This position paper on periodontal considerations in the management of the cancer patient was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to provide information regarding the effects of head and neck radiation, total body radiation, chemotherapy, and bone marrow transplantation on the oral tissues. In addition, the paper offers suggestions for the prevention and treatment of periodontal and oral side effects of cancer therapy. Reliance on this position paper for patient management will not guarantee a successful outcome. Cancer therapy may be associated with complex problems. Ultimately, decisions regarding the diagnosis and treatment of oral disease in an individual patient must be made by the treating practitioner in light of the specific facts presented by that patient and in consultation with the patient's physician.

This article is the result of a multiconstituency consortium's 18-month collaboration on the critical issue of quality of life for people undergoing chemotherapy for cancer and those who care for them. It is intended to supplement existing practice guidelines by establishing some easy-to-use guiding principles that can be understood by all concerned constituencies and that are practical to apply.

Surveillance of the patient on infusional cancer chemotherapy (ICC) is paramount to patient safety. Key to this issue is diligence in monitoring for complications of infusion catheters. Nursing knowledge and awareness are essential for the early detection of such complications. The following is a composite of the manifestations of commonly experienced catheter-related complications. The incidence, detection and management issues are presented from the perspective of 15 years experience with ICC at The Cancer Center of Boston (TCC).

The role of nursing in infusional cancer chemotherapy (ICC) may vary depending on the practice setting. Nurses in free-standing centers and office practices perform many duties that nurses in other facilities may not, because of the lack of many of the supports that benefit hospitals with their multidepartmental and hierarchical structures. Nurses function collaboratively with physicians in the planning and the implementation of patient treatment. Patient-related nursing responsibilities include patient/family education, drug preparation and administration, patient assessment for treatment toxicity, recognition and management of complications related to the catheter or infusion device, and telephone triage. Other duties more removed from patient care might include inventory management, research data collection and management, quality assurance and improvement, compliance with regulatory issues, and a myriad of other responsibilities. The transition of patient care to the outpatient setting has broadened the scope of nursing to include nonpatient care responsibilities due to financial constraints brought about by health care reform, changes in reimbursement patterns, and overhead required to maintain and deliver quality patient care. As a result of nursing responsibilities, it becomes paramount that the aforementioned constructs for program support are in place and that all nurses are consistently trained and have a template to follow for patient treatment and management. Nursing ability to perform patient-related tasks should be proven by formal written and practical competencies repeated annually and as procedural changes are implemented. The paragraphs to follow suggest nursing management of patients receiving ICC using a model developed at The Cancer Center of Boston (TCC).

The Intravenous Nurses Society recognizes the inherent risks to the patient and the caregiver associated with the administration of antineoplastic agents. Individuals involved in the administration of these agents should have specialty education and validation of competency on a continuum and be licensed as a physician or a registered nurse.

The hematopoietic colony-stimulating factors have been introduced into clinical practice as additional supportive measures that can reduce the likelihood of neutropenic complications due to chemotherapy. Clinical benefit has been shown, but the high cost of colony-stimulating factors has led to concern about their appropriate use. The American Society of Clinical Oncology has established evidence-based, clinical practice guidelines for the use of colony-stimulating factors in patients who are not enrolled in clinical trials. An expert multidisciplinary panel reviewed the clinical data documenting the activity of colony-stimulating factors. For each common clinical situation, the panel formulated a guideline to encourage reasonable use of colony-stimulating factors to preserve effectiveness but discourage excess use when little marginal benefit is anticipated. Outcomes considered in evaluating colony stimulating factor benefit included duration of neutropenia, incidence of febrile neutropenia, incidence and duration of antibiotic use, frequency and duration of hospitalization, infectious mortality, chemotherapy dose intensity, chemotherapy efficacy, quality of life, colony-stimulating factor toxicity, and economic impact. To the extent that these data were available, the panel placed greatest value on survival benefit, reduction in rates of febrile neutropenia, decreased hospitalization, and reduced costs. Lesser value was placed on alterations in absolute neutrophil counts.

Cytoprotection utilising amifostine (Ethyol, WR-2721) is an evolving strategy to protect normal cells from the toxicity of chemotherapy. The dosing and administration guidelines are reviewed. The recommended dose of amifostine is 910 mg/m2 as a 15-min infusion prior to chemotherapy. Toxicity of this agent is moderate with hypotension and nausea/vomiting being observed in variable numbers of patients. Administration of amifostine with chemotherapy is simple and is associated with acceptable toxicity.

To establish guidelines for use of ondansetron.

Increased numbers of cancer patients are treated with chemotherapy. Patients who receive antineoplastic agents can be at serious risk from dental infections and should be provided appropriate dental care. In many instances, indicated treatment can be accomplished by the patient's private dentist. Certain precautions, however, are necessary when treating dental patients medically compromised by chemotherapy. Dental conditions which may increase morbidity are identified and treatment recommendations are made. Guidelines for dental intervention before, during, and after chemotherapy are discussed with emphasis on the hematologic parameters necessary for safe dental care. The cyclic relationship between chemotherapy and oral complications is also reviewed.

