Curr. Oncol., Volume 25, Issue 1 (February 2018) – 29 articles

Merkel cell carcinoma (MCC) is an uncommon malignancy of the skin arising from cells located in the deeper layers of the epidermis called Merkel cells. This malignancy rarely presents as a metastatic disease, and the field is therefore deficient in regards to management. We report the case of a 49-year-old woman who presented with a presumptive diagnosis of osteomyelitis of the left fifth digit that was resistant to treatment with antibiotics; she underwent debridement of the digit that revealed mcc and was later to have metastatic disease to her lungs, liver, and musculoskeletal system. The management of mcc, although simple in the early stage of the disease, can become challenging when it is more advanced. Multiple new modalities for its treatment have emerged over the last few years, and more recently, clinical trials are being conducted for the use of immunotherapy agents in the treatment of this malignancy. Full article

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful necrotic ulceration affecting preferentially the lower extremities. Diagnosis is challenging, and a thorough workup (including biopsy) is required. In this case report, we describe a 67-year-old patient with a diagnosis of myelodysplastic syndrome (MDS) who developed fever and PG two days after the first cycle of subcutaneous azacitidine (Vidaza; Celgene Corporation, Summit, NJ, USA). On physical examination, the patient had four erythematous plaques at sites of subcutaneous injections of azacitidine on the arms, as well as three other plaques in proximity. A skin biopsy demonstrated a dense neutrophilic interstitial infiltrate in the dermis. After the diagnosis of PG, prednisone 1 mg/kg was started and the fever subsided rapidly. This was followed by the resolution of the cutaneous lesions. Changing the route of administration of azacitidine from subcutaneous to intravenous and adding a daily dose of prednisone during the treatment allowed the patient to receive a total of 10 cycles of azacitidine. This is the second case reported in the literature. Because azacitidine is frequently used in mds and acute myeloid leukemia, clinicians should be aware of this rare cutaneous adverse event. Our approach can be used to avoid the recurrence of PG when continuing azacitidine treatment. Full article

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of the central nervous system that most often affects immunocompromised individuals. It is caused by the reactivation of the John Cunningham virus (JCV), which is found in latent form in the majority of adults. We describe a 59-year-old man with multiple myeloma who developed severe neurological deficits during treatment with ixazomib-based chemotherapy. A diagnosis of PML was established with gadolinium-enhanced magnetic resonance imaging (MRI) and by detection of JCV in the cerebrospinal fluid. Despite cessation of chemotherapy and treatment with mirtazapine, he had an inexorable neurological decline and died two months after presenting to hospital. Multiple myeloma and its treatments can predispose patients to opportunistic infections including PML. Although there have been case reports of PML in patients with multiple myeloma treated with bortezomib (a different proteosome inhibitor), this is, to our knowledge, the first documented case of PML in a patient treated with a regimen that includes ixazomib. Full article

Through a “virtual clinic,” we used the electronic medical record to identify and intervene upon patients with chronic lymphocytic leukemia (CLL) who were not current for pneumococcal vaccines. Within 180 days, 100/160 patients (62%) received the recommended pneumococcal vaccine. A virtual clinic may improve vaccination rates among high-risk patient populations. Full article

The 2017 annual meeting of the American Society of Hematology took place 9–12 December in Atlanta, Georgia. At the meeting, the oral presentations included results from key studies on the first-line treatment of chronic lymphocytic leukemia. A series of phase ii studies focusing on the efficacy and safety of novel treatment strategies were especially notable. One concerned the health-related quality of life results from the gibb study, which had examined the combination of obinutuzumab and bendamustine. A second evaluated the venetoclax–ibrutinib regimen in patients with high-risk disease. The third assessed the combination of ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab in patients with mutated immunoglobulin heavy-chain variable region genes. The fourth examined the combination of ibrutinib, fludarabine, cyclophosphamide, and rituximab in younger patients. And the final study evaluated obinutuzumab–ibrutinib followed by a minimal residual disease strategy in fit patients. Our meeting report describes the foregoing studies and presents interviews with investigators and commentaries by Canadian hematologists about the potential effects on Canadian practice. Full article

