Curr. Oncol., Volume 24, Issue 5 (October 2017) – 23 articles

Prostate cancer frequently metastasizes to bone, but bone marrow involvement is relatively less common. In advanced prostate cancer, significant bone marrow infiltration can result in hematologic abnormalities such as anemia and thrombocytopenia. We report the case of a patient who presented with a new diagnosis of thrombocytopenia at the same time that he presented with prostate cancer metastatic to bone. He was found to have immune thrombocytopenia (ITP) which responded to treatment with steroids. We discuss this case and review the literature on ITP in the setting of advanced malignancy. Full article

A 49-year-old woman presents with an extensive violaceous rash, rapidly progressive proximal muscle weakness, and dysphagia to solids, consistent with a diagnosis of dermatomyositis. Two weeks later, she palpates a mass in her left breast and is diagnosed with her2-positive metastatic invasive ductal carcinoma of the breast. There is a well-established association between dermatomyositis and malignancy. However, the specific association between breast cancer and dermatomyositis has not been well characterized. No guideline for oncologists managing these patients has been established. Recently, 3 cases of breast cancer and dermatomyositis were diagnosed at our institution. A review of the literature was pursued to characterize the association between breast cancer and dermatomyositis. A review of 178 papers identified 22 cases of breast cancer with dermatomyositis. Most patients (71%) presented with stage iii or iv breast cancer. The median time between the diagnosis of breast cancer and the onset of dermatomyositis symptoms was 1 month. Three quarters of the patients were steroid-responsive and able to taper. Half the women with follow-up data experienced a documented cancer relapse associated with a new flare of cutaneous symptoms. The presence of dermatomyositis appears to be associated with more-advanced breast cancer stage and is most commonly associated with invasive ductal carcinoma. In our review, treatment of cancer alone is insufficient to adequately control the cutaneous and myopathic manifestations of dermatomyositis, which can significantly affect quality of life. A multidisciplinary approach, including close collaboration with rheumatologists and dermatologists, is therefore important in the diagnosis and management of oncology patients with dermatomyositis. Full article

Tuberous sclerosis complex (TSC), a phacomatosis, is a rare genetic disease (autosomal dominant; incidence: 1 in 6,800–17,300) associated with mutations in the TSC1 and TSC2 genes, 70% of which are sporadic. The disease causes benign tumours in the brain, kidneys, heart, lungs, skin, and eyes; thyroid lesions are extremely rare. A 13-year-old euthyroid boy with a hereditary form of TSC (del 4730G in TSC2, also seen in 2 sisters and the father) was admitted to hospital with a thyroid nodule. Physical examination revealed a nodular left lobe with increased consistency. Thyroid ultrasonography revealed a heterogeneous left lobe, predominantly hypoechoic with multiple microcalcifications and the presence of suspicious cervical lymph nodes on the left side. A macrocalcification was observed on the right lobe. Fine-needle biopsy results showed a few groups of cells with discrete atypical characteristics, including abundant cytoplasm, nuclei with conspicuous nucleoli, intra-nuclear inclusions, and nuclear grooves. The patient underwent total thyroidectomy with lymphadenectomy. Histopathology examination confirmed papillary thyroid carcinoma. The coincidence of endocrine neoplasia including thyroid cancer and TSC is rare, and TSC with papillary thyroid carcinoma has never been described in a child. Studies of mutations in the tumour suppressor genes TSC1, TSC2, and STK11, activating the mtor (mammalian target of rapamycin) pathway, might support their role in the pathogenesis of thyroid cancer. Full article

