The Impact of Hospice Services in the Care of Patients with Advanced Stage Nonsmall Cell Lung Cancer.

INTRODUCTION: Prior research has shown that advanced stage nonsmall cell lung cancer (NSCLC) patients enrolled in hospice care receive less aggressive treatment at the end of life (EOL) without compromising survival. Our purpose was to profile the continuum of care of these patients, exploring the connection between hospice enrollment and quality indicators for excellence in EOL cancer care. METHODS: One hundred ninety-seven deceased stage IV NSCLC patients diagnosed between 2008 and 2010 at two separate tertiary care centers within the same county were identified. A retrospective review was conducted, collecting data from electronic medical records regarding antitumor treatment, postdiagnosis hospital visits and admissions, hospice referrals and enrollments, and circumstances surrounding the patient's death. Patients were grouped by their status of hospice enrollment, and the remainder of the measures compared accordingly. RESULTS: There was no significant difference found in total number of postdiagnosis hospital admissions between the patients who were enrolled in hospice and those who were not. However, the group who received hospice services had a significantly lower number of hospitalizations (p < 0.001), emergency department visits (p < 0.01), and intensive care unit admissions in the last 30 days of life (p < 0.001). The number of lines of chemotherapy received did not differ significantly between the groups. Median survival, measured by the length of time between diagnosis and death, was significantly longer for hospice patients (p = 0.02). CONCLUSIONS: This study demonstrates that, among patients with metastatic NSCLC, hospice enrollment was associated with optimized EOL oncological care and a significantly longer median survival.

Phase II trial of dose-dense chemotherapy followed by dose-intense erlotinib for patients with newly diagnosed metastatic non-small cell lung cancer.

This phase II study investigated dose-intense erlotinib maintenance after dose-dense chemotherapy for patients with metastatic non-small cell lung cancer and examined two cell cycle biomarkers. Patients with newly diagnosed metastatic non-small cell lung cancer received docetaxel 75 mg/m² and cisplatin 75 mg/m² on day 1 and pegfilgrastim on day 2 every 14 days for four cycles. Patients then received erlotinib with initial doses based on smoking status. Doses were increased in 75 mg increments every two weeks depending on toxicities until each patient's maximal tolerable dose (MTD) was achieved. Cyclin D1 and D3 biomarkers were measured by immunohistochemistry. The objectives of the study were to evaluate time to progression (TTP) and overall survival (OS) for the entire population and biomarker subgroups. Forty-five patients were enrolled. Intra-patient erlotinib MTD ranged from 0 to 525 mg. Median MTD achieved in smokers was higher than in non-smokers (300 vs. 150 mg; P=0.019). TTP for the entire cohort was not significantly improved compared to historical controls. Patients with high cyclin D1 expressing tumors demonstrated improved TTP on erlotinib (8.2 vs. 4.7 months; hazard ratio, 4.1; 95% CI, 1.6-0.6; P=0.003) and improved OS (20.5 vs. 8.0 months; hazard ratio 2.8; 95% CI, 1.2-6.3; P=0.016). Intratumoral cyclin D3 expression did not impact clinical outcomes. Current smokers but not former smokers exhibit a higher erlotinib MTD. High cyclin D1 expression was associated with favorable TTP and OS.

Myocardial necrosis in patients with thrombotic thrombocytopenic purpura: pathophysiology and rationale for specific therapy.

Myocardial necrosis is now recognized as a common feature of thrombotic thrombocytopenic purpura (TTP), usually due to platelet plugging in the microvasculature. Despite reports that TTP patients with myocardial damage have higher morbidity and mortality, there are no established guidelines for managing these high-risk patients. The universal occurrence of thrombocytopenia and variable findings including renal dysfunction present unique challenges in this setting. Established therapies including plasma exchange and immunosuppression are the mainstay of therapy for all TTP patients. For the subset of patients with myocardial damage, therapy with more potent antiplatelet drugs, agents that enhance NO availability and alleviate vasospasm and drugs that suppress von Willebrand factor levels may have additional benefit. However, clinical trials are needed to optimize therapy for this subset of TTP patients.