Hiten Naik

Socioeconomic status and lifestyle behaviours in cancer survivors: smoking and physical activity.

PURPOSE Smoking cessation and increased physical activity (pa) have been linked to better outcomes in cancer survivors. We assessed whether socioeconomic factors influence changes in those behaviours after a cancer diagnosis. METHODS As part of a cross-sectional study, a diverse group of cancer survivors at the Princess Margaret Cancer Centre (Toronto, ON), completed a questionnaire about past and current lifestyle behaviours and perceptions about the importance of those behaviours with respect to their health. The influence of socioeconomic indicators on smoking status and physical inactivity at 1 year before and after diagnosis were assessed using multivariable logistic regression with adjustment for clinico-demographic factors. RESULTS Of 1222 participants, 1192 completed the smoking component. Of those respondents, 15% smoked before diagnosis, and 43% of those smokers continued to smoke after. The proportion of survivors who continued to smoke increased with lower education level (p = 0.03). Of the 1106 participants answering pa questions, 39% reported being physically inactive before diagnosis, of whom 82% remained inactive afterward. Survivors with a lower education level were most likely to remain inactive after diagnosis (p = 0.003). Lower education level, household income, and occupation were associated with the perception that pa had no effect or could worsen fatigue and quality of life (p ≤ 0.0001). CONCLUSIONS In cancer survivors, education level was a major modifier of smoking and pa behaviours. Lower socioeconomic status was associated with incorrect perceptions about pa. Targeting at-risk survivors by education level should be evaluated as a strategy in cancer survivorship programs.

Cancer Patients? Willingness to Routinely Complete the EQ-5D Instrument at Clinic Visits.

Evidence from literature illustrates that from a pathophysiological perspective, sulfonylureas (SU) may impact the heart three ways: directly by intrinsic properties from a pharmacological receptor perspective, indirectly by adverse effects related to hypoglycemia, and obesity. From a pharmacologlogical receptor perspective, SU can bind to ATP-sensitive potassium channels in cardiomyocytes. Channel binding by SU in cardiac tissue may prevent ischemia myocardial protective mechanisms. From a pathophysiological perspective, obesity is associated with cardiac issues such as pulmonary hypertension, left ventricular hypertrophy, arrhythmia, and atrial fibrillation. From a pathophysiological perspective, hypoglycemia is associated with cardiac sympathetic activation and QT prolongation. With the high prevalence and incidence of diabetes, obesity and aging, future basic and clinical studies should further explore the questions related to the pathophysiology of SU utilization and potential cardiac impact in randomized clinical trials and real-world outcome research settings.Chronic obstructive pulmonary disease (COPD) is a chronic progressive respiratory disease with partially reversible airway obstruction and lung hyperventilation progressing to increasingly frequent and severe exacerbations. The condition is mainly caused by smoking but may result from other causes such as environmental exposure or occupational hazards. Based on Statistics Canada survey data the prevalence of COPD is approximately 4% of the general population, or about 780,000 adults in Canada with 28,000 in Manitoba.

Canadian cancer site-specific health utility values: Creating the basis for measuring value and costs of therapy.

7 Background: Health utility values (HUVs) play an integral role when conducting health economic analyses, but a paucity of reference HUVs exists for cancer patients. Using EQ-5D, we generated reference HUVs for multiple malignancies. We further assessed patient willingness to compete the instrument on a regular basis by adding the EQ-5D to an Ontario-wide patient-reported symptom tool mandated by Cancer Care Ontario, the provincial cancer government agency. METHODS 1,831 cancer patients across all non-CNS solid and hematologic cancer sites at the Princess Margaret Cancer Centre completed the EQ-5D instrument; a subset (n=618) were asked about the acceptability of regularly completing the EQ-5D. HUVs were calculated using Canadian valuations. RESULTS The mean±SD HUV for all patients was 0.81±0.15, but were significantly different across different disease sites (p<0.0001): Testicular cancer, 0.87±0.13; prostate, 0.87±0.15; colorectal, 0.83±0.12; head/neck, 0.82±0.15; lymphoma, 0.82±0.15; breast, 0.81±0.17; esophageal, 0.81±0.16; ovarian, 0.79±0.15; leukemia, 0.78±0.15; lung, 0.78±0.13 and myeloma, 0.77±0.14. Confirming the validity of these HUVs, patients with PRO-ECOG scores of 0, 1, 2 and 3 had HUVs of 0.90±0.14, 0.77±0.11, 0.65±0.14 and 0.59±0.19, respectively (p<0.0001). In patients with solid tumors, those with local disease had HUVs of 0.82±0.15; metastatic disease, 0.80±0.15; p=0.015. 88% of patients reported that the EQ-5D was easy to complete, 92% took less than 5 minutes, 89% were satisfied with its length and 86% were satisfied with the types of questions asked. Importantly, 92% reported that they would complete the EQ-5D, even if it was used solely for research purposes and 73% agreed with the notion of completing it regularly at their clinic visits. CONCLUSIONS We present the first Canadian reference dataset of HUVs for common cancers; stage-and site-specific reference values will be presented at the meeting. Mean HUVs varied by disease site, performance status, and disease severity. Furthermore, a majority of patients surveyed were willing to complete the EQ-5D on a regular basis, suggesting that routine administration is feasible across Ontario.

