The clinical stakes are enormous. Digestive system cancers are among the most common malignancies in China and worldwide, and HER2-positive subtypes account for a meaningful share of them: roughly 12 to 13 percent of gastric cancers test positive for HER2, along with about 7 percent of colorectal cancers and between 5 and 20 percent of biliary tract cancers. Two HER2-targeted ADCs, trastuzumab deruxtecan and disitamab vedotin, have already been approved by China’s National Medical Products Administration for later-line treatment of advanced HER2-positive gastric or gastroesophageal junction adenocarcinoma, while trastuzumab deruxtecan has gained approvals in more than 65 countries since its first United States authorization in December 2019. As these drugs move into routine practice across primary and secondary care settings, the experts argue, standardized safety management becomes as important as the drugs’ celebrated efficacy.

At the heart of the consensus is a clear-eyed explanation of why ADCs cause harm at all. These drugs couple a HER2-directed monoclonal antibody to a cytotoxic payload through a chemical linker, and toxicity arises from both on-target and off-target mechanisms. On-target toxicity occurs when normal cells that also express HER2 internalize the conjugate and release the payload, an unavoidable consequence of imperfect antigen specificity. Off-target toxicity follows at least four distinct routes: Fc receptor-mediated nonspecific binding by immune cells; macropinocytosis-driven uptake driven by the drug’s surface charge or hydrophobic properties; premature payload release when linkers hydrolyze in the bloodstream or are cleaved by extracellular proteases; and the so-called bystander effect, in which released payloads diffuse out of tumor cells and are taken up by neighboring healthy tissue. Understanding these pathways, the authors contend, is the foundation for rational monitoring and intervention.

Hematologic toxicity dominates the safety profile. Neutropenia, driven by the direct suppressive effect of free payload on bone marrow myeloid progenitors and by Fc-mediated immune activation, occurs in 63 percent of gastric cancer patients treated with trastuzumab deruxtecan, with more than half of those cases reaching grade 3 or worse, and febrile neutropenia arising in 4.8 percent. With disitamab vedotin, neutrophil counts fall in 50.6 percent of patients. The consensus recommends primary prophylaxis with granulocyte colony-stimulating factor for high-risk patients—those over 65, with prior chemotherapy, bone marrow involvement, liver or renal impairment, or a history of febrile neutropenia—and advises patients to check their temperature, practice rigorous hand and oral hygiene, and avoid crowds. Thrombocytopenia, linked to off-target uptake of the drugs by megakaryocytes, affects 39 percent of gastric cancer patients on trastuzumab deruxtecan and prompts strong recommendations for thrombopoietic agents when platelets fall below 50 × 10⁹ per liter, along with practical precautions such as soft toothbrushes and electric razors.

Anemia is equally pervasive, reaching incidences of 58 percent with trastuzumab deruxtecan, 49.6 percent with disitamab vedotin, and as high as 68.8 percent in biliary tract cancer, where more than half of cases are grade 3. The consensus attributes this to direct damage of erythroid progenitors and nonspecific injury to the bone marrow microenvironment, and it calls for a multidisciplinary approach combining red cell transfusion, iron supplementation, erythropoiesis-stimulating therapy, and nutritional support. Notably, the experts emphasize patient education: monitoring hemoglobin, recognizing warning signs such as resting heart rates above 100 beats per minute and exertional breathlessness, eating heme iron–rich foods paired with vitamin C while avoiding coffee and tea with supplements, and restricting vigorous activity when hemoglobin drops below 80 grams per liter.

Gastrointestinal side effects receive equally granular attention. Nausea strikes 63 percent of gastric cancer patients on trastuzumab deruxtecan and vomiting 26 percent, driven by the topoisomerase I inhibitor payload damaging GI epithelium and triggering serotonin release from enterochromaffin cells. Real-world evidence proved dual antiemetic prophylaxis insufficient for some patients, prompting the NCCN to reclassify trastuzumab deruxtecan as highly emetogenic in January 2023, though ESMO retains the moderate label. The Chinese consensus recommends prophylactic antiemetics 30 minutes before infusion, continued for two to four days afterward, using dexamethasone plus a 5-HT3 receptor antagonist for standard-risk patients and adding an NK1 antagonist for high-risk ones, with olanzapine or mirtazapine reserved for refractory cases. Diarrhea, affecting 32 percent of gastric cancer patients on trastuzumab deruxtecan, is managed by a graded scheme: oral rehydration and loperamide for mild cases, hospitalization with fluid resuscitation and octreotide for severe or complicated presentations.

The most feared toxicity is interstitial lung disease, whose mechanisms include uptake by alveolar macrophages, bystander payload release, and possibly the amino-methylene spacer in the linker itself. Incidence ranges from 3.2 percent in Chinese gastric cancer patients in the DESTINY-Gastric06 trial to 20 percent with ARX788, with median onset around 84.5 days for trastuzumab deruxtecan. Because ILD is a diagnosis of exclusion, the consensus mandates ruling out infection, metastasis, and radiation pneumonitis, classifying subtypes on chest CT—organizing pneumonia is most common at 63.1 percent, while diffuse alveolar damage carries the gravest prognosis with roughly 42 percent mortality—and recommends high-resolution chest CT every 8 to 12 weeks, serum KL-6 monitoring, and pulse oximetry at each visit. Treatment is strictly graded: brief corticosteroids and a treatment pause for grade 1 disease, permanent drug discontinuation with at least 1 milligram per kilogram daily of prednisolone for grade 2 or higher, and immunosuppressants, antifibrotics, or biologics for refractory cases.

