[Does consumption of tobacco, alcohol, and cannabis in adolescents and young adults with cancer affect the use of analgesics during hospitalizations?]. / La consommation de tabac, alcool et cannabis chez les adolescents et jeunes adultes atteints de cancer a-t-elle un impact sur l'utilisation hospitalière des traitements antalgiques pendant la période de traitement ?

INTRODUCTION: The specificities of adolescents and young adults (AYAs) aged 15-25 years with cancer are now well recognized. Dedicated care was initiated in 2012 in France under the leadership of the INCa (National Cancer Institute). Research on supportive care and particularly pain management are still rare. This study aimed to evaluate the consumption of toxic substances (tobacco, cannabis, alcohol) in AYAs with cancer as well as its progression during the month following the diagnosis and to analyze its influence on opioid analgesic prescriptions during treatment. METHODS: This is a prospective study including all new patients aged 15-25 years in two centers between January and June 2013. Data on consumption of psychoactive substances were obtained during an individual interview with a questionnaire. National surveys were used to compare this cohort with the general population. Data on opioid treatments were collected from the computerized prescription software and computerized patient record. RESULTS: Thirty-seven AYAs were eligible and 30 were included; 67% of them were male and the median age was 18.7 years. The questionnaire on tobacco, alcohol, and cannabis consumption at diagnosis was well accepted. Consumption profiles were comparable to the general population. Changes in behavior were observed during the 1st month after diagnosis, with a decrease or cessation of consumption, particularly among young people. This study showed differences in the use and requirements for opioid analgesics during hospitalization according to these consumption data. CONCLUSION: Prevention and support for AYAs who are regular consumers of toxic substances must be organized during initial care in oncology.

[Setting up supportive care in oncology: reflexions and suggestions.]. / A propos de la mise en place des soins de support en cancérologie : pistes de réflexions et propositions.

A group of 19 health professionals implicated in supportive care wanted to suggest some reflexions for organization, setting and evaluation of the supportive care in institutions and health territories. The suggested organization must be applicable to any cancer patient and the place of the care whatever the age, the stage of the disease; in the future, must be applicable to any patient with serious chronic illness. This organization must allow to optimize the accompaniment and the care of the patients and their close relations by 1) precise and regular analysis of their needs; 2) the respect of the continuity of the health care; 3) the setting of collaborative practice and transversality in the care. It is not a new medical speciality but a coordination of competences for patients and their families.

[End of chemotherapy decision for metastatic breast cancer patients.]. / La décision d'arrêt de chimiothérapie pour les patients atteints de cancer du sein métastatique.

If chemotherapy beyond the third line often gives sum clinical benefits, it is sometimes prescribed only to avoid telling bad news to patients. Palliative chemotherapy can lead to symptom reduction and greater health related quality-of-live, but longer survival is unlikely. Physician's questioning about chemotherapy continuation is an ethical duty so is the discussion with patients and caregivers about prognosis and possibility to receive principally palliative care. Medical information about prognosis must be told "step by step", following patients questioning and their capacity listening to the answers. Exhaustion of chemotherapy efficacy is the best argument to explain chemotherapy stop, which does not mean end-of-life, particularly for patients with slow growing tumour. Maintain hope for patients in regard with their medical situation is vital in a psychological way, to stay alive and to be able to project himself in the close future. Modalities of decisions taking about end of chemotherapy have to be defined but consultation of all caregivers implicated in the palliative patients care is essential.

[Requests for active euthanasia: which reality in an oncology center.]. / Demandes d'euthanasie : quelle réalité dans un centre anticancéreux.

Euthanasia is a controversial issue in today's society. In countries where euthanasia is legal, it is mainly associated with people with cancer. We retrospectively studied the frequency and basis of patients' requests for active euthanasia in the oncology setting.MethodsRecurrent requests for euthanasia made by the patients of Leon-Berard cancer center (Lyon, France) between 2001 and 2003 were recorded by questioning the physicians and nurse supervisors in charge or by collecting information from the minutes of multidisciplinary palliative care meetings. We also collected information on the general health status of the patients, their motives and their evolution over time, as well as responses from caregivers.ResultsWe identified 16 requests for euthanasia. These involved 8 men, 7 women and 1 child (median age, 56 years), corresponding to 1% of the total deaths recorded during the period. In 2 cases, the request had come from the family only. The most frequent motives were psychological distress (38%), desire for self-autonomy (31%) and pain (31%). Half of the patients, particularly those striving for autonomy, persisted with their request until death, whereas 2 of 3 requests motivated by physical or psychological distress were not maintained. Sedation was administered to 3 patients in response to recurrent requests.ConclusionRequests for euthanasia in cancer patients are rare but may occur. Sometimes suffering is not relieved by palliative care and the request is maintained. Dealing with these patients puts caregivers in a difficult situation.

