Cancer-Associated Thrombosis: A Taiwanese Perspective on Therapeutic Options with Focus on Non-Vitamin K Antagonist Oral Anticoagulants.

Cancer-associated thrombosis (CAT) is a common complication of malignancies. Patients with CAT are at risk of venous thromboembolism recurrence, but also at risk of bleeding while anticoagulated. Taiwanese patients are perceived to have a lower incidence of CAT, likely leading to false reassurance for Taiwanese patients with cancer. Because of this, oncologists and cardiologists from multiple medical institutions in Taiwan have set forth to provide clinical consensus guidelines on the management of CAT, based on local clinical practices and guided by predominant international clinical practice guidelines. This paper aims to describe the current disease burden of cancer-associated venous thromboembolism in Taiwanese cancer patients, and discusses the unmet needs and gaps in the management of this medical complication. It also outlines diagnostic and management strategies relevant to the different treatment options available, such as non-vitamin K antagonist oral anticoagulants.

Type of Androgen Deprivation Therapy and Risk of Dementia Among Patients With Prostate Cancer in Taiwan.

Importance: It remains unclear whether androgen deprivation therapy (ADT) is associated with subsequent dementia risk in patients with prostate cancer. There are limited data regarding dementia risk across ADT types. Objective: To examine the association between all-cause dementia, including Alzheimer disease (AD), and different ADT types in patients with prostate cancer. Design, Setting, and Participants: This cohort study used linked data from the Taiwan National Cancer Registry, the National Health Insurance Research Database, and the Taiwan National Death Registry. A cohort of 23 651 patients with newly diagnosed prostate cancer between January 1, 2008, and December 31, 2015, was identified and followed up from 1 year after diagnosis until December 31, 2017. Data analysis was performed between January 2019 and May 2020. Exposures: Patients who received and did not receive ADT, including gonadotropin-releasing hormone (GnRH) agonists, orchiectomy, or antiandrogen monotherapy. Main Outcomes and Measures: The primary outcomes were all-cause dementia or AD. Stabilized inverse probability of treatment weighting was used to balance baseline covariates. The association between dementia and various ADT types was examined using the Cox proportional hazards model. Furthermore, a multivariate Cox proportional model with age as the time scale was conducted for complementary comparison. Results: In the cohort of 23 651 male patients (median [interquartile range] age, 73 [66-79] years), 6904 (29.2%) did not receive ADT, 11 817 (50.0%) received GnRH agonists, 876 (3.7%) received orchiectomy, and 4054 (17.1%) received antiandrogen monotherapy. Overall, 1525 patients were diagnosed with incident dementia (1.72 per 100 person-years) during a median (interquartile range) follow-up of 3.46 (1.92-5.51) years. Compared with those who did not receive ADT, those using antiandrogen monotherapy showed an increased risk of dementia (weighted hazard ratio [HR], 1.34; 95% CI, 1.16-1.55) and AD (weighted HR, 1.52; 95% CI, 1.13-2.04). The risk of dementia was similar between GnRH agonist use or orchiectomy and no ADT use (GnRH agonist: weighted HR, 1.13; 95% CI, 1.00-1.28; orchiectomy: 1.00; 95% CI, 0.74-1.37). Several sensitivity analyses revealed consistent findings for both outcomes. Conclusions and Relevance: In this study, the use of antiandrogen monotherapy was associated with increased risk of dementia or AD, while GnRH agonist use and orchiectomy had no significant difference compared with patients who did not receive ADT. Further prospective studies are warranted to confirm these findings.

Retrospective Analysis of Mortality Cases in Advanced and Metastatic Solid Tumors With Concurrent Prerenal Azotemia.

