Curr. Oncol., Volume 25, Issue 4 (August 2018) – 19 articles

Objectives: To date, no “gold standard” technique has been developed for sternum replacement in cases of radioinduced sarcoma, which is a rare and aggressive disease. Current techniques rely on metallic prostheses, meshes, or bone grafts—procedures that that are associated with several complications. We therefore tried a new solution that might simplify and optimize this surgery. Methods: We used a porous alumina ceramic prosthesis (Ceramil: I.CERAM, Limoges, France) that has several interesting characteristics, such as osseointegration, biocompatibility, radiolucency, and high mechanical strength. Results: We report the first case of sternal replacement surgery involving the implantation of a ceramic prosthesis after radio-induced sternal sarcoma. In 2005, a 54-year-old woman was diagnosed with local breast cancer for which she underwent all appropriate treatment. Ten years later, she developed radio-induced sarcoma of the sternum. A complete sternal replacement was performed on 24 April 2015, with no postoperative complications. Imaging by ¹⁸F-flurodeoxyglucose positron-emission tomography–computed tomography performed 26 months after the surgery showed no local recurrence. The patient seems to have fully recovered and has resumed normal activity. Conclusions: This new technique is promising. For the first time, we highlight the feasibility, safety, and efficacy of sternal replacement using a porous alumina ceramic prosthesis. Full article

Background: Many tools have been developed for the standardized collection of cancer family history (fh). However, it remains unclear which tools have the potential to help health professionals overcome traditional barriers to collecting such histories. In this review, we describe the characteristics, validation process, and performance of existing tools and appraise the extent to which those tools can support health professionals in identifying and managing at-risk individuals. Methods: Studies were identified through searches of the medline, embase, and Cochrane central databases from October 2015 to September 2016. Articles were included if they described a cancer fh collection tool, its use, and its validation process. Results: Based on seventy-nine articles published between February 1978 and September 2016, 62 tools were identified. Most of the tools were paper-based and designed to be self-administered by lay individuals. One quarter of the tools could automatically produce pedigrees, provide cancer-risk assessment, and deliver evidence-based recommendations. One third of the tools were validated against a standard reference for collected fh quality and cancer-risk assessment. Only 3 tools were integrated into an electronic health records system. Conclusions: In the present review, we found no tool with characteristics that might make it an efficient clinical support for health care providers in cancer-risk identification and management. Adequately validated tools that are connected to electronic health records are needed to encourage the systematic identification of individuals at increased risk of cancer. Full article

Lung cancer is the leading cause of cancer-specific death among Canadians, with non-small-cell lung cancer (NSCLC) being the most common histologic variant. Despite advances in the understanding of the molecular biology of NSCLC, the survival rate for this malignancy is still poor. It is now understood that, to evade detection and immune clearance, NSCLC tumours overexpress the immunosuppressive checkpoint protein programmed death ligand 1 (PD-L1). Inhibiting the PD-1/PD-L1 axis with monoclonal antibodies has significantly changed the treatment landscape in NSCLC during the last 5 years. Despite evidence of clinical response in some patients, only approximately 20% of patients obtain any durable benefit, and many of the patients who do respond ultimately relapse with drug-resistant disease. The identification of patients who are most likely to benefit from such therapy is therefore important. In the present review, we cover the basics of the PD-1/PD-L1 axis and its clinical significance in NSCLC, biomarkers that are predictive of treatment response, relevant clinical trials of PD-1/PD-L1 blockade completed to date, and proposed mechanisms of acquired therapeutic resistance. Full article