Chemotherapy remains the mainstay of treatment for advanced pancreatic ductal adenocarcinoma (PDA). Two randomized trials have demonstrated superiority of the combination regimens FOLFIRINOX (5-fluorouracil, leucovorin, oxaliplatin, and irinotecan) and gemcitabine plus nab-paclitaxel over gemcitabine monotherapy as a first-line treatment in adequately fit subjects. Selected PDA patients progressing to first-line therapy can receive second-line treatment with moderate clinical benefit. Nevertheless, the optimal algorithm and the role of combination therapy in second-line are still unclear. Published second-line PDA clinical trials enrolled patients progressing to gemcitabine-based therapies in use before the approval of nab-paclitaxel and FOLFIRINOX. The evolving scenario in second-line may affect the choice of the first-line treatment. For example, nanoliposomal irinotecan plus 5-fluouracil and leucovorin is a novel second-line option which will be suitable only for patients progressing to gemcitabine-based therapy. Therefore, clinical judgement and appropriate patient selection remain key elements in treatment decision. In this review, we aim to illustrate currently available options and define a possible algorithm to guide treatment choice. Future clinical trials taking into account sequential treatment as a new paradigm in PDA will help define a standard algorithm. Full article

The 2017 annual meeting of the American Society of Hematology took place 9–12 December in Atlanta, Georgia. At the meeting, results from key studies in the treatment of relapsed and refractory mantle cell lymphoma were presented. Of those studies, oral presentations focused on the efficacy and safety of therapy with Bruton tyrosine kinase (BTK) inhibitors. One study presented pooled data from three trials using ibrutinib, with a median follow-up of 3.5 years. A second phase ii study presented data on the efficacy and safety of acalabrutinib, a highly selective BTK inhibitor with minimal off-target activity. The final study presented early phase ib data on the efficacy and safety of zanubrutinib, a novel, highly selective BTK inhibitor, in patients with non-Hodgkin lymphoma. Our meeting report describes the foregoing studies and presents interviews with investigators and commentaries by Canadian hematologists about potential effects on Canadian practice. Full article

Human papillomavirus (HPV) infection is the cause of anal squamous cell cancer (ASCC) in 80% of cases. Available research has also shown high prevalence of anal HPV infection among men who have sex with men (MSM). However, HPV vaccination is low among msm in Canada. In light of this information, we conducted a scoping review with the aim of exploring (1) the knowledge of HPV and anal cancer among HIV-positive msm and (2) the acceptability of HPV and anal cancer self-sampling in this population. In conducting the review, we searched five electronic databases for peer-reviewed articles and abstracts published in English, between 2007 and 2017. A total of 803 articles were retrieved; after accounting for duplicates (n = 40) and unmet criteria (n = 754), a total of 794 articles were excluded. A final total of nine articles were used in this review. Results of this review show that HIV-positive msm have limited knowledge regarding the risks of anal cancer associated with HIV and HPV coinfection. Furthermore, there is limited research on HPV and anal cancer self-sampling in this population. However, the review of available studies suggested that HIV-positive msm were open to anal cancer self-sampling. It also identified potential barriers to self-sampling. In conclusion, we provide suggestions and future directions for policy-makers and educators to develop inclusive and accessible strategies to reach HIV-positive msm regarding anal cancer education and self-screening. Full article