Patterns, perceptions, and perceived barriers to physical activity in adult cancer survivors

PurposePhysical activity (PA) during and after cancer treatment is associated with improved cancer- and non-cancer-related outcomes. We assessed for predictors of change in PA levels among cancer survivors.MethodsAdult cancer survivors from a comprehensive cancer center completed a one-time questionnaire retrospectively assessing PA levels before, during, and after cancer treatment along with their perceptions of PA. Multivariable logistic regression models evaluated the association of clinico-demographics variables and perceptions of PA with changes in whether patients were meeting PA guidelines after cancer diagnosis.ResultsAmong the 1003 patients, 319 (32%) met moderate to vigorous PA (MVPA) guidelines before diagnosis. Among those meeting guidelines before diagnosis, 50% still met guidelines after treatment; 12% not meeting MVPA guidelines initially met them after treatment/at follow-up. Among patients meeting guidelines before diagnosis, better ECOG performance status at follow-up, receiving curative therapy, and spending a longer time on PA initially were each associated with meeting guidelines at follow-up. After controlling for other variables, perceiving that PA improves quality of life (adjusted odds ratio, aOR = 11.09, 95%CI [1.42–86.64], P = 0.02) and overall survival (aOR = 8.52, 95%CI [1.12–64.71], P = 0.04) was each associated with meeting MVPA guidelines during/after treatment, in patients who did not meet guidelines initially. Only 13% reported receiving counseling, which was not associated with PA levels. Common reported barriers to PA included fatigue, lacking motivation, and being too busy.ConclusionsPatient perceptions of PA benefits are strongly associated with improving PA levels after a cancer diagnosis. Clinician counseling should focus on patient education and changing patient perceptions.

Favourable health-related quality of life reported in survivors of thymic malignancies†

OBJECTIVES The management of patients with locally advanced thymic malignancies remains controversial. Differing combinations of surgical resection, chemotherapy and radiation are used in the management of initial and relapsed disease. Treatment-related toxicities and quality of life could inform therapeutic options. This study describes health utility scores (HUS) in survivors with locally advanced thymic malignancies and investigates the impact of multimodality regimens on HUS. METHODS In a cross-sectional study (2014-2017), patients with Masaoka Stage II-IVa thymic malignancies completed various self-reported questionnaires, including EuroQol-5-Dimensions with visual analogue scale (VAS), Eastern Cooperative Oncology Group (ECOG) and Edmonton Symptom Assessment Scale tools. Trimodality versus uni- or bimodality regimens and aggressive versus non-aggressive management of recurrent disease were compared using regression analyses. RESULTS Of the 72 patients, 43 (60%) were male with a median age of 58 years, 65 (90%) had thymoma while 7 (10%) had thymic carcinomas; and median time since diagnosis was 50.5 months (range: 3-266). Median HUS and VAS did not differ between groups (trimodality n = 24 vs uni- or bimodality n = 48: HUS = 0.77 vs 0.80, P = 0.29; VAS = 80 vs 75, P = 0.79, respectively). The distributions of patient-reported ECOG were also similar (P = 0.86). Edmonton Symptom Assessment Scale scores for every assessed symptom were similar for different modalities of therapy. Median scores on these tools were also similar regardless of recurrence status or management of relapsed disease (aggressive versus non-aggressive). CONCLUSION Survivors with Stage II-IVa thymic malignancies report favourable HUS, VAS and self-reported ECOG with minimal symptom burden. These outcomes may be independent of number and type of initial treatment modalities or management of recurrence.

Real-World EQ5D Health Utility Scores for Patients With Metastatic Lung Cancer by Molecular Alteration and Response to Therapy.

