy shows
some efficacy, toxic effects often make it unsuitable for elderly
patients, she remarked. None of the patients had detectable KRAS
or BRAF mutations, which made EGFR inhibition by cetuximab an
attractive option, especially in elderly patients for whom
chemotherapy may not be appropriate, she concluded.
Tumour testing for gene status to optimise
personalised therapy approach becoming
standard
T
esting of individual patients’ tumour tissue for biomarkers is
increasingly being used to tailor treatment for optimal ben-
efit, researchers said during ASCO. A global survey led by
Fortunato Ciardiello, Professor of Medical Oncology, Naples, Italy,
found the percentage of patients with metastatic colorectal cancer
(mCRC) whose tumours were tested for KRAS gene status had risen
from 2.5% in 2008 to 42% within a year. In 2008, Belgian investi-
gators demonstrated that mCRC patients whose tumours exhibited
wild type KRAS genes had a much better response to anti-EGFR
therapy than patients with mutant KRAS. By 2009 the National
Comprehensive Cancer Network had recommended testing all
mCRC patients for KRAS mutation status at diagnosis and the
European Medicines Agency restricted use of cetuximab to mCRC
patients with the wild type KRAS gene. Now almost half of patients
with wild type KRAS receive treatment with the EGFR inhibitor
cetuximab, Prof Ciardiello said.
The survey looked at awareness and use of KRAS testing among
1254 physicians in 20 European countries, Latin America and Asia.
Awareness of the need for KRAS testing was shown by 86%, of
whom 53% wanted information prior to prescribing cetuximab.
Tumour KRAS status was evaluated in 1895 of 4517 patients (42%)
with 59% of tumours assessed as wild type. Of these, 44% were
subsequently treated with cetuximab, 7% with the VEGF-inhibitor
bevacizumab and 2% with another anti-EGFR antibody, panitu-
mumab, compared with 3, 2 and 0% in 2008.
KRAS testing was spurred mainly by a subgroup analysis of the
phase III CRYSTAL study of first-line FOLFIRI chemotherapy with
or without cetuximab in mCRC, which showed a 32% reduced
risk of disease progression in patients with wild type KRAS get-
ting cetuximab.
Volume 5 Issue 3 • July/August 2010
 BRAF not predictive of response to
cetuximab
F
inal survival data from
CRYSTAL on the asso-
ciation of biomarkers
KRAS and the serine-threo-
nine BRAF with outcome
were presented at ASCO this
June. Of the 1198 patients,
89% were evaluated for
KRAS and 83% for BRAF sta-
tus. Wild type KRAS was
found in 63%. Of 625
patients tested for BRAF, Professor Tim Maughan.
91% exhibited WT BRAF. The
9% with mutant BRAF had a poor prognosis in both study arms.
A pooled analysis of CRYSTAL and OPUS data presented by
Carsten Bokemeyer of the Universitatsklinikum Hamburg,
Germany, found the presence of BRAF mutation alongside WT
KRAS reduced overall and progression-free survival and
response rate but did not prevent cetuximab improving on the
results seen in these patients when treated with chemotherapy
alone.
Survival was significantly prolonged by 3.5 months in the
WT KRAS group treated with FOLFIRI plus cetuximab (HR
0.796 p=0.009) said study leader, Professor Eric Van Cutsem,
Leuven, Belgium. He concluded: “For all efficacy end-points
including survival, this analysis confirms the value of KRAS
mutational status as a predictor of treatment outcomes in
patients with mCRC treated with first-line FOLFIRI and cetux-
imab.”
The analysis also suggested that mutations in BRAF, a down-
stream effector of KRAS, were an indicator of poor prognosis
after first-line mCRC therapy; but, he noted, these had no pre-
dictive value for response to cetuximab.
Similar findings emerged from a subset analysis of the MRC
COIN study of 2445 mCRC patients presented at ASCO by
Professor Tim Maughan, Cardiff University, Wales. He found
patients with mutations of all 3 biomarkers, KRAS, BRAF and
NRAS, had the poorest prognosis, irrespective of treatment
received. “Only 10% of patients with mutant BRAF were alive
at 2 years compared with 40% of those with all WT”, he
remarked.
Adding cetuximab to chemotherapy significantly increased
overall response rate in WT KRAS patients from 50 to 59% at
12 weeks (OR 1.44 p=0.01) and from 57 to 64% overall (OR
1.35 p=0.04), but did not increase overall or progression-free
survival when prescribed with oxaliplatin-based therapy and
capecitabine or 5-FU. A new study FOCUS-3 is now studying
cetuximab with irinotecan in patients stratified by KRAS, BRAF
and Topo-1 status. Patients with mutant KRAS will receive
bevacizumab, he said.
Lung cancer tumour-testing infrastructure well
established
I
n lung cancer, Dr Mark Kris, chief of Thoracic Oncology at
Memorial Sloan-Kettering, said a lung tumour testing infras-
tructure has become widely available since EGFR mutation
status has been shown to influence outcomes following treat-
ment with gefitinib and erlotinib. He said that it is now possi-
ble to test all tumours for known gene mutations that affect
response to treatment.
Volume 5 Issue 3 • July/August 2010
At this year’s ASCO, the small percentage of non-small cell
lung cancer patients with the EML4-anaplastic lymphoma
kinase (ALK) fusion gene were reported to respond well to treat-
ment with the ALK inhibitor, crizotininb. Overall response rate
was 64% and disease control rate 90%.
Oncologist David Johnson, of Vanderbilt University Medical
School,Tennessee, US, said cancer genome mapping was zero
in 2004, but 25% of cancer genomes would be mapped by
2015 and half by 2020. This will allow more cancers to be
studied for protein signatures that can be targeted with specif-
ic treatments as and when these became available.
EMBRACE study shows eribulin is first
single agent to improve overall survival
in metastatic breast cancer
W
omen with metastatic breast cancer lived a signifi-
cant 2.5 months longer when treated with eribulin
mesylate - a new drug derived from a marine sponge
- rather than standard chemotherapy, endocrine therapy or
with other biological agents. Interim analysis data from
EMBRACE, an open-label phase III study involving 762 women
with heavily pre-treated locally recurrent or metastatic breast
cancer (MBC), were presented in an oral session at ASCO by
lead investigator Professor Chris Twelves, University of Leeds,
UK. The trial produced “striking findings”, he said.
Eribulin significantly prolonged overall survival compared
to a range of other therapies that physicians were permitted
to choose as the best option for their patients. Median sur-
vival was 13.1 months in the eribulin arm and 10.6 months
in the Treatment of Physicians’ Choice (TPC) arm (HR 0.81
p=0.041). One-year survival was 53.9% in the eribulin arm
and 43.7% in the TPC arm – a 10% absolute increase.
The overall response rate as evaluated by a blinded panel
of independent experts favoured eribulin, which showed a
12.2% response rate compared to 4.7% in the TPC arm. The
independent review panel also found the rate of clinically
meaningful benefit at 6 months (complete plus partial
response and disease stabilisation) was greater for eribulin
(22.6 vs 16.8%).
Eribulin is a halichondrin B drug, the first of a new class of
antineoplastic agents, Prof Twelves told the audience. The
drug targets microtubules at different sites, inhibiting their
lengthening; it has a wide therapeutic index with less neuro-
toxicity than paclitaxel. The proportion of serious adverse
events reported were the same in each treatment arm (25%).
“There was more grade 3/4 febrile neutropenia in the eribu-
lin arm, but the incidence was low”, he noted.
The trial design had been challenging because restricting
the control arm to one particular therapy would have meant
that physicians might view results as not relevant, he
explained. “They have wide-ranging beliefs on how women
with MBC should be treated. The trial was therefore designed
as a real-life comparison reflecting the current range of dif-
ferent treatment options.”
“This is the first phase III single agent study in heavily pre-
treated MBC to meet its primary end-point of prolonged
overall survival” he concluded. “These data potentially estab-
lish eribulin as a new therapeutic option for such women.”
Olwen Glynn Owen,
Medical Journalist
75
High Grade Glioma Through the Ages
Chris Jones,
PhD, FRCPath,
Team Leader, Paediatric
Molecular Pathology.
Correspondence to:
The Institute of Cancer
Research,
15 Cotswold Road,
Sutton, Surrey,
SM2 5NG, UK.
Email: chris.jones@icr.ac.uk
The Institute of Cancer
Research is Europe's
leading cancer research
centre, working towards
a vision that people may
live their lives free from
the fear of cancer as a life
threatening disease.
76
A
lthough brain tumours represent <2% of all
human cancers, they are the leading cause of
cancer-related deaths in patients under 40.
Of these, the high grade gliomas represent the most
significant burden to health, with ~90% of patients
with glioblastoma multiforme (GBM), the most
malignant of these tumours, dying within two years
of diagnosis [1]. Genetic analysis conducted at The
Institute of Cancer Research in London and other
organisations has begun to reveal the many genetic
variants of high grade glioma, including particular
differences between its adult and paediatric forms.
These findings are important because ultimately
they are likely to have a major impact on disease
management.
Glioblastoma – even more ‘multiforme’ than we
thought
Glioblastomas can be thought of as a disease of the
elderly, the majority of cases developing after the
age of 55, with a peak incidence at 70-80 years.
Recent large-scale molecular profiling of these
tumours has uncovered in exquisite detail the key
genetic aberrations driving and maintaining
tumorigenesis, as well as providing novel
therapeutic targets for drug development [2].
As well as the specific genetic changes present at
the DNA level, mRNA expression profiling has
revealed the existence of several subtypes of high
grade glioma based solely on their gene expression
signatures [3]. These have been defined according
to the predominant functions of the specific genes
involved, and are known as ‘proneural’,
‘proliferative’ and ‘mesenchymal’. Such molecular
fingerprints may reflect important differences in
the origin and progression between different
tumours that would otherwise appear
indistinguishable.
In addition to adult primary glioblastomas, there
are distinct clinical presentations which we are only
now beginning to recognise as different diseases
from the most common form. These include so-
called secondary glioblastoma, which arises in
young adults (35-45 years) on the back on a pre-
existing lower grade lesion. They have long been
hypothesised as belonging to a different genetic
developmental pathway, but it is only a recent
discovery of the highly restricted mutations in
IDH1/2 in these cancers that has provided
confirmation [4].
High grade gliomas of childhood - an unmet
clinical and biological need
Ideas about high grade gliomas that arise in children
have, in contrast, been controversial. Although these
The timing seems right for us to finally make some progress in
our understanding of these devastating childhood tumours
tumours are rare (0.5 cases per 100,000 person-
years), as in adults they make up ~75% of all
malignant brain tumours. Their low incidence has
made it difficult for single institutions to carry out
sufficient studies to provide robust evidence for how
biologically different, or similar, they may be to the
adult disease(s).
Despite this, clinical evidence suggests that they
are different. Gliomas in children have distinct
patterns of presentation in the brain, they rarely
undergo malignant transformation like the
secondary glioblastomas of young adulthood, and
very young children appear to respond better to
chemotherapy with an improved clinical outcome
compared with older patients.
With the flood of data on adult glioblastoma, the
ease and accessibility of genome-wide profiling
techniques, and an increased awareness of the gap
in our understanding of this key element of
gliomagenesis, the timing seems right for us to
finally make some progress in our understanding of
these devastating childhood tumours.
Paediatric high grade gliomas have a distinct
genetic make-up
2010 is shaping up to be the year that paediatric
high-grade glioma research went prime-time. After
years of neglect, several studies have been, or are
due to be, published that shed light into the
genomics of these enigmatic tumours. From
smaller single institution studies [5,6] to large
multi-centre collaboratives, the amount of DNA
copy number and expression profiling data has
increased by an order of magnitude. For our own
part, besides taking part in the largest study
published to date along with the Children’s Cancer
and Leukaemia Group in the UK and St Jude
Children’s Research Hospital in the US [7], we have
provided the first large validation set of paediatric
high-grade glioma amenable to copy number
profiling by array comparative genomic
hybridisation from archival formalin-fixed paraffin-
embedded specimens [8].
These datasets reveal significant differences in the
DNA copy number alterations in childhood versus
adult high-grade gliomas. The most common
chromosomal abnormalities in adult glioblastoma,
i.e. gains of chromosome 7 and losses of 10q (seen
in >75% of cases), are considerably less frequent in
the paediatric setting. Conversely, childhood
tumours have high levels of 1q gain and losses of 4q
and 16q, all of which are rare in adults.
Perhaps the most striking of the differences in
chromosomal changes has been an absence – the
finding that ~1/7th of paediatric high grade gliomas
Volume 5 Issue 3 • July/August 2010
Figure: PDGFRA is amplified and overexpressed in paediatric high-grade glioma. (A) fluorescent in situ hybridisation showing an increased copy number of specific probes direct-
ed against the PDGFRA gene (pink). (B) Immunohistochemical staining using an antibody specific to PDGFRA protein showing widespread receptor expression in an amplified
tumour.
have no detectable changes in DNA copy
number following profiling on numerous array
platforms. This is a surprising observation for
such malignant tumours, and one that is not
seen in adult lesions. Whether there are
epigenetic or more subtle mutational changes
occurring in these cases is not yet clear;
however, it is intriguing that these stable
genome tumours have also been reported in
paediatric ependymoma and supratentorial
primitive neuroectodermal tumours, perhaps
hinting at some commonality in paediatric
brain tumour biology.
Platelet-derived growth factor alpha
(PDGFRA) comes in from the cold
In terms of bona fide high level gene
amplifications, there is a clear winner in
paediatric high grade glioma. Although
numerous genes reported in adult
glioblastoma are also represented in
children, most only occur at very low
frequencies, often in single cases. In
contrast, amplification of PDGFRA at
chromosome 4q12 is by far the most
common, being amplified in fully 20% of
paediatric glioblastoma. This event is even
more common in two childhood-specific
specific instances of the disease – diffuse
intrinsic pontine glioma, which affects the
brainstem, and post-irradiation glioma,
which is a second malignancy arising after
cranio-spinal irradiation for an earlier
cancer. In these subtypes, PDGFRA
amplification rises to ~50% of cases.
PDGFRA amplification had previously been
noted in glioblastoma, and specific small
molecule inhibitors were used in early phase
clinical trials with little success. To determine
whether the gene was playing a critical role in
these tumours, or just an incidental role,
expression profiles of childhood and adult
tumours were compared. Surprisingly, when
Volume 5 Issue 3 • July/August 2010
a set of genes defined as being upregulated
after PDGFRA had been amplified were
examined in the two age groups, completely
distinct sets of genes were differentially
expressed in the paediatric versus adult
tumours. Furthermore, this paediatric-specific
PDGFRA signature was active in over half the
childhood tumours, and was therefore present
even in the absence of gene amplification.
In adults, those (less frequent) cases with
PDGFRA amplification were associated with
the ‘proneural’ subclass, as defined by
expression profiling. This group of tumours
was also tightly linked to IDH1/2 mutations,
and thus to the secondary glioblastoma
pathway. In childhood high-grade glioma,
IDH1/2 mutations are almost entirely
absent, creating another clear distinction
from a form of the adult disease. It is
perhaps not surprising then, that PDGFRA
in children is not associated with the
proneural group, but rather with expression
of numerous cell cycle-associated genes
which place these tumours firmly in the
‘proliferative’ subclass.
In retrospect, this makes sense, as these
tumours in adults appear to be driven by the
most commonly amplified gene in that age
group, viz. EGFR. Such an abnormality is
considerably less common in paediatric
cases, and instead the proliferative
pathways are driven by the distinct receptor
tyrosine kinase, PDGFRA. Clearly, a fresh
look at strategies targeting this receptor in
children is warranted, where novel
predictive markers may be at play.
High-grade glioma across all ages
comprises a genomic spectrum of disease
Although clear evidence is starting to
emerge for differences between childhood
and adult high-grade gliomas, it is important
to recognise that there is still a high degree
of overlap between the two age groups. Of
particular note, there are a proportion of
paediatric tumours which do look rather like
their adult counterparts – EGFR amplified,
with gains of chromosome 7, losses at 10q,
etc., and with a ‘classical’ or ‘mesenchymal’
gene expression signature. However, these
tumours are in the minority.
Similarly, there are (less frequent)
tumours from elderly patients whose
genetics places them firmly of the type that
is rather prevalent in children – PDGFRA
amplified, with a specific proliferative
signature, and possibly with gains of 1q and
losses of 16q. We have come to call these
cases ‘Group P’ – predominantly paediatric,
PDGFRA-driven and proliferative. What is
fundamental is that these tumours are
clearly distinct from the adult proliferative
subtype, which is EGFR-driven, and also
separate from the proneural groupings. In
adults, this subtype is associated with
IDH1/2 mutations, absent in children; in the
paediatric disease, however, the proneural
gene expression group is still evident, but
not associated with PDGFRA.
It seems clear that rather than a small
number of highly segregated subclasses,
high- grade glioma across all the groups
forms a genomic spectrum of disease, and
only by studying tumours at whatever age
they arise will we fully understand all the
different subtleties of how they fit
together.
Perspectives on progress in a
particularly paediatric puzzle
Having defined this ‘Group P’ end of the
genomic spectrum of high-grade glioma,
how can we use this knowledge to
understand the differences between similar
tumours that arise at different stages of life?
There are already hints from secondary
77
 Table: Key genetic differences between paediatric and adult high-grade glioma
Paediatric
Predominant amplification PDGFRA
Chromosomal gains 1q
Chromosomal losses 16q
IDH1/2 mutation No
Stable genomes Yes
Expresson signatures PDGFRA:proliferative
versus primary adult glioblastoma, as
well as the IDH1/2 mutation story,
that very distinct development
processes play a key role in disease
initiation. Given the short time to
malignancy apparent in paediatric
tumours, this is probably even more
critical in children.
The differential targeting of
receptor tyrosine kinases in childhood
and adult tumours suggests that the
developing brain may be more
sensitive to PDGFRA-directed cancer
78
Adult
EGFR
7 characterization defines human glioblastoma genes and core
10q
Yes (Secondary GBM)
No
PDGFRA & IDH1/2: proneural
initiation than more mature cells of
the central nervous system. This in
turn may reflect a unique cell of
origin for the majority of childhood
high-grade gliomas in comparison
with their adult counterparts.
Identifying the key genetic differences
which separate these diseases is only
the first part in the process of
understanding the prospect of treating
and preventing these highly
aggressive, and currently incurable,
tumours. n
References
1. CBTRUS. CBTRUS Statistical Report: Primary Brain and
Central Nervous System Tumours Diagnosed in the United
States in 2004-2006. Source: Central Brain Tumour Registry of
the United States, Hinsdale, IL. 2010.
2. McLendon R, Friedman A, Bigner D, Van Meir EG, Brat DJ,
Mastrogianakis M, et al. Comprehensive genomic
pathways. Nature. 2008 Sep 4;455:1061-8.
3. Phillips HS, Kharbanda S, Chen R, Forrest WF, Soriano RH,
Wu TD, et al. Molecular subclasses of high-grade glioma
predict prognosis, delineate a pattern of disease progression,
and resemble stages in neurogenesis. Cancer Cell. 2006
Mar;9(3):157-73.
4. Parsons DW, Jones S, Zhang X, Lin JC, Leary RJ, Angenendt
P, et al. An integrated genomic analysis of human
glioblastoma multiforme. Science. 2008 Sep
26;321(5897):1807-12.
5. Qu HQ, Jacob K, Fatet S, Ge B, Barnett D, Delattre O, et al.
Genome-wide profiling using single-nucleotide polymorphism
arrays identifies novel chromosomal imbalances in pediatric
glioblastomas. Neuro Oncol.
2010 Feb;12(2):153-63.
6. Zarghooni M, Bartels U, Lee E, Buczkowicz P, Morrison A,
Huang A, et al. Whole-Genome Profiling of Pediatric Diffuse
Intrinsic Pontine Gliomas Highlights Platelet-Derived Growth
Factor Receptor {alpha} and Poly (ADP-ribose) Polymerase As
Potential Therapeutic Targets. J Clin Oncol. 2010 Feb 8.
7. Paugh BS, Qu C, Jones C, Liu Z, Adamowicz-Brice M, J. Z, et
al. Integrated molecular profiling of pediatric high grade
gliomas reveals key differences with the adult disease. J Clin
Oncol. 2010;DOI:10.1200/JCO.2009.26.7252.
8. Bax DA*, Mackay A*, Little SE, Carvalho D, Viana-Pereira M,
Tamber N, Grigoriadis A, Ashworth A, Reis RM, Ellison DW,
Al-Sarraj S, Hargrave D and Jones C (2010). A distinct
spectrum of copy number aberrations in paediatric high grade
gliomas. Clin Cancer Res doi: 10.1158/1078-0432.CCR-10-0438.
Volume 5 Issue 3 • July/August 2010
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Nursing
2010 Top Priorities for Cancer Nurses
Maureen
Morris
Chair,
NZNO Cancer
Nurses Section.
Correspondence to:
maureen.morris@
northlanddhb.org.nz
‘Education and Change Top Priorities
for Cancer Nurses’ was the headline of
an article published in the journal Kai
Tiaki Nursing, New Zealand, in
November 2008.
The article described the launching
of a clinical document compiled by the
Palliative Care and Cancer Nursing
Education Working Group, called ‘A
National Professional Development
Framework for Cancer Nursing in
Aotearoa, New Zealand.’ This was an
opportunity for nurses working in the
speciality of cancer care to have a
structured professional pathway for
career development and self-directed
learning. The document, which can be
found on the New Zealand Nurses
Organisation (NZNO) Cancer Nurses
Section and the Ministry of Health
websites, defines the agreed levels of
practice in cancer nursing as a
specialty, as well as the core
competencies for nurses working with
those families with a cancer diagnosis
in a generalist setting. The
endorsement by the NZNO Cancer
Nurses Section opened up further
opportunities with information
regarding the availability and
accessibility of the document being
disseminated to 600 members within
New Zealand. Alongside this, the
Ministry of Health worked with the
Directors of Nursing/Midwifery within
District Health Boards to ensure
“cancer nursing workforce capacity alongside patient and nurse safety concerns”
issues highlighted by cancer nurses
80
distribution to each of the six cancer
centres and the regional centres.
With the knowledge and skills for
each level of practice defined, this is an
opportunity to use a document to guide
cancer nursing education, seek funding
to support that education, and assist
nursing managers to facilitate
professional development programmes
for cancer nurses that build on and
promote the goals of the New Zealand
Cancer Control Strategy Action Plan
2005-2010.
By November 2009, there was
evidence from nurses working in the
cancer and regional centres that other
workforce issues were also causing
concern. These issues, presented to
the NZNO Cancer Nurses Section
committee, related to cancer nursing
workforce capacity alongside patient
and nurse safety concerns, due to
increasing numbers and complexity of
chemotherapy treatments being
delivered.
The NZNO Cancer Nurses Section
facilitated a written survey of nurses
working in chemotherapy administration
units throughout New Zealand, with the
areas requiring comment being those
highlighted as issues by the members.
Included in this survey was a request for
feedback on their knowledge and
regional use of the document the
‘National Professional Development
Framework for Cancer Nursing in
Aotearoa NZ.’ With comprehensive
feedback from 12 chemotherapy
administration units and some
community services, an initial collation
of the results followed a number of
themes. I have chosen four to address
here.
Health Needs
There was strong acknowledgement of
the 2009 ‘Voice of Experience’ study
from the Cancer Control, where
patients’ experiences of their cancer
journey were analysed with areas for
improvement identified. These included
areas where cancer nurses, because of
their knowledge and skills, would be the
appropriate workforce and fit for
purpose to address these areas for
improvement e.g. provision of
information about possible changes in
relationships, sexual activity and
emotion, help with anxiety and fears
about their diagnosis and treatment,
taking into account patients’ living
situations when planning treatment,
including travel concerns. From the 6
cancer centres, there was feedback on
the health needs of both patients and
staff, as many treatment regimens were
being delivered as in-patient therapy
due to the extended time taken for
complex programmes with sicker
patients. For those areas with no in-
patient area, there was pressure on staff
to get treatment delivered in an 8-hour
day and an identified lack of community
support following administration of
therapies with high toxicity profiles.
Workloads
Concern was expressed by all areas
about the increasing workloads and the
constant lack of space in the form of
beds and chairs, resulting in some
treatments being delayed. The
complexity of treatments and the new
treatment modalities allowed
opportunities for treatment to be
delivered to a greater number of
patients, many with advancing age,
thus adding to the complexities of care
for a nurse who may be delivering care
to patients with a range of ages across
the lifespan all at the same time. In
many areas the nurses were working
over their current contracted hours and
there seemed limited ability to recoup
Volume 5 Issue 3 • July/August 2010
the hours attached to this. Alongside this was the report of
staff turnover being high, 50% in one area, an identified lack