Background: The development and approval of both targeted and immune therapies for patients with advanced non-small cell lung cancer (NSCLS) has significantly improved patient survival rates and quality of life. Biomarker testing for patients newly diagnosed with NSCLS, as well as for patients progressing after treatment with epidermal growth factor receptor (EGFR) inhibitors, is the standard of care in Canada and many parts of the world. Methods: A group of thoracic oncology experts in the field of thoracic oncology met to describe the standard for biomarker testing for lung cancer in the Canadian context, focusing on evidence-based recommendations for standard-of-care testing for EGFR, anaplastic lymphoma kinase (ALK), ROS1, BRAF V600 and programmed death-ligand (PD-L1) at the time of diagnosis of advanced disease and EGFR T790M upon progression. As well, additional exploratory molecules and targets are likely to impact future patient care, including MET exon 14 skipping mutations and whole gene amplification, RET translocations, HER2 (ERBB2) mutations, NTRK, RAS (KRAS and NRAS), as well as TP53. Results: The standard of care must include the incorporation of testing for novel biomarkers as they become available, as it will be difficult for national guidelines to keep pace with technological advances in this area. Conclusions: Canadian patients with NSCLS should be treated equally; the minimum standard of care is defined in this paper. Full article

Cervical cancer rates are disproportionately high among women living with the human immunodeficiency virus (WLHIV). Cervical cancer is preventable through HPV screening, regular Pap tests, and early cancer detection. Evidence indicates that HPV and cervical cancer screening are suboptimal among WLHIV, who face a myriad of access barriers. Considering that screening is an effective first-line defense to cervical cancer, we conducted a scoping review with the aim of gaining a better understanding about: (1) the knowledge and perceptions of HPV and cervical cancer screening among WLHIV; and (2) the acceptability of self-sampling for HPV among WLHIV. We searched five electronic databases for peer-reviewed articles that were published in English within the last ten years, reported on studies with hiv-positive women who were aged 16 or older, and satisfied the topics of the review. A total of 621 articles were found. After accounting for duplicates and unmet criteria, 17 articles and 1 abstract, reporting on studies in the United States and Africa, were included in this review. The review highlighted that most WLHIV had inadequate knowledge of HPV transmission and cervical cancer prevention, which influenced their perceptions of risk and susceptibility. Screening barriers included misconceptions about Pap tests, fear of diagnosis of serious illness, perceived pain, embarrassment, bodily modesty, and limited access to female health care providers. This review also affirms that self-sampling is an acceptable and promising screening option for WLHIV. Implications for policy, research, and practice are discussed. Full article

Background: Operating room slowdowns occur at specific intervals in the year as a cost-saving measure. We aim to investigate the impact of these slowdowns on the care of oral cavity cancer patients at a Canadian tertiary care centre. Methods: A total of 585 oral cavity cancer patients seen between 1999 and 2015 at the London Health Science Centre (LHSC) Head and Neck Multidisciplinary Clinic were included in this study. Operating room hours and patient load from 2006 to 2014 were calculated. Our primary endpoint was the wait time from consultation to definitive surgery. Exposure variables were defined according to wait time intervals occurring during time periods with reduced operating room hours. Results: Overall case volume rose significantly from 2006 to 2014 (p < 0.001), while operating room hours remained stable (p = 0.555). Patient wait times for surgery increased from 16.3 days prior to 2003 to 25.5 days in 2015 (p = 0.008). Significant variability in operating room hours was observed by month, with lowest reported for July and August (p = 0.002). The greater the exposure to these months, the more likely patients were to wait longer than 28 days for surgery (odds ratio per day [OR]: 1.07, 95% confidence interval [CI]: 1.05 to 1.10, p < 0.001). Individuals seen in consultation preceding a month with below average operating room hours had a higher risk of disease recurrence and/or death (hazard ratio [HR]: 1.59, 95% CI: 1.10 to 2.30, p = 0.014). Conclusions: Scheduled reductions in available operating room hours contribute to prolonged wait times and higher disease recurrence. Further work is needed to identify strategies maximizing efficient use of health care resources without negatively affecting patient outcomes. Full article

