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Regional Oncology Update - Summer 2004 (click here to download as a PDF)
Evansville Cancer Center Announces New Medical Oncologist on Staff
Lotfi Hadad, M.D.

Dr. Hadad received his Medical Degree with honors in 1993 from Aleppo University, Syria. He completed his residency program in Internal Medicine at Cook County Hospital in Chicago, Illinois.

His fellowship in Medical Oncology was completed at John H. Stroger, Jr. Hospital of Cook County and RUSH Medical Center in Chicago, Illinois. Dr. Hadad is board certified in Internal Medicine and board eligible in Medical Oncology.

Dr. Hadad and his wife and two daughters have made their home in Newburgh, Indiana.

Ovarian Cancer... A Chronic Illness
Many patients with ovarian cancer never hear the word “cure” and the reality is that some patients, who have been informed they’re cured, relapse. Today due to the advances in detection and treatment, ovarian cancer is becoming a chronic illness for many. With the increasing population of” cancer survivors” an important role for the medical oncologist is to assist the patient and family in learning how to live with a chronic illness. By framing cancer as a chronic illness, healthcare professionals interact with the patient in a manner that in turn assists them in learning to cope with “living with cancer”.

Ovarian cancer is a common disease affecting about 26,000 women in the United States with 16,000 deaths annually. It is the second most common gynecological cancer, the fifth most common cancer in women, and the fourth cause of cancer deaths in women. The known risk factors are: age over 50 with peak incidence between 60-64 years, low parity, higher socioeconomic status, and a positive family history. Most women present with locally advanced disease (65% of patients have stage III or stage IV) often accompanied by malignant pleural effusion and parenchymal liver metastasis thus our ability to control long-term survival is paramount. There are many controversial issues in the treatment management of ovarian cancer.

In the surgical arena, which procedure is optimal? Is there a role for interval surgical cytoreduction following 3-4 cycles of primary chemotherapy? Is there a role for a second look laparotomy after complete clinical response? What is the role for secondary cytoreduction when at present there is no phase III clinical trial evidence that demonstrates an impact on survival? Finally, neoadjuvant chemotherapy is being used for bulky advanced disease to reduce tumor burden thus minimizing surgical time and morbidity however we lack randomized clinical trials demonstrating the benefits of this treatment scenario.

The standard regimens prescribed for chemotherapy are Carboplatin AUC 6-7.5 plus Paclitaxel 175 mg/m2 over 3 hours times 6 cycles or Carboplatin AUC 6 plus Docetaxel 60-75 mg/m2 over 1 cycle for 6 cycles. To date there is no evidence of benefit for adding a third or fourth drug though there is an ongoing GOG trial with 5 arms that includes 3 drugs (Doxorubicin HCL Liposome, Gemcitabine) in doublets and triplets. As the treatment regimen is completed, the physician should discuss with the patient the role of maintenance chemotherapy. The clinical trials addressing maintenance therapy utilizing Cisplatin have had negative results but the SWOG 9701/GOG 168 trial has shown positive results with Paclitaxel. In this trial Paclitaxel was given in either three or twelve monthly cycles in patients who had experienced a clinical complete remission. The positive results were significant but the trial was not completed due to ethical issues.

Recurrent disease is usually classified by the number of months that lapse before clinical evidence of disease is noted. The management of early relapsing ovarian cancer (6-12 months platinum free interval) is challenging and controversial. For the patients who relapse in 6 months or less, a non-platinum based treatment (Doxorubicin HCL Liposome, Topotecan HCL, Gemcitabine, oral Etoposide, or Docetaxel) is recommended but for those patients who experienced a treatment free interval of more than 12 months a platinum based regimen (Carboplatin plus Paclitaxel or Docetaxel) is advised. Thus patients who have experienced a 6-12 month disease free interval can be treated with the aforementioned single agents or combination of Carboplatin and either Paclitaxel or Docetaxel. ICON 4 demonstrated Carboplatin and Paclitaxel have a superior survival rate when compared to Carboplatin alone for those patients who had a disease free interval in excess of 6 months. This study changed physician practice and many now choose the aforementioned combination for a platinum sensitive relapse. Even though there is no clinical confirmation of Carboplatin/Docetaxel as treatment for first relapse, the efficacy of Carboplatin/Paclitaxel in the primary treatment setting makes it a reasonable choice particularly for patients with significant neuropathy. At ASCO this year, Carboplatin plus Gemcitabine was presented by the AGO who demonstrated superiority to Carboplatin alone. Studies comparing other platinum based combinations will be ongoing by the GOG.

