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When we first envisioned The MD Anderson Manual of Medical Oncology, we hoped it would fill an important void in oncology reference material by serving as a hands-on resource for the practicing oncologist. The first edition, published in 2006, was written exclusively by our faculty and fellows with the idea of giving a bird's eye view of how multidisciplinary care was practiced at our institution. We were proud of that initial effort and pleased that the book received very positive reviews from several high-impact journals, including the JAMA, Lancet, and the New England Journal of Medicine. In addition, feedback from our broad multinational readership inspired us to move forward with an enhanced second edition.

In the second edition, we have remained faithful to the guiding principles of our first effort, providing a visually stimulating, practice-oriented reference which articulates our unique multidisciplinary approach to cancer care. We have also continued the tradition of including evidence-based management algorithms in the form of flowcharts and diagrams shaped by the clinical experience of our world-class faculty to provide readers with a practical guide to the diagnostic and therapeutic strategies used at MD Anderson.

Importantly, our new version is not merely an update of the first, but contains new chapters on myelodysplastic syndrome, myeloproliferative neoplasms, T-cell lymphomas, small bowel and appendiceal cancers, inflammatory breast cancer, and penile cancer. In addition, some chapters now provide embedded comments sharing the perspective of other experts at MD Anderson, including our colleagues in surgical oncology, radiotherapy, pulmonology, and pathology. Also in this edition, we have asked our authors to discuss future directions with special emphasis on personalized cancer care.

We hope this edition serves to help oncologists everywhere provide high-quality, state-of-the-art cancer care to their patients, who deserve nothing less.

Hagop M. Kantarjian, MD
Robert A. Wolff, MD
Charles A. Koller, MD

Foreword

The MD Anderson Manual of Medical Oncology, Second Edition articulates the personalized, multidisciplinary approach to cancer management pioneered by The University of Texas MD Anderson Cancer Center. This approach has contributed to our ranking as number one in cancer care in 8 of the past 10 years in the U.S. News & World Report's "America's Best Hospitals" survey. Our unique perspective has evolved from decades of clinical practice and research with more than 800,000 patients treated. This volume is designed to bring a pragmatic approach to cancer management that may serve as a guide for oncologists around the world. The text reflects how MD Anderson currently operates, including many patient care practices that would not have been recognized by practitioners just a decade ago. In a single year, 96,500 people with cancer—33,200 of them new patients—seek care at MD Anderson. Many of them participate in the largest clinical research program in the nation exploring novel therapies as well as our personalized approach to treatment evident in the nearly 12,000 patients enrolled in therapeutic clinical trials. Since the first edition, we have improved our ability to identify biomarkers that are predictive for survival, a major triumph in medical oncology that is demonstrated throughout the text.

The current edition emphasizes and discusses recent developments in diagnostic procedures, which include the incorporation of new molecular markers and revised staging systems. This edition also emphasizes how imaging and molecular profiling can prevent administration of overly aggressive, toxic treatment regimens, or invasive surgery to treat superficial or indolent tumors.

Two major advances in therapeutic approaches over the past decades are emphasized in The MD Anderson Manual of Medical Oncology, Second Edition: (1) better timing of therapeutic modalities to enhance response and (2) a growing capacity to individualize treatment to target-specific patterns of genomics, proteomics, growth factors, and cell signaling pathways identifiable today through high-throughput microarray and other advanced technologies. Most chapters offer a thorough review of relevant signaling pathways as well as major clinical studies of potential therapeutic agents that target components of these pathways.

The Manual emphasizes new therapies that have emerged from progress in our understanding of the biology of various cancers. As the genetic and epigenetic events driving carcinogenesis, invasion, metastasis, and the interaction of the tumor cells with host's microenvironment are elucidated, the development and testing of targeted molecules have mushroomed, resulting in a wider selection of therapeutic drug combinations. Discussion of new therapeutic agents used alone or in combination with preexisting therapies is expanded in the new edition. Case examples illustrate successful treatment strategies throughout the text, often using a personalized approach to selecting appropriate targeted therapies.