Background: No standardized measures specifically assess cancer survivors’ and healthcare providers’ experience of Survivor Care Plans (SCPS). We sought to develop two care plan evaluation (CPE) measures, one for survivors (CPE-S) and one for healthcare providers (CPE-P), examine initial psychometric qualities in Alberta, and assess generalizability in Manitoba, Canada. Methods: We developed the initial measures using convenience samples of breast (n = 35) and head and neck (n = 18) survivors who received scps at the end of active cancer-centre treatment. After assessing Alberta’s scp concordance with Institute of Medicine (IOM) recommendations using a published coding scheme, we examined psychometric qualities for the CPE-S and CPE-P. We examined generalizability in Manitoba, Canada, with colorectal survivors discharged to primary care providers for follow-up (n = 75). Results: We demonstrated acceptable internal consistency for the cpe-s and cpe-p subscales and total score after eliminating one item per subscale for cpe-s, two for cpe-p, resulting in revised scales with four 7-item and 6-item subscales, respectively. Subscale scores correlated highly indicating that for each measure the total score may be the most reliable and valid. We provide initial cpe-s discriminant, convergent, and predictive validity using the total score. Using the Manitoba sample, initial psychometrics similarly indicated good generalizability across differences in tumour groups, scp, and location. Conclusions: We recommend the revised cpe-s and cpe-p for further use and development. Studies documenting the creation and standardization of scp evaluations are few, and we recommend further development of patient experience measures to improve both clinical practice and the specificity of research questions. Full article

Background: The Ottawa Hospital (TOH) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, TOH used a learning health system (LHS) vision to redesign regional diagnostic processes. A LHS is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a LHS is a collaborative platform that provides connectivity across silos, organizations, and professions. Methods: To operationalize a LHS, we developed the Ottawa Health Transformation Model (OHTM) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (COP) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation. Results: The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days. Conclusions: The initiative optimized regional integration from referral to initial treatment. Use of a LHS lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations. Full article

Background: Patients with metastatic non-small-cell lung cancer (NSCLC) experience great pain and stress. Our study aimed to explore the effect of early palliative care on quality of life in patients with NSCLC. Methods: A total of 150 patients were randomly divided into two groups: control group with conventional care and study group with early palliative care. The quality of life (QOL) rating scale and self-rating scale of life quality (SSLQ) were used to analyze the patients’ quality of life. The Hospital Anxiety and Depression Scale-D/A (HADS-D/A) and Patient Health Questionnaire 9 (PHQ-9) were used to analyze the patients’ mood. Pulmonary function indexes of peak expiratory flow (PEF), functional residual capacity (FRC), and trachea-esophageal fistula 25% (TEF 25%) were analyzed using the lung function detector. Results: The QOL and SSLQ scales scores of patients receiving early palliative care were significantly higher than those in the control group (p < 0.05). Moreover, the questionnaire results of the HADS-D/A and PHQ-9 were better in patients receiving palliative care than in the control group (p < 0.05 or p < 0.01). In addition, analytical results of pulmonary function showed that the levels of PEF, FRC, and TEF 25% in patients assigned to early palliative care were remarkably higher than those in the control group (p < 0.01 or p < 0.001). Conclusions: These data demonstrate that early palliative care improves life quality, mood, and pulmonary function of NSCLC patients, indicating that early palliative care could be used as a clinically meaningful and feasible care model for patients with metastatic NSCLC. Full article

