Streptozocin (STZ)-based chemotherapy has been used for over 30 years in the treatment of neuroendocrine tumours (NET); however, there have been few randomised trials in homogeneous and well-characterised patient populations. With the recent approval of sunitinib and everolimus for pancreatic NET (PNET) and the emergence of a more stratified approach to cancer therapy, it is timely to reevaluate the role of chemotherapy. Here we review the evidence base for STZ-based chemotherapy, the toxicity associated with treatment and the role of predictive markers such as Ki67 to select patients who may benefit most from therapy. Although there are no trials comparing chemotherapy with best supportive care, there is evidence that multi-agent STZ-containing regimens are associated with improved survival compared with control therapy. Compared with other therapies, chemotherapy appears to be associated with the highest response rate, particularly in PNET and remains the first-line treatment of choice for those patients in whom response is required. This includes those who are symptomatic from tumour burden and those with locally advanced disease who may be down-staged for resection. The role of Ki67 and other predictive markers requires further assessment in prospective studies as does the relative efficacy of alternative agents such as temozolomide.
66 Background: Cancer of Unknown Primary (CUP) is the 4th most common cause of cancer death in England and Wales. [(Office for National Statistics, Mortality Statistics: Deaths registered in England and Wales. http://www.ons.gov.uk/ons/search/index.html?newquery=series+dr (accessed 1/7/14).] Patients with CUP have poor outcomes secondary to delayed, inappropriate investigations and poor treatment response. In line with NICE guidance [(NICE guidelines: CG 104 (July 2010).]. Metastatic malignant disease of unknown primary: diagnosis and management of metastatic malignant disease of unknown primary.) a CUP service was set-up at the Royal Free in June 2012. This analysis assessed its impact on patients diagnosed with metastatic cancer who were not fit for active treatment. Methods: Clinical notes were reviewed for all admissions with an imaging-based diagnosis of metastatic cancer. A retrospective analysis (January-April 2009) was compared to prospective data following the launch of the CUP service (June-December 2012). Results: The notes of 9 patients (2009) and 15 patients (2012) were compared (see table). Age and length of stay (LOS) were analysed using t-test, other data were compared using chi-squared test. All patients were reviewed by Oncology and Palliative Care teams. There was a significant reduction in mean LOS (6.7 days, 18.6 days p<0.004) and the number who died in hospital (7%, 67% p<0.002) with only one patient not dying in his preferred place. Conclusions: Prompt assessment by the CUP service facilitates early input from Oncology and Palliative Care teams resulting in reduced LOS and fewer deaths in hospital in keeping with the agenda of the End of Life Care Strategy [(End of Life Care Strategy: Promoting high quality care for all adults at the end of life (July 2008). DOH (England).]. [Table: see text]
the hospice with non-malignant conditions had risen from 11% (2015) to 21% (2018) during this time.Staff training Teaching sessions were provided for staff to highlight key considerations when caring for patients with necrotising fasciitis, including symptoms and infection control advice. Feedback was gathered from staff attending teaching with 82% rating it as 'useful' or 'very useful' and 90% indicating that they would be interested in future education sessions. Conclusion The breadth of patients referred for inpatient hospice management is growing. The case outlined may represent an emerging patient subgroup; those without a prior palliative diagnosis whereby active treatment of an acute complication has failed. Teaching sessions proved beneficial to hospice staff and should be considered in the future to promote individualised integration of care across disciplines.
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