Liver injury, neurotoxicity, and ocular toxicity round out the organ-specific guidance. Hepatotoxicity, an on-target effect demonstrated in studies of trastuzumab emtansine binding HER2 on hepatocytes, manifests as AST and ALT elevations in up to 58 percent of patients, yet the consensus explicitly advises against routine prophylactic hepatoprotective drugs, reserving close monitoring for high-risk patients such as those with viral hepatitis, who should receive antiviral therapy before starting an ADC. Peripheral neuropathy, driven by free monomethyl auristatin E disrupting the neuronal microtubule network, affects nearly a third of patients on disitamab vedotin and is managed with B vitamins, neuroprotective agents, and gabapentinoids. Ocular toxicity is essentially confined to ARX788, which caused dry eye in 63.3 percent of treated patients, prompting recommendations for baseline eye screening and prompt ophthalmology referral. The document also flags the uncertain but potentially synergistic pulmonary risk when ADCs are combined with immune checkpoint inhibitors.

Dosing philosophy and team structure complete the framework. The consensus endorses 6.4 milligrams per kilogram every three weeks as the standard starting dose of trastuzumab deruxtecan in HER2-positive gastric cancer, based on superior efficacy over 5.4 milligrams per kilogram in phase I expansion and confirmation in DESTINY-Gastric01 and 06, with stepwise reductions to 5.4 and then 4.4 milligrams per kilogram and no re-escalation once reduced; disitamab vedotin starts at 2.5 milligrams per kilogram every two weeks, reducible to 2.0 or 1.5. Complex or severe adverse events should be routed through a structured multidisciplinary team led by an oncologist and including pulmonology, hepatology, ophthalmology, neurology, radiology, and clinical pharmacy. Perhaps most distinctively, the guideline champions a physician-led, patient-engaged model of education, arguing that informed patients who recognize early symptoms of infection, bleeding, breathlessness, or numbness are the first line of defense—experience the authors believe will transfer directly to the next generation of ADCs targeting other oncogenic pathways.

Subject of Research: Safety management of adverse events from HER2-targeted antibody–drug conjugates in digestive system cancers

Article Title: Chinese expert consensus on the management of adverse events to HER2-targeted antibody–drug conjugates in digestive system cancers (2025 edition)

Article References: Yu, Y., Wu, J., Lv, M., Cui, Y., Dai, G., Deng, T., Gong, L., Li, J., Li, H., Lin, R., Liu, Y., Peng, Z., Rao, S., Wang, F., Wang, F., Wei, J., Wu, S., Xue, J., Yang, W., … Liu, T. (2026). Chinese expert consensus on the management of adverse events to HER2-targeted antibody–drug conjugates in digestive system cancers (2025 edition). Clinical Cancer Bulletin, 5(1), Article 1. https://doi.org/10.1007/s44272-025-00053-z

Image Credits: AI Generated

DOI: 10.1007/s44272-025-00053-z

Keywords: HER2, antibody-drug conjugates, trastuzumab deruxtecan, disitamab vedotin, gastric cancer, biliary tract cancer, interstitial lung disease, adverse event management, expert consensus, drug safety, oncology, multidisciplinary team

The survey, conducted by researchers affiliated with the European Geriatric Medicine Society’s special interest groups in gero-oncology and perioperative geriatric medicine, was distributed between April 10 and May 23, 2025. An anonymous 35-item questionnaire reached 11,189 professionals via international and national geriatric societies, generating 2,160 responses from 37 countries. After excluding incomplete or ineligible responses, the analysis focused on 395 geriatricians and internal medicine physicians with at least 26 percent survey completion across 34 countries. Most respondents were consultants in general hospitals, and more than half worked in university-affiliated academic centers, giving the dataset a strong institutional footprint, although the authors caution that the anonymous design and overlapping distribution networks prevent country-level results from being treated as nationally representative estimates.

The technical heart of geriatric oncology is the comprehensive geriatric assessment, or CGA, a multidimensional evaluation performed by a geriatrician-led team that maps medical, functional, psychological, and social vulnerabilities and converts them into a coordinated care plan. Because chronological age is a poor proxy for physiological resilience, international bodies including the International Society of Geriatric Oncology and the American Society of Clinical Oncology recommend CGA or an abbreviated geriatric assessment to guide treatment selection in older patients. The survey found that implementation of this principle varies enormously. Nineteen percent of respondents reported no formal geriatric oncology model at all, meaning older patients are simply not referred for geriatric evaluation. The two dominant approaches elsewhere were referral based on the referring physician’s clinical judgment, reported by 43 percent, and a structured two-step pathway in which patients are first screened for frailty and those at risk receive a full CGA, reported by 42 percent.

Even where screening exists, the tools and triggers differ from country to country. Frailty screening guided referral in 63 percent of practices, with the G8 questionnaire the most popular instrument at 50 percent, followed by the Clinical Frailty Scale at 32 percent and the Eastern Cooperative Oncology Group performance status at 10 percent. The national contrasts are telling: the G8 was nearly universal in France, used by 94 percent of respondents, and dominant in the Netherlands and Spain, while the United Kingdom relied predominantly on the Clinical Frailty Scale. Referral criteria based purely on chronological age, an approach geriatricians widely regard as outdated, persisted in 39 percent of practices, particularly in Italy and France and in several smaller Eastern European systems. Most referrals occurred at diagnosis or at the start of oncological treatment, and the CGA itself was carried out by geriatricians in 70 percent of settings, with nurse specialists contributing in 22 percent.

Perhaps the survey’s most consequential finding concerns the multidisciplinary team meeting, the tumor board where oncologists, surgeons, radiologists, and pathologists jointly plan treatment. Only 30 percent of respondents routinely attended these meetings, and just 20 percent were involved in treatment decisions on a routine basis, although another 49 percent participated case by case. The exploratory statistical analysis, adjusted for country group, institution type, and years of experience, showed that routine multidisciplinary team participation was associated with a sixfold increase in the odds of active involvement in treatment decision-making, an adjusted odds ratio of 6.01. It was also associated with a nearly sixfold increase in the odds of producing CGA-based recommendations that address both geriatric optimization and the oncological treatment itself, rather than generic conclusions filed in the patient record. Among geriatricians who regularly sat at the tumor board table, 47 percent actively shaped treatment decisions; among those who did not, the figure was just 11 percent.