BACKGROUND/AIM: A retrospective study of cases with metastatic or advanced solid tumors complicated with AKI (acute kidney injury) with prerenal azotemia. PATIENTS AND METHODS: Criteria included: (1) advanced or metastatic solid tumors that led to mortality; (2) prerenal azotemia identified upon renal function evaluation and (3) BUN to Cr ratio (BCR)≥15. We also compared the outcomes of patients with BCR>20 with those of patients with BCR=15-20. RESULTS: A total of 218 patients with solid tumors were enrolled. One hundred and forty (64%) and 78 (36%) patients had BCR>20 and 15-20, respectively. Before AKI occurrence, 136 (62%) had thromboembolic complications and 96 (44%) paraneoplastic syndromes. Median survival time was 1 week in all patients. Median survival time was statistically different between the groups with BCR15-20 and BCR>20 (p<0.005, log-rank test). CONCLUSION: Cancer patients with concurrent AKI and prerenal azotemia carry a very poor prognosis.

Extrahepatic Portal Venous Obstruction With Hepatic Enzyme Elevation Resembling Hepatitis in Patients With Cancer.

BACKGROUND/AIM: Chemotherapy is often halted due to abnormal liver function resembling hepatitis. But the cause can be extrahepatic portal venous obstruction (EHPVO) with hepatic enzyme elevation rather than being an adverse effect of chemotherapy. We investigated EHPVO with hepatic enzyme elevation in patients with cancer. PATIENTS AND METHODS: Data of these hospitalized patients with solid tumors between January 2013 and September 2017 were collected. The criteria for study inclusion were: (i) Extrahepatic malignancy; (ii) computed tomographic scans showing a tumor with external compression of the extrahepatic portal vein; and (iii) serum aminotransferase (AST) or alanine transaminase (ALT) level three times above the normal value. RESULTS: Thirteen out of 377 (3%) patients developed EHPVO with hepatic enzyme elevation, as demonstrated from computed tomographic scan. Four cases (31%) also had vascular thrombosis (three portal vein and one inferior vena cava). Serum AST increased from 34±11 to 169±94 U/l. ALT increased from 9±38 to 177±104 U/l. There was no relationship of EHPVO with viral markers and cirrhosis. Six cases received chemotherapy with liver function improvement. CONCLUSION: EHPVO occurred in patients with metastatic cancer, leading to hepatic enzyme elevation resembling hepatitis without hepatitis risk factors and cirrhosis. Before withholding chemotherapy due to hepatic enzyme elevation, the possibility of EHPVO should firstly be excluded.

Survival Benefit for Patients With Metastatic Urothelial Carcinoma Receiving Continuous Maintenance Chemotherapy.

BACKGROUND/AIM: Urothelial carcinoma is a chemo-sensitive cancer. We investigated the contributory factors to survival benefit of metastatic urothelial carcinoma (MUC) patients receiving continuous maintenance chemotherapy. PATIENTS AND METHODS: Inclusion criteria were: i) pathology-confirmed urothelial carcinoma, ii) metastatic lesions identified mainly on pre-therapy computed tomography (CT) scans, and iii) inpatient-administered chemotherapy of at least three cycles. Chemotherapy regimens included 5-fluorouracil, leucovorin, cisplatin, and gemcitabine. RESULTS: A total of 139 cases were enrolled in this study. The overall objective response rate was 60% and the median survival time was 17 months. Eight-two (59%) patients had inflammation-related symptoms following the course of chemotherapy. Fifty-five (41%) patients survived more than two years. All patients exhibited various fibrosis formations. No patient experienced unfavorable metastatic conditions. Inflammation-related symptoms remained in 28 (51%) patients. We found that surgery, invasive procedures, and infection likely led to a rapid tumor progression. CONCLUSION: Continuous maintenance chemotherapy targeting chemo-sensitive tumors, administered at metronomic intervals and focus on tumor microenvironment, can increase MUC survival benefits.

Differences in Pain Intensity of Tumors Spread to the Anterior versus Anterolateral/Lateral Portions of the Vertebral Body Based on CT Scans.