Background: This clinical practice guideline was developed to determine the level of evidence supporting the clinical utility of commercially available multigene profiling assays and to provide guidance about whether certain breast cancer patient populations in Ontario would benefit from alternative tests in addition to Oncotype DX (Genomic Health, Redwood City, CA, U.S.A.). Methods: A systematic electronic Ovid search of the MEDLINE and EMBASE databases sought out systematic reviews and primary literature. A systematic review and practice guideline was written by a working group and was then reviewed and approved by Cancer Care Ontario’s Molecular Oncology Advisory Committee. Results: Twenty-four studies assessing the clinical utility of Oncotype DX, Prosigna (NanoString Technologies, Seattle, WA, U.S.A.), EndoPredict (Myriad Genetics, Salt Lake City, U.S.A.), and MammaPrint (Agendia, Irvine, CA, U.S.A.) were included in the evidence base. Conclusions: The clinical utility of multigene profiling assays is currently established for an appropriate subset of patients with estrogen receptor–positive, HER2-negative, node-negative breast cancer for whom a decision to give chemotherapy is difficult to make. For patients with estrogen receptor–positive tumours who receive tamoxifen alone, Oncotype DX, Prosigna, and EndoPredict validly identify a low-risk population with favourable outcomes, indicating that a low-risk assay result is actionable and the decision to withhold chemotherapy is supported. Clinical evidence indicates that a high Oncotype DX recurrence score can predict for chemotherapy benefit, but a high Prosigna or EndoPredict score, although prognostic, is not, based on clinical trial evidence, directly actionable. Prosigna and EndoPredict are statistically more likely to identify a population at risk for recurrence beyond 5 years, but that information is currently not actionable because of a lack of interventional studies. Full article

Background: Oncoplastic breast surgery combines traditional oncologic breast conservation with plastic surgery techniques to achieve improved aesthetic and quality-of-life outcomes without sacrificing oncologic safety. Clinical uptake and training remain limited in the Canadian surgical system. In the present article, we detail the current state of oncoplastic surgery (OPS) training in Canada, the United States, and worldwide, as well as the experience of a Canadian clinical fellow in OPS. Methods: The clinical fellow undertook a 9-month audit of breast surgical cases. All cases performed during the fellow’s OPS fellowship were included. The fellowship ran from October 2015 to June 2016. Results: During the 9 months of the fellowship, 67 mastectomies were completed (30 simple, 17 modified radical, 12 skin-sparing, and 8 nipple-sparing). The fellow participated in 13 breast reconstructions. Of 126 lumpectomies completed, 79 incorporated oncoplastic techniques. Conclusions: The experience of the most recent OPS clinical fellow suggests that Canadian OPS training is feasible and achievable. Commentary on the current state of Canadian OPS training suggests areas for improvement. Oncoplastic surgery is an important skill for breast surgical oncologists, and access to training should be improved for Canadian surgeons. Full article

Background: In 2009, a Rapid Access Breast Clinic (RABC) was opened at our urban hospital. Compared with the traditional system (TS), the navigated care through the clinic was associated with a significantly shorter time to surgical consultation. Since 2009, many radiology facilities have introduced facilitated-care pathways for patients with breast pathology. Our objective was to determine if that change in diagnostic imaging pathways had eliminated the advantage in time to care previously shown for the RABC. Methods: All patients seen in the RABC and the office-based TS in November–December 2012 were included in the analysis. A retrospective chart review tabulated demographic, surgeon, pathology, and radiologic data, including time intervals to care for all patients. The results were compared with data from 2009. Results: In 2012, time from presentation to surgical consultation was less for the RABC group than for the TS group (36 days vs. 73 days, p < 0.001) for both malignant (31 days vs. 55 days, p = 0.008) and benign diagnoses (43 days vs. 79 days, p < 0.001). Comparing the 2012 results with results from 2009, a decline in mean wait time was observed for the TS group (86 days vs. 73 days, p = 0.02). Compared with patients having investigations in the TS, RABC patients with cancer were more likely to undergo surgery within 60 days of presentation (33% vs. 15%, p = 0.04). Conclusions: The coordination of radiology and clinical care reduces wait times for diagnosis and surgery in breast cancer. To achieve recommended targets, we recommend implementation of more systematic coordination of care for a breast cancer diagnosis and of navigation to surgeons for patients needing surgical care. Full article