Background: The Spinal Instability Neoplastic Score (SINS) was developed to identify patients with spinal metastases who may benefit from surgical consultation. We aimed to assess the distribution of SINS in a population-based cohort of patients undergoing palliative spine radiotherapy (RT) and referral rates to spinal surgery pre-RT. Secondary outcomes included referral to a spine surgeon post-RT, overall survival, maintenance of ambulation, need for re-intervention, and presence of spinal adverse events. Methods: We retrospectively reviewed ct simulation scans and charts of consecutive patients receiving palliative spine rt between 2012 and 2013. Data were analyzed using Student’s t-test, Chi-squared, Fisher’s exact, and Kaplan-Meier log-rank tests. Patients were stratified into low (<7) and high (≥7) sins groups. Results: We included 195 patients with a follow-up of 6.1 months. The median SINS was 7. The score was 0 to 6 (low, no referral recommended), 7 to 12 (intermediate, consider referral), and 13 to 18 (high, referral suggested) in 34%, 59%, and 7% of patients, respectively. Eleven patients had pre-RT referral to spine surgery, with a surgery performed in 0 of 1 patient with sins 0 to 6, 1 of 7 with sins 7 to 12, and 1 of 3 with sins 13 to 18. Seven patients were referred to a surgeon post-RT with salvage surgery performed in two of those patients. Primary and secondary outcomes did not differ between low and high sins groups. Conclusion: Higher SINS was associated with pre-RT referral to a spine surgeon, but most patients with high sins were not referred. Higher SINS was not associated with shorter survival or worse outcome following RT. Full article

Angiosarcomas of the breast are rare parenchymal malignancies of the chest wall. Surgery is the main treatment modality with chemotherapy and radiotherapy used in case of recurrence. With generally unfavourable prognosis and lack of clear treatment guidelines due to its rarity and scarcity of available data, angiosarcoma of the breast is a challenging clinical situation for both oncologist and patient. We present here the results of a series of 11 consecutive primary angiosarcoma cases treated at our institute between 2000 and 2015. Full article

Background: Across our province, post-radiotherapy (RT) handover notes are sent to family physicians (FPS) after RT. Based on previous FP feedback, we created a revised post-radiotherapy handover note with more information requested by FPS. The purpose of this study was to determine whether the revised handover note improved the note as a communication aid. Methods: Potential common and rare treatment side effects, oncologist contact information, and treatment intent were added to the revised handover note. Both versions were sent alongside a questionnaire to FPS. Paired t-tests were carried out to compare satisfaction differences. Results: There was a response rate of 37% for the questionnaires. Significantly greater clarity in the following categories was observed: responsibility for patient follow-up (mean score improvement of 1.2 on a 7-point Likert scale, p < 0.001), follow-up schedule (1.1, p < 0.001) as well as how and when to contact the oncologist (1.4, p = 0.001). Family physicians were also more content with how the institute transitioned care back to them (1.5, p = 0.012). Overall, FPS were generally satisfied with the content of the revised post-RT handover note and noted improvement over the previous version. The frequency of investigations and institute supports initiated such as counselling services were suggested further additions. Conclusions: The inclusion of potential treatment side effects, oncologist contact information, treatment intent and a well-laid out follow-up schedule were essential information needed by FPS for an effective post-RT completion note. With these additions, the revised post-RT handover note showed significant improvement. Full article

Background: Pediatric survivors of childhood cancer are at increased risk of poor quality of life and social-emotional outcomes following treatment. The relationship between parent psychological distress and child adjustment in pediatric cancer survivors has been well established. However, limited research has examined the factors that may buffer this association. The current study examined the associations between psychosocial family risk factors, parental psychological distress, and health-related quality of life (HRQL) in pediatric cancer survivors. Methods: Fifty-two pediatric cancer survivors (34 males, 18 females, mean age = 11.92) and their parents were recruited from a long-term cancer survivor clinic. Children and their parents who consented to participate completed the Pediatric Quality of Life Inventory 4.0. Parents completed a demographic information form, the Psychosocial Assessment Tool (PAT 2.0) and the Brief Symptom Inventory (BSI). The Intensity of Treatment Rating (itr-3) was evaluated by the research team. Results: Multiple regression analyses revealed that parental psychological distress negatively predicted parent-reported hrql, while treatment intensity, gender, and psychosocial risk negatively predicted parent and child-reported hrql. Psychosocial risk moderated the association between parent psychological distress and parent-reported child hrql (p = 0.03), whereby parents with high psychological distress but low levels of psychosocial risk reported their children to have higher HRQL. Conclusion: Low levels of family psychosocial risk buffer the impact of parent psychological distress on child HRQL in pediatric cancer survivors. The findings highlight the importance of identifying parents and families with at-risk psychological distress and psychosocial risk in order to provide targeted support interventions to mitigate the impact on HRQL. Full article