The anthracycline antibiotics, daunorubicin, doxorubicin, and the newer derivatives, are important components of many antineoplastic chemotherapeutic regimens. Their usefulness is limited by their cardiotoxicity. Sequential monitoring of cardiac function of patients undergoing chemotherapy allows identification of subclinical cardiotoxicity. In many patients monitoring can thus guide the modification of the chemotherapy to minimize cumulative cardiotoxicity, reducing acute and long-term clinical and subclinical sequelae. Such monitoring also aids in the comparison of cardiotoxicity produced by different drugs and different methods and schedules of drug administration. The considerable variability of monitoring regimens between institutions and in the literature has detracted from its usefulness. The Cardiology Committee of the Childrens Cancer Study Group has, therefore, reviewed the field and has formulated recommendations for standardized noninvasive monitoring of children during and immediately after chemotherapy and for the modification of the chemotherapy where indicated.

The National Cancer Institute (NCI)-sponsored Chronic Lymphocytic Leukemia (CLL) Working Group was convened to develop a set of standardized eligibility, response, and toxicity criteria for clinical trials. We recognized the previous efforts in 1967 (published again in 1973 as the report of the Chronic Leukemia-Myeloma Task Force [1] and 1978 of Cancer and Leukemia Group B (CALGB) [2]). We have used these reports for guidance during the current effort. Several noteworthy developments in the past few years have made it necessary to modify the previous guidelines. First, the diagnostic criteria for CLL and its clinical staging have been developed and well defined. Second, although staging systems facilitated entry of comparable and relatively homogeneous groups of patients in clinical trials, the definitions of response (CR) and partial response (PR) were not uniformly adopted from the previous guidelines in the clinical trials (Tables IA, IB); therefore, comparisons of results obtained in different studies became difficult. Third, there has been an improvement in our understanding of the immunology and biology of CLL. Finally, we are witnessing the emergence of several chemotherapy agents that promise impressive activity in CLL (e.g., 2'-deoxycoformycin [3], fludarabine monophosphate [4, 5]), and thereby offer the potential for improving survival time in this disease. To best identify regimens worthy of continued pursuit in large comparative trials, standardized guidelines for evaluation are essential. A number of laboratory investigations are also presented for which scientific interest is high yet relevance remains to be determined; thus, they are presented as companion studies to the clinical trials. This mechanism allows for flexibility in the testing of these questions and for additional ideas in the future without requiring modification of an entire treatment protocol. The following guidelines were developed to be used as a form of standardization for clinical trials, incorporating current technologies, yet remaining relevant to the general hematology/oncology community. Based on the membership of the Working Group, it is expected that these guidelines will serve as the criteria for most clinical trials in the near future.

In 1985, breast cancer will be diagnosed in approximately 120,000 women; in 90% of these women, the disease will apparently be limited to the breast and axillary lymph nodes. Despite advances in early diagnosis and primary treatment with surgery, radiation therapy, or both, more than a third of these patients will develop systemic disease and ultimately die. In the broadest sense, all of these patients are potential candidates for some form of systemic adjuvant therapy. Adjuvant therapy of breast cancer involves the use of cytotoxic drugs or endocrine therapy after definitive primary therapy. The rationale is to eradicate occult metastatic disease that otherwise would be fatal. The goal of adjuvant therapy is to significantly prolong survival, while maintaining an acceptable quality of life. Three measures are important in evaluating whether this goal is met by specific treatments: 1. The effect of therapy on overall survival: the length of time a woman survives following a diagnosis of breast cancer. 2. The effect of therapy on disease-free survival: the length of time a woman remains free of any recurrence of disease. Prolonged periods of disease-free survival may be advantageous in their own right, since quality of life is likely to be better before than after relapse. There is also some evidence that longer periods of disease-free survival may translate into better overall survival rates. 3. The effect of therapy on quality of life: in choosing an adjuvant therapy program, potential benefits must be balanced against both short-term and long-term side effects. Also important are the substantial psychological, social, and economic problems women may experience as a result of treatment. An increasing number of important prognostic variables have been identified that define the natural history of breast cancer. These include well-established factors such as histological status of axillary lymph nodes, primary tumor size, steroid hormone receptors, menopausal status or age, and histopathology. Assessment of cell differentiation and proliferation, which can be determined by newer techniques, may also be significant. The pathological status of the axillary lymph nodes remains the single most important prognostic variable, and four lymph node categories have been defined (negative, one to three positive nodes, four to nine positive nodes, and ten or more positive nodes). Since definitions of menopausal status vary widely among clinical trials, age (less than 50 vs greater than or equal to 50 years) can be substituted as a prognostic variable.(ABSTRACT TRUNCATED AT 400 WORDS)