We investigated whether the intensity of cancer pain differs for malignant tumors that have spread to anterior or anterolateral/lateral portions of the vertebral body. We hypothesize that tumor spread to the anterolateral/lateral vertebral body elicits more serious pain due to increased irritation of the spinal nerve. The selection criteria were as follows: (1) advanced or metastatic solid tumor; (2) radicular pain without extremity weakness; (3) malignant lesions anteriorly, anterolaterally, or laterally located at the vertebral body either spread locoregionally or over a greater distance via metastasis based on CT scan diagnosis; and (4) patient needs to use opioids for pain relief. Severe spinal pain intensity was defined as spinal pain for which patients required either strong opioids or spinal irradiation for relief. Eighty-six patients were enrolled in the study. Bone lesions were mainly osteolytic. Thirty-nine tumors spread to the vertebral body in the anterior direction, and 47 in the anterolateral/lateral direction. Severe pain intensity related to vertebral body lesions was due to anterolateral/lateral spread, primary sites of nonurothelial carcinoma, metastatic vertebral lesions, multiple lesions within a vertebrum, and location within the cervical-thoracic spine. In conclusion, patients with tumor spread to the anterolateral/lateral portion of vertebrae bodies based on CT scan diagnosis experienced severe cancer pain. These patients needed strong opioids or palliative spinal irradiation for pain relief.

Invasion of Adjacent Lumbar Vertebral Body from Renal Pelvis Carcinoma: Associated With Bone Metastasis But Easily Overlooked on Initial CT Scan.

BACKGROUND/AIM: We hypothesized that regional tumor growth into L1 and L2 vertebral bodies from renal pelvis carcinoma was linked to the development of bone metastases. MATERIALS AND METHODS: Criteria for the study were: (i) Metastatic renal pelvis carcinoma confirmed via pathology and computed tomographic (CT) scan, (ii) L1 and L2 invasion confirmed from retrospective CT scan review, and (iii) detection of bone metastases using radionuclide images/CT scans. RESULTS: A total of 71 cases were enrolled in the study. Initial L1 and L2 vertebral body invasion. were detected in 45 (63%) patients. As well as L1 and L2 invasion, 32 (71%) had development of bone metastases. All bone lesions were osteolytic. Initial L1 and L2 invasion (p<0.00001) was associated with the development of bone metastasis. CONCLUSION: CT scan can help to detect L1 and L2 vertebral body invasion in patients with renal pelvis carcinoma. Early identification and optimal management of such patients is necessary.

Pre-therapy CT scan showing peritoneal thickening from metastatic renal pelvis carcinoma patients.

We investigated clinical significance of peritoneal thickening from metastatic renal pelvis based on pretherapy computed tomography (CT) scan findings. The criteria for inclusion were as follows: (1) pathology and CT scan confirmed metastatic renal pelvis carcinoma and (2) peritoneal thickening based on pre-therapy CT scan findings. We investigated the route of spread, gastrointestinal (GI) complications, and response to chemotherapy. A total of 68 cases were enrolled in this study, including seven patients with liver metastases and three with abdominal wall invasion. GI complications included obstruction in ten patients and bleeding in three. Response to chemotherapy demonstrated by reduced peritoneal thickening was noted in 24 patients. IN CONCLUSION: peritoneal thickening with clinical suspicion of peritoneal involvement can get indirect evidence from route of spread (liver or abdominal wall), GI complications (obstruction or bleeding) or response to chemotherapy (obvious decrease peritoneal thickening) from metastatic renal pelvis carcinoma patients. Pretherapy CT scan with peritoneal thickening should be alert that tumor has spread to the peritoneum.

Under-stage and Overlook of Peritoneal Spread from Bladder Urothelial Carcinoma.

BACKGROUND/AIM: Bladder cancer can spread from the sub-peritoneal space superior and posterolateral to the peritoneal cavity via the peritoneal lining. The aim of this study was to improve the identification of peritoneal spread from bladder urothelial carcinoma based on computed tomography (CT) scans. MATERIALS AND METHODS: This is a retrospective study including patients selected with the following criteria: (i) pathology-confirmed urothelial carcinoma; (ii) peritoneal spread identified on CT scans from axial and corona views, either initially or after radical/partial cystectomy, concomitant chemoradiotherapy (CCRT), or radiotherapy. One hundred and fifty-nine cases met the selection criteria. RESULTS: Routes of spread to the peritoneum included the superior to anterior direction in 59 patients (37%), the superior to posterolateral direction in 19 (12%), and the superior to both anterior and posterolateral directions in 81 (51%). Invasion of specific sites included the abdominal wall in 101 patients (70%), bowel/mesentery in 84 (53%), prostate, uterus, and rectum in 30 (19%), and circumferential tumors that outlined the whole bladder wall in 59 (37%). Initial modes of therapy were chemotherapy in 86 patients (54%), cystectomy in 55 (35%), CCRT in eight (5%), radiotherapy in two (1%), and no therapy in eight (5%). Peritoneal spread due to under-staging (clinical/pathological stage) after local therapy was found in 84 patients (53%). CONCLUSION: Initial pre-therapeutic staging is easily overlooked regarding peritoneal spread from bladder urothelial carcinoma. Combined axial and coronal views of CT scans can help identify peritoneal involvement.