DEXAMETHASONE
of experienced cancer nurses on the teams, the sickest
patients often being cared for by the most inexperienced
nurses. One area identified data from January 2007 to
January 2009 that indicated a 10% increase in chemotherapy For the
administration in the in-patient ward. This increase is seen
across the board – the concern expressed is that staffing
numbers for nursing are not being increased to accommodate
treatment
this increase.
of raised
Complexity
Further to the discussion about the complexity of treatments, intra-
high turnover of staff and increased working hours was the
employment of new graduate nurses into the oncology arena.
New graduate nurses were reported as having difficulty with
cranial
the complexity of patients and felt obliged to take
responsibility for complex patients since there was no one
pressure
else due to low skill mix in the area. A number of nurses
reported a lack of nursing authority to say when safe staffing secondary
was not happening, and thus the need to limit treatment
deliveries. Alongside this, and recognised as a risk, was a lack
of consultation with nursing about the introduction of new
to cerebral
regimens and the resource allocation surrounding them.
Telephone triage of patients receiving complex therapies in
tumours
an outpatient setting was adding a further dimension to the
nursing teams who had had no training in the knowledge and
skills required for telephone triage of oncology patients, in an
environment where skill mix was low and often medical
cover was difficult to access.
A number of regional areas reinforced the lack of constant
medical support from their local medical teams.

National Professional Development Framework

Knowledge of the development of this Professional
Development Framework for Cancer Nurses in Aotearoa NZ
was small, despite some evidence of a roll-out to the Directors
of Nursing/Midwifery in each District Health Board. No area
identified that it was being used to guide education in the
specialty of cancer nursing or being used to facilitate
professional development programmes for cancer nurses.
Since this time, the National Nursing Consortium has been
established as a national endorsement process for Please read Summary of Product
professional standards of practice. I envisage The National Characteristics before prescribing,
particularly in relation to side-effects,
Professional Development Framework for Cancer Nurses in precautions and contra-indications.
Market Authorisation Holder: Chemidex
Aotearoa NZ being added to the central repository of Pharma Limited, Chemidex House,
7 Egham Business Village, Crabtree Road,
consortium approved standards and knowledge and skills Egham, Surrey TW20 8RB, UK.
frameworks. Legal Category: POM

Adverse events should be

Conclusion reported. Reporting forms and
EG/DE/MAR/2009/01

information can be found at

The feedback from the survey requires more analysis and www.yellowcard.gov.uk. Adverse
some recommendations forwarded in order to address the
concerns of over 600 cancer nurses in New Zealand.
events should also be reported
to Chemidex Pharma Limited 500mcg
on 01784 477167.
Advanced practice nursing supports evidence-based care and
cancer nursing follows other specialties in identifying the
TABLETS
need to use evidence-based care in the drive for continuous PIP: 114-6091
quality improvement and improved outcomes for patients and
families. LINK: DEX418F
This pathway leads to revisiting the need for up-to-date
For further information, please contact: PROSPER: 359570
national guidelines on safe administration of chemotherapies Essential Generics, 7 Egham Business
and biotherapies and the development of a transferable Village, Crabtree Road, Egham, MOVIANTO: DEX500T
Surrey TW20 8RB, UK
national education programme for nurses delivering complex
toxic therapies to those in our care. n

Volume 5 Issue 3 • July/August 2010 81

Imaging
The Use of Imaging in Breast Cancer
Diagnosis and Triple Assessment
Dr Tom Lynch

Imaging section is edited
by Dr Tom Lynch
Authors
Melvyn Ang1,2, Gavin Briggs,2 Tom Lynch1, Colin R James3,4
1. Department of Radiology, Belfast Health and Social Care Trust.
2. Department of Radiology, Southern Heath and Social Care Trust.
3. Department of Oncology, Belfast Health and Social Care Trust.
4. Centre for Cancer Research and Cell biology, Queen’s University Belfast.
Correspondence to:
Melvyn Ang, Clinical Radiology Specialist Registrar, Department of Radiology,
Belfast Health and Social Care Trust, Lisburn Road, Belfast BT9 7AB, N. Ireland.
Email: ahkmelvyn@yahoo.com

Key Words: breast cancer, radiology, imaging, screening.

enhanced by compressing the breast to

B
reast cancer is the most prevalent
cancer amongst women and is
estimated to affect one in nine
women in their lifetime. Recent statistics
indicate that the incidence of breast cancer
has increased annually, likely due to
increased public awareness and the
introduction of screening programmes. Over
the last few decades there has been a real
drive to diagnose breast cancer as early as
possible in an attempt to improve survival
rates. This means the vast majority of
women are diagnosed with early stage
disease. Surgery remains the main treatment
modality but improvements in adjuvant
systemic treatments mean that most women
can be treated with the aim of cure.
The majority of patients diagnosed with
breast cancer are symptomatic and the most
common finding is of a lump. All patients
are assessed using the triple assessment of
clinical examination, imaging and
pathological biopsy. Thus radiological
imaging plays a major role in preoperative
assessment and diagnosis of breast cancer
and aids decision making regarding the type
of surgical procedure that is considered.
A number of different imaging techniques
are useful in the assessment of breast cancer
including mammography, ultrasonography
and magnetic resonance imaging (MRI).
The purpose of this review is to focus on
these three imaging modalities to describe
the common radiological features of
malignancy and also the use of these
techniques in screening.
Mammography
Mammography was first used routinely in
the investigation of breast abnormalities in
1960 but it was not until 1976 when it was
used as a screening modality. The technique
uses low energy x-rays to create detailed
images of the breast and accuracy can be
maximise the amount of tissue that can be
imaged and reduce x-ray scatter. Two
mammographic views are routinely
obtained including cranio-caudal (CC) and
medio-lateral-oblique (MLO) views (Figures
1a and b). Further supplemental views such
as latero-medial (LM), medio-lateral (ML),
exaggerated CC, magnification and spot
compression views may be used to improve
the diagnostic procedure. Abnormalities are
described and located to a quadrant or
ascribed a clock face position while the
depth of the lesion is assigned to the
anterior, middle or posterior third of the
breast.
The most common feature of a malignant
lesion on mammography is a dense
spiculated mass. Other features suggestive
of malignancy should also be assessed
including associated clusters of pleomorphic
microcalcification (different sizes and
shapes), asymmetric density or distortion,
skin thickening, puckering, nipple retraction
and axillary lymphadenopathy. These
features may be present separately or
variably together (Figure 1c). A few notable
exceptions to this are inflammatory and
lobular carcinomas which may present as
subtle asymmetry or distortion or be occult
on mammography.
Mammography is a very accurate
technique depending on patient age and
density of the breast. Carney et al concluded
that the adjusted sensitivity increased with
age from 68.6% in women 40 to 44 years of
age to 75.4% in women 50-54 years and up
to 83.3% in women 80 to 89 years of age.
Adjusted specificity increased from 89.1%
in women with extremely dense breasts to Figures 1a and b (top and middle): Normal
96.9% in women with almost entirely fatty mammogram medio-lateral oblique and craniocaudal
views.
breasts [2]. Ultimately, it may not be
Figure 1c (bottom): Right medio-lateral oblique
possible to determine if lesions seen in the mammographic view showing a dense spiculated
mammogram represent a malignancy and mass typical for a carcinoma.

82 Volume 5 Issue 3 • July/August 2010

 Table 1: BIRADS and the RCRBG classification for breast imaging.
Category BI-RADS
0 Assessment incomplete. Need to review prior studies and/or
complete additional imaging
1 Negative. Continue routine screening.
2 Benign finding. Continue routine screening.
3 Probably benign finding. (<2% chance of malignancy) Short-term
follow-up mammogram at 6 months, then every 6- 12 months
for 1- 2 years
4 Suspicious abnormality. Perform biopsy, preferably needle biopsy
5 Highly suspicious of malignancy: appropriate action should be
be taken. Biopsy and treatment, as necessary.
6. Known biopsy-proven malignancy, treatment pending.
BI-RADS, American College of Radiology Breast Imaging Reporting and Data System; RCRBG, Royal College of Radiologists Breast Group.
Adapted from Maxwell AJ, Ridley NT, Rubin C, Wallis MG, Gilberte FJ, Michell MJ. The Royal College of Radiologists Breast Group breast imaging classification. Clinical Radiology
2009;(64):624-7.
Figure 2: Ultrasound image showing an irregular hypoechoic mass, taller than long,
crossing tissue planes, with distal acoustic shadowing typical for carcinoma.
benign lesions may initially have an indeterminate or suspicious
appearance on mammography. Moreover, the Royal College of
Radiologists Breast Group UK have adapted the breast imaging
reporting data systems (BI-RADS) classification to determine if there
is a requirement to further evaluate breast lesions (Table 1). Thus
mammography is commonly the first line investigation for patients
over the age of 35 with breast symptoms and is often followed by
further investigation such as ultrasonography and biopsy for
definitive diagnosis.
Given success in the investigation of symptomatic breast lumps,
mammography was subsequently introduced to screen asymptomatic
women for breast abnormalities. The aim of this strategy is to
diagnose cancers at the earliest possible stage in order to maximise
chances of cure. In support of this, a meta-analysis of seven
multinational randomised controlled trials demonstrated that breast
cancer screening with mammography reduced breast cancer
mortality by 20-30% in women above the age of 50 years [3]. Similar
findings were presented to the Milan Global Summit on
mammographic screening [4]. The National Health Service Breast
Screening Programme (NHSBSP) invites women aged 50-70 years of
age for mammography every three years and over 2.2 million women
were invited for screening in England between 2007 and 2008, an
increase of 5% from the year before and 52.5% over 1997 [1]. This
programme was responsible for the detection of 14,110 cases of breast
cancer out of 1.7 million women screened above the age of 45 years
between 2007 and 2008, double the number detected between 1997
and 1998 [1]. However, part of this increase could also be due to
extension in the age for screening from 64 to 70 years.
Volume 5 Issue 3 • July/August 2010
RCRGB
Normal/no significant abnormality. There is no significant imaging
abnormality.
Benign findings. The imaging findings are benign.
Indeterminate/probably benign findings. There is a small risk
of malignancy. Further investigation is indicated.
Findings suspicious of malignancy. There is a moderate risk of
malignancy. Further investigation is indicated.
Findings highly suspicious of malignancy. There is a high risk of
malignancy. Further investigation is indicated.
Recent advances in mammography including digital images and
computer-aided detection have been investigated to determine their
role in improving success of screening. The digital mammography
imaging screening trial (DMIST) conducted by the American college
of radiology imaging network (ACRIN) over a two year period
involving 49,528 women revealed that digital mammography is more
sensitive than conventional plain film mammography in patients
under the age of 50 years and in those with radiographically denser
breasts [5-7]. Digital mammography provides easier access, storage
and retrieval of images and makes teleradiology possible. More
importantly, there will be improved diagnostic accuracy by means of
transmission and manipulation of images.
Screening mammograms in the UK are typically read by two
radiologists, or non radiologist screen readers. The sensitivity is
increased by 5-15% in detecting malignant lesions when reviewed in
this way.[8-10] However, this approach requires increased resources
and recent age extension in breast screening has increased workload
and provides a challenging task. Computer-aided detection (CAD)
may represent a solution to these challenges. CAD systems use
computer algorithms to analyse digital mammographic images by
identifying and marking suspicious areas to the reader. In support of
this, several studies have been performed in the UK and US regarding
the sensitivity and specificity of CAD systems. Cancer Research UK
invited 28,000 women to have their mammograms read both by the
conventional two radiologist reader method and via computer-aided
detection using only a single radiologist. The outcomes were
presented at the National Cancer Research Institute’s conference in
Birmingham in October 2008. Single reading with CAD was found to
be as sensitive as the conventional method. A similar study,
computer-aided detection trial (CADET) II involved over 30,000
women in England to determine if the performance of a single reader
using computer-aided detection system would match the
performance achieved by two radiologist readers [11]. The conclusion
was similar to Cancer Research UK. Based on current evidence, there
may be a role for CAD in breast screening reporting. However, the
implementation of this new technology will take time due to the cost
involved. There is also a known increased rate of false positive
results, recall and biopsy procedures with CAD [12-15]. This will
directly increase the requirement for further investigations and
increase patient anxiety. It has also been suggested that single
reading with CAD doubles the reading time therefore making it no
more time efficient.
Ultrasound
Ultrasonography of the breast is the second most common imaging
modality used in the investigation of breast lumps. It is a relatively
simple, straightforward and inexpensive imaging technique that does
83
 age of 35 years, who commonly have denser
breast tissues and benign breast lesions that
make interpretation of mammograms
difficult. It can also be used in evaluating
the post mastectomy scar site to assess
palpable lesions suspicious of recurrence.
Often these are due simply to fibrous
scarring but to exclude local recurrence, an
ultrasound guided biopsy is frequently
required for a definitive diagnosis.
Further applications of this modality have
evolved since the emergence of sentinel
lymph node biopsy as an increasingly
accepted standard of care for treatment of
the ipsilateral axilla during surgery for
breast cancer. This has resulted in increased
use of ultrasound assessment of the axilla as
part of the pre-surgical work up of breast
Figures 3a: Contrast enhanced MRI showing an enhancing irregular mass with a spiculated margin in the outer left cancer. Fine needle aspiration and/or core
breast with a corresponding type 3 dynamic enhancement curve typical of a carcinoma. biopsy of any detectable axillary lymph
nodes is performed at the time of diagnosis
and involvement precludes a sentinel lymph
node procedure. The typical appearances of
a malignant lymph node are thickened or
eccentrically bulging cortex and a
diminished or absent fatty hilum. There is a
wide range of sensitivity and specificity in
ultrasound of the axilla ranging from 57-
92% and 44-100% due to the use of
different morphology, sonographic criteria
and subjectivity in the interpretation of the
images [18-22]. BI-RADS category 5 lesions
have an overall sensitivity and specificity of
94% and 89%, respectively, with a positive
predictive value of 97% and negative
predictive value of 80% [18].
The major limitation of ultrasound is that
unfortunately it is not sensitive in detecting
the microcalcifications of early cancer and
ductal carcinoma in situ (DCIS) therefore it
is not appropriate as a widespread screening
technique.