Background: The efficacy of carboplatin–paclitaxel in the trimodality setting was demonstrated in the cross trial. Because of better tolerance, that regimen has been adopted as an alternative for patients receiving definitive chemoradiation (dCRT). The purpose of our study was to compare outcomes in patients with localized esophageal and gastroesophageal junction (GEJ) cancer who received dCRT using either platinum–5-fluorouracil (5FU) or carboplatin–paclitaxel. Methods: Medical records and outcomes for all patients diagnosed with localized carcinoma of the esophagus and GEJ at our centre between 2008 and 2015 were reviewed. All patients who underwent dCRT using cisplatin–5FU, carboplatin–5FU, or carboplatin–paclitaxel were included. Results: The 73 identified patients (34 cisplatin–5FU, 13 carboplatin–5FU, 26 carboplatin–paclitaxel) were all prescribed concomitant radiotherapy of 50 Gy in 25 daily fractions. The diagnosis was adenocarcinoma in 64% and squamous cell carcinoma in 36%. Median overall survival (OS) duration for the cisplatin–5FU group was 28 months [95% confidence interval (CI): 19 to 41 months], with a 3-year OS rate of 44%, in contrast to the 15 months (95% CI: 11 to 17 months) and 15% in the carboplatin–paclitaxel group (log-rank p = 0.0047). Median OS duration for the carboplatin–5FU group was 17 months (95% CI: 11 to 68 months) with a 3-year OS rate of 31%. Adjusting for patient and disease factors, better OS durations and rates were associated with cisplatin–5FU (hazard ratio: 0.34; p = 0.0016) and carboplatin–5FU (hazard ratio: 0.55; p = 0.20) than with carboplatin–paclitaxel. Conclusions: In a dCRT regimen, a better OS is associated with cisplatin–5FU than with carboplatin–paclitaxel. Clinical trials to determine optimal chemotherapy regimens are warranted for patients who are not suitable for surgery. Full article

Objective: We estimated the frequency of occult gynecologic primary tumours (GPTS) in patients with metastatic cancer from an uncertain primary and evaluated the effect on disease management and overall survival (OS). Methods: We used Manitoba administrative health databases to identify all patients initially diagnosed with metastatic cancer during 2002–2011. We defined patients as having an “occult” primary tumour if the primary was classified at least 6 months after the initial diagnosis. Otherwise, we considered patients to have “obvious” primaries. We then compared clinicopathologic and treatment characteristics and 2-year OS for women with occult and with obvious GPTS. We used Cox regression adjustment and propensity score methods to assess the effect on OS of having an occult GPT. Results: Among the 5953 patients diagnosed with metastatic cancer, occult primary tumours were more common in women (n = 285 of 2552, 11.2%) than in men (n = 244 of 3401, 7.2%). In women, GPTS were the most frequent occult primary tumours (n = 55 of 285, 19.3%). Compared with their counterparts having obvious GPTS, women with occult GPTS (n = 55) presented with similar histologic and metastatic patterns but received fewer gynecologic diagnostic examinations during diagnostic work-up. Women with occult GPTS were less likely to undergo surgery, waited longer for radiotherapy, and received a lesser variety of chemotherapeutic agents. Having an occult compared with an obvious gpt was associated with decreased OS (hazard ratio: 1.62; 95% confidence interval: 1.2 to 2.35). Similar results were observed in adjusted analyses. Conclusions: In women with metastatic cancer from an uncertain primary, GPTS constitute the largest clinical entity. Accurate diagnosis of occult GPTS early in the course of metastatic cancer might lead to more effective treatment decisions and improved survival outcomes. Full article