Reflecting new advances in our approach to cancer management, the second edition of The MD Anderson Manual of Medical Oncology features several new chapters. For example, special chapters on myelodysplastic syndromes and Philadelphia chromosome-myeloproliferative neoplasms have been added to be based on the 2008 changes in the WHO classification of these disorders as neoplasms, as well as significant new advances in their diagnosis, risk assessment, and management. In the new edition, aggressive B-cell and peripheral T-cell lymphomas now warrant separate focused chapters to enable greater attention to novel treatment strategies for T-cell lymphomas. Likewise, pancreatic cancer and hepatobiliary malignancies are now covered separately to devote more attention to promising novel strategies that have the potential to improve the prognosis for pancreatic cancer. A new chapter on neoplasms of the small bowel and appendix has also been added. Inflammatory breast cancer, previously mentioned briefly alongside locally advanced breast cancers, now has its own expanded chapter. In addition, this edition now contains a chapter on penile cancer.

Also new to the second edition are special commentaries invited from other subspecialists from fields such as pulmonary medicine, radiation oncology, and surgery to discuss other perspectives on management:

• A radiation oncologist discusses new strategies to reduce the long-term toxic effects of treatment of the Hodgkin lymphoma such as the risk of future secondary cancers.
• A new, minimally invasive technology for tissue sampling is recommended to improve the diagnostic accuracy of mediastinal lymph node staging in non–small cell lung cancer.
• Surgical perspectives are added to the chapter on appendiceal carcinoma, including how the surgical plan is individualized for patients whose cancer treatment began outside of MD Anderson.
• A pathologist contributes discussion of immunohistochemical markers shared by all neuroendocrine carcinomas regardless of their anatomic location.
• A special discussion of surgical options after neoadjuvant chemotherapy is embedded within the chapter on early-stage and locally advanced breast cancer.
• A research scientist adds his assessment of how a personalized medicine approach to the management of urothelial cancers would dramatically improve patient outcomes.
• Two commentaries on the role of radiation therapy and surgical management of brain tumors are introduced in the chapter on tumors of the central nervous system.
• A microbiologist comments on specific adaptations, laboratories need to make to provide adequate microbiological diagnosis of mold and viral infections in cancer patients.
• A surgeon adds his perspective on how he integrated referral to palliative care services into management of his patient with pancreatic cancer.

While the Manual discusses special considerations in the treatment of populations such as the elderly and those with comorbidities, the book stresses the many ways that recent progress in reducing treatment-associated toxicity has made advanced age less of a contraindication to many effective therapeutic regimens. Morbidity associated with surgery and radiation therapy has greatly decreased over the past decade, and many of the new, targeted oral agents have little or no toxicity.

To help clinicians quickly assess cancer management options, every chapter includes abundant tables, diagrams, and imaging photos. These include, for example, treatment algorithms and decision trees developed at MD Anderson for specific cancers or disease subtypes; promising novel therapy targets and the latest clinical trial phase of drugs targeting them; and new molecular therapies recommended to overcome resistance to previously effective therapies.

The new era of novel personalized, targeted therapeutics has also sparked the recent evolution of another crucial advancement in management of metastatic disease: the transition from sequential care culminating in the sole delivery of palliative care, to integration of ongoing active disease treatment with simultaneous interdisciplinary symptom control, palliative care, and rehabilitation to improve quality of life. Clinicians at MD Anderson no longer approach advanced metastatic disease management with palliative care goals alone; now these patients are often offered frontline cancer treatment and the opportunity to participate in clinical trials for investigational drugs. The chapter on defining palliative care in oncology starts with a traditional case vignette of a patient with metastatic pancreatic cancer who did not receive palliative care until he/she had discontinued chemotherapy, then explains the various ways in which integration of palliative and symptom care earlier in the treatment could have benefited him/her and his/her family.

In recognition of the growing pool of patients who are surviving their cancer, MD Anderson has greatly expanded programs for cancer survivors since publication of the first edition. Chapters on long-term survival and follow-up demonstrate the additional utility of this book for clinicians outside the specialty of oncology, as a high proportion of the growing number of cancer survivors will be followed by a primary care physician, cardiologist, or other specialist in their home community. The text's description of the results from MD Anderson's survey of cancer survivors serves as an essential guide to typical long-term health problems both physicians and rehabilitation specialists can expect to manage.

Over the past decade, the practice of medical oncology at MD Anderson has truly evolved to epitomize the translational research concept of "bench to bedside and back," along with an increasingly personalized approach that considers the "molecular fingerprint" of the patient's cancer in treatment decisions—a paradigm shift that this volume pertinently exhibits.

Waun Ki Hong, MD
American Cancer Society Professor
Samsung Distinguished University Chair in Cancer Medicine
Division Head, Cancer Medicine
Professor, Thoracic/Head and Neck Medical Oncology
The University of Texas MD Anderson Cancer Center
Houston, Texas
May 2011

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