There are other chemotherapy modalities in the treatment of ovarian disease. For platinum sensitive patients, response rates are approximately 30% when Topotecan HCL and Doxorubicin HCL Liposome are used as single agents in patients with a greater than six month disease free interval. Topotecan can be used at a daily dose of 1.25 mg/m2 for five days on a cycle of every 28 days or as a 4 mg/m2 weekly dose. Doxorubicin HCL Liposome is prescribed at a dose of 40 mg/m2 to be given every 28 days. It will take approximately 3-4 months to assess effectiveness thus an extended treatment for 8 months is recommended. Complete response rate for theses single agents appears to be low but the overall objective response rates are similar to platinum treatments. These drugs also have been recommended for treatment regimens in platinum refractory patients whom have experienced a less than 6 months disease free interval. Etoposide is an active drug with response rate in excess of 25% for both platinum sensitive and platinum refractory disease. As an oral drug it is easy to administer and has little associated toxicity but there is a possibility of the development of secondary leukemia. Gemcitabine is well tolerated but there is little supportive clinical data for its use in ovarian cancer .

Overall it is best to administer the Carboplatin/Paclitaxel doublet. The drugs are easy to administer, have limited toxicity and an efficacy that is at least equal to any of the other combinations. Any of the other aforementioned medications are likely to be used in a majority of patients during the course of their chronic illness. Before a patient enters a palliative stage of their illness, multiple medications will have been used over a period of about 4-5 years from initial diagnosis. It is estimated that approximately 30% of stage III and 15% of Stage IV survive beyond 5 years.

Over the last two decades intra-peritoneal chemotherapy has been studied as a primary modality in 3 phase III trials showing improvement in progression free survival and 2 phase III trials demonstrating increased overall survival. Still most medical oncologists and gynecological oncologists don’t utilize this modality due to adverse events that can occur. Thus far it is not been established as first or second line therapy for ovarian cancer .

We are making progress in the battle against ovarian cancer. As noted, ovarian cancer responds well to chemotherapy and most patients experience a complete remission with primary treatment only to experience disease recurrence. Hopefully the research focus on prevention of disease recurrence will provide answers to the ongoing quest for therapies to extend survival and improve quality of life for women living with ovarian cancer.

- Lotfi Hadad, M.D., Medical Oncologist

Prostate Brachytherapy Program to be Internationally Spotlighted Once Again!
The Evansville Cancer Center’s prostate program will be featured at ESTRO23 in Amsterdam, The Netherlands October 24th through the 28th.

“A Comparison of Acute Toxicity of The Prostate Cancer Patients Treated with High Dose Rate and Low Dose Rate Interstitial Brachytherapy” was selected by the ESTRO Scientific Committee and will be presented.

In Barcelona, Spain this past May at the joint meeting of the American Brachytherapy Society (ABS), European Society for Therapeutic Radiology & Oncology (ESTRO), Groupe Europee de Curietherape (GEC), and Groupe Latino Americano de Curieterapia (GLAC) Radiation Oncologists Dr. Al Korba, Dr. Aly Razek, and Physicist Dr. Saiyid Shah presented “
Prostate HDR Brachytherapy: An Outpatient Approach” which defined the treatment and outcomes.

The Evansville Cancer Center’s prostate program better known as the Tri-State Prostate Center began delivering care in 1999. This is a cooperative program utilizing the skills of Dr. W. Fisher, Dr. K. Foertsch, Dr. T. Gadient, Dr. P. Gilson, Dr. A. Korba, Dr. S. Lamb, Dr. A. Razek, Dr. B. Romick, Dr. B. Samm, Dr. P. Siami, Dr. S. Shah, and Arnold Sorensen. In 2002, the treatment protocol that combined external beam radiotherapy with high dose rate brachytherapy became the modality of choice for localized prostate cancer. This multimodality protocol reduces the acute rectal and bladder symptomology.

Evansville Cancer Center and Area Dermatologists Team Together during Skin Cancer Awareness Month
Dermatologists Drs. Shari Barrett, Jane Lim and Mary Tisserand in partnership with the Evansville Cancer Center conducted free full-body skin cancer screenings on May 4th, 6th and 11th at Washington Square Mall and Evansville Cancer Center. Approximately 165 people, many of whom had never been examined before by a dermatologist, attended the screenings. The screenings were conducted as part of Melanoma/Skin Cancer Detection and Prevention Month in May. Of the 165 people screened, 63 had suspected cancerous or suspicious lesions and were instructed to seek follow-up care. Doctors said that 21 of those could possibly be melanoma, the most serious form of skin cancer.

In addition to the screenings, Robin Lawrence-Broesch, Director of Marketing at Evansville Cancer Center and a melanoma skin cancer survivor, has conducted over 50 educational presentations on skin cancer which included her personal testimony to area grade schools, middle schools, high schools, universities, and industries.

About 95,880 new cases of melanoma are expected to occur in 2004 and 7,910 people are expected to die of the disease. Since the 1930s, the incidence of melanoma has increased more than 2000 percent. One person dies of melanoma every hour. However, if detected and treat cured.

Evansville Cancer Center would like to thank Drs. Barrett, Lim & Tisserand who volunteered their time in support of the national program sponsored by the American Academy of Dermatology and Evansville Cancer Center.
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