Renal Pelvis Carcinoma with Renal Vein or Inferior Vena Cava Involvement Linked to Early-onset Lung Metastasis Based on CT Scan Diagnosis.

BACKGROUND/AIM: Renal pelvis cancer with invasion of the renal vein or inferior vena cava (IVC) carries a poor prognosis. The present study investigated whether early-onset lung metastasis in these patients contributes to their poor outcome. PATIENTS AND METHODS: Data were retrospectively collected from hospitalized patients with metastatic renal pelvis urothelial cancer. The parameters used to estimate the risk of lung metastasis were based on computed tomographic (CT) scans. The parameters included sex, age (≤65 years or >65 years), site (right or left side), metastasis to para-aortic lymph nodes (LNs), suspicion of peritoneal spread, IVC involvement, and renal vein involvement. There were 71 cases including: 40 (56%) patients with lung metastasis (22 early-onset and 18 late-onset), 68 (96%) with suspicion of peritoneal spread, 38 (54%) with para-aortic LN metastasis, 10 (14%) with IVC involvement, and 53 (74%) with renal vein involvement. Sixty-four cases were evaluated to estimate the risk of lung metastasis. RESULTS: Tumor involvement in the IVC (p=0.01) and in the renal vein (p<0.00001) were high risk factors for lung metastasis. CONCLUSION: Tumor involvement of the renal vein or IVC is linked to early-onset lung metastasis in renal pelvis cancer based on CT scan diagnosis.

Avascular Necrosis of Bone following Chemotherapy in Cancer Patients with Coagulopathy: Report of Two Cases.

We report 2 cases of patients with solid tumors and coagulopathy who experienced avascular necrosis (AVN) of the bone following chemotherapy. Both cases exhibited nontraumatic bilateral AVN of the femoral heads, and one also showed bilateral AVN of the humeral heads. One case had multiple thromboembolic complications, including pulmonary obstructive syndrome and paraneoplastic pain. The other showed multiple paraneoplastic syndromes, with hypercalcemia and thrombocytosis. Groin pain and claudication of the lower extremities developed and persisted. Both patients eventually received bilateral hip arthroplasty due to AVN of both femoral heads.

Risk of Cardiovascular Ischemic Events After Surgical Castration and Gonadotropin-Releasing Hormone Agonist Therapy for Prostate Cancer: A Nationwide Cohort Study.

Purpose Our aim was to determine whether cardiovascular (CV) risk in patients with prostate cancer (PCa) differs between those who receive androgen-deprivation therapy by surgical castration and those who receive gonadotropin-releasing hormone agonist (GnRHa) therapy. Patients and Methods By using the Taiwan National Health Insurance Research Database, we analyzed data from 14,715 patients with PCa diagnosed from January 1, 1997, through December 31, 2011. The patients were treated with bilateral orchiectomy or GnRHa therapy. We used inverse probability of treatment weighting with propensity scores to adjust for the imbalance in covariate baseline values between these two groups. Cox regression models were used to identify risk factors for myocardial infarction (MI), ischemic stroke (IS), and cardiac-related complications. Results Overall, 3,578 patients with PCa (24.3%) underwent bilateral orchiectomy and 11,137 patients (75.7%) received GnRHa therapy. Both groups had a similar risk of CV ischemic events (ie, MI or IS; hazard ratio, 1.16; 95% CI, 0.97 to 1.38) during a median follow-up time of 3.3 years. However, during the first 1.5 years of follow-up, there were higher CV ischemic events in the orchiectomy group than in the GnRHa group (hazard ratio, 1.40; 95% CI, 1.04 to 1.88), particularly in patients who were ≥ 65 years of age, had hypertension, had a Charlson comorbidity index score ≥ 3, and had a previous history of MI, IS, or coronary heart disease. Conclusion Compared with bilateral orchiectomy, use of GnRHa does not increase the risk of CV ischemic events in patients with PCa. Nonetheless, orchiectomy is associated with higher rates of CV ischemic events in older patients and those with a history of CV comorbidities within 1.5 years of initiating androgen-deprivation therapy. These findings can help clinicians decide on the optimal castration strategy for individual patients.