Background: Baseline symptom burden as measured using the Edmonton Symptom Assessment System (ESAS), a patient-reported, validated, and reliable tool measuring symptom severity in 9 separate domains, might yield prognostic information in patients receiving treatment for metastatic renal cell carcinoma (MRCC) and might add to the existing prognostic models. Methods: In this retrospective single-centre cohort study, we included patients receiving first-line sunitinib therapy for MRCC between 2008 and 2012. Baseline variables included information relevant to the pre-existing prognostic models and pre-treatment ESAS summation scores (added together across all 9 domains), with higher scores representing greater symptom burden. We used Kaplan–Meier curves and Cox regression modelling to determine if symptom burden can provide prognostic information with respect to overall survival. Results: We identified 68 patients receiving first-line therapy for MRCC. Most had intermediate- or poor-risk disease based on both the Memorial Sloan Kettering Cancer Center (MSKCC) and the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) models. The median baseline ESAS summation score was 16 (range: 6–57). In univariable analysis, the hazard ratio for overall survival was 1.270 (p = 0.0047) per 10-unit increase in summation ESAS. In multivariable analysis, the hazard ratio was 1.208 (p = 0.0362) when controlling for MSKCC risk group and 1.240 (p = 0.019) when controlling for IMDC risk group. Conclusions: Baseline symptom burden as measured by ESAS score appears to provide prognostic information for survival in patients with mrcc. Those results should encourage the investigation of patient-reported symptom scales as potential prognostic indicators for patients with advanced cancer. Full article

Background: Oncotype DX [ODX (Genomic Health, Redwood City, CA, U.S.A.)] is an approved prognostic tool for women with node-negative, hormone receptor–positive, her2-negative breast cancer. Because of cost, optimal use of this test is crucial, especially in a publicly funded health care system. We evaluated adherence with our provincial guidelines for ODX requests, the management of patients with an intermediate recurrence score (RS), and the cost impact of ODX. Methods: This retrospective study included 201 consecutive patients with an ODX request from two university institutions in Quebec between May 2012 and December 2014. Concordance with provincial guidelines was estimated, with its 95% confidence interval (CI). For patients with an intermediate RS, factors influencing the final treatment decision were assessed. The cost impact of ODX was derived from the proportion of patients for whom chemotherapy was not recommended. Results: In 93.0% of patients (95% CI: 89.5% to 96.6%), ODX was ordered according to guidelines. The concordance was similar in both institutions (92.7%; 95% CI: 88.1% to 97.3%; and 93.6%; 95% CI: 88.2% to 99.0%). In 112 (55.7%), 78 (38.8%), and 9 (4.5%) patients, the RS suggested low, intermediate, and high risk respectively. In the intermediate-risk group, most patients (n = 58, 74.4%) did not receive chemotherapy, mainly because of patient preference and the absence of a clear proven benefit. Savings of CA$100,000 for the study period (2.5 years) were estimated to be associated with ODX use. Conclusions: In our experience, the use of ODX was concordant with published recommendations and had a positive cost impact. Full article

Background: The choice of vascular access for systemic therapy administration in breast cancer remains an area of clinical equipoise, and patient preference is not consistently acknowledged. Using a patient survey, we evaluated the patient experience with vascular access during treatment for early-stage breast cancer and explored perceived risk factors for lymphedema. Methods: Patients who had received systemic therapy for early-stage breast cancer were surveyed at 2 Canadian cancer centres. Results: Responses were received from 187 patients (94%). The route of vascular access was peripheral intravenous line (IV) in 24%, a peripherally inserted central catheter (picc) in 42%, and a surgically inserted central catheter (port) in 34%. Anthracycline-based regimens were associated with a greater use of central vascular access devices (cvads— that is, a picc or port; 86/97, 89%). Trastuzumab use was associated with greater use of ports (49/64, 77%). Although few patients (7%) reported being involved in the decisions about vascular access, most were satisfied or very satisfied (88%) with their access type. Patient preference centred mainly on avoiding delays in the initiation of chemotherapy. Self-reported rates of complications (183 evaluable responses) were infiltration with peripheral IVs (9/44, 20%), local skin infections with piccs (7/77, 9%), and thrombosis with ports (4/62, 6%). Perceived risk factors for lymphedema included use of the surgical arm for blood draws (117/156, 75%) and blood pressure measurement (115/156, 74%). Conclusions: Most patients reported being satisfied with the vascular access used for their treatment. Improved education and understanding about the evidence-based requirements for vascular access are needed. Perceived risk factors for lymphedema remain variable and are not evidence-based. Full article