Purpose: We assessed response to treatment, toxicity, time to progression, progression-free survival, and overall survival in patients newly diagnosed with multiple myeloma who were ineligible for or unwilling to undergo transplantation and who were treated with a combination of lenalidomide and low-dose dexamethasone for a fixed 6 cycles in a resource-constrained environment. Methods: This pragmatic study, conducted in a single tertiary cancer centre in South India, enrolled patients from May 2009 till April 2011. Treatment included lenalidomide 25 mg daily for 21 days, with dexamethasone 40 mg on days 1, 8, 15, and 22 of a 28-day cycle, for 6 cycles. Response was evaluated after the 3rd and 6th cycles of treatment. All patients were followed for 5 years. Results: The study enrolled 51 patients. Median age in the group was 61 years (range: 38–76 years). Immunoglobulin G or A myeloma constituted 70.6% of the diagnoses, and light-chain myeloma constituted 29.4%. Stages I, II, and III (International Staging System) disease constituted 21.4%, 28.6%, and 50% of the diagnoses respectively. All patients were transplantation-eligible, but 34 (66.7%) refused for economic reasons. After treatment, 19.6% of the patients achieved a stringent complete response; 35.3%, a complete response; 5.9%, a very good partial response; and 29.4%, a partial response, for an overall response rate of 90.2%. Stable disease was seen in 3.9% of patients, and progressive disease, in 5.9%. Grade 3 or greater nonhematologic and hematologic toxicity occurred in 35.2% and 11.7% of patients respectively. Pulmonary embolism occurred in 1 patient. No patient experienced deep-vein thrombosis or peripheral neuropathy. The median follow-up duration was 66 months. All patients experienced disease progression. Median progression-free survival was 16 months. In 10 patients, re-challenge with lenalidomide and dexamethasone achieved a second complete response. At the time of writing, 19 patients had died. The overall survival rate at 5 years was 62.74%. Median overall survival is not yet reached. Conclusions: In a resource-constrained setting, lenalidomide with low-dose dexamethasone is an effective treatment with acceptable toxicity in patients newly diagnosed with multiple myeloma and not planned for transplantation. Complete responses were significantly more frequent than reported in the Western literature. Occurrence of clinical deep-vein thrombosis was rare, but hyperglycemia was common. An abbreviated course of treatment is suboptimal in multiple myeloma. Maintenance regimens should be advocated. Full article

Objectives: Diagnostic assessment programs (DAPS) appear to improve the diagnosis of cancer, but evidence of their cost-effectiveness is lacking. Given that no earlier study used secondary financial data to estimate the cost of diagnostic tests in the province of Ontario, we explored how to use secondary financial data to retrieve the cost of key diagnostic test services in DAPS, and we tested the reliability of that cost-retrieving method with hospital-reported costs in preparation for future cost-effectiveness studies. Methods: We powered our sample at an alpha of 0.05, a power of 80%, and a margin of error of ±5%, and randomly selected a sample of eligible patients referred to a dap for suspected breast cancer during 1 January–31 December 2012. Confirmatory diagnostic tests received by each patient were identified in medical records. Canadian Classification of Health Intervention procedure codes were used to search the secondary financial data Web portal at the Ontario Case Costing Initiative for an estimate of the direct, indirect, and total costs of each test. The hospital-reported cost of each test received was obtained from the host-hospital’s finance department. Descriptive statistics were used to calculate the cost of individual or group confirmatory diagnostic tests, and the Wilcoxon signed-rank test or the paired t-test was used to compare the Ontario Case Costing Initiative and hospital-reported costs. Results: For the 191 identified patients with suspected breast cancer, the estimated total cost of $72,195.50 was not significantly different from the hospital-reported total cost of $72,035.52 (p = 0.24). Costs differed significantly when multiple tests to confirm the diagnosis were completed during one patient visit and when confirmatory tests reported in hospital data and in medical records were discrepant. The additional estimated cost for non-salaried physicians delivering diagnostic services was $28,387.50. Conclusions: It was feasible to use secondary financial data to retrieve the cost of key diagnostic tests in a breast cancer dap and to compare the reliability of the costs obtained by that estimation method with hospital-reported costs. We identified the strengths and challenges of each approach. Lessons learned from this study have to be taken into consideration in future cost-effectiveness studies. Full article

