Prunella Blinman

The shortage of medical oncologists: the Australian Medical Oncologist Workforce Study

Objective: To determine current and projected supply, demand and shortfall of medical oncologists (MOs) and the Australian chemotherapy utilisation rate.

Adjuvant chemotherapy for early colon cancer: What survival benefits make it worthwhile?

BACKGROUND We sought to determine the minimum survival benefits that patients judged sufficient to make adjuvant chemotherapy for early colon cancer worthwhile, factors associated with these judgments; and, to compare a self-administered questionnaire with a validated, scripted interview. PATIENTS AND METHODS One twenty three subjects who completed adjuvant chemotherapy for early colon cancer 3-60 months earlier completed a questionnaire; 97 were randomised to complete an interview before or after the questionnaire. Preferences were elicited by the time trade-off method in 4 hypothetical scenarios. Concordance between the interview and questionnaire was assessed with the intraclass correlation coefficient (ICC). RESULTS Median age was 65 years (range 19-86), 52% were female and 74% had involved lymph nodes. Over 60% of patients judged an additional 1 month beyond life expectancies of 5 years or 15 years, and an additional 1-2% beyond 5-year survival rates of 85% or 65%, sufficient to make chemotherapy worthwhile. Subjects with tertiary education (p=0.003) or aged 75 years or less (p=0.02) judged larger benefits necessary to make chemotherapy worthwhile. Concordance between the interview and questionnaire was high (ICCs 0.71-0.82). CONCLUSIONS Most subjects judged small survival benefits sufficient to make adjuvant chemotherapy worthwhile. A self-administered questionnaire was a valid and acceptable way of eliciting preferences.

Estimating typical, best-case and worst-case life expectancy scenarios for patients starting chemotherapy for advanced non-small-cell lung cancer: A systematic review of contemporary randomized trials

INTRODUCTION We sought to estimate life expectancy scenarios for patients starting chemotherapy for advanced non-small-cell lung cancer (NSCLC). METHODS We searched for randomized first-line chemotherapy trials published from January 2000 to April 2008. We recorded median time to progression (TTP) and median overall survival (OS) and extracted the following percentiles (represented scenario) from each OS curve: 90th (worst-case), 75th (lower-typical), 25th (upper-typical) and 10th (best-case). For each OS curve we divided these percentiles (scenarios) in turn by the median to determine if a simple relationship existed between each scenario and the median. RESULTS From 60 trials (29,657 patients), the mean for median TTP was 4.8 months (interquartile range [IQR] 4.0-5.3), the mean for median OS was 9.2 months (IQR 8.1-10.1) and the mean ratio for median OS to median TTP was 2.0 (IQR 1.7-2.2). The mean (IQR) in months for each OS scenario was: worst-case, 2.4 (1.9-2.7); lower-typical, 4.8 (4.2-5.4); upper-typical, 16.3 (14.4-18.1); and best-case, 25 (21.0-28.0). The mean values (IQR) for each scenario divided by the median were: worst-case/median 0.26 (0.21-0.29); lower-typical/median 0.53 (0.5-0.57); upper-typical/median 1.81 (1.69-1.93) and best-case/median 2.84 (2.57-3.19). These values can be approximated by the simple multiples: 0.25, 0.5, 2 and 3. Independent predictors of longer OS were ECOG PS<2, adenocarcinoma, and longer TTP; all p-values<0.001. CONCLUSION Simple multiples of an OS curves median provided accurate estimates of typical (half to double the median), best-case (triple the median), and worst-case (one quarter of the median) life expectancy scenarios for patients starting chemotherapy for advanced NSCLC.

Impact of physical activity on fatigue and quality of life in people with advanced lung cancer: A randomized controlled trial

Background Physical activity (PA) improves fatigue and quality of life (QOL) in cancer survivors. Our aim was to assess whether a 2-month PA intervention improves fatigue and QOL for people with advanced lung cancer. Methods Participants with advanced lung cancer, Eastern Cooperative Oncology Group performance status (PS) ≤2, >6 months life expectancy, and ability to complete six-min walk test, were stratified (disease stage, PS 0-1 versus 2, centre) and randomized (1:1) in an open-label study to usual care (UC) (nutrition and PA education materials) or experimental intervention (EX): UC plus 2-month supervised weekly PA and behaviour change sessions. Assessments occurred at baseline, 2, 4, and 6 months. The primary endpoint was fatigue [Functional Assessment of Cancer Therapy-Fatigue (FACT-F) questionnaire] at 2 months. The study was designed to detect a difference in mean FACT-F subscale score of 6. Analysis was intention-to-treat using linear mixed models. Results We recruited 112 patients: 56 (50.4%) were randomized to EX, 55(49.5%) to UC; 1 ineligible. Male 55%; median age 64 years (34-80); 106 (96%) non-small cell lung cancer; 106 (95.5%) stage IV. At 2, 4 and 6 months, 90, 73 and 62 participants were assessed, respectively, with no difference in attrition between groups. There were no significant differences in fatigue between the groups at 2, 4 or 6 months: mean scores at 2 months EX 37.5, UC 36.4 (difference 1.2, 95% CI - 3.5, 5.8, P = 0.62). There were no significant differences in QOL, symptoms, physical or functional status, or survival. Conclusions Adherence to the intervention was good but the intervention group did not increase their PA enough compared to the control group, and no difference was seen in fatigue or QOL. Trial Registration Australian New Zealand Clinical Trials Registry No. ACTRN12609000971235.