Collaboration also appeared to change how the wider cancer team views geriatric input. Seventy-four percent of routine multidisciplinary team participants reported positive feedback from oncology and surgery colleagues, compared with only 31 percent of non-attendees, and participation remained independently associated with positive feedback after adjustment. The authors are careful to stress that these are cross-sectional associations and cannot prove causation; it may be that engaged geriatricians seek out tumor boards rather than the reverse. Still, the pattern aligns with prior evidence that multidisciplinary discussion incorporating functional status, comorbidity, and patient priorities helps avoid both overtreatment and undertreatment in older adults, and it identifies tumor board membership as a plausible and testable target for improving integrated cancer care.

If medical geriatric oncology is a patchwork, geriatric surgical oncology emerges as the discipline’s most underdeveloped frontier. Only 39 percent of respondents were involved in the care of hospitalized patients undergoing cancer surgery, and more than half reported no structural collaboration with surgical services whatsoever. The prevailing arrangement was a liaison model, in which geriatricians are consulted for specific problems such as delirium or preoperative assessment, reported by 37 percent, while a formal co-management model with geriatricians structurally embedded on the surgical ward existed in only 9 percent of settings. This stands in sharp contrast to orthogeriatrics, where co-management of hip fracture patients is well established and has demonstrably improved outcomes. Involvement concentrated in colorectal, upper gastrointestinal, and bladder cancers, and the Netherlands, Portugal, Belgium, and Denmark led in overall engagement. Just over half of respondents offered prehabilitation programs for surgical oncology patients, most commonly combining exercise training and nutritional support.

The survey also exposed systemic weaknesses in education and guidance. Nearly half of respondents, 48 percent, reported having no structured educational system in geriatric oncology in their country, and 23 percent said their nation lacked specific treatment guidelines for older patients with cancer. In several smaller countries, every respondent reported the absence of both. The barriers cited most often were a lack of engagement from other specialists, reported by 47 percent, a shortage of geriatricians at 44 percent, and insufficient education at 42 percent, with limited funding, staffing, and communication compounding the problem. Respondents’ proposed remedies were strikingly convergent: 45 to 50 percent supported dual training or fellowship programs combining geriatrics with oncology, around 42 percent backed regulatory measures, and 40 percent called for advocacy toward policymakers. More than 80 percent said they would attend a masterclass in perioperative geriatric medicine if one were established, signaling substantial pent-up demand for training.

The survey’s authors situate their findings within two decades of European development. France pioneered formal geriatric oncology with its Pilot Oncogeriatric Coordination Units, created by the National Cancer Institute in 2005, and unsurprisingly reported some of the highest integration in the current survey, with referral at diagnosis in 87 percent of cases and strong G8 uptake. Belgium and the Netherlands have repeatedly documented barriers such as workload and staffing, and a Spanish national questionnaire found older patients often routed to palliative care rather than geriatricians. An interview study of five European cancer centers published in 2024 reached similar conclusions despite unanimous agreement on the value of interdisciplinary collaboration. The new survey is, however, the first to capture real-world practice at this scale and breadth, and its country-level tables for Italy, France, Spain, the Netherlands, Denmark, the United Kingdom, Turkey, Ireland, Portugal, and Belgium offer a benchmark clinicians and policymakers can use to locate their own systems.

The study’s limitations deserve clear acknowledgment. The response rate was modest, many countries provided fewer than ten responses or none at all, and self-selection likely favored geriatricians with an existing interest in oncology, meaning the true extent of inequality across Europe is probably even greater than the results indicate. Because the survey was anonymous and center identifiers were not collected, over-representation of interested institutions cannot be excluded, and residual confounding cannot be ruled out of the statistical associations. Yet the overall message is difficult to dispute. The authors argue that the goal should not be to crown a single best model, but to guarantee core elements everywhere: frailty screening, geriatric assessment, and genuine geriatrician participation in multidisciplinary decision-making, with progressively stronger co-management pathways for surgery. Harmonized European guidelines, structured training, and longitudinal monitoring, they conclude, are essential if the growing population of older adults with cancer is to receive equitable, high-quality care regardless of borders.

Subject of Research: Geriatric oncology and geriatric surgical oncology care models for older cancer patients across Europe

Article Title: A survey among geriatricians on geriatric oncology and geriatric surgical oncology models in Europe

Article References: Sobrini-Morillo, P., Moens, I., Cruz-Jentoft, A., Ciccone, A. S., Dhesi, J. K., Gonzalez-Senac, N. M., Hamaker, M., Lund, C., Mattace-Raso, F., Neuendorff, N., Rostoft, S., Shipway, D., Testa, G. D., Velghe, A., Polinder-Bos, H. A., & on behalf of the SIG Perioperative Geriatric Medicine and the SIG Gero-Oncology of the European Geriatric Medicine Society (2026). A survey among geriatricians on geriatric oncology and geriatric surgical oncology models in Europe. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01575-y

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01575-y

Keywords: geriatric oncology, comprehensive geriatric assessment, frailty screening, multidisciplinary team, surgical oncology, Europe, older adults, cancer care, G8 screening tool, prehabilitation, co-management, health services survey

Dr. Bamji’s path to the archive was anything but planned. Trained at the Middlesex Hospital Medical School and qualifying in 1973, he arrived at Queen Mary’s Hospital, Sidcup in 1983 as a consultant rheumatologist, a specialty seemingly far removed from facial reconstruction. When the retired consultant who managed the hospital’s modest archives died, Bamji, a lifelong collector like his father before him, was asked to take over. The turning point came when a New Zealand orofacial surgeon, Sandy McAllister, contacted the hospital out of the blue: he was giving a lecture at the College of Surgeons in London based on the New Zealand section records from Sidcup, which he had stored in boxes in his garage. After listening to the lecture, Bamji asked whether the records could be returned to the hospital that had created them. McAllister later suffered a stroke, and after Bamji wrote to him in New Zealand, his son agreed to send the records back, with the hospital paying the considerable shipping costs. That first recovery yielded around 280 records, together with watercolors painted by New Zealand and Australian artists.

