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A Cancer and Haematology Newsletter
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| Leading Article Haematology and Oncology - Our First Issue Drugs in Haematology/Oncology The Resurgence of Thalidomide Thalidomide and therapy have not appeared together for over 40 years. Now the drug is back. It was used first in lepra reactions, but now it finds use in cancer treatment. It has given hopr to many relpased myeloma patients Aetiology of Cancer Hormone replacement therapy linked to endometrial cancer Hormone replacement therapy has never been free of contraversy. The 10th report of the National Institute of Environmental Health has added another twist to the story. Haematology in General Practice Diagnosis of iron deficiency anaemia Anaemia may be a manifestation of a serious disease. Clinical experience has tought most of us that it is possible to get away with emperic iron therapy in majority of patients with anaemia. The approach is sound in a good number of cases but is not without pitfalls. Read about when you can get away without investigating a patient of anaemia. Oncology in General Practice Conservative Breast Surgery The year was 1894, the surgeon William Halsted and the patient has breast cancer. In another surgeons hands this patient has a 60% chance of developing a relapse. But the new surgery which halsted performed brought this down to 6%. Halsted's Radical mastectomy become a gold standard for cancer syurgery. In early the 1960 an italian surgeon had a young patient who refused mastectomy. Faced with a delima he did what few would accept in those days. He only removed the tumour and preserved the breast . Is this a sound approach. Two studies reporting 20 year follow up of conservative breast surgery have been published. Read more about them Link of the Fortnight Bloodline.net A comprehensive haematology site. |
Leading ArticleHaematology And Oncology - Our First IssueThe new millennium has seen us a the threshold of remarkable discoveries in molecular biology. Molecular biology is term for scientists! Have you received the news letter by mistake!! One of the biggest medical story of 2002 has been imatinib mesylate (Glivac). It is the most effective drug we have for chronic myeloid leukaemia (CML). Now, how does that make it big! Most of you will probably count the number of patients of CML you will see in your career on the fingertips of one hand. You probably see more patients of ischaemic heart disease in a week. Glivac is the first engineered drug against a cancer. CML has a translocation (exchange of material between chromosomes) which results in the formation of what is known as the Philadelphia chromosome. The Philadelphia chromosome produces an abnormal protein which is responsible for CML. The scientists at have been able to synthesize Glivac to target this abnormal protein. The traditional drug therapy for cancer is chemotherapy. Chemotherapy is like a shotgun. It damages normal tissue causing adverse effects. Glivac acts against what causes cancer. Glivac does not cause adverse effects of chemotherapy. ..... AND Glivac is not the only drug of this type. There will be many such drugs available in the near future. These discoveries are possible bacause of advances in molecular biology and the Human Genome Project. Molecular biology has also seen the resurrection of Thalidomide, a drug discarded in the 1960s because of horrific adverse effects (a story on thalidomide is carried in this issue). Engineered drugs, molecular biology, cytogenetics (study of chromosome structure), angiogenesis, micrometastasis, adjuvant chemotherapy, combined modality of cancer treatment are just some of the terms which are a part of the oncologist's vocabulary and were not a part of medical textbooks as early as 5 years ago (some of them still are not). As the career of most medicos spans five to six times this period periodic update of knowledge is necessary. I am sure that the words listed in the first line are intimidating. Haematology and Oncology will ensure that your knowledge of haematology and oncology remains up to date and will do so with analgesia (not anaesthesia .. that would defeat the purpose). Drugs In Haematology/Oncology Thalidomide in Cancer Treatment Thalidomide is one of the most tragic stories in medical science which few medicos can afford to forget. After the reports of phocomelia in the 1960s the words thalidomide and treatment took almost 40 years to appear together. Thalidomide is today under investigation for treatment of conditions as diverse as brain tumours, breast cancer, renal cell carcinoma, AIDs related apthous ulcers, wasting syndrome and mycobacterial infections and some autoimmune diseases. Tumours can not grow without formation of new vessels. Thalidomide has many effects on tumours but the most prominent