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Updated USPSTF Guidelines on Ovarian Cancer Screening

Despite the incidence of ovarian cancer, routine screening for ovarian cancer has not generally shown a mortality benefit for asymptomatic women not at high risk. The US Preventive Services Task Force (USPSTF) 2018 statement continues to recommend against screening for ovarian cancer for asymptomatic women who are not known to have a high-risk hereditary cancer syndrome. The USPSTF notes that a woman with a family history of ovarian or breast cancer or symptoms should talk with her clinician. These recommendations are consistent with our approach.

Lenvatinib Versus Sorafenib for Advanced Hepatocellular Cancer

Sorafenib is the only tyrosine kinase inhibitor that is approved for first-line treatment of advanced hepatocellular cancer (HCC). The phase III REFLECT trial compared first-line lenvatinib with sorafenib in 954 patients with unresectable HCC and no prior systemic therapy (99 percent Child-Pugh A). Lenvatinib was noninferior to sorafenib in terms of the primary endpoint of median overall survival, and the objective response rate and median time to tumor progression were improved. Rates of grade 3 or 4 hypertension were higher with lenvatinib, while hand-foot skin reaction was more frequent with sorafenib. Lenvatinib represents a reasonable option for first-line treatment of advanced HCC, particularly for patients who are intolerant of sorafenib.

High-Grade, Low-PSA Localized Prostate Cancer

Patients with localized, high-grade (Gleason 8 to 10), low-prostate specific antigen (PSA, <=2.5 ng/dL) prostate cancer constitute a distinct subset with high-risk disease. In a retrospective review of patients with localized prostate cancer, this subset experienced poor response to hormonal therapy and increased prostate cancer-specific mortality. Additional clinical studies will be required to define the optimal treatment approaches for patients with high-grade, low-PSA localized prostate cancer.

Chemoradiotherapy for Locally Advanced Cervical Cancer

In a phase III trial of over 600 women with locally advanced squamous cervical cancer, those randomly assigned to neoadjuvant chemotherapy followed by radical hysterectomy experienced worsened five-year disease-free survival compared with those assigned to definitive chemoradiotherapy (69 versus 77 percent). These results support our approach of treating locally advanced cervical cancer with definitive chemoradiotherapy.

Adjuvant Immunotherapy With Pembrolizumab for Cutaneous Melanoma

Patients with cutaneous melanoma and positive lymph nodes (stage III) at initial definitive surgery are at increased risk for recurrence and subsequent death due to metastatic melanoma. In a phase III trial, pembrolizumab, a checkpoint inhibitor targeting programmed cell death protein 1 (PD-1), increased recurrence-free survival compared with placebo, with a level of activity similar to that of nivolumab in the adjuvant setting. Immunotherapy targeting PD-1 remains the preferred approach for patients with resected stage III melanoma. Results are similar for pembrolizumab and nivolumab; nivolumab, but not pembrolizumab, is approved by the US Food and Drug Administration for this indication.

Chronic Opioid Therapy and Infection Risk

In preclinical studies, some opioids have immunosuppressive properties, and epidemiologic studies have reported an association between prescription opioid use and serious infection. In a case control study in a state Medicaid population, over 1200 patients with laboratory-confirmed invasive pneumococcal disease were matched to 24,300 controls. After adjusting for several potential confounders, individuals with invasive pneumococcal disease had a 62 percent greater odds of being current opioid users. Associations were strongest for long-acting opioids, high-potency opioids (morphine, codeine, oxycodone, hydromorphone, fentanyl), and higher opioid doses. Additional research is needed to elucidate the comparative risk with individual opioids.

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