Chance then compounded the discovery. As Director of Medical Education at Sidcup, Bamji received an invitation from the Institute of Medical Illustrators, offered to give a talk on medical illustration in the First World War, and wrote an accompanying article. A month after publication, he was contacted with astonishing news: the entire British section of the First World War records, roughly two and a half thousand files, were sitting in the photographic department of Queen Mary’s Hospital in Roehampton, unknown to the Sidcup staff. Bamji believes Gillies had removed the records from Sidcup to write his book and kept them personally, taking them with him when he moved to Rooksdown House, part of Park Prewett Hospital in Basingstoke, during the Second World War. When Basingstoke closed in 1960, the unit relocated to Roehampton, taking every record from 1914 through 1960 with it. The haul included not only the First World War files but Second World War records as well, among them the first documented case of female-to-male gender confirmation surgery. Faced with an archive nobody else possessed, Bamji set out to write about it; his book, Faces from the Front, took twenty-three years to complete, a process accelerated when his daughter, a historian, demanded a thorough rewrite of his first draft.

The files document a revolution in surgical thinking. As Bamji explains, before Gillies, reconstructive procedures were performed in a haphazard, occasional fashion, guided by textbooks such as that of Nelaton and Ombredanne, which were filled with diagrams of nasal reconstruction but contained no photographs, leaving surgeons no way to judge whether the techniques actually worked. Gillies tested them and found that many did not. One fundamental lesson, Bamji notes, is that a reconstructed nose cannot stand up unless the created structure is supported with soft tissue and a cartilage graft. What made Gillies’s systematic approach possible was the unprecedented scale and variety of facial injury in the First World War, a conflict in which, uniquely for its time, many soldiers survived wounds and disease that would have killed them in earlier wars, producing thousands of disfigured patients who required sustained reconstructive care.

Equally important to Bamji’s work is the second story the archive tells: that of the patients themselves. While much scholarship has focused on surgical innovation, Bamji investigated the psychology of facial injury, testing the widespread assumption that these men hid from society, could not work and lived in misery. The archives revealed a different reality. Many patients disliked their disability and refused to be photographed on the affected side, yet they held down jobs, married, had children and became loving grandparents. Bamji’s focus on patients’ lives was made possible by Gillies’s own approach, which Bamji describes as a complete change of surgical direction: instead of the authoritative old model in which surgeons simply told patients what would happen, Gillies asked whether a proposed plan appealed to them and built a multidisciplinary team of surgeon, dentist, technician, anesthetist, artist, photographer, nurses and occupational therapists, with the patient as a genuine member of the team. That personalized philosophy, now standard in plastic surgery, and Gillies’s meticulous recordkeeping together created a resource that lets modern readers watch procedures evolve through trial, error and refinement.

Art was central to that recordkeeping. Black-and-white photography alone could not convey what Gillies needed to document, so he employed illustrators including Henry Tonks, a former surgeon; Daryl Lindsay, who had once worked as a ranger on an Australian farm; and Herbert Cole, an artist in the New Zealand Army Medical Corps who was drafted to Sidcup once his talent was discovered. Gillies insisted that color was indispensable: in burns cases, he argued, one must understand the lividity of a burned scar, which no photograph could recreate. The watercolors in the archive capture skin necrosis, perfusion complications, bruising, infection-related discoloration and ischemic signs, visual information that, combined with Gillies’s extensive experience, helped establish now well-known rules of flap management that remain embedded in surgical training.

The conversation also turns to the ethics of publishing patients’ stories. Bamji decided to use patients’ names in his book because every relative he contacted welcomed the recognition, asking why wounded veterans of these pioneering procedures should be less visible than the war dead honored on television. He notes a revealing contrast: in Gillies’s second book, The Principles and Art of Plastic Surgery of 1957, patient details in the gender confirmation section were altered because, after the founding of the National Health Service in 1948, rules prohibited access to medical notes, extending a restriction long applied to psychiatric records. For the First World War files, however, the stories and the families’ wishes permitted openness, and Bamji argues that honoring these patients is essential to teaching new generations of surgeons where today’s seemingly obvious surgical rules came from. If you do not tell the story, he says, nobody can understand it.

The human cost of the work, for surgeons and archivists alike, receives careful attention. Bamji recalls that early in his research he could not examine more than about 30 case files at a time before the imagery became unbearable, yet over years of review he found the technical medicine gradually taking over from the person behind each wound, a coping mechanism he compares to that of frontline surgeons. He stresses that empathy must survive this adaptation, echoing Gillies’s near-indefinite follow-up of patients, including a man he encountered in Australia thirty years after surgery, to whom Gillies declared he had not finished with him; the patient firmly disagreed. The archive also preserves remarkable documents of surgical accountability, such as Thomas Pomfret Kilner’s letter to the family of a patient who died of a cerebral abscess, explaining what went wrong, apologizing and offering help with the pension. Bamji recounts the tragic case of Henry Ralph Lamley, who survived severe burns only to die months later as a consequence of a plastic operation, a loss that prompted Gillies’s remorse and his principle: never do today what can honorably be put off until tomorrow. Such tragedies, Bamji argues, shaped the specialty’s standards and belong in medical education, alongside training in empathetic communication with grieving relatives, a lesson he instilled through role-play with his own students.