Background: Crizotinib has shown greater efficacy in clinical trials than chemotherapy in patients with anaplastic lymphoma kinase-positive (ALK+) non-small cell lung cancer (NSCLC), but little information is available on its use and outcomes in real-world settings. We therefore assessed treatment patterns and outcomes in ALK+ NSCLC patients treated with crizotinib in regular clinical practice. Methods: A retrospective medical record review was conducted in North America for adults with ALK+ NSCLC treated with crizotinib as first- or later-line therapy for metastatic disease between 1 August 2011 and 31 March 2013 (for the United States) or 1 May 2012 and 31 March 2013 (for Canada). Crizotinib-related trial enrollees were excluded. Descriptive analyses were conducted to assess treatment patterns and objective response rate (ORR). Progression-free survival (PFS) and overall survival (OS) were descriptively analyzed using Kaplan-Meier methods. Results: Data were extracted for 212 patients in the United States (n = 147) and Canada (n = 65). Mean (standard deviation [SD]) age was 58.9 (9.5) years, and 69% were male. Seventy-nine patients (37%) were deceased at record abstraction. Sixty-five percent (n = 137) initiated crizotinib as first-line therapy. Mean (SD) duration of crizotinib treatment was 8.7 (4.9) months. Objective response rate was 66% (69% for first-line recipients, 60% for second-/later-line). Median (95% CI) PFS and OS from crizotinib initiation were 9.5 (8.7, 10.1) and 23.4 (19.5, −) months, respectively. One- and two-year survival probabilities were 82% and 49%, respectively. One- and two-year survival probabilities were 82% and 49%, respectively. Conclusions: Outcomes for crizotinib recipients in this study align with previous trials, with ORR appearing more favourable in first-line recipients. Our findings indicate that crizotinib outcomes in clinical studies may translate to regular clinical practice. Full article

Background: Procarbazine, lomustine, and vincristine (PCV) significantly improve survival outcomes in LGG (low-grade gliomas). Administration of PCV to LGG patients increased tremendously over the past years as it went from 2 patients per year between 2005 and 2012 to 23 patients in 2015 only in our centre. However, serious hematological and non-hematological adverse events may occur. The purpose of this study was to evaluate the toxicity of PCV and its clinical relevance in our practice. Methods: We retrospectively reviewed the charts of 57 patients with LGG who received PCV at the Centre hospitalier de l’Université de Montréal between 1 January 2005 and 27 July 2016. Results: Procarbazine, lomustine, and vincristine were associated with severe hematological toxicity as clinically significant grade 3 anemia, neutropenia, and thrombocytopenia occurred in 7%, 10%, and 28% of patients, respectively. Other frequent adverse events such as the increase of liver enzymes, cutaneous rash, neurotoxicity, and vomiting occurred in 65%, 26%, 60%, and 40% of patients, respectively. Patients with prophylactic trimethoprim/sulfamethoxazole had more grade 3 hematological toxicity with PCV, especially anemia (p = 0.040) and thrombocytopenia (p = 0.003) but we found no increase in PCV toxicity in patients on concurrent anticonvulsants. Patients with grade 3 neutropenia had a significantly lower survival (median survival 44.0 months vs. 114.0 months, p = 0.001). Patients who were given PCV at diagnosis had more grade 3 anemia than those who received it at subsequent lines of treatment (p = 0.042). Conclusion: Procarbazine, lomustine, and vincristine increase survival in LGG but were also associated with major hematologic, hepatic, neurologic, and cutaneous toxicity. Anti-Pneumocystis jiroveci pneumonia (PJP) prophylaxis, but not anticonvulsants, enhances hematologic toxicity. Full article