Magnetic resonance imaging (MRI)

MRI is a noninvasive imaging modality
which uses a powerful magnetic field and
Figure 3B: Examples of normal, benign and malignant appearances in the dynamic enhancement curves. radio frequency pulses to produce detailed
Type 1: Steady enhancement - persistent gradual increase in signal intensity, typically seen with normal and images of the breast. The major benefit of
benign entities.
Type 2: Plateau - early increased enhancement with maximum signal intensity achieved after two minutes which this technique involves the use of
plateaus and remains constant, typically seen in fibroadenomas (benign), but can be seen in some carcinomas intravenous contrast agents such as
(malignant). gadolinium due to the fact that invasive
Type 3: Washout - early increased enhancement with maximum signal by two minutes which washes out and
decreases over time, typically seen in malignant lesions. breast cancers have increased vascularity
Adapted from E.A. Morris and L. Lieberman. Breast MRI - Diagnosis and Intervention. 2005 ISBN 0-387-21997-8. and permeability resulting in early uptake
and early washout of contrast agents (Figure
3a and 3b). MRI also images the breast in
not involve ionising radiation. However, the solid breast masses were established in multiple planes with delineation of soft
major drawback is that it is operator 1995. Using specific criteria solid lesions can tissues allowing detection of small cancers.
dependent and should only be performed by be broadly categorised into malignant, A number of potential applications of MRI
experienced radiologists and sonographers indeterminate and benign categories. The scanning in the detection and management of
familiar with breast imaging and features suggestive of a malignant lesion breast cancer have been suggested. For
intervention. It is more commonly used as include spiculated margin, posterior example, MRI may be potentially useful in the
an adjunct to mammography in the acoustic shadowing, microcalcifications, pre-operative assessment by accurately
evaluation of focal masses and to determine duct extension, microlobulation, angular delineating disease and identifying multifocal
solid or cystic characteristics. It is also margins, marked hypoechogenicity and lesions. This question was prospectively
particularly valuable in guidance of taller-than-long (not parallel) orientation examined in the COMICE trial that
interventional procedures and has been (Figure 2a) [16]. randomised 1623 patients with biopsy proven
shown to be a safe and accurate means of Ultrasound can be particularly useful as a primary breast cancer, scheduled for wide
guiding fine needle aspiration and core first line investigation tool and is a preferred local excision following triple assessment
biopsy to obtain cytohistopathology. imaging modality to evaluate palpable between December 2001 and January 2007
The ultrasound criteria for characterising masses or nodularity in women under the [23]. The aim of this study was to determine

84 Volume 5 Issue 3 • July/August 2010

if MRI with triple assessment reduced the rate
of reoperation within six months or rate of
avoidance of mastectomy at initial surgery.
Patients were randomised to receive
additional imaging by the means of MRI and
triple assessment or triple assessment only.
The results revealed that the addition of MRI
to prior to surgery did not significantly alter
patient management and reoperation rates
were similar in both groups.
A further potential application of MRI
scanning is to improve screening detection
rates especially in patients at high risk of
breast cancer (e.g. a positive gene test or
strong family history). Previous systematic
reviews of the relevant literature have
summarised data from 11 prospective studies
and conclude that screening high risk women
for breast cancer with both MRI and
mammography is more effective than
mammography alone [24,25]. Sensitivities
were quoted to range from 80-100% for the
combination examination and 25-59% for
mammography alone [24,25]. One of the
largest studies in this area is the multicentre
MARIBS (MAgnetic Resonance Imaging for
Breast Screening) that compared standard
mammographic screening with MRI in 649
high risk women between the ages of 35-49
years. In this study, mammography
successfully identified only 40% of the
tumours compared to 77% detected by MRI.
The sensitivity of MRI was even higher in
BRCA1 mutation carriers at 92% compared to
23% with mammography [26]. The authors
of this study concluded that MRI is superior
to mammography in this population of high
risk patients. This and other studies have
resulted in a number of national societies
developing guidelines for use of MRI in
screening for breast cancer such as the
American Cancer Society (ACS) and National
Comprehensive Cancer Network (NCCN)
and NICE. The ACS and NCCN recommend
use of MRI as an adjunct to mammography
for patients with documented BRCA
mutation, untested women with first degree
relative with BRCA mutation, women with
lifetime risk of developing cancer >20-25%
(calculated from family and personal history)
and women who previously received
radiation to chest between the ages of 10-30
years. In the UK, NICE recommends offering
MRI screening to women according to their
age and risk.
In addition to primary screening of a high
risk group, MRI has also been evaluated in
follow-up screening of patients. The
American College of Radiology Imaging
Network (ACRIN) conducted a study of 969
patients with a previous diagnosis of
unilateral breast cancer and no
abnormalities on either mammogram or
clinical examination of the contralateral
breast. Lesions requiring biopsy were
detected in 121 of women of which 30 of
these being positive for cancer. Eighteen
were invasive carcinoma, whilst the
remaining 12 were ductal carcinoma in situ.
The authors concluded that MRI could
detect cancers in the contralateral breast
that were missed by mammography and
clinical examination [27].
Taken together, these results suggest that
the place of MRI in breast cancer screening
has yet to be fully defined. MRI has
demonstrated value in detecting some
cancers not apparent by clinical
examination and mammography especially
in high risk patients but it should also be
noted that MRI may not detect some lesions
that are detected via mammography and as
yet none of the studies have demonstrated
any mortality reduction from MRI screening.
Thus in current practice mammography
remains the first line imaging investigation
in the search for breast cancer.
Conclusion
Breast imaging plays a crucial role in the
management of breast cancer. The gold
standard is mammography but other
modalities such as ultrasound, MRI and
nuclear medicine are useful or potential
adjuncts to diagnosis. In the future other
modalities including computerised
tomography and nuclear medicine could
provide support in staging and determining
response to treatment. Therefore, it is
important that clinicians are fully aware of
the benefits and limitations of each imaging
modality. n

References

1. National Statistics. Breast Screening Programme England 2007-2008.
2. Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined effects
of age, breast density, and hormone replacement therapy use on the accuracy of
screening mammography. Ann Intern Med 2003;138:168–75.
3. Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a
summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern
Med 2002;137:347–60.
4. Boyle P. Global summit on mammographic screening. Annals of Oncology
2003;14:1159-60.
5. Pisano ED et al. Diagnostic Performance of Digital versus Film Mammography for
Breast-Cancer Screening. N Engl J Med 2005;353(17):1773-83.
6. Pisano ED et al. Cancer cases from ACRIN digital mammographic imaging
screening trial: radiologist analysis with use of a logistic regression model.
Radiology. 2009;252(2):348-57.
7. Pisano ED et al. Diagnostic accuracy of digital versus film mammography:
exploratory analysis of selected population subgroups in DMIST. Radiology.
2008;246(2):376-83.
8. Gilbert FJ et al. Single Reading with Computer-aided Detection and Double
Reading of Screening Mammograms in the United Kingdom National Breast
Screening Program. Radiology, 2006;241:47-53.
9. Harvey SC, Geller B, Oppenheimer RG, Pinet M, Riddell L, Garra B. Increase in
cancer detection and recall rates with independent double interpretation of
screening mammography. AJR Am J Roentgenol 2003;180:1461–7.
10. Blanks RG, Wallis MG, Moss SM. A comparison of cancer detection rates achieved
by breast cancer screening programmes by number of readers, for one and two
view mammography: results from the UK National Health Service breast screening
programme. J Med Screen 1998;5:195–201.
11. Gilbert FJ et al. Single Reading with Computer-Aided Detection for Screening
Mammography. NJEM 2008;359:1675-84.
12. Fenton el al. Influence of Computer-Aided Detection on Performance of Screening
Mammography. NJEM 2007;356(14):1399-409.
13. Cupples TE, Cunningham JE, Reynolds JC. Impact of computer-aided detection in
a regional screening mammography program. AJR Am J Roentgenol
2005;185:944-50.
14. Freer TW, Ulissey MJ. Screening mammography with computer-aided detection:
prospective study of 12,860 patients in a community breast center. Radiology
2001;220:781-6.
15. Khoo LA, Taylor P, Given-Wilson RM. Computer-aided detection in the United
Kingdom National Breast Screening Programme: prospective study. Radiology
2005;237:444-9.
16. Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid
breast nodules: use of sonography to distinguish between benign and malignant
lesions. Radiology 1995;196:123 –34.
17. Abe H et al. US-guided Core Needle Biopsy of Axillary Lymph Nodes in Patients
with Breast Cancer: Why and How to Do It. RadioGraphics, 2007;27:S91-S99.
18. Duchesne N, Jaffey J, Florack P, Duchesne S. Redefining ultrasound appearance
criteria of positive axillary lymph nodes. Can Assoc Radiol J. 2005;56:289-96.
19. Deurloo EE, Tanis PJ, Gilhuijs KG, et al. Reduction in the number of sentinel
lymph node procedures by preoperative ultrasonography of the axilla in breast
cancer. Eur J Cancer 2003;39:1068–73.
20. Sapino A, Cassoni P, Zanon E, Fraire F, Croce S, Coluccia C, et al.
Ultrasonographically-guided fine-needle aspiration of axillary lymph nodes: role in
breast cancer management. Br J Cancer 2003;88:702–6.
21. Kuenen-Boumeester V, Menke-Pluymers M, de Kanter AY, Obdeijn IM, Urich D,
Van Der Kwast TH. Ultrasound-guided fine needle aspiration cytology of axillary
lymph nodes in breast cancer patients. A preoperative staging procedure. Eur J
Cancer 2003;39:170–4.
22. Podkrajsek M, Music MM, Kadivec M, et al. Role of ultrasound in the
preoperative staging of patients with breast cancer. Eur Radiol. 2005;15:1044-50.
23. Turnbull LW, Brown SR, Olivier C, Harvey I, Brown J, Drew P, Hanby A, Manca
A, Napp V, Sculpher M, Walker LG and Walker S, on behalf of the COMICE Trial
Group. Multicentre randomised controlled trial examining the cost-effectiveness of
contrast-enhanced high field magnetic resonance imaging in women with primary
breast cancer scheduled for wide local excision (COMICE). Health Technol Assess
2010;14(1):1-182.
24. Warner E, Messersmith H, Causer P, Elsen A, Shumak R and Plewes D.
Systematic review: Using magnetic resonance imaging to screen women at high
risk for breast cancer. Ann Intern Med 2008;148:671-9.
25.Lord SJ, Lei W, Craft P, Cawson, JN, Morris I, Walleser S, Griffiths A, Parker S
and Houssami N. A systematic review of effectiveness of magnetic resonance
imaging (MRI) as an addition to mammography and ultrasound in screening
young women at high risk of breast cancer. Eur J Cancer 2007;43:1905-17.
26. Leach MO. MRI for breast cancer screening. Annals of Oncology 17 (Supplement
10): 2006.
27. Lehman CD et al. MRI evaluation of the contralateral breast in women with
recently diagnosed breast cancer. N Engl J Med. 2007 Mar 29;356(13):1295-303.

Volume 5 Issue 3 • July/August 2010 85

Colorectal Cancer
Andrew Riddell,
MB ChB MRCS, SpR
Colorectal Surgery,
The Royal Free Hospital,
London.
Richard Novell,
MChir FRCS,
Consultant Coloproctologist
The Royal Free Hospital,
London.
Correspondence:
Richard Novell,
University Dept. of Surgery,
The Royal Free Hospital,
Pond St,
London NW3 2QG, UK.
86
Developments in the Radiological
Management of Rectal Cancer
C
olorectal cancer (CRC) is one of the
commonest malignancies throughout the
world, affecting two thirds of a million people
every year and resulting in 400,000 deaths
worldwide [1]. In the UK colorectal cancer has a
mortality rate second only to lung cancer, with rectal
cancers comprising approximately 40% of the total.
The management of rectal cancer has steadily
advanced over the last two decades since Quirke et al
demonstrated the importance of local recurrence
following surgical resection [2], leading to the
widespread adoption of total mesorectal excision
(TME) [3] as a gold standard. TME has led to a
reduction in local recurrence rate from over 20% to
less than 10% [4]. There has also been a steady
increase in the rate of anterior resection (which
restores bowel continuity) and a decrease in the rate of
abdomino-perineal resection and permanent
colostomy for low rectal tumours. This has been due in
part to patient choice and the evolution of better
stapling devices to facilitate low colo-anal anastomosis
but principally as a result of increasing specialisation of
surgeons. A 1cm distal resection margin is now
considered safe, allowing ultra-low rectal resection
with preservation of the anal sphincter. The successful
application of TME requires an adequate, tumour-free
radial resection margin to demonstrate the benefits of
enhanced disease-free survival, and accurate
preoperative imaging is essential for both selection of
the correct operation and of appropriate pre- and post-
operative oncological management.
Imaging techniques
Endorectal ultrasound is the oldest tool for
evaluation of rectal cancer and in experienced hands
can be very accurate at assessing the tumour (T)
stage. However it can be difficult or impossible to
perform in very low or stenosing tumours, poorly
tolerated by patients and limited by both depth of
scan and examiner experience.
Computerised tomography (CT) is superior to other
modalities in scanning the entire abdomen, thorax
and pelvis for metastatic disease but is of limited
accuracy in staging rectal cancers. Older studies report
low accuracy in assessment of T stage with rates of 52-
70%. This has improved with newer scanners and
scanning techniques but even recent studies have
shown that CT does not correlate well enough with
the superior results of magnetic resonance imaging to
replace it in rectal cancer staging [5].
MRI allows the surgeon to differentiate between favourable and
unfavourable rectal tumours by accurately predicting R0 and R1
resections and therefore disease-free survival
Over the last decade advances in the resolution of
magnetic resonance imaging (MRI), particularly the
development of phased array surface coils, coupled
with increasing availability have led to MRI of the
pelvis becoming a standard part of pre-operative
staging in rectal cancer. This evolution in imaging and
pre-operative staging has mirrored that of TME in
colorectal surgery. The UK National Institute for
Clinical Effectiveness (NICE) guidelines now state that
all patients with invasive rectal cancers for whom
surgery is being considered should undergo MRI
scanning.
Surgical circumferential resection margin (CRM)
The mesorectal fascia is a thin layer enveloping the
fatty mesorectum, which in turn surrounds the
smooth muscle of the rectal wall. High resolution
MRI consistently demonstrates this mesorectal plane
which marks the circumferential resection margin
following optimal surgery [6]. Images recorded in a
plane perpendicular to the rectum and mesorectum
correspond precisely to equivalent radial slices
through the histological specimen [7].
Because MRI is unique amongst scanning
modalities in identifying the mesorectal fascia and
because a competent TME will proceed along this
plane, the CRM may be accurately predicted pre-
operatively [8]. In 2001 Beets-Tan demonstrated that
although MRI staging of rectal tumours had a
moderate accuracy (67-83%) in predicting
histological stage [9], the more important CRM was
predictable with a high degree of accuracy and
consistency, a tumour-free margin of only 2mm
being predicted with an accuracy of 97%.
Preoperative staging
The purpose of preoperative staging is to predict the
histological extent of the tumour and thus the
likelihood of local recurrence and disease free
survival. The presence or absence of residual tumour
following surgical resection strongly determines future
outcome. The American Joint Committee on Cancer
Prognostic Factors Consensus Conference defines R0
as the absence of residual disease, R1 as residual
microscopic disease and R2 as residual macroscopic
disease. MRI allows the surgeon to differentiate
between favourable and unfavourable rectal tumours
by accurately predicting R0 and R1 resections and
therefore disease-free survival (Figure 1).
The MERCURY trial demonstrated that MRI
Volume 5 Issue 3 • July/August 2010