of these is the ability of thalidomide to inhibit new vessel formation (angiogenesis). The most promising results for thalidomide have been in patients with multiple myeloma. Most studies have been conducted in patients who have failed after aggressive chemotherapy. One third to one fourth of the patients have shown response. The adverse effects have been mild to moderate. The common side effects of thalidomide include sedation, peripheral neuropathy, constipation and cutaneous reactions. It is absolutely contraindicated pregnancy. Thalidomide is the first of a new class of drugs which inhibit angiogenesis and modulate immunity. One such agent CC-5013 is under evaluation. Aetiology of CancerOestrogens linked with cancerThe tenth report on carcinogens of the National Institute of Environmental Health has classified sterodal oestrogens as carcinogens. The report states "Steroidal oestrogens are known to be human carcinogens based on sufficient evidence of carcinogenicity in humans, which indicates a causal relationship between exposure to steroidal oestrogens as human cancer. Human epidemiology studies show that use of oestrogen replacement therapy by post-menopausalwomen is associated with a consistent increase in the risk of uterine endometrial cancer and a less consistent increase in the risk of breast cancer. Some evidence suggests that oral contraceptive use also may increase the risk of breast cancer". Does this mean that one should not use oestrogens as HRT. The answer to this lies in the risk benefit of hormone replacement therapy. Where oestrogen as are used a careful screening for endometrial cancer is indicated. Haematology in General PracticeThe diagnosis of iron deficiency anaemiaIron deficiency anaemia is the commonest anaemia world-wide. Women in the childbearing age and growing children are particularly susceptible to iron deficiency. Iron deficiency is so common that if one were to treat every anaemia with iron more often than not one will cure the patient of anaemia. Clinical experience has taught many of us to take this approach and we do so very succesfully. This unfortunately is a potentially hazzardous approach for two reasons.
It is not sufficient to establish the presence of iron deficiency. The cause of iron deficiency has to be determined. It is not practical to investigate every patient of iron deficiency anaemia. The following categories may be excluded from a through investigation of the cause of anaemia if the anaemia is hypochromic microcytic.
The following patients need a through investigation for the cause of anaemia
Iron deficiency is a manifestation of chronic blood loss which is hidden or for which the patient has not consulted a doctor. The commonest site of pathological blood loss the gastrointestinal tract. The causes of gastrointestinal blood loss are
Oncology in General PracticeConservative Breast Surgery is SafeWhat should you tell a patient of breast cancer who wants a breast conserving surgery? Conventional wisdom has it that one should remove the tumour, draining lymphatics the draining nodes to prevent spill of tumor get optimal results. If you think that violating this principle is sacrilage, you are to be pardoned. About 25 years ago the late Jerome Urban lamented the loss of a rational approach to the treatment of breast cancer, which he thought had been replaced “by an emotional appeal to the patient's vanity. A great cry has been raised in the public media to save the breast, despite the long-term consequences.” He was referring to the trend towards conservative breast surgery. Conservative breast surgery removes only a part of the breast. Is the survival compromised by a failure to perform a mastectomy? Recently 20 years results of trials (one from Italy by Veronesi and the other from USA by Fisher) comparing conservative surgery with modified radical mastectomy have been published recently. Breast cancer can have late relapses and 5 year follow up periods used for evaluating most other tumours are inadequate for breast cancer. However the two studies have shown no difference in survival between conservative surgery and modified radical mastectomy. Though conservative surgery is as effective as modified radical mastectomy, patient selection for the surgery is vital. Conservative surgery is more demanding for the patient as it includes surgery followed by 4-6 weeks of radiation and about 6 months of chemotherapy in patients with axially node metastasis. Radiation is critical to achieving local control. Patients who can not take radiation or are unwilling to take radiation should not be advised conservative surgery. You may read the read the full papers at Veronesi, Fisher You may download the PDF format reprints at Veronesi, Fisher There is also an editorial comment on the two articles. Figer  |
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