Bladder Urothelial Carcinoma with Peritoneal Involvement: Benefit of Continuous Maintenance Chemotherapy.

AIM: We investigated bladder urothelial carcinoma with peritoneal involvement. PATIENTS AND METHODS: Inclusion criteria were: pathology-confirmed urothelial carcinoma; peritoneal spread identified on computed tomographic (CT) scans performed initially or after either cystectomy or concomitant chemoradiotherapy (CCRT), and absence of visceral metastases; and chemotherapy administered after peritoneal spread was diagnosed. RESULTS: Forty-seven cases included initial modes of therapy with chemotherapy in 24 patients (51%), cystectomy in 17 (36%), and CCRT in six (13%), only given as a result of under-staging. After local therapy, these patients received a continuous maintenance chemotherapy regimen of 5-fluorouracil, leucovorin, cisplatin, and gemcitabine. The overall response rate was 85%, and the side-effects were mild and tolerated. The median survival time was 28 months. The survival time of cases initially treated only with chemotherapy was not statistically different to that of those with local disease. CONCLUSION: Bladder urothelial carcinomas with peritoneal involvement can benefit from continuous maintenance chemotherapy.

Iliofemoral Venous Thrombosis Mainly Related to Iliofemoral Venous Obstruction by External Tumor Compression in Cancer Patients.

BACKGROUND: To study iliofemoral venous thrombosis related to iliofemoral venous obstruction in cancer patients. METHODS: In this case series study, 829 cancer patients were surveyed for iliofemoral obstruction/thrombosis within 10 years. The criteria for inclusion were: (1) presence of unilateral lower-extremity swelling; (2) computed tomography (CT) scans showing a tumor with external compression of the iliac or femoral vein, and (3) duplex ultrasound scans showing venous thrombosis or venous flow insufficiency over a femoral vein or saphenous vein. RESULTS: Sixty-three patients (8%) developed an iliofemoral venous obstruction. The presence of iliofemoral venous thrombosis was detected in 21 of these patients (33%). The rate of iliofemoral venous thrombosis was significantly higher in patients with an invasion of the inguinal region, D-dimer levels >3,000 ng/ml, gastrointestinal cancer, or invasion of the inguinal lymph nodes. However, none of our patients with iliofemoral venous thrombosis had a detection of iliofemoral venous obstruction. Improved lower-extremity swelling was reported in 84% of the patients following combination therapy involving low-molecular-weight heparin (LMWH) and systemic therapy. CONCLUSION: Patients with an iliofemoral venous thrombosis mainly had iliofemoral venous obstruction by external tumor compression. Combination therapy with LMWH and systemic therapy were mandatory for these patients.

The Role of Pulmonary Veins in Cancer Progression from a Computed Tomography Viewpoint.