Figure 1: Tumour of middle third of rectum extending through the rectal wall but not invading the mesorectal
fat which appears white on MRI: predicted R0 resection (negative CRM involvement).
predicts extension beyond the rectal wall to
within 0.5mm tolerance[6]. With increasing
confidence in the ability of MRI to predict
radial clearance between tumour and CRM
some groups are now limiting the
indications for pre-operative radiotherapy
(designed to downstage the tumour and
improve resectability) to tumours extending
to within 1mm of the mesorectal fascia[10]
as a minimum distance of 1 mm appears to
discriminate between those patients with a
high (85%) or low (3%) risk of local
recurrence[2]. However, a recent review of
the worldwide literature reveals variation in
the precise definition of a positive CRM[11].
Additional Advantages of MRI
As an investigation MRI is fast (taking 20-
30mins including planning), generally well
tolerated by patients and involves no
exposure to ionising radiation. In addition
to defining the CRM, MRI also provides
information regarding depth of invasion,
involvement of other organs such as
prostate and anal sphincters, extramural
venous invasion and involvement of the
peritoneal reflection for tumours of the
middle third of the rectum.
Abdomino-perineal excision (APE) is now
undertaken infrequently for very low rectal
tumours involving the levator plate (pelvic
floor) or anal sphincter muscles and the
resection margins are thus different to those
in anterior resection. The mesorectum
becomes increasingly attenuated distally,
disappearing completely just above the anus
Volume 5 Issue 3 • July/August 2010
at the level of the pelvic floor: it therefore
presents less of a barrier to radial spread of
tumours at this level, particularly anteriorly.
Technical difficulties relating to surgical
access to the lower rectum, particularly in
the narrow male pelvis, may increase the
risks of incomplete tumour clearance. The
structures of the lower rectum are well
identified at MRI which can demonstrate
possible lines of surgical excision by
defining sphincter and levator plate
involvement[6]. Through careful selection
of candidates for radical APE it is to be
hoped that MRI can facilitate a reduction in
positive CRM rates comparable to that seen
in anterior resection with TME.
Limitations
Although MRI is currently the best option for
preoperative staging of rectal cancers, some
limitations remain. Due to the enclosed
design of present scanners MRI is not well
tolerated by claustrophobic patients. It
cannot at present detect small-volume
peritoneal invasion, nor demonstrate
microscopic tumour invasion within peri-
tumoral fibrosis. In patients with disease
encroaching on the mesorectum and little
fibrotic stranding this may lead to incorrect
tumour staging, but is usually of little
consequence in predicting resection margin
[9]. Although accurate pre-op staging of
lymph node spread with MRI is currently a
significant limitation of the procedure, the
use of ultra-small super-paramagnetic iron
oxide particles (USPIO) as a contrast
medium for MR lymphography has shown
some promising initial results. The particles
are taken up by nodal macrophages and give
a decreased signal in normal or relatively
unchanged lymph nodes [12].
Conclusion
Over the last decade MRI has proved itself
superior to all other modalities for pre
operative imaging of rectal cancer. Rectal
MRI has been demonstrated to be an
accurate predictor of a positive surgical CRM,
thus allowing the correct choice of both
operation and adjuvant therapy (usually pre-
operative radiotherapy in Europe or post
operative therapy in the USA). This ability to
predict the likelihood of complete tumour
resection and therefore disease-free survival
is vital in ensuring both adequate treatment
where necessary and the avoidance of
overtreatment and its attendant morbidity. n
References
1. McArdle C. ABC of colorectal cancer: primary
treatment-does the surgeon matter? BMJ. 2000
Nov 4;321(7269):1121-3. Review. No abstract
available.PMID: 11061734.
2. Quirke P, Durdey P, Dixon MF, Williams NS.
Local recurrence of rectal adenocarcinoma due to
inadequate surgical resection: histopathological
study of lateral tumour spread and surgical
excision. Lancet 1986;ii:996-9.
3. MacFarlane JK, Ryall RD, Heald RJ. Mesorectal
excision for rectal cancer. Lancet 1993 Feb
20;341(8843):457-60.PMID: 8094488.
4. Klessen C, Rogalla P, Taupitz M. Local staging of
rectal cancer: the current role of MRI. Eur Radiol.
2007 Feb;17(2):379-89. Epub 2006 Sep 29.
Review.PMID: 17008990.
5. Maizlin ZV, Brown JA, So G, Brown C, Phang
TP, Walker ML, Kirby JM, Vora P, Tiwari P. Can
CT replace MRI in preoperative assessment of the
circumferential resection margin in rectal cancer?
Dis Colon Rectum. 2010 Mar;53(3):308-14.PMID:
20173478.
6. Salerno G, Daniels IR, Moran BJ, Wotherspoon
A, Brown G. Clarifying margins in the
multidisciplinary management of rectal cancer:
the MERCURY experience. Clin Radiol. 2006
Nov;61(11):916-23. Review.PMID: 17018303.
7. Brown G, Daniels IR, Richardson C, Revell P,
Peppercorn D, Bourne M. Techniques and
trouble-shooting in high spatial resolution thin
slice MRI for rectal cancer. Br J Radiol. 2005
Mar;78(927):245-51.PMID: 15730990.
8. Goh V, Halligan S, Bartram CI. Local radiological
staging of rectal cancer. Clin Radiol. 2004
Mar;59(3):215-26. Review.PMID: 15037133.
9. Beets-Tan RG, Beets GL, Vliegen RF, Kessels AG,
Van Boven H, De Bruine A, von Meyenfeldt MF,
Baeten CG, van Engelshoven JM. Accuracy of
magnetic resonance imaging in prediction of
tumour-free resection margin in rectal cancer
surgery. Lancet. 2001 Feb 17;357(9255):497-
504.PMID: 11229667.
10. Rödel C, Sauer R, Fietkau R. The role of
magnetic resonance imaging to select patients
for preoperative treatment in rectal cancer.
Strahlenther Onkol. 2009 Aug;185(8):488-92.
Epub 2009 Aug 4. Review. German.PMID:
19652930.
11. Glynne-Jones R, Mawdsley S, Novell JR. The
clinical significance of the circumferential
resection margin following pre-operative pelvic
chemo-radiotherapy in rectal cancer: why we
need a common language. Colorectal Disease
2006;8:800-7.
12. Koh DM, Brown G, Temple L, Raja A, Toomey P,
Bett N, Norman AR, Husband JE. Rectal cancer:
mesorectal lymph nodes at MR imaging with
USPIO versus histopathologic findings--initial
observations. Radiology. 2004 Apr;231(1):91-9.
Epub 2004 Feb 19.PMID: 14976266.
87
Sponsored Feature
First-line maintenance (1LM) treatment:
a new strategy to treat advanced NSCLC
L
ung cancer is the most common
cause of cancer death in men and
women, both worldwide [1] and
in the UK [2], with non-small-cell
lung cancer (NSCLC) accounting
for approximately 85% of cases [3]. Most
patients present at an advanced, inoperable
stage of disease with no prospect of cure
and a poor prognosis. Most patients die
within five years of diagnosis.
The current standard front-line treatment
for advanced NSCLC is with 4–6 cycles of a
modern platinum-based chemotherapy
regimen, which offers a modest survival
benefit and improvements in patient quality
of life (QoL) over best supportive care (BSC)
[4,5]. This is despite the recent
identification of patients with activating
Epidermal Growth Factor Receptor (EGFR)
mutations, who survive significantly longer
and achieve dramatically high response
rates when treated with EGFR tyrosine
kinase inhibitors (TKIs) compared with
chemotherapy, although EGFR-mutant-
positive (EGFR-mut+) tumours are only
seen in around 8% of the non-Asian
population of lung cancer patients [6] and
overall prognosis remains poor. For patients
who have a measurable response or who
have disease stabilisation following first-line
(1L) treatment, adopting a ‘watch-and-wait’
policy has generally been the customary
approach. However, response rates for 1L
chemotherapy are low (20–40%), prognosis
remains poor, with a median survival time
of 7–12 months [7,8], and most patients will
eventually experience disease progression.
Extending 1L chemotherapy beyond 4–6
cycles is not recommended because
cumulative toxicities and impaired QoL
outweigh any potential advantage in
progression-free survival (PFS) and overall
survival (OS) that may be gained with the
increased duration of therapy [9,10].
For patients with evidence of disease
progression after initial chemotherapy,
second-line (2L) treatment confers benefits
and should be offered to those patients with
a good performance status (PS) [4,5,11].
However, studies have shown that only
30–50% of patients that received 1L
treatment went on to get 2L therapy [12–14]
due to rapid disease progression, worsening
of symptoms and declining PS, which
reduce the opportunity to administer 2L
treatment. Consequently, better processes to
This article was commissioned by Roche Products Ltd. Medical writing support was provided by Darwin Healthcare Communications
and was paid for by Roche Products Ltd however the views expressed are those of the author
88
By
Dr Siow Ming Lee, PhD, FRCP
Consultant Medical Oncologist,
University College London Hospitals and
UCL Cancer Institute,
London, UK.
identify disease progression earlier, as well
as better treatment options, are needed to
improve outcomes for patients with NSCLC
after 1L therapy.
In recent years, investigations have
focused on 1L maintenance (1LM)
treatment following 1L chemotherapy in an
attempt to improve disease control rates and
survival because of the availability of better
tolerated 2L treatment drugs. In 2009 two
large, phase III trials demonstrated the
clinical benefits, including significant OS
benefits, of 1LM therapy with pemetrexed
and erlotinib, two agents that are well-
established treatments for NSCLC. As a
result of these landmark trials, both agents
have had their licensed indications extended
to include 1LM treatment of NSCLC. This
article examines the current evidence for
1LM treatment for advanced NSCLC,
reviews the role of this treatment strategy in
current clinical practice and considers how
the implementation of 1LM is likely to
impact on the way patients are treated in
future.
The concept of 1LM treatment
Maintenance therapy is defined by the
National Cancer Institute as treatment given
to help keep cancer from returning after it
has responded to initial therapy. The goals
of maintenance are to prolong survival, and
improve or maintain QoL. There are two
forms of maintenance therapy: continuation
maintenance and switch maintenance.
Continuation maintenance therapy is
defined as continuation of one of the agents
given as 1L treatment after 4–6 cycles of
initial therapy in the absence of disease
progression. One of the earliest studies to
suggest that continuation maintenance is
effective is the Eastern Cooperative
Oncology Group (ECOG) 4599 study, a
phase III, randomised study of 878 patients
who received 1L paclitaxel-carboplatin
therapy (6 cycles) with or without
bevacizumab, which was continued until
disease progression. A significant 2-month
OS benefit was seen with bevacizumab (p
= 0.003) [15]. Another maintenance trial
with the biologic agent, cetuximab,
significantly prolonged OS by 1.2 months (p
= 0.044) in patients following cisplatin-
vinorelbine-cetuximab 1L treatment [16].
However, there is no direct comparison of
maintenance vs no maintenance with these
biological agents after initial therapy and the
contribution of each drug to the
maintenance effect remains unclear. Unlike
the survival benefits reported with
biological agents as continuation
maintenance, this approach with cytotoxic
agents used in 1L chemotherapy remained
unproven [17,18]. Furthermore, recent data
from two maintenance trials reported at
ASCO in 2010 with gemcitabine
maintenance after initial platinum-
gemcitabine chemotherapy did not show
survival benefits, though one trial
demonstrated an improvement in PFS but at
the expense of increased toxicity [19,20].
In contrast to continuation maintenance,
more encouraging results are reported with
the switch maintenance approach. This is
defined as the initiation of a different agent,
not included as part of the 1L regimen, after
4–6 cycles of initial therapy in the absence
of disease progression. In a study reported
by Fidias and colleagues, comparing
immediate with delayed docetaxel
(essentially, maintenance vs conventional
2L treatment) after 1L gemcitabine-
carboplatin, docetaxel maintenance was
associated with statistically improved PFS
and a trend to improved OS. The latter was
due towards the fact that more patients in
the immediate arm (94.8%) received
docetaxel compared with those who
received 2L treatment (62.8%). However if
the analysis included only patients
receiving 2L treatment, OS time was similar
in both arms [21].
Currently there are two FDA- and EMEA-
approved indications for pemetrexed and
erlotinib as ‘switch’ maintenance after
response and/or stable disease (SD)
following 1L chemotherapy, based on the
JMEN and SATURN trials, respectively.
These trials will be examined in more detail
and compared with conventional 2L
treatment.
Volume 5 Issue 3 • July/August 2010

1LM vs early 2L: Assessing the evidence
JMEN
This randomised, double-blind trial
compared pemetrexed 1LM with placebo in
663 patients with stage IIIB/IV disease (PS
0–1) that had not progressed after 4 cycles
after platinum-based chemotherapy (the
regimens used did not include pemetrexed).
Maintenance pemetrexed significantly
improved median PFS by 1.7 months (p <
0.0001) and median OS by 3.2 months (p =
0.012) with pemetrexed [22]. In a further
report, the survival benefits of pemetrexed
were demonstrated only in the subgroup of
patients with non-squamous histology in the
1L (hazard ratio [HR], 0.84, p = 0.011) and
2L (HR 0.78, p = 0.048) settings [23] and
this finding was confirmed in the
maintenance setting (5.2 month
improvement in median OS, HR 0.70, p =
0.002) [22]. Subgroup analysis of OS revealed
a greater benefit for patients with SD
following 1L treatment compared with those
who had a complete or partial response
(CR/PR; HR 0.68 vs 0.9) [24]. Unfortunately
only 18% of patients in the placebo arm
received 2L pemetrexed [22] and this perhaps
had an impact on OS. Pemetrexed is licensed
in Europe for the treatment of locally
advanced or metastatic NSCLC other than
predominantly squamous cell histology [25].
SATURN
SATURN was a randomised, double-blind
trial that compared erlotinib 1LM vs placebo
in 889 patients with stage IIIB/IV disease that
had not progressed after 4 cycles of platinum-
based chemotherapy. Erlotinib demonstrated
a significant 29% improvement in PFS vs
placebo and benefit was also seen across the
majority of patient subgroups, irrespective of
histology, race, gender or smoking status. A
modest improvement in OS was also seen
with erlotinib vs placebo, with a 19%
reduction in risk of death (median OS 12.0 vs
11.0 months, respectively). A survival benefit
was also seen with erlotinib in the subgroup
of patients with EGFR wild-type tumours (HR
0.77, p = 0.02). When analysed according to
response to 1L chemotherapy, patients with
SD had a significantly greater survival benefit
with erlotinib vs placebo (median 11.9 vs 9.6
months; p = 0.0019) than patients with
CR/PR [26]. In fact, erlotinib conferred the
greatest OS benefit in the SD group (HR 0.72)
and on the basis of these data was licensed
as maintenance treatment in patients with SD
after 4 cycles of standard platinum-based 1L
chemotherapy [27]. As expected, erlotinib
maintenance was highly effective in patients
with activating EGFR mutations (PFS HR
This article is supported by Roche Products Ltd
Volume 5 Issue 3 • July/August 2010
Table 1: Progression-free survival (PFS) and overall survival (OS) in the intent-to treat (ITT) and
licensed populations in trials of 1LM treatment
Maintenance treatment PFS*
Erlotinib (vs placebo)
ITT population [26] 0.71
Stable disease population [34] 0.68
Pemetrexed (vs placebo) [22]
ITT population 0.50
Non-squamous population 0.44
Docetaxel
(immediate vs delayed) [21] 5.7 vs 2.7 months
Gemcitabine
(vs BSC) [19] 3.9 vs 3.8 months
Gemcitabine
(vs observation) [20] 0.55
*Values are hazard ratios unless otherwise stated. BSC, best supportive care; NR, not reported; NS, not significant.
0.10, p < 0.0001) [26] but it can be argued
that these patients should be treated with a
TKI upfront, based on the IPASS [28] and
Spanish Lung Cancer Group data [29]. In
SATURN, only 21% of the patients in the
placebo arm went on to receive subsequent
treatment with a TKI and this may explain
the OS benefit seen in the trial [26].
Both the JMEN and SATURN trials
demonstrated a significant improvement in
PFS and OS with 1LM treatment (compared
with placebo) (Table 1). However, it must be
emphasised that less than 50% of the
patients who received 1L chemotherapy in
both JMEN and SATURN went on to receive
maintenance treatment, and these results
are, therefore, not comparable to 1L
treatment trials because of the selection of
only those patients with SD or CR/PR for
subsequent maintenance therapy.
Who is eligible for 1LM treatment?
Current evidence from JMEN and SATURN
indicates that 1LM offers many patients the
chance to receive further effective therapy
that can improve survival, especially patients
with SD after initial chemotherapy. For
oncologists, the introduction of maintenance
increases the number of available therapy
options and several factors must be taken into
consideration when deciding who to treat in
this setting.
The JMEN and SATURN trials did not ask a
clear question of switch maintenance vs early
2L treatment because patients in the placebo
arms were not required to switch to the
effective drug after progression. Evidence
shows that switch maintenance improves PFS
and OS with pemetrexed and erlotinib but
these agents do have side effects, and there is
no evidence to show that patients receiving
active treatment have an improved QoL. It is
possible that patients live just as long if they
Sponsored Feature
p value OS* p value
< 0.0001 0.81 0.0088
< 0.0001 0.65 0.0041
< 0.0001 0.79 0.012
< 0.0001 0.70 0.002
0.0001 12.3 vs 9.7 months 0.0853
NS 0.97 0.84
< 0.0001 0.86 NR
are actively monitored and receive an active
2L treatment immediately on progression. An
overview of PFS and OS in trials of four
agents currently licensed for 2L treatment
(Table 2) suggests that receiving effective
treatment in the 2L treatment setting prolongs
survival. Whether or not 1LM is as effective
as early 2L treatment remains uncertain.
What is clear, however, is that patients should
be given the opportunity to receive additional
therapy while they are fit enough to do so.
Receiving maintenance therapy allows many
patients to be treated with further lines of
effective therapy after progression. In SATURN,
71% of the patients who received active 1LM
went on to receive further post-study treatment
[26], indicating clear benefits of 1LM for eligible
patients, in addition to 2L or subsequent
treatment. If patients are symptomatic,
improving PFS may be beneficial, and clinicians
may want to consider maintenance treatment if
it is well tolerated. However, if patients have
significant treatment-related toxicities from 1L
treatment or marginal PS, clinicians may want
to consider a treatment break and to monitor
patients closely for disease progression to
ensure they receive an effective 2L treatment.
Close surveillance with appropriate 2L therapy
given on progression may be just as effective as,
and more cost-effective than, maintenance
therapy. This strategy will allow patient to have
better QoL and fewer side effects from cancer
treatments.
Selecting 1LM treatment
Once eligibility for 1LM has been
established, clinicians must consider which
drug to recommend for a particular patient.
Working within the licensed indications of
the available options, pemetrexed can only
be used in patients with non-squamous
disease, while erlotinib is licensed
specifically for patients with SD following
89
Sponsored Feature
Table 2: Progression-free survival (PFS) and overall survival (OS) in the intent-to treat (ITT)
populations in trials of 2L treatment
2L treatment PFS*
Erlotinib (vs placebo) [31] 0.61
Pemetrexed (vs docetaxel) [30] 0.97
Docetaxel (vs BSC) [35] 10.6 vs 6.7 weeks
(time to progression)
Gefitinib (vs docetaxel) [36] 1·04
Network meta-analysis [37] NR
*Values are hazard ratios unless otherwise stated.
BSC, best supportive care; NR, not reported.
1L chemotherapy. Data from SATURN show
that erlotinib 1LM has shown benefits in all
patients including those with squamous
disease. For patients with non-squamous
disease, both pemetrexed and erlotinib can
be used. Patient preference is an important
consideration in choosing which treatment
will be most suitable for an individual.
Common issues that concern patients
include oral vs IV therapy, dosing regimen,
home- vs hospital-based treatment, and
toxicity profile.
Treatment-related adverse events most
commonly associated with pemetrexed are
fatigue and neutropenia [22,30]. Rash and
diarrhoea are commonly associated with
erlotinib [26, 31]. Pemetrexed must be
administered intravenously and all patients
require administration of pre- or
concomitant medications, including
supplementation with vitamin B12 (prior to
and at intervals during treatment) and folic
acid (during treatment) to reduce the risk of
toxicity, and a corticosteroid on the day
This article is supported by Roche Products Ltd
90
A new concept when choosing 1LM
treatment is the response to 1L chemotherapy.
In both the SATURN and JMEN trials, patients
p value OS* p value with SD after 1L chemotherapy had a more
favourable outcome to 1LM treatment
< 0.001 0.70 < 0.001 compared with patients who had a CR/PR
0.759 0.99 0.226 [24, 26]. SD accounts for at least half of all
outcomes after 1L chemotherapy [21, 22, 26]
0.001 7.0 vs 4.6 months and the evidence suggests that this
(median survival time) 0.047 substantial proportion of patients should be
0·47 1·020 NR considered for 1LM.
Increasingly, the identification of predictive
NR Erlotinib 0.71† NR
biomarkers in NSCLC will play an important
Pemetrexed 0.85†
Docetaxel 0.85† role in treatment decision-making. For
Gefitinib 0.88† patients with activating EGFR mutations, an
EGFR TKI is the most effective treatment and
†
Estimated hazard ratio relative to placebo. should be offered as 1L therapy. A pooled
analysis evaluating clinical outcome in
patients with activating EGFR mutations has
demonstrated longer PFS with erlotinib (13.2
months) and gefitinib (9.8 months) than
chemotherapy (5.9 months) [33]. Gefitinib is
now licensed for 1L treatment in this
subgroup of patients, although to date 1L
gefitinib has demonstrated only a significant
improvement in PFS, and not OS, in the
subgroup of patients with EGFR mutations
[28]. Results from an ongoing, prospective,
phase III study of 1L erlotinib vs platinum
doublet in EGFR-mut+ NSCLC (EURTAC),
initiated by the Spanish Lung Cancer Group,
are expected to be available in the near future
Figure 1: Potential treat- to confirm the IPASS data [28] in a Caucasian
ment algorithm for NSCLC
for UK physicians follow-
population. A similar study in China
ing the recent introduction (OPTIMAL) is also expected to report first
of 1LM treatment. NB. findings later this year. EGFR TKIs are a
Pemetrexed is only licensed
for use in non-squamous
clearly highly effective therapy for EGFR-
disease. mut+ tumours, but these patients comprise
only a small percentage of the total NSCLC
prior to, the day of and the day after population and the majority of patients have
pemetrexed administration to reduce the EGFR wild-type disease. Nevertheless, for
incidence and severity of skin reactions patients with stable, EGFR wild-type disease,
[25]. Erlotinib is a once-daily oral therapy. a significant survival benefit is seen with
Unlike cytotoxic chemotherapy, erlotinib is erlotinib 1LM (HR 0.65, p = 0.0041) [34].
not associated with myelotoxicity, and most
adverse events are mild or moderate [27]. Implications of 1LM on the overall
The chemotherapy agents used as 1L treatment pathway for NSCLC
treatment will also influence the choice of The introduction of 1LM treatment offers
1LM. Currently, using pemetrexed patients an important new therapy option and
maintenance after using pemetrexed in a 1L oncologists must review the way the disease
regimen has not been confirmed as is treated. Instead of 1L chemotherapy,
effective. A randomised, placebo-controlled followed by a period of ‘watch and wait’ until
phase III study of maintenance pemetrexed disease progression and 2L treatment
immediately following induction treatment (assuming the patient is fit enough), a new
with pemetrexed-cisplatin for advanced treatment algorithm is emerging, as outlined
non-squamous NSCLC is currently below and summarised in Figure 1.
underway and results are eagerly
anticipated [32]. Until the results of this First-line treatment
study are known, there is no evidence to Platinum doublet chemotherapy remains the
recommend pemetrexed maintenance after standard of care for most patients.
1L pemetrexed-cisplatin chemotherapy and Pemetrexed is emerging as the treatment of
these patients should be considered for choice for patients with non-squamous
erlotinib maintenance if they have SD. disease, with gemcitabine the choice for
Volume 5 Issue 3 • July/August 2010