The discussion closes with reflections that range across artificial intelligence, peer review, academic publishing and healthcare systems, converging on Bamji’s conviction that medical history deserves a central place in training. Asked what advice he would give students entering medicine, he offers a distillation of both his clinical career and his archival one: think before you do, look back at history, ask whether someone has encountered the problem before, keep up to date with medical advances, examine research critically, beware of becoming tied to the pharmaceutical industry, and always examine the patient. It is advice that resonates with Gillies’s own late reflections, written in longing for the New Zealand bush, the tūī, painting and a few holes of golf, a reminder that medicine is ultimately a path chosen by those who want to help others with their knowledge, empathy and compassion, and that the surgical rules considered obvious today were written, painfully and painstakingly, by the patients and surgeons of Sidcup.

Subject of Research: Historical origins of plastic and reconstructive surgery based on the Gillies Archives of First World War surgical case files

Article Title: The origins of plastic and reconstructive surgery: a discussion with Dr. Andrew Bamji

Article References: Sinelnikov, M., & Bamji, A. (2026). The origins of plastic and reconstructive surgery: a discussion with Dr. Andrew Bamji. BMC Plastic and Reconstructive Surgery, 2(1), Article 12. https://doi.org/10.1186/s44452-026-00025-9

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00025-9

Keywords: Harold Gillies, plastic surgery, reconstructive surgery, Gillies Archives, Queen Mary's Hospital Sidcup, First World War, facial injury, medical history, medical illustration, patient psychology, multidisciplinary team, Andrew Bamji

Molecular radiotherapy, or MRT, is a treatment in which radioactive drugs such as radioactive iodine, iodine-131 labelled meta-iodobenzylguanidine, or lutetium-177 DOTATATE are administered orally or intravenously to target tumour cells from within. Because these treatments render the patient temporarily radioactive, strict radiation safety protocols governed by the UK’s Ionising Radiation Regulations 2017 require children to remain in isolation until their radioactivity falls to acceptable levels. Parents or other consenting non-pregnant adults may be legally designated as ‘comforters and carers’, wearing protective equipment, monitoring their radiation dose, and managing their time in close contact with the child. The result is a treatment experience that is physically confined, emotionally demanding, and unlike almost any other form of paediatric cancer care.

The research, published in the journal Supportive Care in Cancer, was conducted at a single tertiary referral centre between 2018 and 2022. The team prospectively assessed the holistic needs of parents and caregivers of 50 paediatric and adolescent patients receiving their first cycle of MRT, using holistic needs assessment forms completed before admission. The median age of the patients was 13 years, with ages ranging from 3 to 17. Treatments included radioactive iodine for differentiated thyroid cancer, iodine-131 mIBG for neuroblastoma and related tumours, and lutetium-177 DOTATATE for neuroendocrine tumours. Thematic and axial coding of the assessment responses revealed a consistent pattern of concerns across the families.

The most striking finding concerned money. Ninety-eight percent of participants reported financial stress related to the treatment, and 51 percent had specific financial concerns, mainly linked to lost income from time off work. The longer the hospital stay, the greater the financial strain, a correlation that was particularly strong for families undergoing complex double-administration mIBG protocols, which can require up to five weeks of inpatient care and represented between 75 and 83 percent of those reporting such concerns. Families also cited travel, accommodation, and parking costs, with 20 percent flagging these as stressors. Fourteen percent reported unemployment. Many parents described having to take career breaks or leave jobs entirely to provide care, a burden that national data on cancer caregiving has long suggested but which has never been quantified in the MRT context.

Separation from family emerged as the second most common concern, cited by 52 percent of participants. Parents worried about who would look after siblings, how household responsibilities would be managed, and how the child in isolation would cope with missing school. Isolation itself was reported as a concern by 36 percent, and anxiety about isolation rose sharply with the length of stay. Half to two-thirds of caregivers whose children received two mIBG administrations two weeks apart, with admissions lasting four to five weeks, reported isolation-related worries, compared with just 24 percent of those whose children had shorter radio-iodine treatments. Parents described feeling ‘worried about being confined and claustrophobic’ and emphasised the need for activities, play support, and attention for their child.

The emotional toll was evident throughout the responses. Parents reported feeling ‘helpless, anxious, depressed, struggling, overwhelmed’, and ‘frustrated’, with some describing the period as ‘a very stressful time for us all’. One parent noted that her child might cope, but that she herself would need family support. Fear of recurrence, doubts about treatment effectiveness, and the potential loss of a child accounted for 24 percent of concerns. Yet only 20 percent of participants reported receiving support from medical professionals, a figure the authors attribute to the fact that care is often coordinated locally before treatment and that parents, prioritising their child’s needs above their own, may not seek help even when they need it. The study’s authors stress that careful, iterative handover of information between referring and treatment centres is critically important, not a one-off communication.

Spiritual and religious life also played a role. Fifty-two percent of participants identified with a religion or spiritual belief, primarily Christian or Muslim, and 16 percent highlighted the importance of prayer in coping, with comments such as ‘praying strengthens our body and soul’ and ‘spiritual belief helped immensely in coping with the current situation’. Notably, 48 percent reported no religious or spiritual affiliation, but the study found that many of these individuals nevertheless held personal faith, distinguishing spirituality from organised religion. A six percent minority expressed that they were losing or questioning their faith. The authors argue that ignoring spiritual needs can reduce patient satisfaction and quality of life, and that ethical guidelines urge health professionals to address spirituality as part of holistic care.

The study also identified practical gaps. Twenty-two percent of participants provided additional comments, highlighting concerns about the child’s education, logistical issues such as parking and cooking facilities, and the need for play specialist support. Schools are legally required to arrange education for children in hospital, but radiation protection guidelines mean that MRT patients may not receive face-to-face teaching, and input from schools before admission is described as vital. The authors point to virtual platforms, remote learning, and online peer support groups as promising tools that could help maintain social and educational connections during isolation, drawing on developments accelerated by the COVID-19 pandemic. They also recommend resources such as play specialists and charities like Spread a Smile to provide respite and support.

