Neoadjuvant Chemotherapy with Gemcitabine plus Cisplatin in Patients with Locally Advanced Bladder Cancer.

BACKGROUND: Neoadjuvant chemotherapy with methotrexate-vinblastine-doxorubicin-cisplatin (MVAC) is the standard of care for muscle-invasive urothelial bladder cancer. Gemcitabine plus cisplatin (GC) shows similar efficacy with less toxicity in the metastatic setting and has therefore often been used interchangeably with MVAC. We report on the efficacy and safety of neoadjuvant GC in patients with locally advanced urothelial cancer. MATERIALS AND METHODS: We prospectively evaluated 87 patients in 2 centers. Their median age was 68 years. Treatment consisted of 3× GC prior to radical cystectomy. The primary endpoint was pathologic response. The secondary endpoints were safety, progression-free survival (PFS), and overall survival (OS). RESULTS: In all, 83 patients finished chemotherapy; 80 patients were evaluable for the primary endpoint. Pathologic complete response (pCR) was achieved in 22.5% and near pCR was seen in 33.7% of the patients. The 1-year PFS rate was 79.5% among those patients achieving ≤pT2 versus 100% among those patients achieving pCR or near pCR (p = 0.041). Five-year OS was 61.8% (95% CI 67.6 to NA). GC was well tolerated. Grade 3/4 toxicities occurred in 38% of the patients. There was no grade 3/4 renal toxicity, febrile neutropenia, or death. CONCLUSION: Neoadjuvant GC is a well-tolerated regimen. Although the pathologic response is lower than that reported with MVAC, our data support GC as a feasible option in the absence of a prospective randomized comparison, particularly for older patients, since its toxicity is lower than that of MVAC.

[Austrian guideline for palliative sedation therapy (long version) : Results of a Delphi process of the Austrian Palliative Society (OPG)]. / Leitlinie zur Palliativen Sedierungstherapie (Langversion) : Ergebnisse eines Delphiprozesses der Österreichischen Palliativgesellschaft (OPG).

BACKGROUND: Palliative sedation therapy (PST) is an important and ethically accepted therapy in the care of selected palliative care patients with otherwise unbearable suffering from refractory distress. PST is increasingly used in end-of-life care. Austria does not have a standardized ethical guideline for this exceptional practice near end of life, but there is evidence that practice varies throughout the country. OBJECTIVE: The Austrian Palliative Society (OPG) nominated a multidisciplinary working group of 16 palliative care experts and ethicists who established the national guideline on the basis of recent review work with the aim to adhere to the Europeans Association of Palliative Care's (EAPC) framework on palliative sedation therapy respecting Austrians legal, structural and cultural background. METHODS: Consensus was achieved by a four-step sequential Delphi process. The Delphi-process was strictly orientated to the recently published EUROIMPACT-sedation-study-checklist and to the AGREE-2-tool. Additionally national stakeholders participated in the reflection of the results. RESULTS: As a result of a rigorous consensus process the long version of the Austrian National Palliative Sedation Guideline contains 112 statements within eleven domains and is supplemented by a philosophers excursus on suffering. CONCLUSIONS: By establishing a national guideline for palliative sedation therapy using the Delphi technique for consensus and stakeholder involvement the Austrian Palliative Society aims to ensure nationwide good practice of palliative sedation therapy. Screening for the practicability and efficacy of this guideline will be a future task.

War and peace? The oncologic and the palliative care perspective on personalized cancer treatment in a patient with advanced cancer.

Personalized cancer treatment utilizing targeted therapies in a tailored approach is based on tumor and/or patient-specific molecular profiles. Recent clinical trials continue to look for new potential targets in heavily pretreated patients or rare disease entities. Careful selection of patients who may derive benefit from such therapies constitutes a challenge. This case report presents an experimental personalized cancer treatment in an advanced cancer patient and provides a list of issues for discussion: How can we combine treatment goals and simultaneously meet the individual needs in advanced cancer reconciling both perspectives: oncology and palliative care?

[Case report of a patient with renal cell cancer and his fateful progress - Breaking Bad News]. / Ein Patient mit schicksalhaftem Verlauf nach Nephrektomie bei Hypernephrom Überbringen schlechter Nachrichten ("Braking Bad News").

"Breaking Bad News" outlines a pathway for medical and other professional staff to deliver bad news to patients, clients, their families and carers. Bad news can mean different things to different people. Basically, it means any information which adversely and seriously affects an individual point of view of future or situations without any feeling of hope. The way a doctor or other health or social care professionals deliver bad news places an indelible mark on the doctor/professional-patient relationship. The debate about the levels of truth given to patients about their diagnosis has developed significantly over the last few years. While doctors and professionals now increasingly share information it has been the practice to withhold information because it was believed to be in the best interests of the patient. We discuss the situation of a patient with renal cancer who developed metastases after surgery. Unfortunately a tumour embolism from the kidney flashed into the pulmonary arteries. First it was not for sure if there were any metastases beside the tumour embolus. Months after embolectomy by thoracic surgery there was certain evidence of multiple pulmonary nodal lesions. First and second line chemotherapies failed and the patient died within several months after start of pharmacologic treatment. The case report discusses diagnosis and procedures, how the patient was supported and the way he got information at any critical date.