Introduction: Patients with breast cancer (BCa) who overexpress HER2 (the human epidermal growth factor receptor 2) are at risk for cardiotoxicity when treated with anthracycline-based chemotherapy and HER2-targeted agents. The Framingham risk score (FRS) is a validated tool that stratifies patients into high-, intermediate-, or low-risk groups and calculates their 10-year risk of developing cardiovascular disease (CVD) based on past medical history, systolic blood pressure, and measurement of serum lipids. We retrospectively analyzed patients with HER2-positive BCa to determine whether the FRS predicts adverse cardiovascular (CV) events or cardiotoxicity in patients treated using anthracyclines or HER2-targeted therapy, or both. Methods: The FRS was determined for patients with BCa referred to The Ottawa Hospital Cardiology–Oncology Clinic from October 2008 to August 2014. The patients were stratified into high (≥20%), intermediate (10%–20%), and low (<10%) 10-year CV risk groups. Primary outcomes included CVD-related hospitalizations and deaths, and cardiotoxicity [drop in left ventricular ejection fraction (LVEF) of >10% to a LVEF ≤50%]. Results: Of the 152 patients included in the analysis (median follow-up: 40.7 months; range: 3.5–263 months), 47 (31%) were classified as high risk; 36 (24%), as intermediate risk; and 69 (45%), as low-risk. The number of CVD-related hospitalizations and deaths was 22, for an overall prevalence of 14%, with significantly more events occurring in high-risk than in low-risk patients (odds ratio: 4.18; 95% confidence limits: 1.47, 11.89). The FRS predicted a 10-year risk of any cv event of 11.2% and underestimated the actual rate of cv events in the entire cohort. High FRS was not associated with cardiotoxicity (p = 0.82). Conclusions: In a population of patients with HER2-positive BCa referred to a cardiology–oncology clinic, the FRS does not accurately predict the risk of cv events or cardiotoxicity. Full article

Background: “Conditional survival probability” is defined as the probability that a patient will survive an additional time, given that the patient has already survived a defined period of time after diagnosis. Such estimates might be more relevant for clinicians and patients during post-diagnosis care, because survival probability projections are based on the patient’s survival to date. Here, we provides the first population-based estimates of conditional survival probabilities by histology for brain cancer in Canada. Methods: Canadian Cancer Registry data were accessed for patients diagnosed with primary brain cancers during 2000–2008. Kaplan–Meier survival probabilities were estimated by histology. Conditional survival probabilities at 6 months (short-term, denoted SCS) and 2 years (long-term, denoted LCS) were derived from the Kaplan–Meier survival estimates for a range of time periods. Results: Among the 20,875 patients who met the study criteria, SCS increased by a margin of 16–18 percentage points from 6-month survivors to 2-year survivors for the three most aggressive brain cancers. The LCS for 2-year survivors was 66% or greater for all tumour groups except glioblastoma. The LCS for 4-year survivors was 62% or greater for all histologies. For glioblastoma and diffuse astrocytoma, the LCS increased each year after diagnosis. For all other histologies, the LCS first increased and then plateaued from 2 years after diagnosis. The LCS and SCS both worsened with increasing older age at diagnosis. Summary: We report histologically specific conditional survival probabilities that can have value for clinicians practicing in Canada as they plan the course of follow-up for individual patients with brain cancer. Full article

Background: Communication with health care providers during diagnosis and treatment planning is of special importance because it can influence a patient’s emotional state, attitude, and decisions about their care. Qualitative evidence suggests that some patients experience poor communication with health care providers and have negative experiences when receiving their cancer diagnosis. Here, we use survey data from 8 provinces to present findings about the experiences of Canadian patients, specifically with respect to patient–provider communication, during the diagnosis and treatment planning phases of their cancer care. Methods: Data from the Ambulatory Oncology Patient Satisfaction Survey, representing 17,809 survey respondents, were obtained for the study. Most respondents (92%) felt that their care provider told them of their cancer diagnosis in a sensitive manner. Results: Most respondents (95%) also felt that they were provided with enough information about their planned cancer treatment. In contrast, more than half the respondents who had emotional concerns upon diagnosis (56%) were not referred to services that could help with their anxieties and fears. Also, 18% of respondents reported that they were not given the opportunity to discuss treatment options with a care provider, and 17% reported that their care providers did not consider their travel concerns while planning for treatment. Conclusions: Measuring the patient experience allows for an understanding of how well the cancer control system is addressing the physical, emotional, and practical needs of patients during diagnosis and treatment planning. Although results suggest high levels of patient satisfaction with some aspects of care, quality improvement efforts are still needed to provide person-centred care. Full article