The study had limitations. Eighteen percent of assessment data was missing, attributed to families not completing the form, as completion was not mandatory during the study period. The authors argue that routine use of holistic needs assessment for all patients, in line with national guidelines, is essential, and that healthcare staff need training in sensitive conversations, particularly around financial and social issues. Without follow-up and allocation of resources to address identified needs, they warn, the assessment tool risks becoming ineffective. Signposting to charities or benefits-support groups should be explored before hospital stays begin, and longer stays heighten the case for flexible working arrangements supported by employers and social policy.

Ultimately, the study’s central message is that support must extend beyond the patient. Molecular radiotherapy for children is concentrated in only a few specialised centres in the United Kingdom because it requires round-the-clock paediatric nursing, medical care, and nuclear medicine facilities in co-location. That centralisation means many families travel long distances, spend weeks away from home, and carry the weight of treatment largely alone. The authors conclude that a coordinated, family-centred, multidisciplinary approach is essential, and that future improvements should include enhanced training for healthcare professionals, virtual peer support, support for education continuity, and better integration of local resources throughout the treatment journey. Holistic needs assessments, they argue, are not a bureaucratic exercise but the first step in identifying unmet needs, fostering engagement, and building the kind of personalised care that families navigating this uniquely isolating treatment genuinely require.

Subject of Research: Holistic care needs of parents and caregivers of children and teenagers receiving molecular radiotherapy for cancer

Article Title: Exploring holistic care needs in paediatric and teenage molecular radiotherapy: a parent and carer perspective

Article References: Exploring holistic care needs in paediatric and teenage molecular radiotherapy: a parent and carer perspective. (n.d.). https://doi.org/10.1007/s00520-026-11214-8

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11214-8

Keywords: molecular radiotherapy, paediatric cancer, holistic needs assessment, caregiver burden, financial toxicity, radiation isolation, family-centred care, psychosocial support, multidisciplinary team, mIBG therapy, radioactive iodine, supportive care

The scale of the problem the guidelines address is stark. Approximately 15 to 25 percent of colorectal cancer patients already have liver metastases when their cancer is first diagnosed, and a further 15 to 25 percent develop such metastases after curative resection of the primary tumor. Critically, 80 to 90 percent of these liver metastases are initially unresectable with curative intent. Left untreated, patients with colorectal liver metastases have a median survival of only 6.9 months, and the five-year survival rate for unresectable disease falls below 5 percent. By contrast, patients who achieve complete resection of their liver metastases, or reach a status of no evidence of disease, experience median survival of 35 to 60 months and five-year overall survival rates of 40 to 57 percent. This dramatic gap between the untreated and the successfully treated is precisely what the new guidelines are designed to close.

On the diagnostic front, the 2025 edition codifies a tiered imaging strategy. For every newly diagnosed colorectal cancer patient, liver ultrasound and contrast-enhanced abdominal computed tomography are recommended as routine screening tools, alongside serum tumor markers such as carcinoembryonic antigen and CA19-9. When ultrasound or CT findings are suspicious but inconclusive, the guidelines endorse supplemental testing with serum alpha-fetoprotein, contrast-enhanced liver ultrasound, and contrast-enhanced liver MRI. Liver-specific contrast-enhanced MRI earns a particularly strong endorsement because it demonstrates higher accuracy for detecting lesions smaller than one centimeter, a critical threshold since tiny metastases are the ones most easily missed and most consequential for surgical planning. PET-CT and PET-MRI are explicitly not recommended for routine use, reserved instead for selected clinical scenarios where additional information is genuinely needed.

The guidelines also formalize a rigorous surveillance program after radical resection of the primary colorectal tumor. Patients should undergo history-taking, physical examination, liver ultrasound and tumor marker testing every three to six months for the first two years, then every six months until five years, and annually thereafter. For patients with stage II and III disease, annual contrast-enhanced CT of the chest, abdomen and pelvis is recommended for three to five years. Electronic colonoscopy should be performed within one year of surgery, with repeat examination at three years and then every five years if no abnormalities are found. After patients achieve no evidence of disease status for liver metastases, the surveillance intensifies further, with tumor markers checked every three months for two years and abdominal imaging every three months during the same period, reflecting the high risk of recurrence in this population.

Perhaps the most consequential section of the 2025 update concerns molecular profiling. The guidelines recommend mismatch repair and microsatellite instability testing for all colorectal cancer patients, a recommendation grounded in the transformative role of immune checkpoint inhibitors in tumors with deficient mismatch repair or high microsatellite instability. RAS genotyping, covering exons 2, 3 and 4 of both KRAS and NRAS, is recommended for all patients with colorectal liver metastases, both for its prognostic value and its role in predicting response to anti-EGFR therapy. BRAF V600E mutation testing is endorsed as both a prognostic indicator and a guide to treatment selection, while HER2 testing is recommended for metastatic patients to inform post-progression decisions. The guidelines also acknowledge emerging biomarkers including tumor mutational burden, POLE and POLD1 mutations, NTRK fusions, RET rearrangements and c-MET alterations, and highlight circulating tumor DNA-based minimal residual disease assessment as a promising but not yet fully validated tool.

On prevention, the guidelines are unequivocal that standardized radical treatment of the primary colorectal cancer remains the most effective strategy for reducing liver metastasis risk. For colon cancer, this means complete mesocolic excision with adequate proximal and distal margins and removal of the associated mesentery and lymphatic drainage. For rectal cancer, total mesorectal excision is mandatory for mid and lower tumors. The update also embraces neoadjuvant approaches aimed at eradicating micrometastases invisible to imaging. For patients with deficient mismatch repair or microsatellite instability-high rectal cancer, immune checkpoint inhibitors can achieve such favorable outcomes that many patients may avoid surgery altogether through a watch-and-wait approach. For proficient mismatch repair tumors staged T3 or higher, or with positive lymph nodes, neoadjuvant radiotherapy, chemoradiotherapy or chemotherapy is recommended, and total neoadjuvant treatment is endorsed as an option that increases complete response rates and facilitates organ preservation.