squamous histology. For patients with EGFR-
mutation-positive tumours, gefitinib may be
an option.
First-line maintenance
For patients with non-progressive disease
after 1L chemotherapy, current treatment
options are pemetrexed (non-squamous
disease, in patients not getting pemetrexed
1L) and erlotinib (SD), as discussed above.
Second-line treatment
The NICE-approved agents are erlotinib or
docetaxel, although pemetrexed may be an
option where it is funded (e.g. Scotland. In
contrast, NICE does not recommend use of
References
1. Velez M, Belalcazar A, Domingo G, et al. Accelerated
second-line or maintenance chemotherapy versus
treatment at disease progression in NSCLC. Expert Rev
Anticancer Ther 2010;10:549–57.
2. Cancer Research UK. Available at
http://info.cancerresearchuk.org/cancerstats/types/lun
g/mortality/#source1. Last accessed 11 June 2010
3. Herbst RS, Heymach JV, Lippman SM. Lung cancer. N
Engl J Med 2008;359:1367–80.
4. Azzoli CG Baker S Jr, Temin S, et al. American Society
of Clinical Oncology clinical practice guideline update
on chemotherapy for Stage IV non-small-cell lung
cancer. J Clin Oncol 2009;27:6251–66.
5. National Comprehensive Cancer Network (NCCN)
Practice Guidelines in Oncology – v.2.2010. Available at
http://www.nccn.org/professionals/
physician_gls/recently_updated.asp. Last accessed 11
June 2010.
6. Shigematsu H, Lin L, Takahashi T, et al. Clinical and
biological features associated with epidermal growth
factor receptor gene mutations in lung cancers. J Natl
Cancer Inst 2005;97:339–46.
7. Pfister DG, Johnson DH, Azzoli CG, et al. American
Society of Clinical Oncology treatment of unresectable
non-small-cell lung cancer guideline: update 2003. J
Clin Oncol 2004, 22:330–53.
8. Wakelee H, Belani CP: Optimizing first-line treatment
options for patients with advanced NSCLC. Oncologist
2005, 10(Suppl 3):1–10.
9. Von Plessen C, Bergman B, Andresen O, et al. Palliative
chemotherapy beyond three courses conveys no survival
or consistent quality-of-life benefits on advanced non-
small-cell lung cancer. Br J Cancer 2006;95:966–73.
10. Soon YY, Stockler MR, Askie LM, Boyer MJ. Duration
of chemotherapy for advanced non-small-cell lung
cancer: a systematic review and meta-analysis of
randomized trials. J Clin Oncol 2009;20:3277–83.
11. De Marinis F, Grossi F. Clinical evidence for second- and
third-line treatment options in advanced non-small cell
lung cancer. Oncologist 2008;13 (suppl 1):14–20.
12. Lilenbaum RC, Herndon JE, List MA, et al. Single-agent
versus combination chemotherapy in advanced non-
small-cell lung cancer: the cancer and leukemia group B
(study 9730). J Clin Oncol 2005;23:190–6.
13. Fosella F, Pereira JR, von Pawel J, et al. Randomized,
multinational Phase III study of docetaxel plus platinum
combinations versus vinolerbine plus cisplatin for
advanced non-small-cell lung cancer. J Clin Oncol
2003;21:3016–24.
14. Scagliotti GV, De Marinis F, Rinaldi M, et al. Phase III
randomized trial comparing three platinum-based
doublets in advanced non-small-cell lung cancer. J Clin
Oncol 2002;20:4285–91.
This article is supported by Roche Products Ltd
Volume 5 Issue 3 • July/August 2010
2L pemetrexed in England and Wales). If not
previously prescribed, erlotinib has become
the 2L treatment of choice because it is
effective across all patient subgroups
(including EGFR wild-type tumours), is
generally well tolerated, improves
symptoms and, unlike docetaxel, is not
associated with myelotoxicity [31].
Summary and conclusions
Maintenance therapy represents a new
strategy to improve outcomes for patients
with advanced NSCLC. There remains
uncertainty as to whether or not the
beneficial effect demonstrated by 1LM is
due to use of early 2L treatment.
15. Sandler A, Gray R, Perry MC, et al.
Paclitaxel–carboplatin alone or with bevacizumab for
non–small-cell lung cancer. N Engl J Med
2006;355:2542–50.
16. Pirker R, Pereira JR, Szczesna A, et al. Cetuximab plus
chemotherapy in patients with advanced non-small-cell
lung cancer (FLEX): an open-label randomised phase III
trial. Lancet 2009;373:1497–8.
17. Belani CP, Barstis J, La Rocca R, et al. Meta-analysis of
weekly paclitaxel as maintenance therapy fo radvanced
non-small cell lung cancer (NSCLC) patients following
intitial chemotherapy. Lung Cancer 2005;49(suppl
2):S33.
18. Brodowicz T, Krzakowski M, Zwitter M, et al. Cisplatin
and gemcitabine first-line chemotherapy followed by
maintenance gemcitabine or best supportive care in
advanced non-small cell lung cancer: a phase III trial.
Lung Cancer 2006;52:155–63.
19. Belani CP, Waterhouse DM, Ghazal H, et al. Phase III
study of maintenance gemcitabine (G) and best
supportive care (BSC) versus BSC, following standard
combination therapy with gemcitabine-carboplatin (G-
Cb) for patients with advanced non-small cell lung
cancer (NSCLC). J Clin Oncol 2010;28(7s):Abstract
7506.
20. Perol M, Chouaid M, Milleron BJ, et al. Maintenance
with either gemcitabine or erlotinib versus observation
with predefined second-line treatment after cisplatin-
gemcitabine induction chemotherapy in advanced
NSCLC: IFCT-GFPC 0502 phase III study. J Clin Oncol
2010;28(7s):Abstract 7507.
21. Fidias P, Dakhil SR, Lyss AP, et al. Phase III study of
immediate compared with delayed docetaxel after front-
line therapy with gemcitabine plus carboplatin in
advanced non-small-cell lung cancer. J Clin Oncol
2009;27(4):591–8.
22. Ciuleanu T, Brodowicz T, Zielinksi C, et al.
Maintenance pemetrexed plus best supportive care
versus placebo plus best supportive care for on-small-cell
lung cancer: a randomised, double-blind, phase 3 study.
Lancet 2009;374:1432–40.
23. Scagliotti G, Hanna N, Fossella F, et al. The differential
efficacy of pemetrexed according to NSCLC histology: a
review of two Phase III studies. Oncologist
2009;14:253–63.
24. Belani CP, Brodowicz T, Ciuleanu T, et al. Maintenance
pemetrexed (Pem) plus best supportive care (BSC)
versus placebo (Plac) plus BSC: A randomized phase III
study in advanced non-small cell lung cancer (NSCLC).
Presented at ASCO 2009; J Clin Oncol
2009;27:15s,(Abstract CRA8000).
25. Alimta Summary of Product Characteristics 2009.
Available at
http://www.ema.europa.eu/humandocs/PDFs/EPAR/ali
mta/emea-combined-h564en.pdf
Last accessed 11 June 2010.
Sponsored Feature
‘Watch-and-wait’ is no longer an
automatic standard treatment option for
patients who have SD following 1L
treatment because the evidence shows a
survival benefit of 1LM for these patients. If
a treatment break is considered necessary,
the patient should be closely monitored for
any evidence of disease progression and 2L
treatment started so that the opportunity for
effective treatment is not lost. As
implementation of 1LM enters routine
clinical practice and a new treatment
algorithm emerges, it is important for
oncologists to ensure that the most effective
treatment is prescribed for the appropriate
patient at the right time. n
26. Cappuzzo F, Ciuleanu T, Stelmakh L, et al. Erlotinib as
maintenance treatment in advanced non-small-cell lung
cancer: a multicentre, randomised, placebo-controlled
phase 3 study. Lancet Oncol 2010;11:521–9.
27. Tarceva Summary of Product Characteristics 2010.
Available at
http://www.medicines.org.uk/emc/medicine/16781
Last accessed 11 June 2010.
28. Mok TS, Wu YL, Thongprasert S, et al. Gefitinib or
carboplatin-paclitaxel in pulmonary adenocarcinoma.
New Engl J Med 2009;361:947–57.
29. Rosell R, Moran T, Queralt C, et al. Screening for
epidermal growth factor receptor mutations in lung
cancer. New Engl J Med 2009;361:958–67.
30. Hanna N, Shepherd FA, Fossella FV, et al. Randomized
phase III trial of pemetrexed versus docetaxel in patients
with non–small-cell lung cancer previously treated with
chemotherapy. J Clin Oncol 2004;22:1589–97.
31. Shepherd FA, Rodrigues Pereira J, Ciuleanu T, et al.
Erlotinib in previously treated non-small-cell lung
cancer. N Engl J Med 2005;353:123–32.
32. Paz-Ares LG, Altug S, Thareau Vaury A, et al.
Treatment rationale and study design for a phase III,
double-blind, placebo-controlled study of maintenance
pemetrexed plus best supportive care versus best
supportive care immediately following induction
treatment with pemetrexed plus cisplatin for advanced
nonsquamous non-small cell lung cancer. BMC Cancer
2010;10:85–92.
33. Paz-Ares L, Soulières D, Melezínek I, et al. Clinical
outcomes in non-small-cell lung cancer patients with
EGFR mutations: pooled analysis. J Cell Mol Med
2010;14:51–69.
34. Coudert B, Ciuleanu T, Park K, et al. Survival benefit
with erlotinib maintenance therapy relative to prior
chemotherapeutic response: a subanalysis of the phase
III SATURN study in NSCLC. J Thorac Oncol
2010;5(suppl 1):S80 (Abstract 204O).
35. Shepherd FA, Dancey J, Ramlau R, et al. Prospective
randomized trial of docetaxel versus best supportive care
in patients with non-small-cell lung cancer previously
treated with platinum-based chemotherapy. J Clin Oncol
2000;18:2095–103.
36. Kim ES, Hirsh V, Mok T, et al. Gefitinib versus docetaxel
in previously treated non-small-cell lung cancer
(INTEREST): a randomised phase III trial. Lancet
2008;372:1809–18.
37. Hawkins N, Scott DA, Woods BS, Thatcher N. No study
left behind: a network meta-analysis in non-small-cell
lung cancer demonstrating the importance of
considering all relevant data. Value Health
2009;12:996–1003.
TARC00592 Date of Preparation June 2010
91
Urological Cancer
Bladder Cancer – Poor
Understanding Jeopardises Care
On behalf of Action on Bladder Cancer (ABC), Dr Alison Birtle, Consultant Oncologist,
Preston, tells us why a new charity, dedicated to bladder cancer, is needed to improve
awareness and patient care.
Public Awareness and Burden of Disease
Bladder cancer: we don’t mind talking about it, but over half of us
have no idea what causes it, according to a general public survey [1]
from the new charity, Action on Bladder Cancer (ABC) –
www.actiononbladdercancer.org. The majority (88%) of 2,055 people
invited to participate in the survey were willing to do so. Yet, over
half of those surveyed had no idea what the most common cause of
bladder cancer might be. A quarter (25%) also had no idea about the
warning signs for the disease. These survey findings mark the launch
of ABC as the only UK charity purely focused on improving the lives
of people with bladder cancer. With over 10,000 people being
diagnosed every year in the UK [2], ABC wants to ensure that bladder
cancer is moved higher up the public health agenda to receive greater
attention alongside prostate, breast and lung cancer.
Bladder cancer is the 4th most common cancer in men [2] and the
12th most common in women [2] with 10,300 new diagnoses per year
in the UK. Approximately 75 to 85% present with non-muscle invasive
(superficial) bladder cancer of whom 31% to 78% will recur and 0.8%
to 45% will progress at five years [3]. Their natural history is dependent
on six clinical and pathological factors: number of tumours, prior
recurrence rate, size, carcinoma in situ (CIS), grade and stage. The first
three are the best predictors of recurrence whereas the last three are the
best predictors of progression [3]. It is quite rare in people under 40, but
risk increases with age. Median age at diagnosis is 74 years, with 89%
of patients aged 60 and older [4]. With an increasingly ageing
population, the incidence of bladder cancer can only increase. The
natural history of superficial bladder cancer is long, which is reflected
in the 10-year relative survival rates for bladder cancer (Figure 1).
Current Management Options
The burden of ongoing, often life-long, surveillance by cystoscopy
after initial diagnosis is therefore significant in terms of costs to the
NHS and to the patient in terms on ongoing anxiety about relapse.
Figure 1: Relative survival (%) up to 10 years after diagnosis of bladder cancer,
England & Wales, diagnosed during 1986-1999 and followed up to 2001. British
Journal of Cancer 2008.
92
Dr Alison Birtle,
Consultant Oncologist,
Preston.
Correspondence to:
Action on Bladder Cancer
(ABC), Barley Mow Centre,
10 Barley Mow Passage,
London W4 4PH, UK.
Email: abc@rightangleuk.com
Tel: 020 3142 6491.
Yoshimura et al [5] found that there was global impairment of health
related quality of life in 133 patients who had undergone multiple
transurethral resections (TUR) of superficial bladder tumours
compared to age-matched controls. Physical, social and role-
emotional functioning all reached a nadir at the third TUR, then
improved after the fourth resection. Less minimally invasive methods
of surveillance may be perceived as more attractive, such as voided
urine microsatellite analysis. However, the additional time incurred in
waiting for laboratory based reporting rather than immediate visual
inspection of the bladder produces additional distress in one in five
patients [6].
Primary muscle invasive transitional cell carcinoma (TCC) carries
significant risks of local progression and distant disease, with five-
year survival figures as a group being poorer stage-for-stage than in
many other tumour types: T2 60%, T3 45% and T4 15%. The
optimum primary management for patients with localised bladder
cancer remains controversial: the standard therapy in many countries
is primary radical cystectomy, a procedure associated with significant
morbidity and mortality rates. Selective bladder preservation using
radical external beam radiotherapy in non-randomised studies seems
to offer similar rates of overall survival [7], but a head-to-head
comparison of radical cystectomy versus bladder preservation in the
UK NCRI SPARE trial closed prematurely due to lower than
anticipated recruitment rates.
Using platinum-based chemotherapy prior to either radical
cystectomy or radical radiotherapy in muscle invasive bladder cancer
can confer a 5% improvement in overall survival at five years,
irrespective of the type of subsequent local treatment. This translates
into a 14% reduction in the risk of death and a 9% improvement in
disease-free survival [8]. Although not all patients are suitable for
chemotherapy, these improvements in survival are comparable to
those seen with the use of adjuvant chemotherapy in a number of
other tumour types, such as breast and colorectal cancer.
Although the debate about optimum treatment of muscle invasive
bladder cancer is ongoing, there is little doubt that raising public and
professional awareness of bladder cancer will lead to earlier
diagnosis and help improve survival rates.
About Action on Bladder Cancer (ABC)
ABC is working with healthcare professionals, patients, their carers
and the general public to help improve the treatment and prevention
rates of bladder cancer through raising awareness, education and
research.
In the ABC survey, the most common cause of bladder cancer was
thought to be drinking too much alcohol (18% of respondents). Only
5% said smoking and 1% using chemicals at work, although these in
fact are the two main causes of bladder cancer. Industries involving
dye, rubber, aluminium and leather are linked to an increased risk of
bladder cancer.
The most common symptom of, or warning sign for, bladder
cancer is blood in the urine, but only half of those surveyed
mentioned this.
People living in Scotland, Yorkshire and East of England are more
likely to understand the symptoms of bladder cancer. Those in
Volume 5 Issue 3 • July/August 2010

Figure 2: Survival outcomes from contemporary series of selective bladder preservation or cystectomy, adapted
from Shipley et al. (7).
Yorkshire and East Midlands are most likely
to know of someone who has, or has had,
bladder cancer. People in Wales tended to
fare worst in terms of knowledge and
understanding of symptoms.
Mr David Gillatt, Chair of ABC and
Consultant Urologist in Bristol, says: “We
don’t expect everyone to be an expert, but
such a huge lack of understanding can lead
to people being mis-diagnosed and/or
diagnosed at a later stage in the disease,
which can narrow down the best treatment
choices. Over the last 15-20 years, bladder
cancer has been in the shadows. Greater
public attention is urgently needed to
improve understanding about the disease so
that people know when and where to go for
help. We also need to help people take steps
to reduce their risk of getting the cancer in
the first place, such as giving up smoking.
In short, greater national funding needs to
become a priority.”
Along with awareness raising and
scientific research, ABC intends to help
improve the standards of care in the health
service for bladder cancer patients. At the
moment, patient care may be influenced by
the local doctor’s expertise and interest, as
well as funding priorities within a specific
Health Authority or Primary Care Trust.
Standards need to be improved and care
needs to be consistent throughout the UK.
“The profile of bladder cancer and, as a
result, the care of patients can be
significantly improved by asking the public
and healthcare professionals and providers
to become involved in our dedicated
advocacy group, ABC (www.actionon
bladdercancer.org) – we want to work
together. We fully appreciate that other
cancer and urology groups are already
offering some valuable support, and where
it makes sense to do so we are obviously
very keen to combine our heavily focused
efforts with them”, concluded Mr Gillatt. n
Volume 5 Issue 3 • July/August 2010
The official foundation of Action on Bladder Cancer is
supported by educational grants from:
Kyowa Hakko Kirin UK Ltd, Alliance Pharma and
GE Healthcare.
The Executive Committee for Action on Bladder
Cancer (ABC)
Mr David Gillatt (Chair), Bristol
Mr Colin Bunce (Secretary), Hertfordshire
Mr Hugh Mostafid (Treasurer), Hampshire
Dr Alison Birtle, Lancashire
Mr Leyshon Griffiths, Leicester
Prof John Kelly, London
Mr Roger Kockelbergh, Leicester
Mrs Alison Palmer, Hertfordshire
Mr Raj Persad (Founding Chair), Bristol
References
1. GfK NOP Survey on bladder cancer for Action on
Bladder Cancer, May 2010. [Survey Technical
Details: GfK NOP interviewed 2,055 adults 16+
using face-to-face interviewing 13-15 May, 2010.
Data has been weighted to bring it in line with
national profiles. The survey is supported by an
educational grant from Kyowa Hakko Kirin UK Ltd.]
2. Cancer Research UK, Cancer Stats Key Facts,
Bladder Cancer: go to
http://info.cancerresearchuk.org/prod_consump/
groups/cr_common/@nre/@sta/documents/
generalcontent/crukmig_1000ast-2778.pdf
3. Sylvester RJ, van der Meijden AP, Ossterlinck W,
Witjes JA, Bouffioux C, Denis L, et al. Predicting
recurrence and progression in individual patients
with stage TaT1 bladder cancer using EORTC risk
tables: a combined analysis of 2596 patients from
seven EORTC trials. Eur Urol. 2006;49:466-75.
4. British Association of Urological Surgeons Cancer
Registry data.
5. Yoshiumra K et al. Impact of superficial bladder
cancer and transurethral resection on general
health-related quality of life. Urology
2005:65(2);290-4.
6. Van der Aa MN, Steyerberg EW, Sen EF, Zwarthoff
EC, Kirkels WJ, van der Kwast TH, Essink-Bot ML.
Patients perceived burden of cystoscopic and
urinary surveillance of bladder cancer: a
randomised comparison BJUI 2008;101(9):1106-10.
Epub 2007 Sep 20.
7. Shipley et al. Selective bladder preservation by
combined modality protocol treatment: long-term
outcomes of 190 patients with invasive bladder
cancer. Urology 2005;60:62-7.
8. Advanced Bladder Cancer (ABC) Meta-analysis
Collaboration. Adjuvant chemotherapy in invasive
bladder cancer: a systematic review and meta-
analysis of individual patient data Eur Urol. 2005
Aug;48(2):189-199; discussion 199-201. Epub 2005
Apr 25.
Action on Bladder Cancer (ABC)
Survey 2010
A picture of public understanding?
How common do people think it is?
• Whereas bladder cancer is the 4th most
common cancer in men and the 12th in
women, only 14% of people surveyed said
they knew of someone with bladder cancer,
but this figure increased with the age of the
person questioned.
• People in Yorkshire, Humberside and the
East Midlands were most likely to know
someone who has or has had bladder
cancer. This could be due to industrialised
regions and a greater willingness to talk
about the subject in these regions.
• One third of men (39%) and women (33%)
thought that men are more likely to get
bladder cancer. Only 18% of men thought
that women would be most likely to get it
and 28% of women thought that women
would be most likely to get it.
Do people know the warning signs of
bladder cancer?
• A quarter of respondents had no idea what
might be a sign of bladder cancer and this
was highest in the younger age groups.
Only half of respondents understood the
most common sign of bladder cancer to be
blood in the urine.
• People living in Scotland, Yorkshire and the
East of England are more likely to
understand the symptoms of bladder cancer.
Those in Yorkshire and East Midlands are
most likely to know of someone who has or
has had bladder cancer. Those people living
in Wales tended to fare worst in terms of
knowledge and understanding of symptoms.
What is the most common cause of
bladder cancer?
• Over half of those surveyed had no idea
what the most common cause of bladder
cancer might be, and 18% thought it was
drinking too much alcohol.
• Only 5% stated they thought smoking to be
the most common cause, which is in fact
the case, and only 1% said using chemicals
at work, which is the second most common
cause.
What was understood about
treatments?
• One-third of people thought that
chemotherapy was the most common
treatment for bladder cancer, but one-third
also had no idea. Twelve percent thought
that removal of the cancer with surgery was
an option.
• The survey revealed that general knowledge
about treatments was poorest in the South
East.
Where to go for help
• Of the respondents, 91% said that they
thought the GP surgery would be the first
port of call for information if someone
suspected they may have bladder cancer.
However, 12% did say that the internet
would be an option for information.
93
Book Reviews
Lung Cancer – The Facts. Third Edition.
Editor: Stephen Falk, Chris Williams. Published by: Oxford University Press. ISBN: 978-0-19-956933-5. Price: £12.99.