Introduction Economic analyses of upcoming treatments for lung cancer benefit from real‐world health utility scores (HUSs) in an era of targeted therapy. Methods A longitudinal cohort study at Princess Margaret Cancer Centre evaluated 1571 EQ5D‐3L‐derived HUSs in 475 outpatients with metastatic lung cancer across various disease states. Patients with epidermal growth factor receptor (EGFR) (n = 183) and anaplastic lymphoma kinase (ALK) (n = 38) driver alterations were enriched through targeted enrolment; patients with wild‐type non–small‐cell lung cancer (WT NSCLC) (n = 224) and small‐cell lung cancer (SCLC) (n = 30) were sampled randomly. Results For patients stable on most appropriate treatment, the mean HUSs were 0.81 and 0.82 in patients receiving EGFR and ALK tyrosine kinase inhibitors (TKIs) respectively (with similar HUSs across agents), which were higher than patients with WT NSCLC (0.78; P = .04) and SCLC receiving chemotherapy (0.72; P = .06). In mutation‐specific comparisons, disease stability on appropriate therapy resulted in significantly higher mean HUSs (P < .002‐.02) than when disease was progressing (mean HUS: EGFR, 0.70; ALK, 0.69; WT NSCLC, 0.66; SCLC, 0.52). When evaluating treatment‐related toxicities, significant inverse relationships were observed between HUS and the severity of fatigue and decreased appetite in the EGFR group. There was also a significant inverse relationship between the total number of clinically significant symptoms and HUS, both in patients who were EGFR‐mutated and patients with WT NSCLC. Conclusions In a North American setting, HUSs generated from patients with metastatic lung cancer are higher in treated, stable patients carrying driver mutations. This is partially explainable by treatment toxicity and patient symptom differences. Such differences in scores should be considered in economic analyses. Micro‐Abstract There is limited data outside of clinical trials on health utility scores in patients with metastatic lung cancer. This longitudinal cohort study evaluated EQ5D‐3L‐derived health utility scores in 475 outpatients. Mean scores were higher in patients carrying driver mutations stable on targeted treatments than in patients without alterations stable on chemotherapy. Such differences should be considered in economic analyses of upcoming treatments.

The relationship between health utility, quality of life, and symptom scores in Canadian patients with esophageal cancer.

149 Background: Health Utility scores (HUS) are an increasingly important tool in helping to determine the cost-effectiveness of therapies worldwide. The EQ-5D is a validated HUS questionnaire, with reference data in numerous populations. Previously, HUS in esophageal cancer (EC) were based on limited datasets, and the relationship between HUS and either quality of life (QOL, through the validated FACT-E) or esophageal-specific symptoms such as dysphagia, has not been studied. Methods: This cross-sectional survey of EC patients at Princess Margaret Cancer Centre (2012-2014) assessed EQ-5D, FACT-E, a Visual Analog Scale (VAS), patient reported performance status (PRO-ECOG), and dysphagia scoring. EQ-5D scores were converted to HUS using Canadian references. Correlation analyses were performed between HUS and global FACT-E scores, global dysphagia scores, and specific esophageal symptom scores included in FACT-E. Results: Of 198 patients, median age was 67 (range 32-93) years, 76% were male, with localized ...

Abstract B15: Second-hand smoke (SHS) and smoking cessation in non-tobacco related cancers