Background: In 2016, everolimus was approved by Health Canada for the treatment of unresectable, locally advanced or metastatic, well-differentiated, non-functional, neuroendocrine tumours (NET) of gastrointestinal (GI) or lung origin in adult patients with progressive disease. This analysis evaluated the cost-effectiveness of everolimus in this setting from a Canadian societal perspective. Methods: A partitioned survival model was developed to compare the cost per life-year (LY) gained and cost per quality-adjusted life-year (QALY) gained of everolimus plus best supportive care (BSC) versus BSC alone in patients with advanced or metastatic NET of GI or lung origin. Model health states included stable disease, disease progression, and death. Efficacy inputs were based on the RADIANT-4 trial and utilities were mapped from quality-of-life data retrieved from RADIANT-4. Resource utilization inputs were derived from a Canadian physician survey, while cost inputs were obtained from official reimbursement lists from Ontario and other published sources. Costs and efficacy outcomes were discounted 5% annually over a 10-year time horizon, and sensitivity analyses were conducted to test the robustness of the base case results. Results: Everolimus had an incremental gain of 0.616 QALYs (0.823 LYs) and CA$89,795 resulting in an incremental cost-effectiveness ratio of CA$145,670 per QALY gained (CA$109,166 per LY gained). The probability of cost-effectiveness was 52.1% at a willingness to pay (WTP) threshold of CA$150,000 per QALY. Conclusions: Results of the probabilistic sensitivity analysis indicate that everolimus has a 52.1% probability of being cost-effective at a WTP threshold of CA$150,000 per QALY gained in Canada. Full article

Background: Commencing 1 December 2017, Australia introduced human papillomavirus (HPV)-based cervical screening. As part of this Australian renewed National Cervical Screening Program (NCSP) women who are either never- or under-screened and who refuse a practitioner collected sample will be able to collect their own sample for cervical screening. The aim of this study is to examine the quantitative results of a pilot study into the acceptability of the self-collection alternative pathway. Methods: Eligible participants were offered the opportunity to collect their own sample. Those who agreed were given a flocked swab and an instruction sheet and took their own sample in an area of the health care clinic that afforded them adequate privacy. These samples were then given to clinic staff who returned them to Victorian Cytology Service (VCS) Pathology for hpv nucleic acid testing. Results: Of 98 eligible women, seventy-nine undertook self-collection for hpv-based cervical screening. Seventyseven produced valid results, 14 were positive for oncogenic hpv, with 10 undertaking follow-up. Three women were found to have cervical squamous abnormalities with two of those being high-grade intraepithelial squamous lesions. Conclusion: The pilot study for self-collection for cervical screening produced quantitative data that were similar to that already reported in the literature, but had a much higher rate of acceptance compared with self-collection programs based in the home. Full article

Background: We designed a phase I study of concurrent chemoradiotherapy (CCRT) with docetaxel (D) and cisplatin (C), followed by consolidation DC, for unresectable stage III non-small cell lung cancer (NSCLC). Methods: Patients with histologically proven and unresectable stage III NSCLC were eligible. During CCRT, C was given every 3 weeks (75 mg/m²) and D given weekly. The starting dose of D was 20 mg/m², escalated in cohorts of 3 to define the maximum tolerated dose (MTD). Radiotherapy was prescribed to a dose of 60 Gy in 30 fractions. This was followed by 2 cycles of consolidation DC, which were dose escalated if CCRT was tolerated. Results: Twenty-six patients were enrolled, with 1 excluded following evidence of metastatic disease. Nineteen patients completed both phases of treatment. There were 7 grade 3 events during CCRT (5 esophagitis, 2 nausea), and 8 grade 3 events during consolidation (2 neutropenia, 2 leukopenia, 1 esophagitis, 2 nausea, and 1 pneumonitis). Three patients had grade 4 neutropenia. No patients died due to toxicities. The MTD of concurrent weekly D was 20 mg/m². Consolidation D and C were each dose escalated to 75 mg/m² in 8 patients. The median overall survival (OS) and progression-free survival (pfs) of all patients were 33.6 months and 17.2 months, respectively, with median follow-up of 26.6 months (range 0.43–110.8). Conclusions: The use of docetaxel 20 mg/m² weekly and cisplatin 75 mg/m² every 3 weeks concurrent with thoracic radiotherapy, followed by consolidation docetaxel and cisplatin, both given at 75 mg/m² every 3 weeks, appears to be safe in this phase I trial. Full article