Background. We studied the role of pulmonary veins in cancer progression using computed tomography (CT) scans. Methods. We obtained data from 260 patients with pulmonary vein obstruction syndrome (PVOS). We used CT scans to investigate pulmonary lesions in relation to pulmonary veins. We divided the lesions into central and peripheral lesions by their anatomical location: in the lung parenchymal tissue or pulmonary vein; in the superior or inferior pulmonary vein; and by unilateral or bilateral presence in the lungs. Results. Of the 260 PVOS patients, 226 (87%) had central lesions, 231 (89%) had peripheral lesions, and 190 (75%) had mixed central and peripheral lesions. Among the 226 central lesions, 93% had lesions within the superior pulmonary vein, either bilaterally or unilaterally. Among the 231 peripheral lesions, 65% involved bilateral lungs, 70% involved lesions within the inferior pulmonary veins, and 23% had obvious metastatic extensions into the left atrium. All patients exhibited nodules within their pulmonary veins. The predeath status included respiratory failure (40%) and loss of consciousness (60%). Conclusion. CT scans play an important role in following tumor progression within pulmonary veins. Besides respiratory distress, PVOS cancer cells entering centrally can result in cardiac and cerebral events and loss of consciousness or can metastasize peripherally from the pulmonary veins to the lungs.

Combination of palonosetron, aprepitant, and dexamethasone as primary antiemetic prophylaxis for cisplatin-based chemotherapy.

BACKGROUND: The purpose of this study was to evaluate the efficacy of combined treatment with the long-acting 5-hydroxytryptamine receptor-3 antagonist, palonosetron, the neurokinin-1 receptor antagonist, oral aprepitant, and dexamethasone as primary antiemetic prophylaxis for cancer patients receiving highly emetogenic cisplatin-based chemotherapy. METHODS: Chemotherapy-naïve patients received the triple combination of palonosetron (0.25 mg), aprepitant (125 mg on day 1 and 80 mg on days 2 and 3), and dexamethasone (20 mg) from the beginning of highly emetogenic chemotherapy with cisplatin-based (≥50 mg/m(2)) regimens. The primary endpoint was a complete response (no emetic episodes and no rescue antiemetics) during the days 1-6. RESULTS: Sixty-nine hospitalized patients receiving chemotherapy from September 2012 to October 2014 were analyzed. Complete response of vomiting and nausea-free was achieved in 97.1% and 85.5% of patients in the first cycle, respectively, and 96.7% and 83.6% of patients in the second cycle, respectively. Common adverse events in all 69 patients included constipation (43%), hiccup (26%), and headache (4%). CONCLUSION: The combination of palonosetron, aprepitant, and dexamethasone as primary antiemetic prophylaxis for cancer patients with highly emetogenic cisplatin-based chemotherapy is effective.

Pulmonary Venous Obstruction in Cancer Patients.

Background. We study the clinical significance and management of pulmonary venous obstruction in cancer patients. Methods. We conducted a prospective cohort study to characterize the syndrome that we term "pulmonary vein obstruction syndrome" (PVOS) between January 2005 and March 2014. The criteria for inclusion were (1) episodes of shortness of breath; (2) chest X-ray showing abnormal pulmonary hilum shadow with or without presence of pulmonary edema and/or pleural effusion; (3) CT scan demonstrating pulmonary vein thrombosis/tumor with or without tumor around the vein. Results. Two hundred and twenty-two patients developed PVOS. Shortness of breath was the main symptom, which was aggravated by chemotherapy in 28 (13%), and medical/surgical procedures in 21 (9%) and showed diurnal change in intensity in 32 (14%). Chest X-rays all revealed abnormal pulmonary hilum shadows and presence of pulmonary edema in 194 (87%) and pleural effusion in 192 (86%). CT scans all showed pulmonary vein thrombosis/tumor (100%) and surrounding the pulmonary veins by tumor lesions in 140 patients (63%). PVOS was treated with low molecular weight heparin in combination with dexamethasone, and 66% of patients got clinical/image improvement. Conclusion. Physicians should be alert to PVOS when shortness of breath occurs and chest X-ray reveals abnormal pulmonary hilum shadows.

The role of surgery in renal cell carcinoma with pancreatic metastasis.