[Meaningfullness and duration of palliative chemotherapy with regard to the quality of life of palliative patients]. / Sinnhaftigkeit und Dauer von palliativer Chemotherapie in Bezug auf die Lebensqualität betroffener Patienten.

I am reporting on a 74-year-old female patient with primary pulmonary and hepatic metastatic colon cancer. In the course of three-and-a-half years the patient decided to receive multiple cycles of palliative chemotherapy, irradiation of the liver and of the upper body. As a result of the extended anti-tumour therapy, remissions of the advanced cancer disease could be achieved repeatedly, which lead to a substantial increase of the patient's quality of life. This case shows that even in an advanced palliative situation the goal of a multimodal treatment is to curb disease progression and to extend the life and increase quality of life of the patient.

[Quality of life and ethics as basic questions in geriatric oncology]. / Lebensqualität und Ethik als wichtige Grundsatzfragen der geriatrischen Onkologie.

Optimal care for elderly cancer patients requires empathy and alertness about impaired autonomy and an exceptional quality of care. Specific to geriatric oncology is the particular need of attention and care for the patients. Most important from a conceptual point of view is to identify that this will result in additional demands. To care for these patients will require more time as any intervention must be adapted to age specific capabilities. The difficult task of shared decision-making should be preferably based on the quality of life assessment of the individual patient and their needs. The process of assessing quality of life is in itself already an act of enhancing autonomy, because it respects the individual's subjectivity. Many ethical questions arise between the contradictory contexts of paternalism and autonomy. There are conditions to be met and limits of autonomy to be considered, which differ for the elderly patients because of their vulnerability and particular dependencies. As the elderly patient is closer to death and dying, questions of care in these situations are frequently more pressing. It is important to distinguish actively intended euthanasia from the goals and concerns of modern palliative care in order to enable dying with dignity.

[Clinical relevance of biomarkers in cancer related bone disease]. / Klinische Relevanz von Biomarkern bei der Skelettmetastasierung von Malignomen.

Biomarkers as biochemical substances of collagen metabolism are produced during bone turnover and can be determined as parameters of bone metabolism not only in serum, but also in urine. These growth and decomposition products of the bone are already used to determine bone metabolism in osteoporosis and to prove efficacy of antiresorptive therapy. Metastases of the bone likewise show a higher rate of bone turnover. Nowadays detection of neoplastic bone lesions and progression of their spread are performed with x-rays, radionucleoide bone imaging and magnetic resonance imaging. In the future, biomarkers might improve early detection of bone lesions and follow-up of skeletal metastases. At present, the clinical use is documented insufficiently. In the foreseeable future the determination of the bone turnover markers and additional serum parameters of bone metabolism such as OPG, RANKL might be available for early diagnosis and follow-up in patients with bone metastatic diseases.

[The hormone refractory prostate cancer - a challenge for the internal specialist]. / Das hormonrefraktäre Prostatakarzinom - eine internistische Herausforderung.

Prostate cancer is the second-leading cause of cancer-related death among men and the seventh most common cause of death in the United States overall. As prostatic carcinoma is a slowly growing cancer depending on the tumor burden, use of PSA results in early cancer detection. pT2 tumors can be cured with low morbidity by radical prostatectomy. Five years after operation only few patients will experience further PSA recurrences. Adjuvant radiation therapy is effective in about half of patients with pT3 tumors in case of PSA recurrence. Most prostate cancers are androgen-dependent, meaning that they respond to androgen-ablation therapy. However, these tumors eventually become androgen-independent and grow despite androgen ablation. Since androgens are essential to the survival of prostate cells, a major question is how a prostate cell survives after androgen-ablation therapy. The mechanisms by which a prostate cancer cell survives after androgen-ablation therapy are conflicting. Specific targeting of genes involved in such pathways may further increase the chance of inventing new therapeutic options. So far, chemotherapy with docetaxel has been proved to prolong survival time and minimize cancer induced side effects in patients with hormone refractory prostate cancer.

[Leadership strategies--the Bible as a guide to management in the health care system]. / Führungsstrategien--die Bibel als praktikables Führungsmodell im Spitalsbereich.

Management and leadership are an integral part of any organisation, to optimise procedures and increase efficiency. Aims, ideals and structures first need to be defined for tasks to be carried out successfully, particularly in difficult times. A good example for the way communities can effectively and with conviction pass on their values and standpoints from generation to generation, grow in strength and also influence their surroundings is provided by religion. This paper focuses leadership provided by charismatic personalities within the Jewish and Christian religions. Monasteries have run hospitals without governmental support ever since the Middle Ages. Leadership within today's health care system calls for a variety of strategies in the different phases of development. In times of limited resources and multifarious societies, leadership implies both a scientific as well as an ethical challenge.