Background: Despite advances in systemic therapy choices for patients with early-stage breast cancer, optimal practices for intravenous (IV) access remain unknown. That lack of knowledge holds particularly true for the use of central venous access devices (cvads) such as peripherally inserted central catheters (piccs) and implanted vascular access devices (ports). Methods: Using a survey of Canadian oncologists and oncology nurses responsible for the care of breast cancer patients, we evaluated current access practices, perceptions of complications, and perceptions of risk, and we estimated complication rates and evaluated perceived risk factors for lymphedema. Results: Survey responses were received from 25 physicians and 57 oncology nurses. Administration of trastuzumab or an anthracycline was associated with a higher likelihood of a cvad being recommended. Other factors associated with recommendation of a cvad included prior difficult IV access and a recommendation from the chemotherapy nurse. Although the complication rates perceived to be associated with the use of piccs and ports remained high, respondents felt that cvads might improve patient quality of life. Risk factors perceived to be associated with the risk of lymphedema were axillary lymph node dissection, radiation to the axilla, and line-associated infection. Factors known to be unrelated to lymphedema risk (specifically, blood draws and blood pressure measurement) continue to be perceived as posing a higher risk. Conclusions: Despite widespread use of chemotherapy for patients with breast cancer, the type of venous access used for treatment varies significantly, as do perceptions about the risks of cvad use and the risk for lymphedema development. Further prospective studies are needed to identify best-practice strategies. Full article

Background: Advanced non-small-cell lung cancer (NSCLC) represents a major health issue globally. Systemic treatment decisions are informed by clinical trials, which, over years, have improved the survival of patients with advanced NSCLC. The applicability of clinical trial results to the broad lung cancer population is unclear because strict eligibility criteria in trials generally select for optimal patients. Methods: We performed a retrospective chart review of all consecutive patients with advanced NSCLC seen in outpatient consultation at our academic institution between September 2009 and September 2012, collecting data about patient demographics and cancer characteristics, treatment, and survival from hospital and pharmacy records. Two sets of arbitrary trial eligibility criteria were applied to the cohort. Scenario A stipulated Eastern Cooperative Oncology Group performance status (ECOG PS) 0–1, no brain metastasis, creatinine less than 120 μmol/L, and no second malignancy. Less-strict scenario B stipulated ECOG PS 0–2 and creatinine less than 120 μmol/L. We then used the two scenarios to analyze treatment and survival of patients by trial eligibility status. Results: The 528 included patients had a median age of 67 years, with 55% being men and 58% having adenocarcinoma. Of those 528 patients, 291 received at least 1 line of palliative systemic therapy. Using the scenario A eligibility criteria, 73% were trial-ineligible. However, 46% of “ineligible” patients actually received therapy and experienced survival similar to that of the “eligible” treated patients (10.2 months vs. 11.6 months, p = 0.10). Using the scenario B criteria, only 35% were ineligible, but again, the survival of treated patients was similar in the ineligible and eligible groups (10.1 months vs. 10.9 months, p = 0.57). Conclusions: Current trial eligibility criteria are often strict and limit the enrolment of patients in clinical trials. Our results suggest that, depending on the chosen drug, its toxicities and tolerability, eligibility criteria could be carefully reviewed and relaxed. Full article

The treatment of hormone-positive breast cancer (BCA) is a rapidly evolving field. Improvement in the understanding of the mechanisms of action and resistance to anti-hormonal therapy has translated, in the past decade, into multiple practice-changing clinical trials, with the end result of increased survivorship for patients with all stages of hormone-positive cancer. The primary care physician will thus play an increasing role in the routine care, surveillance, and treatment of issues associated with anti-hormonal therapy. The aim of the present review was to provide a focused description of the issues relevant to primary care, while briefly highlighting recent advances in the field of anti-hormonal therapy. Key Points: (1) Hormone-positive bca is the most prevalent form of bca and, compared with the other subtypes, is usually associated with better survival. (2) Survivorship has significantly increased for all stages of hormone-positive bca, making the primary care physician a key player in the care of affected patients. (3) The two most common classes of anti-hormonal agents used in these patients are selective estrogen receptor modulators and aromatase inhibitors. Each class of medication is associated with signature side effects. (4) Within the past decade, multiple novel estrogen receptor blockers (for example, fulvestrant) and agents aimed at circumventing resistance to endocrine therapy [inhibitors of cyclin-dependent kinase 4/6 and of mtor (the mechanistic target of rapamycin)] have gained clinical ground. Understanding their side effects will be increasingly relevant to primary care physicians. (5) Multidisciplinary care is always encouraged in the care of cancer patients receiving anti-hormonal therapy. Full article