T
his small book, written by two consul- to the need for information of these patients.
tant oncologists at the Bristol Chapter 11 on Treatment Of The Symptoms
Haematology and Oncology Centre And Complications Of Lung Cancer gives infor-
(UK) does exactly what the title indicates. mation on all the complications emphasising
Divided into three parts: About Lung Cancer, the emergency nature of spinal cord compres-
‘treatment’ and ‘dealing with lung cancer’, it sion and ends with guidance on how to reme-
explains in easy to understand language every- dy to the most common symptoms: skin rashes,
thing that a lay person or professional looking cough, loss of appetite and weight and pain.
after lung cancer patients needs to know. I would dispute the comment in the severe
Each chapter starts with key points and pain section that “increasing doses are not nor-
there are numerous tables and diagrams mally needed once the right dose (of a strong
which illustrate the text although only some narcotic drug) has been found” (page 105). I
are referenced. At the end of the book, there would have liked information on the symptom
is a glossary re-iterating the meaning of med- of breathlessness and specifically how patients
ical terms used within it, reliable websites to can be helped to cope with it, mentioning the
get help, information and advice and an index work done by Macmillan Cancer Support in this
which is useful for anyone wishing to look at regard with CDs and the excellent booklets on
specific issues very quickly. Coping With Shortness Of Breath, Living with
The first chapter on What Is Lung Cancer Breathlessness, and Managing The Experience
states clearly that lung cancer is not one disease: six different kinds Of Breathlessness’ available to patients.
of lung cancer are listed and explained. The book rightly empha- Overall, this is a comprehensive book that I would recommend
sises the role of smoking as the main cause of lung cancer and I for patients, lay carers and professionals who wish to get informa-
particularly liked the fact that one chapter is devoted to stopping tion on lung cancer. It should be available in public and specialist
smoking, giving comprehensive advice with the added incentive for libraries. n
any smoker that after 15 years the risk falls to a level similar to that
for non smokers. Reviewed by
The chapter on Treatment of Non Small Lung Cancer includes ques- Christiane Banton,
tions a patient should ask his doctor which will be useful for patients Senior Lecturer Cancer Care,
and their carers and will guide and prepare professionals to respond University of Wolverhampton, UK.

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94 Volume 5 Issue 3 • July/August 2010

Case Report
Metastatic Angiosarcoma of Breast: An Unusual Presentation
Case report
A 68-year-old woman presented with bleeding from a
polypoid lesion on the right breast. Six years and four
months prior to presentation, she had had a wide local
excision of her left breast, with axillary dissection for a
screen-detected, node-negative, ER + ve 9mm grade II
mixed ductal and lobular carcinoma. She received
radiotherapy post-operatively to the left breast and
tamoxifen. She responded well and had regular clinical
and mammography follow ups. Five years later she
noticed an increase in the size of the left breast and also
developed lymphoedema with peau-de-orange changes
over the skin. Clinically the breast was swollen and
covered with purplish subcuticular papules (Figure 1).
Magnetic resonance imaging (MRI) of both breasts
showed changes consistent with scarring and marked
thickening of the left breast, consistent with
lymphoedema. Multiple wedge biopsies taken from the
left breast only showed scarring, fibrosis and
lymphoedematous change. A year later, she presented
with bleeding from superficial blebs on the breast.
Multiple deep breast biopsies showed evidence of high
grade angiosarcoma with diffuse infiltration of the breast
and cutaneous tissue (Figure 2). CT scans of her chest and
abdomen were normal. She was referred to the tertiary
referral centre (Sarcoma Unit) for a second opinion for
mastectomy. Due to the extent of the disease, the situation
was considered inoperable as mastectomy would not
have provided adequate normal skin cover. She received
palliative radiotherapy to the left breast. Four months later
she presented again as an emergency this time with
bleeding from the polypoid lesion in the right non-
irradiated breast (Figure 3). The left breast clinically
showed marked resolution of skin changes, especially
subcuticular red-purple papules, swelling and
lymphoedema. A wide local excision of the right breast
including this polypoid mass was performed to control the
bleeding from the polypoid lesion. Histology confirmed
this to be a metastatic angiosarcoma. The patient made an
excellent recovery.
Discussion
Angiosarcomas comprise only 2% of all sarcomas, of
which 60% occurr in the skin or soft tissues [1]. They are
rare but highly malignant vascular and life-threatening
tumours. Aetiology and pathogenesis of angiosarcoma is
poorly understood. Angiosarcoma can occur
independently or in association with chronic
lymphoedema, after radiotherapy, or with lymphoedema
developing after radiotherapy [2]. The overall estimated
Authors
Mr Pravin Sangle, MBBS, MS, FRCS, Associate Specialist Breast Surgery*
Dr David Howlett, MRCP, FRCR, Consultant Radiologist*
Dr Keith Ramesar, MBChB FRCPath, Consultant Pathologist*
Mr Simon Allan, MS FRCS, Consultant Breast Surgeon*
*Eastbourne District general Hospital
Corresponding Author:
Mr Pravin Sangle,
Department of Breast Surgery, Eastbourne General Hospital, King’s Drive - Eastbourne, East Sussex, BN21 2UD, UK,
Tel: +44 (0)1323 417400, Fax: +44 (O)1323 413898, Email: sangle.pravin@esht.nhs.uk
Volume 5 Issue 3 • July/August 2010
risk of developing radiation-induced angiosarcoma is
0.04%, whereas primary breast angiosarcoma occurs in
0.05% of all malignant tumours of the breast[3]. The
clinical presentation of secondary angiosarcoma can be
variable; It may present with a) multifocal bruise-like
pattern; b) papular skin nodules in areas of chronic
lymphoedema, 90% occurring after radical mastectomy
with or without radiation therapy, as reported by Stewart
and Treves in 1948 [4]; and c) developing as a sequel of
previous radiation therapy.
The most common risk factors for development of
Figure 1: Clinical appearance of the cutaneous manifestation of
secondary angiosarcoma are chronic lymphoedema and angiosarcoma. Irregular shaped red-purple maculo-papular lesions
radiotherapy. Secondary angiosarcoma as a sequel of with underlying lymphoedema over the left breast.
conservative treatment for breast cancer was first
described in 1987 [5]. The latent period averages 6.2
years (range of 4.8 to 9 years) post-radiotherapy [6]. This
patient never had her contralateral right breast irradiated
and it never showed lymphoedematous changes until
the appearance of the polypoid mass. These lesions are
difficult to diagnose because they have variable a
‘benign-looking’ appearance. Chronic refractory
lymphoedema with skin changes in a previously
irradiated breast should be considered as a warning sign
of the development of angiosarcoma; therefore, we
strongly recommend that long-term clinical surveillance Figure 2: Histological examination of the left breast tissue showing
in selective patients with breast conservation surgery high grade angiosarcoma. H&E x 400 sections showing spindle cell
angiosarcoma with mitotic figures (blue arrows) and blood within a
and radiotherapy is mandatory. Radiological imaging poorly formed vascular spaces (black arrows).
modalities such as mammogram, CT and MRI play very
little or no role in the early diagnosis of angiosarcoma.
Ablative breast surgery for local control has been
recommended but has its limitations [7]. A combination
of hyper-fractionated radiotherapy followed by surgery
provides the most promising results in selective cases
with high-grade angiosarcoma. The role of systemic
therapy is still unclear. Angiosarcoma is increasingly
diagnosed in a small but significant proportion of breast
carcinoma survivors. More women are treated with
breast conservation therapy for early stage breast cancer, Figure 3. Rare polypoid appearance of metastatic angiosarcoma of the
and hence the incidence of angiosarcoma is expected to right breast, well away from the irradiated field of left breast. Note
also the marked improvement in the skin of the left breast.
rise. We emphasise the need for early clinical detection
with a high index of suspicion by all healthcare
References
providers. After radiotherapy, all patients should be
1. Mark RJ, Poen JC, Tran LM, Fu YS, Julliard GF. Angiosarcoma
educated with hand-out information and advised to alert – A report of 67 patients and a review of literature. Cancer
their physician of any skin changes. Suspicious lesions 1996;77(11):2400-6.
should be biopsied promptly to avoid diagnostic delay of 2. Enzinger F, Weiss S. Soft tissue tumours. 3rd ed. St. Louis:
CV Mosby, 1995;641-77.
this highly aggressive tumour. Angiosarcomas are often
3. Wijnmaalen A, van Ooijen B, van Geel BN, Henzen-
resistant to surgery, chemotherapy and radiotherapy. Logmans SC, Treuniet-Donker AD. Angiosarcoma of the
Specific targeted therapy against biological properties of breast following lumpectomy, axillary node dissection,and
these tumours may be a new approach to the treatment radiotherapy for primary breast cancer: three case reports
and a review of the literature. Int J Radiat Oncol Bio Phys
of angiosarcoma. n 1993;26(1):135-9.
4. Caldwell JB, Ryan MT, Benson PM, James WD. Cutaneous
Angiosarcoma arising in the radiation site of a congenital
hemangioma. J Am Acad Dermatol. 1995;33(5,pt2):865-70.
5. Benda JA, Al-Jurf AS, Benson AB 3rd. Angiosarcoma of the
breast following segmental mastectomy complicated by
lymphedema. American Journal of Clinical Pathology
1987;87(5):651-5.
6. Marchal C,Weber B,de laftontan B,Resbeut M, Mignotte H,
du Chaterland PP, Cutuli B, Reme-Saumon M,Broussier-
Leroux A,Chaplain G, Lesaunier F, Dilhuydy JM, Langrange
JL. Nine breast angiosarcomas after conservative treatment
for breast carcinoma; a survey from French comprehensive
Cancer centres. Int J Radia Oncol Bio Phy 1999;44:113-9.
Review.
7. Roy P,Clark MA,Thomas JM. Stewart-Treves syndrome-
treatment and outcome in six patients from single centre.
Eur J Surg Oncol 2004;30(9): 982-6.
95
Conference News
Are you organising an annual meeting or conference which you would like to tell our readers about? Or would you like to
write a report on a meeting or conference of particular interest? If so, contact Patricia McDonnell at Oncology News on
Tel/Fax: +44 (0)288 289 7023, Email: patricia@oncologynews.biz

1st World Congress of Cutaneous Lymphomas

Date: 22-25 September, 2010. Venue: Chicago, Illinois USA. PREVIEW

T he International Society for Cutaneous

Lymphomas (ISCL), in collaboration
with the United States Cutaneous
Lymphoma Consortium (USCLC) and the
Robert H Lurie Comprehensive Cancer
Center of Northwestern University, will host
the First World Congress of Cutaneous
Lymphomas, on September 22-25, 2010 in
Chicago, Illinois.
The conference will present sessions
focusing on several aspects of cutaneous
lymphomas including:
1. Cutaneous T-Cell Lymphomas
Pathomechanisms: Lymphomagenesis,
Genomics and Epigenomics Gene
Expression (mRNA RT-PCR arrays), gene
defects (CGH, oligonucleotide
microarrays), early events, aetiology,
classification, prognosis and
epidemiology).
2. Cutaneous T-Cell Lymphomas
Pathomechanisms: T-cell Signaling
Dysregulation (immunology, host
response, microenvironment, model
systems, including pre-clinical models,
cell lines, 3-D, tissue models, and
animal models).
3. Cutaneous T-Cell Lymphomas:
Therapies: Clinical Trials and
Investigations with Available Therapy in
Mycosis Fungoides and Sezary
Syndrome: Response Criteria/Endpoints
& Skin-Directed Therapies.
4. Cutaneous T-Cell Lymphomas:
Therapies: Clinical Trials and
Investigations with Available Therapy in
Mycosis Fungoides and Sezary
Syndrome: Systemic Therapies.
5. New/Novel Targets in Cutaneous T-Cell
Lymphomas (emphasis on preclinical or
tissue/animal model investigations;
primarily pre-clinical and phase 1
studies).
6. Investigative Trials with Newer/Novel
Agents and Methods (primarily phase
2/3, pivotal studies).
7. Other Cutaneous T-cell Lymphomas.
8. Cutaneous B-Cell Lymphomas.
9. Quality of Life Issues, Patient
Education, and Support.
On the Wednesday afternoon the USCLC
will host a programme specifically for
clinicians from the multiple specialties
which care for cutaneous lymphoma
patients. This session will focus on the
nuances and challenges seen in practice as
regards to optimizing dermatologic
treatment, optimising systemic therapies,
issues in radiation oncology, and CPC
(difficult cases diagnostic dilemmas).
The conference will provide the ideal
platform to present new results from
pharmaceutical studies and share ideas and
experiences, which will ultimately improve
the quality of care to lymphoma patients.
This activity has been approved for AMA
PRA Category 1 Credit™.
Organizing Committee
Madeleine Duvic, MD
– MD Anderson Cancer Center
Reinhard Dummer, MD
– University of Zurich
Francine Foss, MD – Yale University
Joan Guitart, MD (Co-Director) –
Northwestern University
Richard Hoppe, MD – Stanford University
Steve Horwitz, MD – Sloan-Kettering
Cancer Center
Youn Kim, MD (Co-Director) – Stanford
University
Elise Olsen, MD – Duke University;
President, United States Cutaneous
Lymphoma Consortium
Steven T. Rosen, MD – Robert H. Lurie
Comprehensive Cancer Center of
Northwestern University
Wolfram Sterry, MD – University of Berlin
Eric Vonderheid, MD – Honorary President
Sean Wittaker, MD – University of London;
Secretary – Treasurer, International Society
of Cutaneous Lymphomas
Gary Wood, MD – University of Wisconsin;
President, International Society of
Cutaneous Lymphomas
We look forward to welcoming you to the
beautiful city of Chicago. Chicago has
unparalleled sophistication, class, and style.
Fine dining, world-famous museums,
legendary entertainment, shopping, and
much more await throughout the city.
Chicago's great magic lies in its mix:
sophisticated yet friendly, bustling city
streets adjacent to long stretches of green
parks and sparkling blue Lake Michigan,
and a stunning year-round array of things
to see and do unique in all the world. Come
and discover why so many visitors fall in
love with the city of Chicago every year. n
Joan Guitart, MD; Youn Kim, MD;
Elise Olsen, MD; Gary Wood, MD,
Scientific Committee.
For further information
visit: www.cancer.northwestern.
edu/CTCL

Would you llike to submit a conference preview or cover an event for Oncology News? Email Patricia at
patricia@oncologynews.biz

96 Volume 5 Issue 3 • July/August 2010

 2nd NEON Conference
Date: 14-15 May, 2010 Venue: Auckland, New Zealand.

he second annual Nurse Excellence

T in ONcology and Haematology
(NEON) meeting for oncology and
haematology nurses took place in
Auckland in May 2010.
The objective of NEON was to
“advance the knowledge and skills of
senior oncology & haematology nurses
by sharing expertise and experience”.
Education, networking, sharing of
nursing knowledge and tools are vital
for every nurse’s clinical practice and, in
sponsoring the meeting, Roche created
an environment that encouraged
participation and discussion on
different issues and levels in cancer
care.
The theme of day one was
‘Innovation in Practice.’ The opening
presentation by Jan Campbell (Director
of Medical and Clinical Services Roche,
New Zealand) introduced the group of
approximately 25 to an overview of
Roche and current Roche drug trials
available in New Zealand. Targeted
therapies were shown to be the
emergent trend across the spectrum of
cancer research.
Over the first day many dynamic
speakers offered presentations that
have directly improved patient safety,
satisfaction and prognosis. methods and lifestyle tools to enhance therapies. The audit proved a definite
One such example highlighting this work/life balance. win-win situation!
was from Mid Central Health. Breast Concurrent sessions from our medical The second day was an interactive
Care CNS, Cheryl MacDonald has colleagues presented treatment session facilitated by Vanessa Chapman
developed and led a pilot programme overviews in four of the most common on communication styles. This allowed
looking at actively promoting weight cancers affecting New Zealanders – us to delve into our own innate styles of
management for those undergoing colorectal cancer, lung cancer, breast communication whilst also recognising
breast cancer treatment. Current cancer, and malignant haematology how others may communicate. As a
evidence shows weight maintenance disorders. The themes taken from these group we moved into active listening
not only improves prognostic outcome sessions were that medical treatments skills, a tool that requires a lot of work
but also assists in body image and are increasing long-term survival and to succeed at. I am eagerly challenged
healthy lifestyle gains for this group of concepts to maintain / improve quality to use these skills in my workplace to
people. of life need to be considered. effect open communication.
Other innovative presentations and Dr Samar Issa (Haematologist, I would like to take this opportunity
resources shared by fellow nurses Counties Manukau) gave an interesting to thank Megan, Heff, his bunnies and
during the day one session included address on an audit from her the Roche team for an opportunity to
managing electronic chemotherapy workplace. The utilisation of GCSF attend NEON. It was a fun, energising
scheduling (Otago), patient symptom (Neulastim) in RCHOP in 14 patients has two days, which was intimate in size
self-assessment tools and patient proven to benefit not only patient and facilitated great professional
education resources (Wtgn), evolution scheduling so patients receive optimal networking and opportunities to
of the CNS role in navigating complex therapy in a timely manner thus benchmark within New Zealand's
pathways of care (ACH), integrating an effecting a better prognostic outcome, Oncology and Haematology Nursing
outpatient care plan across the services but also provides significant cost Services. n
(ChCh), the nursing challenges and benefits to Middlemore Hospital by
highlights of establishing a private reducing the need for any Trena Karaitiana,
oncology service (ChCh) and caring for hospitalisation due to neutropenic Oncology Outpatients, Whangarei,
the carers (Anne Morgan, ChCh) sepsis caused by such intensive New Zealand.

