A Primer on the Current State-of-the-Science Neoadjuvant and Adjuvant Therapy for Patients with Locally Advanced Rectal Adenocarcinomas

Patients with rectal cancers, due to the unique location of the tumor, have a recurrence pattern distinct from colon cancers. Advances in adjuvant therapy over the last three decades have played an important role in improving patient outcomes. This article serves to review the clinical studies that lay the basis for our current standard-of-care treatment of patients with locally advanced rectal cancer, as well as touch upon future ongoing experimental clinical trials of adjuvant chemoradiation therapy

The Effect of a Disease Management Algorithm and Dedicated Postacute Coronary Syndrome Clinic on Achievement of Guideline Compliance: Results from the Parkland Acute Coronary Event Treatment Study

BACKGROUND: The application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected populations. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes (ACSs) in a largely indigent county hospital setting. METHODS: Patients admitted for ACS were randomized at the time of discharge to usual followup care versus the same care with additional visits with physician extenders in a dedicated post- ACS clinic. Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines. Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge with key secondary endpoints including the achievement of additional evidence-based practice goals with up to 1 year of follow up assessment. RESULTS: One hundred forty consecutive patients were randomized. Rates of use of all evidencebased therapies assessed were high at the time of hospital discharge, and similar between the study groups. A similar proportion of patients returned for study follow-up in both groups at 3 months (54 [79%]/68 in the usual care group vs. 57 [79%]/72 in the intervention group; P = 0.97). Among those completing the 3-month visit, a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 (69%) of the usual care patients compared with 35 (57%) of those in the intervention group (P = 0.43). There was no statistical difference in implementation of therapeutic lifestyle changes (smoking cessation, cardiac rehabilitation, or exercise) between groups. Prescription rates of evidence-based therapeutics at 3 months were similar in both groups. CONCLUSION: The implementation of a post-ACS clinic run by physician extenders applying a disease management algorithm did not measurably improve adherence to evidence-based secondary prevention treatment goals. Despite initially high rates of evidence-based treatment at discharge, adherence with follow-up appointments and sustained implementation of evidence-based therapies remains a significant challenge in this high-risk cohort

How have we diagnosed early-stage lung cancer without radiographic screening? A contemporary single-center experience.

The National Lung Screening Trial (NLST), which demonstrated a reduction in lung cancer mortality, may result in widespread computed tomography (CT)-based screening of select populations. How early-stage lung cancer has been diagnosed without screening, and what proportion of these cases would be captured by a screening program modeled on the NLST, is not currently known. We therefore evaluated current patterns of early-stage lung cancer presentation.We performed a single-institution retrospective analysis of patients diagnosed with stage I-II non-small cell lung cancer (NSCLC) from 2000-2009. Associations between patient and imaging characteristics were assessed using univariate and multivariate analyses. A total of 412 patients met criteria for analysis. Among those with available reason for initial imaging, the reason was symptoms in 51%, follow-up of other conditions in 43%, and screening in 6%. Reason for imaging was associated with race (P<0.001), insurance type (P=0.005), and disease stage (P<0.001). Type of initial imaging was associated with reason for imaging (P<0.001), year (chest x-ray 67% in 2000-2004 vs. 49% in 2005-2009; P<0.001), and disease stage (P = 0.005). Among patients with available quantified smoking history, 48% were age 55-74 years and smoked 30-plus pack-years, therefore meeting NLST entry criteria.Symptoms remain a dominant but declining reason for detection of early-stage NSCLC. The proportion of cases detected initially by CT scan without antecedent chest x-ray has increased considerably. Because as few as half of cases meet NLST eligibility criteria, clinicians should remain aware of the diverse circumstances of early-stage lung cancer presentation to expedite therapy

Baseline Case Characteristics.

a<p>Includes Medicaid, county health plan, and no insurance.</p>b<p>Of 267 cases with full smoking history data.</p>c<p>Of 158 cases presenting with symptoms.</p><p>CXR, chest x-ray; CT, computed tomography; SD, standard deviation.</p

Proportion of early-stage NSCLC cases initially detected by chest x-ray.

<p>Proportion of early-stage NSCLC cases initially detected by chest x-ray.</p

Association between case characteristics and reason for imaging (univariate analysis).

<p> <b>OR >1: More likely to have imaging performed for evaluation of symptoms than for other reasons.</b></p>a<p>Includes Medicaid, county health plan, and no insurance.</p><p>CI, confidence interval; CXR, chest x-ray; OR, odds ratio.</p

Association between case characteristics and type of initial imaging (univariate analysis).

<p> <b>OR >1: more likely to have CXR than other modalities as initial imaging study.</b></p>a<p>Includes Medicaid, county health plan, and no insurance.</p><p>CI, confidence interval; CXR, chest x-ray; OR, odds ratio.</p