Background: Advanced breast cancer (abc) represents a substantial burden for patients and caregivers. In the present study, we aimed to estimate quality of life (qol), utility, productivity loss, pain, health care resource utilization, and costs for patients with abc, and qol, utility, and productivity loss for their caregivers. Methods: This multicentre prospective non-interventional study was conducted in Canada. Eligible participants were postmenopausal women with estrogen receptor–positive, her2-negative unresectable abc and their caregivers. Validated questionnaires were used to measure qol, utility, productivity loss, and pain. Patients and caregivers were classified into 4 health states typically used in oncology economic modelling: first-line progression-free (1l-pf), first-line progressive disease (1l-pd), second- or subsequent-line progression-free (≥2l-pf), and second- or subsequent-line progressive disease (≥2l-pd). Results: Most patients and caregivers accepted to participate, with total recruitment of 202 patients and 78 caregivers. Compared with patients in pf, patients in pd had lower mean qol scores (52.9 ± 29.9 for 1l-pd vs. 68.2 ± 23.2 for 1l-pf, and 54.0 ± 23.6 for ≥2l-pd vs. 66.0 ± 22.1 for ≥2l-pf), lower mean utility values (0.64 ± 0.22 for 1l-pd vs. 0.73 ± 0.20 for 1l-pf, and 0.65 ± 0.25 for ≥2l-pd vs. 0.74 ± 0.18 for ≥2l-pf), and greater productivity loss (39.4 ± 27.7 for 1l-pd vs. 27.5 ± 30.1 for 1l-pf, and 37.6 ± 29.2 for ≥2l-pd vs. 32.0 ± 29.0 for ≥2l-pf). Compared with caregivers of patients in pf, caregivers of patients in pd had lower qol scores and utility values, and greater productivity loss. Conclusions: Study results indicate that, for patients and caregivers, pd health states are associated with a deterioration of qol and utility and a decrease in productivity in both 1l and ≥2l. Full article

The 19th annual Western Canadian Gastrointestinal Cancer Consensus Conference (WCGCCC) was held in Winnipeg, Manitoba, 29–30 September 2017. The WCGCCC is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer. Full article

Background: Cancer patients are increasingly seeking out complementary and alternative medicine (CAM) and might be reluctant to disclose its use to their oncology treatment team. Often, CAM agents are not well studied, and little is known about their potential interactions with chemotherapy, radiation therapy, or biologic therapies, and their correlations with outcomes. In the present study, we set out to determine the rate of CAM use in patients receiving treatment at a Northern Ontario cancer centre. Methods: Patients reporting for treatment at the Northeast Cancer Centre (NECC) in Sudbury, Ontario, were asked to complete an anonymous questionnaire to assess CAM use. Changes in CAM use before, compared with after, diagnosis were also assessed. Results: Patients in Northern Ontario reported significant CAM use both before and after diagnosis. However, as a function of the CAM type, CAM use was greatly enhanced after cancer diagnosis. For example, the number of patients who reported use of biologic products increased to 51.8% after a cancer diagnosis from 15.6% before a cancer diagnosis. Patients reported much smaller changes in the use of alternative medical systems or spiritual therapy after diagnosis. Vitamin use was reported by 66% of respondents, and the number of different CAMS used correlated significantly with the reported number of vitamins used. Conclusions: Use of CAM, particularly biologic products, increased significantly after a cancer diagnosis. Further studies are required to examine the effect of CAM use on the efficacy and safety of cancer therapies. Full article

