BMJ: Cancer of unknown primary

Lee, M.S. & Sanoff, H. K. (2020)| 371| m4050|Cancer of unknown primary| BMJ|
http://dx.doi.org/10.1136/bmj.m4050

Abstract

Cancers of unknown primary (CUPs) are histologically confirmed, metastatic
malignancies with a primary tumor site that is unidentifiable on the basis of standard
evaluation and imaging studies. CUP comprises 2-5% of all diagnosed cancers
worldwide and is characterized by early and aggressive metastasis. Current standard
evaluation of CUP requires histopathologic evaluation and identification of favorable
risk subtypes that can be more definitively treated or have superior outcomes.
Current standard treatment of the unfavorable risk subtype requires assessment of
prognosis and consideration of empiric chemotherapy. The use of molecular tissue
of origin tests to identify the likely primary tumor site has been extensively studied,
and here we review the rationale and the evidence for and against the use of such
tests in the assessment of CUPs. The expanding use of next generation sequencing
in advanced cancers offers the potential to identify a subgroup of patients who have
actionable genomic aberrations and may allow for further personalization of therapy.

The full text of the artilce is available from BMJ

[NICE Technology Appraisal Guidance] Venetoclax with obinutuzumab for untreated chronic lymphocytic leukaemia

NICE | 09 December 2020 | Venetoclax with obinutuzumab for untreated chronic lymphocytic leukaemia

Evidence-based recommendations on venetoclax (Venclyxto) with obinutuzumab for untreated chronic lymphocytic leukaemia in adults.

Full details from NICE

NIHR: Breast cancer screening for women in their forties could save lives

NIHR| December 2020 | Breast cancer screening for women in their forties could save lives

The Lancet Oncology has recently published the findings of a NIHR- funded longitudinal study that followed two groups of women who either received an annual mammography or were part of the NHS Breast Screening Programme. The trial began in 1990 and the research team randomly assigned 160,000 women into the two groups.

Recently published research from the long-term NIHR-funded UK Breast Screening Age Trial (UK Age Trial) provides further evidence of the benefits and risks of earlier screening for women.  Led by Professor Stephen Duffy, the trial began in 1990 and randomly assigned 160,000 women aged 39–42 to receive annual mammography or the usual NHS Breast Screening Programme. These women have now been followed up for around 23 years and the latest results have been published in The Lancet Oncology.

Currenlty the UK’s breast cancer screening programme offers mammograms to women aged between 50 and 70 years every three years. However, it is still unclear whether screening women from 40 years old is beneficial. Women in their forties are not routinely invited for screening because their risk of developing breast cancers is lower. However, the types of cancers that do develop in younger women are often more aggressive and progress more quickly. In these cases, earlier diagnosis and treatment would greatly benefit those patients. Source: NIHR

Full review is available from the NIHR

Primary paper available from The Lancet Oncology

Duffy, S. W., Vulkan, D., Cuckle, H., Parmar, D., Sheikh, S., Smith, R. A., … & Myles, J. (2020). Effect of mammographic screening from age 40 years on breast cancer mortality (UK Age trial): final results of a randomised, controlled trial. The Lancet Oncology, 21(9), 1165-1172.

Summary

Background

The appropriate age range for breast cancer screening remains a matter of debate. We aimed to estimate the effect of mammographic screening at ages 40–48 years on breast cancer mortality.

Methods

We did a randomised, controlled trial involving 23 breast screening units across Great Britain. We randomly assigned women aged 39–41 years, using individual randomisation, stratified by general practice, in a 1:2 ratio, to yearly mammographic screening from the year of inclusion in the trial up to and including the calendar year that they reached age 48 years (intervention group), or to standard care of no screening until the invitation to their first National Health Service Breast Screening Programme (NHSBSP) screen at approximately age 50 years (control group). Women in the intervention group were recruited by postal invitation. Women in the control group were unaware of the study. The primary endpoint was mortality from breast cancers (with breast cancer coded as the underlying cause of death) diagnosed during the intervention period, before the participant’s first NHSBSP screen. To study the timing of the mortality effect, we analysed the results in different follow-up periods. Women were included in the primary comparison regardless of compliance with randomisation status (intention-to-treat analysis). This Article reports on long-term follow-up analysis. The trial is registered with the ISRCTN registry, ISRCTN24647151.

Findings

160 921 women were recruited between Oct 14, 1990, and Sept 24, 1997. 53 883 women (33·5%) were randomly assigned to the intervention group and 106 953 (66·5%) to the control group. Between randomisation and Feb 28, 2017, women were followed up for a median of 22·8 years (IQR 21·8–24·0). We observed a significant reduction in breast cancer mortality at 10 years of follow-up, with 83 breast cancer deaths in the intervention group versus 219 in the control group (relative rate [RR] 0·75 [95% CI 0·58–0·97]; p=0·029). No significant reduction was observed thereafter, with 126 deaths versus 255 deaths occurring after more than 10 years of follow-up (RR 0·98 [0·79–1·22]; p=0·86).

Interpretation

Yearly mammography before age 50 years, commencing at age 40 or 41 years, was associated with a relative reduction in breast cancer mortality, which was attenuated after 10 years, although the absolute reduction remained constant. Reducing the lower age limit for screening from 50 to 40 years could potentially reduce breast cancer mortality.

Source: NIHR

Primary paper available from The Lancet Oncology