Metastasis of renal cell carcinoma to the pancreas is uncommon and, in most cases, presents as a single pancreatic mass that shows a more favorable prognosis than primary pancreatic tumors. We examined patients with renal cell carcinoma metastatic to the pancreas, and discuss the clinical findings, treatment administered, and final outcomes. The present study is a retrospective analysis of renal cell carcinoma patients with pancreatic metastasis. Pancreatic tumor specimens were obtained by surgical excision, surgical biopsy, fine-needle biopsy, or endoscopic ultrasound biopsy. The surgical approaches included distal splenopancreatectomy, total pancreatectomy, or distal pancreatectomy. The physician determined the postoperative treatment regimen with interferon-α or targeted therapy on the basis of patient's performance. A total of six patients with median age of 50 years were included in the study. The median time from the primary nephrectomy to the development of pancreatic metastasis was 16 years. In the biopsy-only group, the mean stable disease period was 16.5 months. In the patients treated with surgery combined with interferon-α or targeted therapy, the mean stable disease period was 29.5 months. The patients treated with repeat mastectomy showed a mean stable disease period of 33.3 months. Aggressive surgical management is more effective than observation or immunotherapy. Recent advances in the design of targeted therapies may provide alternative treatment strategies. Combination therapy may play an important role in the future. Considering patient compliance and cost-effectiveness, resection of pancreatic metastasis is currently the first choice of treatment.

Prognostic value of complete response in patients with muscle-invasive bladder cancer undergoing concurrent chemoradiotherapy.

AIM: To evaluate the feasibility of concurrent chemoradiotherapy (CCRT) in very advanced bladder cancer (stage IV) and further analyze the prognostic factors in these patients. PATIENTS AND METHODS: We retrospectively reviewed the clinicopathological features and outcomes of patients with muscle-invasive bladder cancer after CCRT. Sixty-one patients with muscle-invasive bladder cancer who underwent CCRT between January 1996 and March 2011 were eligible for evaluation. Chemotherapy consisted of cisplatin (50 mg/m(2)) at day one, and 5-fluorouracil (500 mg/m(2)/day) and leucovorin (50 mg/m(2)/day) at days 1, 2, and 3, every three weeks, for a maximum of six cycles. The radiation dose was 44-45 Gy to the entire pelvis and 60-66 Gy to the entire bladder, with a daily fraction of 1.8-2 Gy. RESULTS: By August 2012, the estimated median progression-free survival (PFS), cancer-specific survival, and overall survival (OS) were 25.7, 64.3 and 35.8 months, respectively; the complete response (CR) rate was 68.8%. Both clinical stage and CR following CCRT, were independent prognostic factors for PFS, cancer-specific survival, and OS. Patients with stage IV disease who achieved CR had significantly better PFS (log-rank p=0.01), cancer-specific survival (log-rank p=0.01), and OS (log-rank p=0.01) than those with stage II/III disease but no CR. The absence of hydronephrosis was the only factor predictive of CR after CCRT (odd ratio, 4.21; p=0.04). CONCLUSION: CR was the most important prognostic factor in muscle-invasive bladder cancer. Selected patients with stage IV bladder cancer could benefit from CCRT if a CR is achieved.

Impact of palliative care consultative service on disease awareness for patients with terminal cancer.

PURPOSE: Awareness of the status of disease among terminally ill cancer patients is an important part of the end-of-life care. We have evaluated how palliative care consultative service (PCCS) affects patient disease awareness and determined who may benefit from such services in Taiwan. METHODS: In total, 2,887 terminally ill cancer patients consecutively received PCCS between January 2006 and December 2010 at a single medical center in Taiwan, after which they were evaluated for disease awareness. At the beginning of PCCS, 31 % of patients (n = 895) were unaware of their disease status. The characteristics of these 895 patients were analyzed retrospectively to determine variables pertinent to patient disease awareness after PCCS. RESULTS: In total, 485 (50 %) of the 895 patients became aware of their disease at the end of PCCS. Factors significantly associated with higher disease awareness included a longer interval between the date of hospital admission and that of PCCS referral (>4 weeks versus ≤2 weeks), a longer duration of PCCS (>14 days versus ≤7 days), the male gender, divorced marital status (versus married), and family awareness (versus lack of family awareness). Lower disease awareness was associated with older age (age > 75 years versus age = 18-65 years), referral from non-oncology departments, and primary cancer localization (lung, colon-rectum, or urological versus liver). CONCLUSIONS: Disease awareness is affected by multiple factors related to the patients, their families, and the clinicians. The promotion of PCCS increased disease awareness among terminally ill cancer patients in Taiwan.