Introduction: Continued smoking after a diagnosis of cancer has been found to lead to poorer treatment response, reduced survival and quality of life and increased risk of second primary cancers. We have previously demonstrated that SHS (exposure at home, with spouses and peers) is a significant barrier to smoking cessation in tobacco-related (lung and head and neck) cancers with adjust odds ratios of 6-9 (PMID: 24419133, 23765604) for quitting 1 year after diagnosis and quitting at any time after diagnosis; relationships stronger than in non-cancer populations. Here, we examined whether this relationship exists in cancers that are not traditionally associated with smoking. Patients and Methods: Cancer survivors from a single tertiary cancer centre, Princess Margaret Cancer Centre (Toronto, Canada) completed a one-time cross-sectional questionnaire assessing their socio-demographics, functional status, smoking history and SHS exposure. Clinico-pathological variables were obtained through review of patient charts. Multivariate logistic regression and Cox-proportional hazard models evaluated the association of SHS with smoking cessation at 1 year after diagnosis and any time after diagnosis, and time-to-quitting respectively, adjusted for significant co-variates. Results: A total of 1011 non-tobacco related cancer survivors were surveyed between 2012 and 2014: 19% breast, 15% gastrointestinal, 16% genitourinary, 12% gynecological, 23% hematologic, 15% other. Median follow-up time after diagnosis was 26 months. Among the 162 patients currently smoking at diagnosis, 35% quit 1 year after diagnosis and 48% quit at any time after diagnosis. None of the 306 ex-smokers and 543 never smokers (re-)started smoking after diagnosis. Home exposure to SHS was found to be strongly associated with reduced smoking cessation in cancer patients at any time after diagnosis (aOR=4.28, 95% CI (1.56-11.78), P =4.8E-3), while there was a less strong and non-significant trend for home exposure to SHS and reduced smoking cessation at 1 year after diagnosis (aOR=2.56, 95% CI (0.91-7.22), P =0.08)). Time-to-quitting analysis for home exposure to SHS were consistent with these results (aHR=2.76, 95% CI (1.15-6.59), P =0.02)). Unlike lung and head and neck cancer patients, spousal and peer smoking were not found significantly associated with smoking cessation at either time-point ( P >0.05). Kaplan-Meier analysis found that 72% of patients who quit, did so within 1 year of their cancer diagnosis. When comparing factors between patients quitting one year after diagnosis versus quitting more than one year after diagnosis, those quitting at one year were more likely older ( P P =0.06). Conclusions: Home exposure to SHS is a significant barrier to quitting smoking after a diagnosis of cancer in both tobacco-related and non-tobacco related cancers; while spousal and peer smoking were not found significantly associated with smoking cessation in non-tobacco related cancers. Unlike in tobacco-related cancers, home exposure to SHS had a weaker association with quitting at 1 year after diagnosis than quitting at any time after diagnosis; suggesting the effect of the “teachable moment” with SHS and cancer may not be as strong in these cancers. Survivorship programs focusing on secondary prevention and smoking cessation in cancer patients should focus on incorporating SHS exposure. Citation Format: Lawson Eng, Xin Qiu, Jie Su, M Catherine Brown, Margaret Irwin, Dan Pringle, Hiten Naik, Chongya Niu, Mary Mahler, Henrique Hon, Kyoko Tiessen, Rebecca Charow, Henry Thai, Valerie Ho, Vivien Pat, Lindsay Herzog, Anthea Ho, Jennifer M. Jones, Doris Howell, David P. Goldstein, Meredith E. Giuliani, Wei Xu, Peter Selby, Geoffrey Liu. Second-hand smoke (SHS) and smoking cessation in non-tobacco related cancers. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B15.

Effect of physical activity (PA) perceptions in cancer survivors on PA behaviors: Helping health care providers improve patient communication.

201 Background: While engagement in PA can lessen fatigue, improve quality of life (QOL) and/or improve survival in cancer survivors, to what extent patients are aware of this and how it affects their behavior is unclear. METHODS 1,244 adult cancer survivors across disease sites and stages (mostly curative) at the Princess Margaret Cancer Centre (PMCC) were surveyed about their perceptions of PA, the barriers that prevent them from being physically active, and their level of PA currently. Multivariable logistic regression evaluated the associations between clinical and socio-demographic factors on these perceptions and current activity levels. Analyses were adjusted for performance status and important covariates. RESULTS Cancer survivors were surveyed at a median of 26 months after diagnosis. 16% had breast, 12% GI, 26% gyne/GU, 14% head and neck, 6% lung and 19% hematologic cancers. 55% of survivors reported being physically active. Overall, 76% believed PA could lessen their fatigue, 91% reported PA could improve their QOL, and 89% felt PA could improve their 5-year survival. Common barriers to PA were: being too ill (41%), too tired (33%), too busy (29%) and having too many home responsibilities (28%). Older patients were more likely to believe that PA would not improve their fatigue (p=0.005) and not improve their 5-year survival (p=0.001). Lower household income was associated with belief in lack of benefit of PA on fatigue (p=0.0001) or QOL (p=0.02). Not perceiving benefit of PA on fatigue, QOL, or survival was associated with substantially lower levels of PA (p<0.01; each comparison), as was being older and having a lower income (p=<0.01, each comparison). CONCLUSIONS Older patients (even those with good performance status) and those coming from a lower socioeconomic status were more likely to have negative perceptions of the effect of PA on major cancer outcomes, resulting in lower PA levels. At PMCC, we are using this information to shape how we communicate with our patients in our survivorship program to help them with their decision-making on PA.