Deep venous thrombosis and pulmonary embolism are well-recognized complications of cancer, especially in patients with a venous access device or receiving chemotherapy. The pathogenic mechanisms of thrombosis in cancer patients involve a complex interaction between the patient's tumor cells and hemostatic system. Chemotherapy and central venous catheters increase the risk of thromboembolism. Prophylactic treatment for these patients remains controversial.

In response to the evolution of the information-seeking behaviour of patients and concerns from health professionals regarding cancer patient information, the French National Federation of Comprehensive Cancer Centres (FNCLCC) introduced, in 1998, an information and education program dedicated to patients and relatives,the SOR SAVOIR PATIENT program. The methodology of this program adheres to established quality criteria regarding the elaboration of patient information. Cancer patient information, developed in this program, is based on clinical practice guidelines produced by the FNCLCC and the twenty French regional cancer centres, the National League against Cancer, The National Cancer Institute, the French Hospital Federation, the National Oncology Federation of Regional and University Hospitals,the French Oncology Federation of General Hospitals, many learned societies, as well as an active participation of patients, former patients and caregivers. The handbookSOR SAVOIR PATIENT Cancer and Fatigue is an adapted version of different publications regarding fatigue in oncology. It is meant to provide a basis for the explanationof the disease and to facilitate discussions with the healthcare team. It is available from the FNCLCC (101, rue de Tolbiac, 75013 Paris, Tel. (0033) 1, 01 76 64 78 00,www.fnclcc.fr). This document has been validated at the end of 2005 and published in January 2006. SOR SAVOIR PATIENT guides are systematically updated when new research becomes available. This article is extract from the handbook SOR SAVOIR PATIENT Cancer and Fatigue and concerns the causes and effects of fatigue and how to cope with fatigue. This information allow patients to better understand the causes and effects of fatigue, how to cope fatigue...which represent important patient information needs. This article is meant to inform patients and relatives about the disease and its treatments. It also offers health professionals a synthetic evidence-based patient information source which facilitates discussions with the patient.

Nurses identified oral mucositis as a recurring issue in clinical practice. To meet this challenge, a group of nurses took a leadership role in developing an oral care guide. The University Health Network Nursing Research Utilization Model and the Neuman Systems Model served as conceptual frameworks. A flowchart was developed to ensure a coordinated and continuous provision of oral care. Educational presentations were conducted to familiarize nurses and members of the multidisciplinary team of the practice changes. The introduction of the oral care regimen as primary prevention, plus systematic oral assessment and monitoring had the potential to reduce the occurrence and severity of oral mucositis in patients undergoing autologous stem cell transplantation.

One of the most recent advances in the management of Her-2/neu positive breast cancer is the validation of a targeted therapy from bench to the clinic, particularly towards the adjuvant setting. The recommended dose of trastuzumab (Herceptin), a humanized monoclonal antibody targeting the HER-2 antigen, has been determined in phase I studies. In the metastatic patients two randomised trials have demonstrated its efficacy when associated to taxanes. In less than 10 years, trastuzumab became the standard of care in the adjuvant treatment of HER-2/neu positive breast cancer. In this setting, two combinations regimen with chemotherapy (concomitant or sequential) have been recently published. The concomitant schedule has been used in three studies (North American Group, BCIRG, FinHer), whereas in the Hera trial trastuzumab was started after the end of neo-adjuvant and adjuvant chemotherapy. In this article, the advantages and uncertainties on efficacy and toxicities of the trastuzumab administration modalities, associated or not to chemotherapy and radiation therapy, are discussed.

Imatinib (Gleevec) is a tyrosine kinase inhibitor used to treat chronic myeloid leukemia. We describe a case of drug reaction with eosinophilia and systemic symptoms (DRESS) after institution of treatment with imatinib.

Thalidomide, administered orally, bortezomib (Velcade) intravenously and lenalidomide (Revlimid), also orally, are three agents that act on myeloma relapse. Thalidomide acts by a variety of mechanisms and is toxic to the peripheral nervous system as well as teratogenic. It acts in synergy with dexamethasone. Recent results prove that its use as first-line treatment combined with oral conventional "MP" chemotherapy improves survival in patients older than 65 years. Its use as first-line treatment with this chemotherapy appears likely. Bortezomib is the first drug in the proteasome inhibitor class. It too is toxic to the peripheral nervous system and synergistic with dexamethasone. Several studies show its efficacy as first-line 'induction treatment' with dexamethasone, in patients to receive a subsequent autologous stem cell transplantation. The combination of bortezomib and "MP" is also promising. Lenalidomide, a structural analog of thalidomide, is effective in relapsing patients. Its toxicity is essentially hematologic. It is also synergistic with dexamethasone and promising as first-line treatment. These different drugs can be used successively at relapse, making myeloma a chronic disease. They can also be used together for greater effectiveness. These combinations will replace conventional chemotherapies in the future.

Nephrotoxicity is an inherent adverse effect of certain anticancer drugs. Anti neoplasic drugs have a narrow therapeutic index and the amount of drug necessary to produce a significant reduction in tumour burden usually produces significant nephrotoxicity. The dosage used in clinical trials represents often the maximum tolerated doses determined during phase I drug evaluation. Greater toxicity is acceptable during curative therapy than during palliative therapy. But cancer patients often exhibit excretory reduced organ function. Modulation of pharmacokinetics and pharmacodynamics of these drugs in cancer patients is therefore necessary in order to improve tolerance. Patients with malignancies are particularly vulnerable to development of renal abnormalities. Conversely, patients with renal abnormalities who have undergone kidney transplantation are at high risk for malignancy. Clinical syndromes of renal involvement are diverse and sometimes insidious. Despite the recent advances in understanding the mechanism of anticancer drug nephrotoxicity, prevention still relies on drug dosage decrease and active screening for renal abnormalities as part of the usual biological work up in patients treated with anticancer drugs.