Volume 5 Issue 3 • July/August 2010 97

2nd National Conference: Haematological Malignancies
Date: 2-3 September, 2010. Venue: London, UK. PREVIEW

F ollowing the success of last year’s meeting, we at MA

Healthcare are delighted to announce the 2nd National
Haematological Malignancies Conference, in association with the
This meeting will be indispensable for all specialists in
haematology, oncology and transplantation to update their
knowledge and skills as well as to exchange ideas with the lading
British Journal of Hospital Medicine. haematology practitioners in the UK. n
This major two-day event features a distinguished line-up of
expert speakers from across the UK to discuss the current issues and
recent advances in the diagnosis and treatment of all the main For further information visit:
haematological malignancies, including the acute and chronic www.mahealthcareevents.co.uk
leukaemias, lymphoma and myeloma.
Line-up of expert speakers and chairs:
The first morning session of the conference will focus on the
clinical issues in acute leukaemia, including diagnosis and • Dr Nick Goulden • Dr Quentin Hill
prognosis of acute lymphoblastic leukaemia (ALL) and acute • Dr Adele Fielding • Dr Chris Pepper
myeloid leukaemia (AML), current and emerging therapies for ALL • Dr Robert Carr • Dr Estella Matutes
and AML, and risks and management of infections and neutropenic • Professor David Grimwade • Dr Claire Dearden
sepsis in acute leukaemia. The afternoon session will concentrate • Dr Brenda Gibson • Professor Jane Apperley
on the advances in stem cell transplantation, promising new • Professor Mary-Frances • Dr Mhairi Copland
therapies including immunoradiotherapy and gene therapy, and McMullin • Professor Barry Hancock, OBE
discussions on optimising patient care. • Professor Graham Jackson • Dr Ayoma Attygale
Day two will begin with lectures on effective management of • Dr Gordon Cook • Professor Stephen Proctor
chronic lymphocytic leukaemia (CLL) and chronic myeloid • Dr Bronwen Shaw • Dr Andrew McMillan
leukaemia (CML), followed by pathogenesis and management of • Dr Prem Mahendra • Dr Robert Marcus
the different lymphomas including aggressive T-cell lymphoma, • Dr Peter Nicholls • Dr Jamie Cavenagh
high-grade B-cell non-hodgkin’s lymphoma (NHL) and indolent and • Dr Katy Rezvani • Dr Faith Davies
low-grade NHL. The conference will close with comprehensive • Dr Tim Littlewood • Professor Gareth Morgan
updates on current and promising new therapies for myeloma.

BLS Annual Conference

Date: 3-5 October, 2010 Venue: Manchester, UK. PREVIEW

T his year sees the biggest and most

exciting annual conference and
exhibition in BLS history. The venue is the
renowned Manchester Town Hall and there
will be nearly 30 exhibitors covering a wide
range of pharmaceutical companies. The
highlight on Monday 4 October will be
keynote speeches from two of the USA’s
leading lymphoedema clinicians.
Firstly, Andrea L Cheville MD, MSCE. Dr
Cheville is currently an Associate Professor
of Physical Medicine and Rehabilitation at
the Mayo Clinic in Rochester. Prior to her
current appointment she founded and
directed the Lymphedema Service and
Cancer Rehabilitation Program at the
University of Pennsylvania Cancer Center
for seven years. She is a graduate of
Harvard Medical School and completed her
training at the Kessler Rehabilitation
Institute and Memorial Sloan Kettering
Cancer Center. In addition to her specialty
of cancer rehabilitation, Dr Cheville is
trained and board certified in pain
medicine. Her clinical practice and research
interests encompass disablement in
advanced cancers, lymphoedema, and
functional preservation in cancer
survivorship. Dr Cheville has written and
lectured extensively on these topics. Dr
Cheville is also a member of the US
National Lymphedema Network Medical
Advisory Committee and active contributor
to the NLN LymphLink.
Secondly, BLS will be welcoming Kathryn
H Schmitz PhD, MPH, FACSM, who is
Associate Professor at University of
Pennsylvania School of Medicine. She has
led multiple trials, including a recently
completed randomised controlled trial to
assess the safety of upper body exercise
among 295 breast cancer survivors with
and without lymphoedema (Physical
Activity and Lymphedema Trial (PAL)). Her
research extends from the role of physical
activity in the prevention and aetiology of
obesity related cancers to the usefulness of
activity for rehabilitation and health
promotion in cancer survivors of all
cancers. Her meta-analysis on the topic of
exercise interventions in cancer patients
and survivors, published in 2005, provides
a starting point for clinicians to understand
the effects of exercise among cancer
survivors. Dr Schmitz has published 76 peer
reviewed scientific papers. She serves on
the expert panel for the YMCA/Lance
Armstrong Foundation Cancer Survivorship
Collaborative, wrote the cancer
survivorship section of the recently
published US DHHS report of the Physical
Activity Guidelines Advisory Committee,
served on the ad hoc committee that
developed the ACSM Cancer Exercise
Trainer certification, and has been named
the lead writer for the document that will
result from the recent ACSM Roundtable
on Exercise for Cancer Survivors held in
June 2009. Dr Schmitz’ long-term
professional goal is to see that all
oncologists, fitness trainers, and cancer
patients will eventually be as cognizant of
the usefulness of exercise for cancer control
as cardiologists already are for its role in
controlling heart disease. n
For further details visit the BLS
website www.thebls.com or
T: 01242 695077

98 Volume 5 Issue 3 • July/August 2010

Awards & Appointments Meet the Editorial Team
ICR’s Chief Executive elected Professor Denys Wheatley is Editor, and is Director of BioMedES. He has strong
research ties in Albany, Davis, Auckland, Valencia, Detroit, Budapest, St Petersburg,
Fellow of the Royal Society Heidelberg, Zürich and Hong Kong. He is eager to establish strong interaction with cancer
and cell biology teams worldwide, and initiate programmes in the areas in which his
The Institute of Cancer Research’s expertise lies. His work in cancer research, other scientific fields, with IFCB, and in
(ICR) Chief Executive Professor Peter publishing and scientific communication has led to his receiving awards in recent years.
Rigby (pictured) has been elected to
the Fellowship of the Royal Society,
the greatest honour that can be Professor Patrick J Bradley (Associate Editor), is a Head and Neck Oncologic
bestowed upon a UK scientist. Surgeon at the University Hospital, Nottingham. He is a member of numerous journals’
UK Editorial Boards; Journal of Laryngology and Otology, Oral Oncology, and International
The Royal Society is the national
Journals: Laryngoscope, Head and Neck, Acta Otolaryngologica Scandinavia, as well as
academy of science of the UK and Section Editor of Head and Neck Oncology, and Current Opinions ORL-HNS.
Commonwealth, and election to its
Fellowship recognises outstanding
scientific contribution. Each year, 44
new Fellows are elected through a Dr Richard J Ablin (Associate Editor), is Research Professor of Immunobiology and
rigorous peer-review process that culminates in a vote by Pathology, University of Arizona College of Medicine and a Member of the Arizona Cancer
existing Fellows. Center, Tucson, Arizona. He received the First Award for scientific excellence from The
Haakon Ragde Foundation for Advanced Cancer Studies. Dr Ablin discovered prostate-
Professor Rigby has been Chief Executive since 1999 and has specific antigen (PSA) in 1970. A pioneer of cryosurgery and cryoimmunotherapy, he has
led the ICR to become one of the UK’s leading academic extensive experience in cancer research.
research centres. He is also Professor of Developmental Biology
and heads the ICR’s Section of Gene Function and Regulation
and the Molecular Embryology Team within that section. His Dr Tom Lynch is Assistant Editor – Imaging, and is a Radiologist and Lead Nuclear
own research interests are in the molecular biology of Medicine Physician in the Northern Ireland Cancer Centre based at the Belfast City Hospital.
vertebrate development, especially gene regulation. Tom specialises in PET/CT scanning and nuclear medicine with a special interest in
The Royal Society commended Professor Rigby for making paediatric nuclear medicine.
“several discoveries in oncogenesis and vertebrate development
which have had major impact on thinking in these fields”.
Professor Rigby says: “I am very honoured to have received
this ultimate acknowledgment from my peer group. I hope it Dr Heidi Sowter is Assistant Editor – Web Review, and is a Lecturer in Forensic
will also be seen as recognition of the important contributions Science and Biology, at the Faculty of Education, Health and Science, University of Derby.
made over many years by my talented students, postdoctoral Heidi continues to pursue her research interests in gynaecological and breast cancer.
researchers and colleagues.”
The Royal Society is the world's oldest scientific academy in
continuous existence, and has been at the forefront of enquiry and
discovery since its foundation in 1660 – 350 years ago this year.
Ms Kathleen Mais is Assistant Editor – Nursing, and is a Nurse Clinician in Head &
Neck Oncology at Christie Hospital, Manchester. Kathleen qualified as a nurse in
ICR’s Professor Paul Workman Newcastle-upon-Tyne. Kathleen is a nurse-prescriber and runs a nurse-led chemotherapy
clinic as well as continuing her work in clinical research.
receives the George & Christine
Sosnovsky Award
Professor Paul Workman Marilena Loizidou is Assistant Editor – Colorectal, and is a Non-Clinical Senior
Lecturer in the Department of Surgery, UCL. Her research program focuses on aspects of
(pictured) from The Institute colorectal cancer and liver metastases, from the basic underlying biology to new potential
of Cancer Research (ICR) has treatments. The current focus of research is the contribution of the peptide endothelin-1 to
received the prestigious tumour growth and progression in the bowel. Additional research areas include breast and
bladder cancer.
George & Christine
Sosnovsky Award in Cancer
Therapy from the Royal
Alan Cooper is Assistant Editor – Urology, and is Lead Scientist with the urology
Society of Chemistry (RSC) research group in Southampton University Hospitals and senior lecturer (albeit with virtually
for his work discovering no lecturing burden) in the Department of Biomedical Sciences at Portsmouth University.
exciting new anti-cancer
drugs.
As Director of the Cancer Research UK Centre for Cancer
Therapeutics at the ICR, Professor Workman heads the
world’s leading academic cancer drug development team. Dr S Gokul is Assistant Editor - Journal Reviews, and is a Consultant Medical
His research involves designing drugs with the ability to Oncologist at The James Cook University Hospital, Middlesbrough. His areas of interest are
block molecules that are essential for cancer cells to grow lung and gynaecological cancer.
and spread. His work at the ICR and elsewhere has led to
the development of a number of new drugs that have
entered clinical trials, including one that has already
received FDA approval.
“Drug discovery is by its very nature a multidisciplinary Helen Evans is a Journal Reviewer for Oncology News. Helen recently worked as a
scientific activity, especially the link between chemistry and Senior Lecturer in Cancer Nursing at the Institute of Nursing and Midwifery, University of
Brighton, but following the birth of her son has returned to clinical practice as a Clinical Nurse
biology. For me, this is one of the most important and
Specialist at St. Wilfrid's Hospice in Chichester.
exciting aspects of my research, along with the potential for
helping cancer patients, and I could not have achieved what
I have without enormous help from many people,” he said.

Volume 5 Issue 3 • July/August 2010 99

Diary of Events
2010
July
Cancer Research UK Beatson
International Cancer Conference
4-7 July, 2010; Glasgow, UK
E: t.wheeler@beatson.gla.ac.uk
www.beatson.gla.ac.uk/conf
Clinical Oncology
5-9 July, 2010; Coventry, UK
E: s.j.hicks@warwick.ac.uk
www2.warwick.ac.uk/fac/sci/bio/
shortcourses/calendar/
Casley-Smith Update
7-9 July, 2010; Glasgow, UK
Mrs Margaret Sneddon,
Programme Director,
T: +44(0)141 330 2071/2072
E: lymph@clinmed.gla.ac.uk
www.gla.ac.uk/departments/nursing
WIN Symposium
7-9 July, 2010; Paris, France
E: mbia@mfcongres.com
Understanding oncology &
palliative care
8 July, 2010; Middlesex, UK
Anni Hall
T: +44 (0)1923 844177
F: +44 (0)1923 844172
E: anni.hall@nhs.net
11th International Lung Cancer
Congress
8-11 July, 2010; Rancho Palos
Verdes, CA
www.CancerLearning.com
NEW
Men with breast cancer - Breast
Cancer Care Teleconference
15 July 2010
Kylie Vilcins
T: 0845 092 0802,
E: nursetraining@
breastcancercare.org.uk
10th International Congress on
Genitourinary Malignancies
16-17 July, 2010; Washington, DC
www.CancerLearning.com
Ninth International Congress on
the Future of Breast Cancer
22-25 July, 2010; La Jolla, CA
www.CancerLearning.com
September
2nd National Conference:
Haematological Malignancies
2-3 September, 2010; London, UK
www.mahealthcareevents.co.uk
E: lisa.f@markallengroup.com
14th Biennial Conference of the
International Association for
Research on Epstein-Barr Virus and
Associated Diseases
4-7 September, 2010; Birmingham, UK
T: + 44 (0)1562 821 715
E: event@ellis-salsby.co.uk
www.medicine.bham.ac.uk/conferences/
ebv2010/index.shtml
100
If you would like an event listed in the Oncology News diary please send the
relevant information to email Patricia@oncologynews.biz by August 5th, 2010.
Late Effects of Radiotherapy: Better
Recognition, Better Intervention,
Better Care
6 September, 2010; London, UK
www.bir.org.uk
NEW
Biotherapy of Cancer (BTOC 10)
8-10 September, 2010; Munich,
Germany
BDA Secretariat
T/F: +44 (0) 1483 271314
E: mike@charters.eu.com
WCRF International 2-day
conference
12-13 September, 2010; London
www.wcrfconference.org/
ESTRO 29
12-16 September, 2010; Barcelona,
Spain
www.estro-events.org
Promoting Quality End of Life Care
3 Day Foundation Course Band 5 &
above
14 September, 2010; Plymouth, UK
Marilyn Prowse
T: +44 (0)1752 401172
E: marilyn.prowse@stlukes-hos-
pice.org.uk
11th Nottingham International
Breast Cancer Conference
15-17 September, 2010; Nottingham,
UK
Wendy Bartlam
T: +44(0)115 9625707
E: wendy.bartlam@nuh.nhs.uk
9th Congress of European
Association of Neurooncology
(EANO)
16-19 September, 2010; Maastrict,
The Netherlands
www.medacad.org/eano2010
NEW
Advanced Assessment Skills and the
Patient with Cancer
21 September – 18 January 2010;
London, UK
T: +44(0)20 7808 2900
E: school@rmh.nhs.uk
W: www.royalmarsden.nhs.uk
NEW
Oncoplastic breast surgery - Breast
Cancer Care Masterclass
22 September, 2010; London, UK
Kylie Vilcins
T: 0845 092 0802,
E: nursetraining@
breastcancercare.org.uk
Training Workshop: Ethical
Principles of Consent for Use of
Samples and Related Data in
Research
22 September, 2010; Manchester, UK
www.oncoreuk.org
E: info@oncoreuk.org
Communication Skills to Support
End of Life Care Band 3 & 4
22 September, 2010; Plymouth, UK
Marilyn Prowse
T: +44 (0)1752 401172
E: marilyn.prowse@stlukes-hos-
pice.org.uk
1st World Congress of Cutaneous
Lymphomas
22-25 September, 2010; Chicago,
Illinois.
E: d-marshall4@northwestern.edu
10th International Conference on
Cancer-Induced Bone Disease
22-25 September 2010; Sheffield, UK
www.cancerandbonesociety.org
NEW
3rd International Meeting of
Oncoplastic and Reconstructive
Breast Surgery
26–28 September, 2011;
Nottingham, UK
W: www.orbsmeetings.com
New Frontiers in Paediatric
Oncology Imaging
28 September, 2010; London, UK
www.bir.org.uk
NEW
Lymphoedema: Diagnosis,
Assessment & Risk Reduction
28 September - 1 October, 2010;
Glasgow, UK
Mrs Margaret Sneddon,
Programme Director,
T: +44(0)141 330 2071/2072,
E: lymph@clinmed.gla.ac.uk
W: http://www.gla.ac.uk/
departments/nursing/
NEW
15th Biennial Urologic Cancer
Course
30 September – 2 October, 2010;
Boston, USA
W: www.cme.hms.harvard.edu/
courses/urologiccancer
Functional and Molecular Imaging
in Clinical Practice
30 September – 1 October, 2010;
London, UK
www.bir.org.uk
October
BAPRAS Advanced Educational
Courses - Breast Surgery
1-2 October, 2010; Manchester, UK
www.coursesinplasticsurgery.org.uk
BLS Annual Conference
3-5 October, 2010; Manchester, UK
www.thebls.com
NEW
The Sciences of Cancer Care
5–20 October 2010; London, UK
T: +44(0)20 7808 2900
E: school@rmh.nhs.uk
W: www.royalmarsden.nhs.uk
Volume 5 Issue 3 • July/August 2010
Non-Malignant Study Day - Motor
Neurone Disease
6 October, 2010; Middlesex, UK
Anni Hall
T: +44 (0)1923 844177
F: +44 (0)1923 844172
E: anni.hall@nhs.net
NEW
Breast cancer and genetics - Breast
Cancer Care Teleconference
7 October, 2010
Kylie Vilcins
T: 0845 092 0802,
E: nursetraining@
breastcancercare.org.uk
35th ESMO Congress
8-12 October, 2010; Milan, Italy
European Society of Medical
Oncology
T: +41 (0)91 973 19 19
E: congress@esmo.org
www.esmo.org
NEW
Chemotherapy in Cancer Care
11–23 October 2010; London, UK
T: +44(0)20 7808 2900
E: school@rmh.nhs.uk
W: www.royalmarsden.nhs.uk
Promoting Quality End of Life Care
3 Day Foundation Course Band 5 &
above
12 October, 2010; Plymouth, UK
Marilyn Prowse
T: +44 (0)1752 401172
E: marilyn.prowse@
stlukes-hospice.org.uk
NEW
An introduction to the nature and
management of lymphoma
13 October, 2010; Manchester, UK
E: helen@lymphomas.org.uk
W: http://www.lymphomas.org.uk/
health/
Promoting Quality End of Life Care
3 Day Foundation Course Band 5 &
above
13 October, 2010; Plymouth, UK
Marilyn Prowse
T: +44 (0)1752 401172
E: marilyn.prowse@stlukes-hos-
pice.org.uk
NEW
Acute Cancer Care
14 October – 18 November 2010;
London, UK
T: +44(0)20 7808 2900
E: school@rmh.nhs.uk
W: www.royalmarsden.nhs.uk
Joint BOPA & UKONS Annual
Conference 2010
14–17 October, 2010; Manchester,
UK
Kirsten Wicke, Succinct Healthcare
Communications and Consultancy
T: +44 (0)1494 549100
E: kirsten@succinctcomms.com
www.succinctcomms.com
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Volume 5 Issue 3 • July/August 2010 101

Courses & Conferences

Organised by

Se fer on
Promote your
co view
pr

e en p9
e
n
ou ce 8
r
event here! 2nd national conference

Haematological
Malignancies
Institute of Physics, London
2nd & 3rd Sept 2010
SESSIONS WILL INCLUDE:
• Management of acute leukaemia
• Management of chronic leukaemia
• Stem cell transplantation
• Promising new treatments
• Lymphoma and myeloma
Promote your course or conference in the
EXPERT SPEAKERS WILL INCLUDE:
next issue for MAXIMUM effect. • Dr Adele Fielding
• Dr Brenda Gibson
Ensure your event is featured in Oncology News, reaching • Professor Mary-Frances McMullin
6500 oncology professionals POTENTIAL DELEGATES across • Dr Gordon Cook
the UK. • Dr Estella Matutes
• Professor Jane Apperley
RAISE AWARENESS by announcing details of your event to • Professor Stephen Proctor
our readers well in advance! • Professor Gareth Morgan
ENHANCE your PROFILE by submitting an eye catching For full programme details please visit our website CPD
advert to us, or use our designer to create the advert for www.mahealthcareevents.co.uk APPLIED
you!
Alternatively call our booking hotline on 020 7501 6762 FOR
For further details contact Patricia McDonnell, Oncology News
Tel: +44 (0)288 289 7023 Email: Patricia@oncologynews.biz 40 YEARS OF MEDICAL EDUCATION

102 Volume 5 Issue 3 • July/August 2010

 ANNOUNCEMENT

9th Annual BTOG The 3rd BTOG

Conference 2011 Small Cell Lung
Dates Cancer (SCLC)
Wednesday 26th to Friday Study Day 2010
28th January 2011
Venue Dates
The Burlington Hotel, Friday 17th September 2010
Dublin, Ireland
Venue
• Wednesday BTOG Symposium Hilton Paddington Hotel,
• Sponsored Satellite Meetings
Wednesday
London, UK
• Thursday & Friday Annual Meeting
• Please visit the website, This meeting and all its associated
www.BTOG.org for details costs have been supported with an
unrestricted educational grant from
BTOG 2011 GlaxoSmithKline UK.
– Registration & Hotel Booking
opens 1st September 2010. Registration opens June 2010

British Thoracic Oncology Group (BTOG) is a lung cancer and mesothelioma research group.
The principal aim of BTOG is to encourage the development of clinical and scientific research in all
areas of Thoracic Oncology and the provision of a multi-disciplinary educational forum.
All individuals involved in any aspect of lung cancer or mesothelioma research, treatment or care
are eligible to become members of the Group.