Background: Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level, including staging, extent of lymphadenectomy (LND), minimum number of lymph nodes that have to be assessed, gross resection margins, use of minimally invasive surgery, and relationship of surgical volumes with patient outcomes and resection in stage IV gastric cancer. Methods: Literature searches were conducted in databases including MEDLINE (up to 10 June 2016), EMBASE (up to week 24 of 2016), the Cochrane Library and various other practice guideline sites and guideline developer Web sites. A practice guideline was developed. Results: One guideline, seven systematic reviews, and forty-eight primary studies were included in the evidence base for this guidance document. Seven recommendations are presented. Conclusions: All patients should be discussed at a multidisciplinary team meeting, and computed tomography (CT) imaging of chest and abdomen should always be performed when staging patients. Diagnostic laparoscopy is useful in the determination of M1 disease not visible on ct images. A D2 LND is preferred for curative-intent resection of gastric cancer. At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an R0 resection margin. In the metastatic setting, surgery should be considered only for palliation of symptoms. Patients should be referred to higher-volume centres and those that have adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as those for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management. Full article

Background: Radiotherapy (RT) has been the standard treatment for early oropharyngeal cancer, achieving excellent outcomes, but with significant toxicities. Transoral robotic surgery (TORS) has emerged as a promising alternative. A decision aid (DA) can help to establish patient treatment preferences. Methods: A DA was developed and piloted in 40 healthy adult volunteers. Assuming equal oncologic outcomes of the treatments, participants indicated their preference. The treatment trade-off point was then established, and participant perceptions were elicited. Results: More than 80% of participants initially selected TORS for treatment, regardless of facilitator background. For all participants, the treatment trade-off point changed after an average 15% cure benefit. Treatment toxicities, duration, novelty, and perceptions all influenced treatment selection. All subjects valued the DA. Conclusions: A DA developed for early oropharyngeal cancer treatment holds promise in the era of shared decision-making. Assuming equal cure rates, TORS was preferred over RT by healthy volunteers. Full article

Background: The use of neoadjuvant systemic therapy (nast) in the treatment of breast cancer is increasing, and the role of adjuvant radiation therapy (rt) in that setting is uncertain. We sought to review and report the use of nast, its trends over time, and its relationship with the prescribing patterns of locoregional rt in a provincial cancer system. Methods: Patients with stages i–iii breast cancer diagnosed during 2007–2012 were identified using a provincial database. Patient, tumour, and treatment characteristics were extracted. Multivariable logistic regression analyses were used to assess associations with the use of nast. Kaplan–Meier and Cox regression were used for survival analyses. Results: Of the 11,658 patients who met the inclusion criteria, 602 (5%) had received nast. Use of nast was more frequent in stage iii patients (53%) than in stages i and ii patients (2%). In clinically lymph-node positive patients, a pathology assessment was made approximately 50% of the time. Higher clinical tumour stage and increasing clinical nodal stage predicted for increasing use of nast and of nodal rt after nast, but pathologic nodal status after nast was not associated with use of nodal rt. A statistically significant survival difference was observed between patients in the nast and no-nast groups, but that significance disappeared in a multivariable Cox regression analysis. Conclusions: This population-based study demonstrated 5% use of nast for breast cancer. Most patients received nodal rt after nast, and nodal rt was not associated with pathologic stage after nast. Findings likely reflect the realities of clinical practice and show that reliance on clinical nodal staging results in outcomes similar to those reported in the literature. Full article