Patients' and clinicians' preferences for adjuvant chemotherapy in endometrial cancer: an ANZGOG substudy of the PORTEC-3 intergroup randomised trial.

Background:To determine the minimum survival benefits that patients, and their clinicians, judged sufficient to make adjuvant chemotherapy (ACT) worthwhile, in addition to pelvic radiotherapy, for women with high risk and advanced stage endometrial cancer.Methods:Eighty-three participants in the PORTEC-3 trial completed a time trade-off questionnaire before and after adjuvant therapy; 44 of their clinicians completed it once only. The questionnaire used four hypothetical scenarios including baseline survival times without ACT of 5 and 8 years, and baseline survival rates at 5 years without ACT of 50 and 65%.Results:Over 50% of patients judged an extra 1 year of survival time or an extra 5% in survival rate sufficient to make ACT worthwhile. Over 50% of clinicians judged an extra 1 year of survival time, or an extra 10% in survival rate, sufficient to make ACT worthwhile. Compared with patients, clinicians required similar survival time benefits (medians both 1 year, P=0.4), but larger survival rate benefits (medians 8.5% vs 5%, P=0.03), and clinicians’ preferences varied less (IQR 0.5–1.5 years vs 0.4–2 years, P=0.0007; 5–10% vs 1–13%, P=0.004). Patients’ preferences changed over time for the survival rate scenarios depending on whether they had ACT or not (change in median benefit - 3 months vs 2.5 months respectively, P=0.028). There were no strong predictors of patients’ or clinicians’ preferences.Conclusions:Patients and clinicians judged moderate survival benefits sufficient to make ACT worthwhile after pelvic radiotherapy for endometrial cancer. These benefits are larger than those judged sufficient by patients with breast or colon cancers, but similar to those judged sufficient by patients with lung or ovarian cancers.

Decision-making in geriatric oncology: systemic treatment considerations for older adults with colon cancer.

ABSTRACT Introduction: Colon cancer is common and can be considered a disease of older adults with more than half of cases diagnosed in patients aged over 70 years. Decision-making about treatment with chemotherapy for older adults may be complicated by age-related physiological changes, impaired functional status, limited social supports, concerns regarding the occurrence of and ability to tolerate treatment toxicity, and the presence of comorbidities. This is compounded by a lack of high quality evidence guiding cancer treatment decisions for older adults. Areas covered: This narrative review evaluates the evidence for adjuvant and palliative systemic therapy in older adults with colon cancer. The value of an adequate assessment prior to making a treatment decision is addressed, with emphasis on the geriatric assessment. Guidance in making a treatment decision is provided. Expert commentary: Treatment decisions should consider goals of care, a patient’s treatment preferences, and weigh up relative benefits and harms.

Use of palliative chemotherapy in patients aged 80 years and over with incurable cancer: experience at three Sydney cancer centres.

Octogenarians represent a growing population reviewed in medical oncology clinics, yet there is a paucity of data on how chemotherapy is tolerated in this age group.

Doctor‐to‐doctor communication of prognosis in metastatic cancer: a review of letters from medical oncologists to referring doctors

Shared understanding of prognosis is vital for optimal, multidisciplinary, clinical decision making.

A case of uterine tumour resembling ovarian sex cord tumour responding to second-line, single agent anastrazole

Uterine tumour resembling ovarian sex cord tumour (UTROSCT) are a histological variant of endometrial stromal sarcomas (ESS). There is no established medical management of metastatic UTROSCT or ESS, although there is evidence supporting the use of hormonal therapy. Given the success of aromatase inhibitors in breast cancer, their potential role in ESS and UTROSCT is of current interest. We report the first case of response to second‐line, single agent anastrazole in a patient with metastatic UTROSCT.

How do oncologists make decisions about chemotherapy for their older patients with cancer? A survey of Australian oncologists

PurposeOncologists are making treatment decisions on increasing numbers of older patients with cancer. Due to comorbidities and frailty that increase with age, such decisions are often complex. We determined factors influencing oncologists’ decisions to prescribe chemotherapy for older adults.MethodsMembers of the Medical Oncology Group of Australia (MOGA) were invited to complete an online survey in February to April 2016.ResultsNinety-three oncologists completed the survey of which 69 (74%) were consultants and 24 (26%) were trainees, with most (72, 77%) working predominantly in a public hospital-associated practice. The three highest ranked factors influencing decisions about (a) adjuvant chemotherapy were performance status, survival benefit of treatment, and life expectancy in the absence of cancer and about (b) palliative chemotherapy were performance status, patient preference, and quality of life. Most geriatric health domains are reportedly assessed routinely by the majority of respondents, though few routinely use geriatric screening tools (14%) or geriatric assessments (5%). In hypothetical patient scenarios, oncologists were less likely to prescribe palliative and adjuvant chemotherapy as age and rates of severe toxicity increased.ConclusionPerformance status was the most influential factor for oncologists when making a decision about chemotherapy for their older patients, and the importance of other factors differed according to treatment intent. Oncologists were less likely to recommend chemotherapy as patient age and treatment toxicity increased. The low uptake of geriatric assessments or screening tools provides scope for improved clinical assessment of older adults in treatment decision-making.