BTOG Secretariat
Dawn Mckinley, Operational Manager, British Thoracic Oncology Group (BTOG)
Hospital Management Offices, Glenfield Hospital, Leicester LE3 9QP England
Tel: 00 44 116 2502811 • Fax: 00 44 116 2502810
Email: dawn.mckinley@uhl-tr.nhs.uk • www.BTOG.org
News update
Latest developments on products and services from the industry. To have your news included contact Patricia McDonnell on
patricia@oncologynews.biz or Tel/Fax:+44 (0)288 289 7023.
Thermo Fisher Scientific updates coverslipper for
greater consistency and ease-of-use
Thermo Fisher Scientific has announced the
launch of its updated ClearVue™
coverslipper with increased ease-of-use
and enhanced tissue positioning to
improve consistency in cytogenetics,
immunohistochemistry and cytology
laboratories. The latest instrument ensures
that coverslips are positioned correctly in
relation to the slides and tissue without
user intervention, improving laboratory
workflow and increasing throughput. By
enabling a smoother workflow,
coverslipper enhancements help ensure
that patients receive faster, more accurate
diagnoses for diseases such as cancer.
The Thermo Scientific ClearVue
coverslipper works by covering the portion
of the slide containing tissue using a thin
glass coverslip and applying a clear synthetic
mounting medium to act as a bond. The
instrument has the capability to manage up
to 11 slide racks simultaneously and
automatically adjusts mountant volume,
WH Bence to showcase digital mammography on
the move
At this year’s Symposium Mammo-
graphicum in Liverpool, mobile vehicle and
trailer specialists W H Bence Coachworks
will be showcasing its latest digital breast
screening trailer.
As the UK’s market leader for mobile
breast screening units, W H Bence has
extensive experience in creating high
quality, bespoke facilities to serve the
needs of the NHS and independent
healthcare providers. Visitors to the event
will be able to meet representatives and
view the demonstrator trailer designed to
meet patient and clinical needs.
“Creating the ideal mobile imaging space
means working to the specific needs of the
digital imaging equipment, the
mammographer and the patient. We’ve
104
Prostate cancer
patient first in Spain
to receive treatment
from Varian
Clinicians at Institut Catala d’Oncologia
(ICO) in Barcelona have carried out the
first treatment in Spain using RapidArc®
radiotherapy from Varian Medical
Systems. A 73-year-old prostate cancer
patient from Barcelona has become the
first patient in the country to receive the
allowing a smooth workflow. The upgraded
fast and efficient treatment.
ClearVue coverslipper ensures the correct
“The treatment went very well and
positioning of slides by featuring an
the patient really noticed the time
enhanced gripper return plate with an
difference compared with previous
extended front face. Additionally, software
treatments,” said Dr. Ferran Guedea,
upgrades allow the easy adjustment of slide
head of the radiation oncology
visibility levels and the dependable covering
department. “It’s very important to
of all slides.
deliver the dose as quickly as possible,
For more information
which makes it a better experience for
T: + 44 (0)800 018 9396,
the patient. Fast dose delivery is
E: sales.ap.uk@thermofisher.com or
especially important in organs such as
W: www.thermo.com/pathology
the prostate that are prone to move
during treatment.”
“We are extremely pleased to be able
to offer the latest in radiotherapy to our
patients,” adds Dr Guedea. “We believe
RapidArc is an enormous leap forward
in precise radiotherapy treatments,
enabling us to offer a precise and
personalized treatment in shorter
time.” He said early RapidArc
treatments would focus on patients
with prostate, head & neck and brain
WH Bence
tumors, as well as any patients with
Coachworks will be tumors located close to sensitive
showcasing its organs.
digital breast For further information contact:
screening trailer at
Symposium
Neil Madle, Varian Medical Systems,
Mammographicum T: +44 7786 526068,
2010. E: neil.madle@varian.com
been working in partnership with medical
equipment manufacturers and the NHS for
many years so have extensive experience,”
states Oliver Brown, Sales Director at W H
Bence Coachworks. “We are looking forward
to taking the mobile breast screening trailer
to Symposium Mammographicum and
highlighting how comfortable interiors and
innovative structural designs can
complement the delivery of breast care.”
Symposium Mammographicum is taking
place at the Arena and Convention Centre
in Liverpool, 11-13 July 2010.
For further information contact:
Oliver Brown Sales Director,
WH Bence Coachworks Ltd
T: +44 (0)1454 310 909,
E: oliver@whbence.co.uk
Volume 5 Issue 3 • July/August 2010
Varian introduced ProBeam™ Proton Therapy Platform at PT COG 2010
Varian Medical Systems introduced the
fully-integrated ProBeam™ proton therapy
system at the 2010 Particle Therapy Co-
operative Group (PT-COG) meeting. The
ProBeam system incorporates imaging,
gating, robotic patient positioning,
treatment planning and oncology
information software to enhance treatment
quality for patients and workflow efficiency
for clinicians.
“ProBeam is the result of decades of
leadership in proton therapy research and
development and it has been designed
from the ground-up to meet the needs of
clinicians and patients alike,” says Moataz
Karmalawy, head of Varian’s particle
therapy group. “This fully integrated system
TomoTherapy proving itself in the NHS: World class IG-IMRT is achievable
Since its first patient treatment in 2003, in
Tennessee, TomoTherapy, the only helical
radiotherapy image-guided IMRT treatment
machine, has continued to grow within the
UK. With a total of ten systems soon to be
available in the UK, proof of the world class
quality of TomoTherapy and its suitability for
busy, NHS services is now truly established.
In spite of difficult financial times, astute
Trusts in England have shown that the most
advanced radiotherapy, is not necessarily
more expensive nor time consuming. In fact,
when resources for treatment planning,
quality assurance, imaging and treatment
are all factored, TomoTherapy is proving to
Nucletron supports ‘Because Life Is For Living’ campaign
Former England Rugby World Cup winner
Matt Dawson recently launched the ‘Because
Life is for Living’ campaign to raise awareness
about brachytherapy as a highly effective form
of radiotherapy to treat cancer. The campaign
and www.aboutbrachytherapy.com website
are supported by Nucletron.
“Having had close family members suffer
from cancer, we obviously wanted to find the
best possible treatment available and having
easy access to information and learning about
our options was a crucial step to helping us
Christie Hospital’s install the Novalis Tx
Brainlab and Varian Medical Systems have
announced that The Christie Hospital’s new
radiotherapy centre in Salford, opening in 2011,
will be the second specialist facility to choose the
Novalis Tx as their radiosurgery platform of choice
and a strategic addition to their provision of
cancer services. Earlier this year it was announced
that Clatterbridge Centre for Oncology in
partnership with The Walton Centre in Liverpool is
to be the first centre in the UK to provide
radiosurgery with the Novalis Tx platform.
As one of the world’s most advanced
radiosurgery platforms, Novalis Tx offers flexible
treatment options for radiosurgery and
Volume 5 Issue 3 • July/August 2010
dose on the target volume, enabling true
intensity modulated proton therapy. The
system also incorporates proprietary pencil-
beam scanning technology, which allows
for precise dose distribution.
Utilizing the proven technology of
Varian’s 250 MeV super-conducting
cyclotron and features, the ProBeam system
includes a streamlined treatment console
with a modern, graphical, easy-to-use
can be used for all forms of advanced interface that consolidates all controls for
proton therapy including image-guided imaging, treatment and motion
proton therapy and intensity-modulated management.
proton therapy.” For further information contact:
The ProBeam system incorporates Neil Madle, Varian Medical Systems,
Dynamic Peak™ integrated scanning T: +44 7786 526068,
technology which paints a precise radiation E: neil.madle@varian.com
for TomoTherapy, realised after six months
that due to demand, and quality of IG-IMRT
deliverable, that a second machine was
needed. They now treat 65 patients a day on
both machines, and this includes many
complex cases, where every patient receives
daily CT image-guidance and adaptive shifts,
to ensure that TomoTherapy’s highly
conformal , precise IMRT is accurately and
safely delivered.
For further information contact
be the most efficient of all radiotherapy Dean Willems
technologies. E: dean.willems@osl.uk.com
Addenbrookes Hospital, Cambridge, T: +44(0)1743 46269,
selected as the Government’s evaluation site W: www.osl.uk.com
deal with the situation,” says Matt Dawson.
Brachytherapy is a highly effective and
well-tolerated technique that facilitates the
treatment of cancer with greater precision
and less trauma to the patient. It brings the
radiation dose directly to the target area,
allowing the physician to apply a higher dose
of radiation directly to the tumour while
sparing healthy tissue and surrounding
organs.
For further information visit:
www.aboutbrachytherapy.com
radiotherapy and enables hospital staff to offer
personalised treatment based on patients’
specific needs, from frameless and frame-based
treatment of cranial indications to extra-cranial
treatment of spine, lung and liver indications.
“Our technology helps increase patient access
to improved, more consistent and more efficient
treatment,” says David James, Area Sales Manager,
Brainlab Ltd. “With the Novalis Tx radiosurgery
platform, treatments that would have taken up to
an hour or more using other techniques can be
completed in just minutes, with equal accuracy.”
For further information contact Brainlab UK
T: +44 (0)1223 597 817.
105
Simple solution for long-term live cell imaging
Adding to Nikon's series of BioStation
incubator imaging systems, which offer
excellent cell care throughout imaging, the
new BioStation IM-Q allows users with minimal
microscopy experience to conduct live cell
imaging without a steep learning curve. This
compact system incorporates a microscope, an
incubator and a high sensitivity, cooled
quantitative CCD camera integrated into a
single package. Providing a stable
environment for live cells and advanced phase
and fluorescence imaging solutions for simple,
long term, cell friendly timelapse data
acquisition, the BioStation IM-Q eliminates the need for a darkroom,
meaning it can be installed anywhere.
The BioStation IM-Q provides fully motorised control from a PC,
allowing users who are not accustomed to
operating a microscope or camera to easily
conduct timelapse imaging. Integrating cell
culture and image capture functions, no complex
setup or alignment procedures, that conventional
timelapse observation systems require, are
necessary. Providing thermal and mechanical
stability, BioStation IM-Q greatly reduces focus
drift, enabling reliable imaging even over long
periods.
For further information contact Nikon
Instruments Europe:
T: +44 (0)208 247 1718
E: info@nikoninstruments.eu
W: http://www.nikoninstruments.eu/Products/Cell-Incubator-
Observation/BioStation-IM-Q

Varian first comprehensive cancer center in India

The first in a planned series of new
radiotherapy centers aimed at improving
access to advanced treatments for millions
of Indian cancer patients has been officially
opened in Noida. Fortis International
Oncology Centre, a joint initiative between
International Oncology and Fortis
Healthcare, is equipped with advanced
radiotherapy equipment and software from
Varian Medical Systems.
Dignitaries at yesterday’s official
inauguration ceremony – including Dr.
Montek Singh Ahluwalia, the deputy
chairman of the Planning Commission of
India – were given a tour of the facility to
see Varian’s Trilogy® medical linear
accelerator in action. Trilogy, capable of
delivering a full range of advanced
radiotherapy and radiosurgery techniques
including RapidArc® radiotherapy, has been
operational at Noida for four months.
Pradeep K. Jaisingh, managing director
and CEO of International Oncology Services
Pvt Ltd, says, “There is a tremendous gap in
advanced radiotherapy services in India and
we are trying to fill this gap by establishing
a number of dedicated oncology centers
closer to the Indian population over the next
two years, the first of which is here in Noida.
The focus of our company is to widen
availability of a US-standard of cancer care
to Indian patients.”
For further information contact:
Neil Madle, Varian Medical Systems,
T: +44 7786 526068
E: neil.madle@varian.com

Royal Cornwall Trust refreshes its breast screening service with five
Siemens systems
The Royal Cornwall Hospitals NHS Trust
has ordered five MAMMOMAT
Inspiration™ Full Field Digital
mammography systems from Siemens
Healthcare as it refreshes its entire
mammography equipment portfolio.
One of the systems will mark Siemens’
500th Inspiration delivered globally.
Three units will be installed at the
Mermaid Centre, the home of
Cornwall’s breast screening service.
The additional two systems will be
located on mobile trailers, providing
asymptomatic imaging in outlying
regions as part of the National Breast
Screening programme.
The static Inspirations will connect
to a number of Siemens’ syngo®
One of the systems installed at Royal Cornwall Hospitals NHS
Trust will mark Siemens’ 500th MAMMOMAT Inspiration™
delivered globally. (Left to right) Vince Golledge, Regional
Sales and Corporate Business Manager at Siemens Healthcare;
and Dr Donna Christensen, Director of Cornwall Breast
Screening Service.
MammoReport workstations, a high speed
solution for reading and reporting
mammograms in both screening and
diagnostics settings. With optimised
connectivity, the workstation ensures easy
integration and will link to the Trust’s
Picture Archiving and Communications
System for storage and evaluation.
“We were looking for a mammography
system that could provide the best possible
patient experience in order to create state-
of-the-art facilities for the ladies of
Cornwall. The Inspiration offered
everything that we needed.” said Simon
Bromage, Unit Manager at the Mermaid
Centre, Royal Cornwall Hospital, Truro.
For further information visit:
http://www.siemens.co.uk/healthcare

To have your news item included in this section contact

Patricia McDonnell on Patricia@oncologynews.biz

106 Volume 5 Issue 3 • July/August 2010

World’s first UNIQUE radiotherapy patient
A 55-year-old female head & neck cancer
patient has become the first person in the
world to be treated clinically using a new,
advanced radiotherapy delivery device
from Varian Medical Systems. Clinicians
in Switzerland carried out the treatment
this week using a UNIQUE™ single energy
medical linear accelerator to deliver fast
and precise RapidArc® radiotherapy, the
leading solution for arc-based treatments.
The treatment took place at the Istituto
Oncologico della Svizzera Italiana (IOSI)
radiation oncology unit here in
Bellinzona, a public comprehensive
cancer center serving 330,000
inhabitants in southern Switzerland, and
part of Ente Ospedaliero Cantonale at San
Giovanni Hospital. Varian’s new UNIQUE
treatment unit, a cost effective single
Al Amal Hospital in Qatar Uses Varian’s RapidArc
Panel of Journal Reviewers
Ms Helen Evans,
Senior Lecturer in Cancer Nursing, Institute of Nursing and Midwifery,
University of Brighton, UK.
Dr Simon Grumett,
BSc MBChB MRCP PhD, Consultant & Honorary Senior Lecturer in Medical
Oncology, Royal Wolverhampton Hospitals NHS Trust & University of
Birmingham, UK.
Mr Mriganka De,
FRCS (ORL-HNS), Consultant ENT Head & Neck/Thyroid Surgeon,
Derby Royal Hospital, UK.
Richard Novell,
MChir FRCS, Consultant Coloproctologist, The Royal Free Hospital, London, UK.
Would you like to review a
journal for Oncology News?
We have new journals available for potential reviewers.
To apply simply email your CV to Patricia
– Patricia@oncologynews.biz
Volume 5 Issue 3 • July/August 2010
energy (6 MV) system with the ability to
deliver advanced treatments such as
RapidArc, has been introduced by Varian
to help bring advanced cancer care to
more patients. “The UNIQUE system is an
important asset in the clinical portfolio of
the center in order to offer the best level
of cancer care to all patients in the
region,” says Dr. Michele Morisoli,
Director of San Giovanni hospital.
“UNIQUE is a very capable machine
that will enable us to treat most of our
patients with a very advanced
technique,” says Dr. Antonella Fogliata,
head medical physicist at IOSI.
For further information contact:
Neil Madle, Varian Medical Systems,
T: +44 7786 526068
E:neil.madle@varian.com
One of the leading cancer centers in
the Middle East has become among
the first in the region to introduce fast
and efficient RapidArc® radiotherapy
treatments from Varian Medical
Systems. Al Amal Hospital in Doha,
Qatar, has treated nine brain cancer,
prostate cancer and head & neck
cancer patients with RapidArc since
commencing treatments in early May,
and it now plans to roll out the
technology for many more indications.
“Faster treatments that adapt
radiation dose to the tumor are always
desirable in radiotherapy and we are
very proud to join other prominent
oncology centers worldwide in offering
this technology,” says Dr. Noora Al
Are you working on an
interesting case?
Oncology News
accepts interesting
case reports.
Submissions are
invited for case
reports to be
included on our
website and/or
printed in the
magazine.
– Email Patricia@oncologynews.biz for more information
Hammadi, director of Al Amal
Hospital’s radiation oncology program.
This achievement was recognized at
a grand opening ceremony at the
hospital in June 2010, attended by
members of the Qatari Royal Family
and government. During the
ceremony, Al Amal Hospital signed an
agreement with Varian for the hospital
to become a reference center in the
gulf region and the Middle East for
RapidArc, image-guided radiotherapy
(IGRT) and other advanced forms of
radiotherapy.
For further information contact:
Neil Madle, Varian Medical Systems,
T: +44 7786 526068
E:neil.madle@varian.com
Case Report
Metastatic Angiosarcoma of Breast: An Unusual Presentation
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 Clinical experts
can be involved
In oncology alone there are a
staggering 1387 active Phase I
to Phase IV clinical trials across
the world4

Research
can be funded
Roche is leading investment
in diagnostic tests that will
impact disease management
for cancer patients in
the future21

Patients can
be heartened
Development We already have an unprecedented
can be focused five medicines with survival benefits
in oncology1
22 new molecules and 39 additional
indications in development are for oncology 2

We hope to help more

people wear purple
Purple is the colour of cancer survivors.
As the world’s number 1 in oncology
we continue to apply our expertise to
the future of cancer care. Each year we
invest over 1.5 billion Swiss francs in the
development of innovative anti-cancer
drugs and diagnostics. We believe in
investing in survival

References 1. Roche in Oncology – an overview. Available at www.roche.com. Accessed February 2009. 2. Oncology: Research and Development at Roche 2008. Available
at www.roche.com. Accessed February 2009. 3. Roche investor update, 4th February 2009. Available at www.roche.com. Accessed February 2009. 4. Roche data on file
Date of preparation: April 2010/ONCO00191

ONCO00191 Roche Ribbon ad Trim 210x297 Type 185x280 Bleed 216x303 A4.indd 1 26/04/2010 16:08