The multidisciplinary team model receives a Grade A recommendation for all patients with colorectal liver metastases. The guidelines specify that the team should include colorectal or gastrointestinal surgeons, hepatobiliary surgeons, medical oncologists, radiation oncologists, interventional radiologists, diagnostic radiologists, ultrasound specialists and pathologists. The documented advantages of this approach include more accurate molecular profiling, more precise staging, fewer treatment delays, more individualized treatment planning, improved coordination, enhanced quality of life, better survival outcomes and superior cost-effectiveness. The MDT framework is then used to stratify patients into distinct therapeutic pathways: those with initially resectable metastases, those with potentially convertible disease, and those whose metastases will never be resectable, each with tailored goals ranging from cure to disease control.

Surgical treatment remains the gold standard for cure, and the 2025 edition reflects how far the boundaries of resectability have expanded. Surgical decisions are no longer restricted by tumor size, number or location alone. The guidelines now support resection with margins smaller than one centimeter, resection of hepatic pedicle lymph node metastases, and resection of resectable extrahepatic disease including pulmonary and peritoneal metastases. For patients with insufficient future liver remnant volume, the guidelines describe a sophisticated arsenal of techniques: portal vein embolization to induce compensatory hypertrophy, the ALPPS procedure for rapid remnant growth, liver venous deprivation as a less invasive alternative, and selective internal radiation therapy with yttrium-90 microspheres, which can shrink tumors while simultaneously stimulating growth of the untouched liver lobe. Liver transplantation combined with systemic therapy is cautiously endorsed for selected patients with liver-limited disease that cannot achieve no evidence of disease status despite multimodal treatment, an approach supported by the recent TransMet randomized trial showing significantly improved overall survival.

For unresectable disease, the guidelines detail an escalating therapeutic ladder. First-line chemotherapy combines fluoropyrimidines with oxaliplatin and/or irinotecan, with molecular targeted agents such as bevacizumab or cetuximab added to increase conversion to resectability. Triplet FOLFOXIRI regimens are endorsed for fit patients when targeted therapy is contraindicated. For tumors with deficient mismatch repair, immune checkpoint inhibitors such as pembrolizumab or the nivolumab-ipilimumab combination are the preferred first-line approach, having demonstrated significantly improved disease control and conversion rates compared with chemotherapy. Maintenance therapy with low-toxicity regimens after induction, sequential switching between FOLFOX and FOLFIRI upon progression, and later-line options including trifluridine/tipiracil, regorafenib and fruquintinib are all codified. Local therapies including radiofrequency ablation for lesions under three centimeters, microwave ablation for lesions under five centimeters, and stereotactic body radiotherapy for oligometastatic disease round out the comprehensive toolkit, ensuring that even patients whose metastases can never be removed can still expect meaningful prolongation of survival and quality of life.

Subject of Research: Clinical guidelines for the diagnosis and comprehensive treatment of colorectal cancer liver metastases

Article Title: Chinese guidelines for the diagnosis and comprehensive treatment of colorectal liver metastasis (2025 Edition)

Article References: Fan, J., Gu, J., Jia, B., Li, J., Qin, X., Wang, X., Xu, J., Xu, R., Ye, Y., Zhang, S., Zhang, Z., & Chinese College of Surgeons, Chinese Medical Doctor Association (CMDA); Gastrointestinal Surgery Group, Chinese Society of Surgery, Chinese Medical Association (CMA); Colorectal Surgery Group, Chinese Society of Surgery, CMA; Colorectal Cancer Professional Committee, Chinese Anti-Cancer Association; Colorectal Cancer Professional Committee, CMDA; Colorectal Cancer Expert Committee, Chinese Society of Clinical Oncology; Colorectal Surgeon Committee, Chinese College of Surgeons, CMDA; Metastasis Research Com (2026). Chinese guidelines for the diagnosis and comprehensive treatment of colorectal liver metastasis (2025 Edition). Clinical Cancer Bulletin, 5(1), Article 10. https://doi.org/10.1007/s44272-026-00062-6

Image Credits: AI Generated

DOI: 10.1007/s44272-026-00062-6

Keywords: colorectal cancer, liver metastases, clinical guidelines, immunotherapy, hepatic surgery, molecular profiling, chemotherapy, multidisciplinary team, precision medicine, radiofrequency ablation, liver transplantation, biomarkers

The scale of the problem the guideline addresses is striking. According to a 2022 systematic review cited in the document, the overall prevalence of pain among cancer patients reaches 44.5 percent, with 30.6 percent experiencing moderate to severe pain. The incidence climbs to roughly 50.3 percent during active treatment, 35.8 percent after effective treatment, and 54.6 percent in advanced, metastatic, or end-stage disease. Under the International Classification of Diseases, 11th Revision, chronic cancer-related pain is formally defined as chronic pain caused by the primary tumor itself or by metastasis, encompassing both chronic cancer pain and chronic post-cancer treatment pain. Because pain profoundly affects physical, psychological, and social functioning, the guideline’s authors argue that its management is an integral component of comprehensive cancer treatment and can even influence survival outcomes.

At the heart of the guideline is the principle of holistic integrative medicine, a philosophy that transforms traditional multidisciplinary team approaches, known as MDT, into a fully integrated care model the authors call MDT-to-HIM. Rather than treating pain as an isolated symptom, this model assembles oncologists, palliative care specialists, pain physicians, surgeons, pharmacists, rehabilitation experts, nutritionists, traditional Chinese medicine practitioners, psychologists, and nurses into a dynamic, patient-centered team. The guideline recommends this collaborative model for patients whose pain is poorly controlled by drug therapy alone, those with intolerable adverse drug reactions, patients with bone metastasis-related pain, and those whose pain coexists with tumor-related complications such as malnutrition, gastrointestinal obstruction, or malignant intracranial hypertension.