[Huriet law: application in a regional cancer centre (Centre Léon-Bérard, Lyon)]. / Loi Huriet: bilan d'application dans un centre régional de lutte contre le cancer (centre Léon-Bérard, Lyon).

Clinical research is one of the main activities in cancer centres and is submitted in France to a specific law (named "loi Huriet") which includes good clinical practices. We are now conducting a general program of quality evaluation and improvement in the regional cancer centre of Lyon (centre Léon-Bérard). Part of this program is an audit of the application of the Huriet law. Since no instrument exist for measuring this application, we have created a specific one, that attribute notation according to the different aspects of the law. Results show a good level of conformity but sometime non sufficient. There is no difference between the two studied years. Quality changes according to promoters (private or academic) and monitoring. Written procedures and specific training for the different actors are required to improve quality of clinical research with focus on the patient interest.

Research controversies in management of oral mucositis.

The management of mucositis is the subject of many controversies, and the optimal treatment is still not known. Several evaluation scoring systems have been described, but no one of these is appropriate to all clinical situations: a simple scale such as that devised by the WHO can be used routinely, and more sophisticated ones can be implemented by trained experimenters working in research. We have considered the impact of each of the treatments currently available on each stage of mucositis. In attempts at prevention, self-care, in the sense of oral hygiene, must remain atraumatic. It is probably advisable to differentiate patients with good previous oral care, in whom tooth brushing is beneficial, from others, in whom the risk of hemorrhage and infection excludes any brushing. Before the dosage of chemotherapy is reduced, the curative or palliative intent of the strategy must be carefully evaluated. In the vascular phase protection of the proliferating cells is attempted by means of vasoconstriction (cryotherapy), cytoprotection (prostaglandin E2 and other antioxidants) or epithelial cell-inhibiting factors such as TGF-B3. Treatments applied in the epithelial phase are directed at increasing the cell proliferation to accelerate epithelial restoration by sucralfate and several growth factors: hematopoietic GF, which has demonstrated a direct effect on the mucosa (GM-CSF), or epithelial growth factors such as keratinocyte GF. In the ulcerative and bacteriological phase attempts are made to attenuate sepsis by means of antiseptics (chlorhexidine), amphotericin B and antiviral agents or antibiotic lozenges. In the healing phase application of the low-energy helium-neon laser has demonstrably been followed by a later time of onset, less pronounced peak severity and shorter duration of oral mucositis. After cancer treatment, oral hygiene, inhibition of oral flora, and pain relief are the main goals. Physiopathogen-specific treatment is the next step, with the emphasis on the inhibition of epithelial cell proliferation during drug exposure and facilitation of epithelial maturation and healing.

[Anticancer chemotherapy. Prevention of toxicity]. / Chimiothérapie anticancéreuse. Prévention de la toxicité.

A MAJOR CHALLENGE: Prevention of short and long term toxicity of chemotherapy is an important challenge in oncology in order to maintain the dose/intensity of protocols and to increase patient comfort. AVAILABLE CHEMOPROTECTORS: Amifostine protects against the blood, kidney and nerve toxicity of cisplatin. Protection is less evident for carboplatin and should be further evaluated for alkylating agents, anthracyclines and taxans. Dexrazoxane protects against the cumulative cardiotoxicity of anthracyclines without reduction of antitumor efficacy. It must be used beyond a cumulative dose of 300 mg/m2 doxorubicin (or equivalent) in responsive patients. Its use in the curative treatment of lymphoma should be assessed by further clinical trials. Mesna must be widely used to prevent the urotoxicity of cyclophosphamide and ifosfamide. An oral preparation is now available for outpatients. Protection of the gonadic function could be achieved by LH-FH analogs in young women. PERSPECTIVES: Due to their high cost and the risk of diminishing the antitumor efficacy in curable diseases, a precise evaluation of present and future chemoprotectors is necessary before wider use.