Objectives: To examine factors that enhance under-screened and never-screened women’s completion of the selfcollection alternative pathway of the Renewed National Cervical Screening Program (NCSP) in Victoria, Australia. Background: With the Australian NCSP changing, starting on 1 December 2017, the Medical Services Advisory Committee (msac) recommended implementing human papillomavirus (hpv) testing using a self-collected sample for under-screened and never-screened populations. In response, a multi-agency group implemented an hpv selfcollection pilot project to trial self-collection screening pathways for eligible women. Methods: Quantitative data were collected on participation rates and compliance rates with follow-up procedures across three primary health care settings. Forty women who self-collected were interviewed in a semi-structured format, and seven agency staff completed in-depth interviews. Qualitative data were used to identify and understand clinical and personal enablers that assisted women to complete self-collection cervical screening pathways successfully. Results: Eighty-five per cent (10 women) of participants who tested positive for hpv successfully received their results and completed follow-up procedures as required. Two remaining participants also received hpvpositive results. However, agencies were unable to engage them in follow-up services and procedures. The overall participation rate in screening (self-collection or Pap test) was 85.7% (84 women), with 79 women self-collecting. Qualitative data indicated that clear explanations on self-collection, development of trusting, empathetic relationships with health professionals, and recognition of participants’ past experiences were critical to the successful completion of the self-collection pathway. When asked about possible inhibitors to screening and to following up on results and appointments, women cited poor physical and mental health, as well as financial and other structural barriers. Conclusion: A well-implemented process, led by trusted, knowledgeable, and engaged health care professionals who can provide appropriate support and information, can assist under-screened and never-screened women to complete the hpv self-collection pathway successfully. Full article

Background: Self-sampling for human papillomavirus (HPV) has the potential to reach marginalized populations that are underserved for cervical cancer screening. However, before implementing an alternative screening strategy such as self-sampling for under- and never-screened women, the key processes, facilitators, and barriers to reform need to be understood. Methods: A descriptive qualitative study was conducted that involved semi-structured interviews with Canadian and international cancer screening health care providers and policy-makers. Respondents were purposively selected from a list of thirty stakeholders generated through an environmental scan. The interviews were transcribed verbatim and analyzed using directed content analysis. Results: Nineteen stakeholders participated in the interviews. Most respondents thought that self-sampling was an appropriate cervical screening alternative for hard-to-reach populations, as it addressed barriers to cervical screening related to various social determinants of health. All respondents emphasized that transitioning to HPV primary screening would catalyze a policy shift towards self-sampling. Clinician respondents were less enthusiastic about self-sampling strategies since that discouraged women’s appointments with primary care providers, because cervical screening offered an opportunity to discuss other preventive health topics. There also was little consensus between respondents on whether the state of evidence was satisfactory to integrate a self-sampling option into policy, or whether more Canadian research was needed. Conclusion: Canadian cervical cancer screening stakeholders should collaborate to identify the knowledge gaps that researchers should address and leverage the existing literature to implement tailored, patient-centred alternative cervical screening strategies. The transition to HPV primary screening would be a key first step in the broad implementation of HPV self-sampling in Canada. Full article