Accurate assessment is positioned as the mandatory first step. The guideline prescribes ‘holistic’ and ‘routine, quantitative, and dynamic’ evaluation, recommending the Numerical Rating Scale and the Faces Pain Rating Scale for universal screening, while offering the Behavioral Pain Scale and the Critical Care Pain Observation Tool for patients who cannot self-report, such as those with cognitive impairment or at the end of life. Diagnosis should follow the ICD-11 hierarchical classification, distinguishing nociceptive pain, which affects roughly 59 percent of cancer patients, from neuropathic pain at about 19 percent, and mixed pain at about 20 percent. Nociceptive pain is further divided into somatic and visceral subtypes, each with distinct treatment implications. The guideline also formally defines the concept of a ‘pain crisis’ as new-onset or severe pain arising on a background of stable control, requiring immediate intervention.

Pharmacotherapy remains the backbone of cancer pain management, and the guideline notes that more than 80 percent of patients can achieve good relief through drugs alone. First-line regimens center on opioids, nonsteroidal anti-inflammatory drugs, and adjuvant analgesics such as calcium channel modulators and antidepressants. Notably, the document endorses pharmacogenomic testing, particularly CYP2D6 genotyping, to individualize prodrug therapy like codeine and avoid both poor efficacy and serious adverse reactions. For moderate pain, the guideline suggests that low-dose strong opioids may actually be preferable to weak opioids, given their lower nausea rates, lower cost, and comparable efficacy, though weak opioids carry a well-known ceiling effect. Acetaminophen in combination preparations should not exceed 2 grams daily because of hepatotoxicity risk.

Detailed dosing protocols form a major strength of the document. For opioid-naive patients, titration typically begins with 5 to 15 milligrams of oral morphine or an equivalent short-acting opioid, while opioid-tolerant patients start at 10 to 20 percent of their previous 24-hour total dose. Once stable control is achieved, patients convert to long-acting formulations with a rescue dose of short-acting opioid set at 10 to 20 percent of the daily total for breakthrough pain. Dose increases during maintenance follow pain intensity, ranging from 25 to 50 percent for mild pain up to 75 to 100 percent for severe pain measured on the numerical scale. The guideline also provides granular instructions for opioid rotation, noting that 20 to 44 percent of patients require a switch and that 40 to 80 percent improve analgesia afterward, with methadone conversions demanding reductions of 75 to 90 percent and, ideally, in-hospital supervision.

Safety receives extensive attention. The guideline catalogs management strategies for opioid-induced constipation, nausea and vomiting, pruritus, delirium, urinary retention, sedation, and respiratory depression, including precise naloxone dosing of 1 to 2 milliliters of a 0.4 milligram per 10 milliliter solution when respiratory rates fall below 8 breaths per minute. It also confronts the growing challenge of opioid misuse: prevalence estimates among long-term users range from 21 to 29 percent, and 8 to 12 percent of cancer patients on long-term opioids develop opioid use disorder. The document recommends validated screening tools such as the SOAPP-R and Opioid Risk Tool before initiating therapy, real-time monitoring with the Current Opioid Misuse Measure during treatment, urine drug testing, and prescription drug monitoring programs as pillars of risk mitigation.

When drugs fall short, the guideline opens the door to an arsenal of minimally invasive techniques that can be deployed before, during, or after standard three-step drug therapy. Patient-controlled analgesia via intravenous or subcutaneous routes offers rapid, individualized titration and can even be managed safely at home. Nerve blocks and neurolysis, particularly celiac plexus neurolysis with 75 to 100 percent ethanol, provide durable relief for refractory visceral pain. Percutaneous vertebroplasty stabilizes painful vertebral metastases, while spinal cord and peripheral nerve stimulation offer reversible neuromodulation for stable-tumor neuropathic pain. Perhaps most remarkable is intrathecal drug delivery, in which morphine infused directly into the cerebrospinal fluid is roughly 100 times more potent than the intravenous route and 300 times more potent than oral administration, dramatically reducing systemic doses and their side effects.

The guideline also integrates palliative antitumor therapies as analgesic tools, noting that a single 8-gray dose of radiotherapy relieves bone metastasis pain in about 40 percent of patients, while microwave and radiofrequency ablation can inactivate tumor tissue and reduce pain indirectly. Adjunctive approaches including traditional Chinese medicine, physical therapy, and structured psychological support such as mindfulness-based cognitive therapy and pain neuroscience education round out the multimodal framework. Ultimately, the authors identify the chief barriers to better care as outdated clinical concepts, restricted opioid access, nonstandard treatment, and weak multidisciplinary collaboration, and they express confidence that disseminating this guideline will extend both the quality of life and the survival of patients with cancer pain across China and beyond.

Subject of Research: Clinical practice guideline for the multidisciplinary management of adult cancer pain developed by the China Anti-Cancer Association

Article Title: CACA guidelines for the management of adult cancer pain

Article References: Jin, Y., Zhang, J., Suo, J., Yu, H., Song, L., Chen, F., Cheng, W., Cui, W., Fan, B., Feng, Z., Gong, L., Gu, N., Guo, L., Jia, Y., Li, S., Lin, F., Lin, R., Liu, B., Lu, G., … Xie, G. (2026). CACA guidelines for the management of adult cancer pain. Holistic Integrative Oncology, 5(1), Article 66. https://doi.org/10.1007/s44178-026-00286-5

Image Credits: AI Generated

DOI: 10.1007/s44178-026-00286-5

Keywords: cancer pain, CACA guideline, opioid therapy, palliative care, intrathecal drug delivery, multidisciplinary team, holistic integrative medicine, breakthrough pain, bone metastasis, neuropathic pain, opioid rotation, patient-controlled analgesia