Session 2: Are we ready for primary chemotherapy in rectal cancer: who, when, why?

The potential of preoperative chemotherapy in rectal cancer is the subject of investigation in a number of global randomized trials. In this overview and expert discussion, Professor Cervantes summarizes the findings of numerous Phase II trials testing neoadjuvant chemotherapy. The crucial points in the next phase of trials include: patient selection, whether radiotherapy can be omitted altogether and whether chemotherapy can be used to augment the initial response to chemoradiotherapy. Finally, with the emergence of Magnetic Resonance Tumour Regression Grade a reliable method for assessing response after initial chemoradiotherapy, we ask if this can be used to drive the use of further selective chemotherapy to augment response.

Session 3: Beyond TME and radiotherapy MRI evaluation of rectal cancer treatment response.

Magnetic resonance imaging plays an increasingly important role in evaluating the effect of cancer treatment. Imaging alone cannot predict pathological complete response and imaging interpretation should be combined with clinical information and endoscopy findings to predict complete response. Professor Blomqvist reviews current and future imaging techniques and whether the quantitative can add significant or important prognostic information over the current qualitative techniques.

MRI assessment and outcomes in patients receiving neoadjuvant chemotherapy only for primary rectal cancer: long-term results from the GEMCAD 0801 trial.

Background: Primary chemotherapy has been tested as a possible approach for patients with high risk features but predicted clear mesorectal margins on preoperative MRI assessment. This study investigates the prognostic relevance of baseline and post-treatment MRI and pathology staging in rectal cancer patients undergoing primary chemotherapy. Patients and methods: Forty-six patients with T3 tumour > =2 mm from the mesorectal fascia were prospectively treated with Neoadjuvant Capecitabine, Oxaliplatin and Bevacizumab prior to surgery between 2009 and 2011. The baseline and post-treatment MRI: T, Nodal and Extra-mural venous invasion (EMVI) status were recorded as well as post-treatment MRI Tumour regression grade (TRG) and modified-RECIST assessment of tumour length. The post-treatment pathology (yp) assessments of T3 substage, N, EMVI and TRG status were also recorded. Three-year disease-free survival (DFS) and cumulative incidence of recurrence were estimated by using the Kaplan-Meier product-limit method, and Cox proportional hazards models were used to determine associations between staging and response on MRI and pathology with survival outcomes. Results: About 46 patients underwent neoadjuvant chemotherapy alone for high risk margin safe primary rectal cancer. The median follow-up was 41 months, 5 patients died and 11 patients experienced relapse (2 local, 8 distant and 1 both). In total 23/46 patients were identified with MRI features of EMVI at baseline. mrEMVI positive status carried independent prognostic significance for DFS (P = 0.0097) with a hazard ratio of 31.33 (95% CI: 2.3-425.4). The histopathologic factor that was of independent prognostic importance was a final ypT downstage of ypT3a or less, hazard ratio: 14.0 (95% CI: 1.5-132.5). Conclusions: mrEMVI is an independent prognostic factor at baseline for poor outcomes in rectal cancer treated with neoadjuvant chemotherapy while ≤ypT3a is associated with an improvement in DFS. Future preoperative therapy evaluation in rectal cancer patients will need to stratify treatment according to baseline EMVI status as a crucial risk factor for recurrence in patients with predicted CRM clear rectal cancer.

Magnetic resonance based texture parameters as potential imaging biomarkers for predicting long-term survival in locally advanced rectal cancer treated by chemoradiotherapy.

AIM: The study aimed to investigate whether textural features of rectal cancer on MRI can predict long-term survival in patients treated with long-course chemoradiotherapy. METHOD: Textural analysis (TA) using a filtration-histogram technique of T2-weighted pre- and 6-week post-chemoradiotherapy MRI was undertaken using TexRAD, a proprietary software algorithm. Regions of interest enclosing the largest cross-sectional area of the tumour were manually delineated on the axial images and the filtration step extracted features at different anatomical scales (fine, medium and coarse) followed by quantification of statistical features [mean intensity, standard deviation, entropy, skewness, kurtosis and mean of positive pixels (MPP)] using histogram analysis. Cox multiple regression analysis determined which univariate features including textural, radiological and histological independently predicted overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS). RESULTS: MPP [fine texture, hazard ratio (HR) 6.9, 95% CI: 2.43-19.55, P < 0.001], mean (medium texture, HR 5.6, 95% CI: 1.4-21.7, P = 0.007) and extramural venous invasion (EMVI) on MRI (HR 2.96, 95% CI: 1.04-8.37, P = 0.041) independently predicted OS while mean (medium texture, HR 4.53, 95% CI: 1.58-12.94, P = 0.003), MPP (fine texture, HR 3.36, 95% CI: 1.36-8.31, P = 0.008) and threatened circumferential resection margin (CRM) on MRI (HR 3.1, 95% CI: 1.01-9.46, P = 0.046) predicted DFS. For OS, EMVI on MRI (HR 4.23, 95% CI: 1.41-12.69, P = 0.01) and for DFS kurtosis (medium texture, HR 3.97, 95% CI: 1.44-10.94, P = 0.007) and CRM involvement on MRI (HR 3.36, 95% CI: 1.21-9.32, P = 0.02) were the independent post-treatment factors. Only TA independently predicted RFS on pre- or post-treatment analyses. CONCLUSION: MR based TA of rectal cancers can predict outcome before undergoing surgery and could potentially select patients for individualized therapy.

Hospital marketing orientation and managed care processes: are they coordinated?

The hospital marketing function has been widely adopted as a way to learn about markets, attract sufficient resources, develop appropriate services, and communicate the availability of such goods to those who may be able to purchase such services. The structure, tasks, and effectiveness of the marketing function have been the subject of increased inquiry by researchers and practitioners alike. A specific understanding of hospital marketing in a growing managed care environment and the relationship between marketing and managed care processes in hospitals is a growing concern. Using Kotler and Clarke's framework for assessing marketing orientation, we examined the marketing orientation of hospitals in a single state at two points in time--1993 and 1999. Study findings show that the overall marketing orientation score decreased from 1993 to 1999 for the respondent hospitals. The five elements of the Kotler and Clarke definition of marketing orientation remained relatively stable, with slightly lower scores related to customer philosophy. In addition, we evaluated the degree to which selected managed care activities are carried out as part of its marketing function. A significant (p < .05) decrease in managed care processes coordinated with the formal marketing function was evident from 1993 to 1999. With increasing numbers of managed care plan enrollees, hospitals are likely focusing on organizational buyers as important customers. In order to appeal to organizational buyers, hospital executives may be focusing more on clinical quality and cost efficiency in the production of services, which will improve a hospital's position with organizational buyers.

Are nurses adequately prepared for end-of-life care?

PURPOSE: To determine end-of-life (EOL) care core competencies and educational needs from practicing oncology nurses and to describe the characteristics of the respondents that are associated with selection of the leading core competencies. DESIGN AND METHODS: A researcher-developed mailed descriptive survey to members of the Oncology Nursing Society in Georgia, Virginia, Washington, and Wisconsin in late 1999. FINDINGS: Nearly all respondents indicated that EOL care was a part of their practice and that continuing education was important, but one-third of the respondents had less than 2 hours of continuing education in 2 years. How to talk to patients and families about dying was the top-rated core competency, consistent across age, educational level, practice role, and practice setting. Pain control and comfort care were also frequently selected as important EOL care issues about which more education is needed. CONCLUSIONS: Results show guidelines for improving educational curricula and considering characteristics of nurses when planning EOL educational programs.