We report the case of a patient with cutaneous T-cell lymphoma treated by bexaroten Targretin, a synthetic retinoid analog with specific affinity for retinoid X receptor. The treatment induced mixed hyperlipidemia and severe central hypothyroidism characterized by reduced TSH and thyroxine serum levels. Only the pituitary thyreotrope function was affected. Targretin therapy can be maintained. Adverse drug events may be managed by fenofibrate Lipanthyl for dyslipidemia and high dose L-thyroxin Lévothyrox requiring serum free thyroxin level measurement for central hypothyroidism.

Inhibitors of epidermal growth factor receptors (EGFR) constitute a new alternative treatment for patients presenting certain advanced stage solid cancers (bowel, breast, ovary). Adverse cutaneous effects of these drugs are now starting to be described.

Carboplatin is a chemotherapeutic agent used frequently in thoracic medicine on account of its relatively good tolerance. Nevertheless hypersensitivity reactions have been described.

Cytotoxic chemotherapy suppresses the haematopoietic system, impairing host protective mechanisms and limiting the doses of chemotherapy that can be tolerated. Febrile neutropenia, the most serious haematological toxicity, is associated with the risk of life-threatening infections as well as chemotherapy dose reductions and delays that may compromise treatment outcomes. The recent literature in chemotherapy-induced neutropenia and its complications and impact was provided an update on research, and the implications for improving the management of patients with cancer who are treated with myelosuppressive chemotherapy was discussed. Despite its importance as the primary dose-limiting toxicity of chemotherapy, much concerning neutropenia and its consequences and impact remains unknown. Recent surveys indicate that neutropenia remains a prevalent problem associated with substantial morbidity, mortality, and costs. The colony-stimulating factors (CSFs) have been used effectively in a variety of clinical settings to prevent or treat febrile neutropenia and to assist patients receiving dose-intensive chemotherapy. A meta-analysis of the available randomized controlled trials (RCTs) has confirmed the efficacy of prophylactic CSFs. Much research has sought to identify risk factors that may predispose patients to neutropenic complications, including febrile neutropenia, in an effort to predict better which patients are at risk and to use preventive strategies, such as prophylactic colony-stimulating factors, more cost-effectively. Research in quantifying the risk of neutropenic complications may make it possible in the near future to target patients at greater risk with appropriate preventive strategies, thereby maximizing the benefits and minimizing the costs.

Febrile neutropenia and anemia are two major complications of chemotherapy. Human recombinant cytokines as G-CSF and erythropoietin allow efficient fight against these secondary effects but require iterative injections due to a short half life. The glycosylation of natural cytokines results in enhanced stability of these molecules of new generation and makes it possible to space the injections which become concomitant of chemotherapies. With regard to the erythropoietin, the prolonged half-life form shows a similar effectiveness with the natural molecule. For the G-CSF, the glycosylated form could still show itself more effective for the prevention of febrile neutropenias. Finally, these new molecules allow an improvement of the quality of life while ensuring an optimal dose-intensity of the treatment.

Hematopoietic growth factors are usually administered in autologous and allogeneic stem cell transplantation. RhuG-CSF and rhuEPO are the most frequently used, either for mobilization of peripheral stem cells or after transplantation for the improvement of hematologic recovery. G-CSF (filgrastim or lenograstim) can be administered alone or in combination with stem cell factor to enhance stem cells mobilization. IL-3 and sargramostim are not used anymore. The protocol of administration of rhuG-CSF is well established. Furthermore, stem cell transplantation with peripheral cells is less expensive than with bone marrow. RhuEPO (erythropoietin) is not effective in mobilization. After transplantation, filgrastim or lenograstim can shorten the neutropenic period and decrease infectious complications. The potential effect of these growth factors on the incidence and the severity of GvHD is still unknown and under debate. The use of rhuEPO after transplantation might be of interest to reduce the need of red blood cell transfusion. Some studies suggest that the administration of rhuEPO should start before delivering the conditioning regimen. The new long acting growth factors such as pegfilgrastim are still under evaluation and their use in mobilization seems promising.

Neutropenia and its subsequent infectious complications represent the most common dose-limiting toxicity of cancer chemotherapy. Febrile neutropenia (FN) occurs with common chemotherapy regimens in 25 to 40 % of treatment-naive patients, and its severity depends on the dose intensity of the chemotherapy regimen, the patient's prior history and comorbidities. Neutropenia is associated with the risk of life-threatening infections as well as chemotherapy dose reductions and delays that may compromise treatment outcome. One of the first, most important and sustained applications of recombinant DNA technology in medicine was the cloning and introduction into clinical practice of several glycoprotein factors involved in the regulation of hematopoiesis. Colony-stimulating factors (CSFs) such as granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) are now an integral part of the prevention of potentially life-threatening FN. Important uses of CSFs in oncology are prevention of FN after chemotherapy, treatment of FN, collection of CSF-mobilised peripheral stem cells and support following peripheral stem cells transplantation. This article reviews the data supporting the clearly clinical applications of CSFs in oncology.