Background: This paper focuses on phase III of a study evaluating the development and implementation of a survivorship care plan (SCP) that could ultimately improve post-treatment quality of life for South Asian (SA) breast cancer survivors (BCSS). Evaluating the utility of the SCP was important to understand how sociocultural influences might affect uptake of the SCP by SA BCSS, especially as they transition from treatment to community care. Methods: Post-treatment discharge planning using an individualized SCP at discharge for SA female breast cancer patients with stage I or II disease was offered as a pilot service to oncologists at BC Cancer’s Fraser Valley and Abbotsford centres. A longitudinal study using a mixed-methods approach was used to evaluate the utility of that service at 1 year after discharge. Results: Participants (n = 16) completed a survey about their SCP delivery experience, and a 1-year post implementation survey about the SCP content and its utility. Most participants reported the discharge appointments to be extremely or very helpful with respect to post-treatment care questions. All have visited their family physicians for follow-up as recommended. The three major sources of support were family, faith, and family physician. Qualitative responses from the health care professionals who developed or implemented the SCPS identified two challenges in SCP delivery: engaging patients or family members in relationship, and translating key information through interpreters. Conclusions: It is important to evaluate the utility of SCPS for SA female survivors, who might differ from the general bcs population because of a different understanding of the disease; language barriers; strong influence of family members; societal stigmas; and personal, social, cultural, and religious beliefs and values. A formal nurse-led discharge appointment with discussions about follow-up care and an individualized SCP outlining the short- and long-term effects of treatment are recommended. Particular attention has to be paid to the practical and psychosocial needs of SA BCSS and their supporting family members. Full article

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2017 was held in St. John’s, Newfoundland and Labrador, 28–30 September. Experts in radiation oncology, medical oncology, surgical oncology, and cancer genetics who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of gastric, rectal, and colon cancer, including (1) identification and management of hereditary gastric and colorectal cancer (CRC); (2) palliative systemic therapy for metastatic gastric cancer; (3) optimum duration of preoperative radiation in rectal cancer—that is, short- compared with long-course radiation; (4) management options for peritoneal carcinomatosis in CRC; (5) implications of tumour location for treatment and prognosis in CRC; and (6) new molecular markers in CRC. Full article

Background: Cancer drug-funding decisions between provinces shows discordance. The pan-Canadian Oncology Drug Review (PCODR) was implemented in 2011 partly to address uneven drug coverage and lack of transparency in the various provincial cancer drug review processes in Canada. We evaluated the underlying reasons for ongoing provincial discordance since the implementation of PCODR. Methods: Participation in an online survey was solicited from participating provincial ministries of health (MOHS) and cancer agencies (CAS). The 4-question survey (with both multiple-choice and free-text responses) was administered between 4 March 2015 and 1 April 2015, inclusive. Anonymity was ensured. Descriptive statistics were used to evaluate responses. Results: Data were available from 9 provinces (all Canadian provinces except Quebec), with a response rate of 100%. The 12 responses received each came from a senior policymaker with more than 5 years’ experience in cancer drug funding decision-making (5 from MOHS, 7 from CAS). Responses for 3 provinces came from both a moh representative and a ca representative. The most common reason for funding a drug not recommended by PCODR was political pressure (64%). The most common reason not to fund a drug recommended by PCODR was budget constraints (91%). The most common reason for a province to fund a drug before completion of the PCODR review was also political pressure (57%). Conclusions: Political pressure and budgetary constraints continue to affect equity of access to cancer drugs for patients throughout Canada. Full article

Background: Patient engagement is a key quality component of cancer guideline development; however, the optimal strategy for engaging patients in guideline development remains unclear. The feasibility and efficacy of two patient engagement models was tested by Cancer Care Ontario’s cancer guideline development program, the Program in Evidence-Based Care (PEBC). Methods: In model 1, patients participated in the guideline development process as active members of a working group. In model 2, patients formed a separate consultation group to review project plans and recommendations generated by multiple working groups. Training included online resources (model 1) and an in-person orientation (model 2). The PEBC’s standard patient engagement process acted as a control. The study was conducted for 1 year. Surveys measured the satisfaction of patients and members of the guideline working groups with the process and the outcome of each model. Results: Three guideline projects used model 1 to engage patients, six projects used model 2 to receive feedback, and one project was used as a control group (14 patients total). Most participants, whatever the model, reported satisfaction with their experience. Key challenges to implementation included patient recruitment and long wait times between meetings (model 1), and difficulty focusing on the discussion topic and poor meeting attendance on the part of patients (model 2). Conclusions: The pilot study demonstrated that, although both models are feasible and effective for the engagement of patients in cancer guideline development, modifications are required to optimize their continued interest. The PEBC will use the study results to inform the implementation of a patient engagement strategy for its program. Full article