Background: Lung cancer continues to be one of the most common cancers in Canada, with approximately 28,400 new cases diagnosed each year. Although timely care can contribute substantially to quality of life for patients, it remains unclear whether it also improves patient outcomes. In this work, we used a set of quality indicators that aim to describe the quality of care in lung cancer patients. We assessed adherence with existing guidelines for timeliness of lung cancer care and concordance with existing standards of treatment, and we examined the association between timeliness of care and lung cancer survival. Methods: Patients with lung cancer diagnosed between 2010 and 2015 were identified from the Pulmonary Division Lung Cancer Registry at our centre. Results: We demonstrated that the interdisciplinary pulmonary oncology service successfully treated most of its patients within the recommended wait times. However, there is still work to be done to decrease variation in wait time. Our results demonstrate a significant association between wait time and survival, supporting the need for clinicians to optimize the patient care trajectory. Interpretation: It would be helpful for Canadian clinicians treating patients with lung cancer to have wait time guidelines for all treatment modalities, together with standard definitions for all time intervals. Any reductions in wait times should be balanced against the need for thorough investigation before initiating treatment. We believe that our unique model of care leads to an acceleration of diagnostic steps. Avoiding any delay associated with referral to a medical oncologist for treatment could be an acceptable strategy with respect to reducing wait time. Full article

Background: The pan-Canadian Oncology Drug Review (pcodr) was implemented in 2011 to address uneven drug coverage and lack of transparency with respect to the various provincial cancer drug review processes in Canada. We evaluated the impact of the pcodr on provincial decision concordance and time from Notice of Compliance (noc) to drug funding. Methods: In a retrospective review, Health Canada’s Drug Product Database was used to identify new indications for cancer drugs between January 2003 and May 2014, and provincial formulary listings for drug-funding dates and decisions between 1 January 2003 and 31 December 2014 were retrieved. Multiple linear models and quantile regressions were used to evaluate changes in time to decision-making before and after the implementation of the pcodr. Agreement of decisions between provinces was evaluated using kappa statistics. Results: Data were available from 9 provinces (all Canadian provinces except Quebec), identifying 88 indications that represented 51 unique cancer drugs. Two provinces lacked available data for all 88 indications at the time of data collection. Interprovincial concordance in drug funding decisions significantly increased after the pcodr’s implementation (Brennan-Prediger coefficient: 0.54 pre-pcodr vs. 0.78 post-pcodr; p = 0.002). Nationwide, the median number of days from Health Canada’s noc date to the date of funding significantly declined (to 393 days from 522 days, p < 0.001). Exploratory analyses excluding provinces with incomplete data did not change the results. Conclusions: After the implementation of the pcodr, greater concordance in cancer drug funding decisions between provinces and decreased time to funding decisions were observed. Full article

Purpose: In this study, we examined the effects of a 30-week community-based exercise program on cancer-related fatigue, quality of life, and other health-related outcomes in a sample of adults with mixed cancer diagnoses. Methods: This prospective cohort study looked at outcomes for participants involved in the Wellspring Cancer Exercise Program in southern Ontario. The program consisted of an initial phase of two supervised sessions weekly for 10 weeks and a transition phase of one supervised session weekly for the subsequent 20 weeks. Outcomes were measured at baseline and every 10 weeks throughout the intervention, as well as at 16 weeks after program completion. Results: During a period of 13 months, 229 of the 355 cancer survivors who enrolled in the exercise program consented to participate in the study. Participants attended 71% of the supervised exercise sessions in the initial phase and 49% in the transition phase. From baseline to the end of the initial phase, significant improvements in cancer-related fatigue, 6-minute walk test, social well-being, systolic blood pressure, balance, and physical activity volume were observed. During the transition phase, health-related quality of life and emotional well-being improved significantly. Conclusions: The Wellspring Cancer Exercise Program is associated with clinically meaningful improvements in cancer-related fatigue and functional aerobic capacity. Several other aspects of well-being in cancer survivors also improved for participants in the program. Community-based cancer exercise programs such as the Wellspring Cancer Exercise Program can improve well-being for cancer survivors and can provide an effective option that enhances sustainability and accessibility to exercise services for this population. Full article