Rachel McDonald

Enteral and parenteral nutrition in cancer patients: a systematic review and meta-analysis

BACKGROUND In cancer patients, weight loss is an ominous sign suggesting disease progression and shortened survival time. As a result, providing nutrition support for cancer patients has been proposed as a logical approach for improving clinical outcomes. Nutrition support can be given to patients through enteral nutrition (EN) or parenteral nutrition (PN). The purpose of the review was to compare the outcomes of PN and EN in cancer patients. METHODS A literature search was conducted in Ovid MEDLINE and OLDMEDLINE, Embase Classic and Embase, and Cochrane Central Register of Controlled Trials. Studies were included if over half of the patient population had cancer and reported on any of the following endpoints: the percentage of patients that experienced no infection, nutrition support complications, major complications or mortality. Risk ratios (RR) and 95% confidence intervals (CIs) using Review Manager Version 5.3 were calculated. Primary endpoints were stratified according to type of EN for subgroup analysis, grouping studies into either tube feeding (TF) or standard care (SC). Additionally, another subgroup analysis was conducted comparing studies with protein-energy malnutrition (PEM) patients and studies without PEM patients. RESULTS The literature search yielded 674 articles of which 36 were included for the meta-analysis. There were no difference in the endpoints between the two study interventions except that PN resulted in more infection when compared with EN (RR =1.09, 95% CI: 1.01-1.18; P=0.03). CONCLUSIONS Other than increased incidence of infection, PN has not resulted in prolonging the survival, increasing nutrition support complications, or major complications when compared with EN in cancer patients.

Stereotactic body radiation therapy for non-spine bone metastases—a review of the literature

BACKGROUND Stereotactic body radiation therapy (SBRT) has the ability to deliver significantly higher biologically equivalent doses (BED) compared to conventional radiation treatment. The main goal of SBRT is to improve local tumor control while reducing pain. The side effects however may be greater than those of conventional treatment. METHODS A review of the literature was conducted and articles pertaining to studies of SBRT in non-spine bone metastases were included. Data on outcomes and toxicities were collected in addition to inclusion and exclusion criteria for each study. RESULTS A total of 14 studies were included in this review. Very rarely were grade 3 and 4 toxicities reported. Endpoints for the studies varied significantly, which made conclusions of overall local control and progression free survival near impossible. In studies that reported local control rates, these rates were all greater than 85%. Progression free survival varied significantly between studies. CONCLUSIONS Due to the lack of consistency in endpoint definitions, it is difficult to compare outcomes across trials. There is a need for consensus in endpoint definitions.

Quality of life and symptom burden in patients with breast cancer treated with mastectomy and lumpectomy

IntroductionMastectomy (MAS) and lumpectomy (LUMP) are the two common local surgical treatments for early breast cancer. There has been a debate whether MAS or LUMP results in better quality of life (QOL). The purpose of this study was to examine the symptom burden (SB) and QOL of both MAS and LUMP patients.MethodsPatients at the Louise Temerty Breast Cancer Centre in Toronto, Canada, were approached to complete two self-administered questionnaires, the Edmonton Symptom Assessment Score (ESAS) and the Functional Assessment of Cancer Therapy—Breast (FACT-B) cancer edition. Additionally, patient demographics were recorded from medical records. Patients were divided into two cohorts depending on their surgical treatment: MAS and LUMP. The QOL and SB, assessed by FACT-B and ESAS, respectively, of MAS and LUMP patients were compared. The analysis was repeated excluding patients with metastases.ResultsFrom January to August 2014, 614 MAS and 801 LUMP patients were accrued. The MAS patients reported a lower QOL in all categories, except social well-being. There was however no statistical difference in ESAS scores for MAS and LUMP patients with non-metastatic breast cancer.ConclusionThis study supports existing literature that SB of MAS and LUMP patients without metastases are similar. QOL of MAS patients including those with metastases was lower than that of LUMP patients.

Quality of life and symptom burden in patients with metastatic breast cancer

PurposeThe goal of this study was to examine the symptom burden (SB) and quality of life (QOL) in patients with metastatic breast cancer.MethodsBreast cancer patients with metastases were asked to complete the Edmonton Symptom Assessment System (ESAS) and FACT-B questionnaires. Statistical analysis was performed to identify (1) any differences in SB and QOL between patients with bone metastases only and patients with visceral +/− bone metastases and (2) any associations between SB and/or QOL and various clinical factors, including treatment with bisphosphonates, participation in a clinical trial and presence of brain metastases.ResultsA total of 174 patients were enrolled. Treatment with bisphosphonates was significantly associated with lower ESAS well-being scores (less symptoms) in patients with bone metastases only. In this same group, receiving treatment prior to diagnosis of metastases was significantly associated with increased fatigue, anxiety and dyspnoea. The presence of brain metastases was associated with higher physical well-being scores (increased QOL). Participation in clinical trials was associated with better QOL.ConclusionBreast cancer patients with metastases have different SB and QOL in relation to the type of the metastases, treatment interventions and participation in clinical trials.

Pelvic insufficiency fractures in women following radiation treatment: a case series

Insufficiency fractures are stress fractures that occur from normal weight-bearing on weakened bone. Radiation treatment to malignancies in the prostate, rectum, anus, or cervix may increase the risk of insufficiency fractures in the pelvic region by damaging osteoblasts that are essential to bone formation. In elderly women with cancer, this risk is greater due to their susceptibility to developing osteoporosis. These fractures may be confused with pathological fractures resulting from bone metastases on imaging and should be identified for proper management. We report two cases in which two women developed painful insufficiency fractures in the pelvic region after receiving radiation treatment to the rectum. After consulting an orthopedic surgeon, one patient underwent a cementoplasty, while the other patient was encouraged to take bone strengthening medications.

Inadequacy of Palliative Training in the Medical School Curriculum

This report examines the literature on palliative training in the current medical school curriculum. A literature search was conducted to identify relevant articles. Physicians and medical students both report feeling that their training in end-of-life care and in palliative issues is lacking. The literature expresses concerns about the varied and non-uniform approach to palliative care training across medical schools. The authors recommend the development of more palliative training assessment tools in order to aid in the standardization of curriculum involving end-of-life care. In addition, increased exposure to dying patients will aid students in building comfort with palliative care issues. Such a goal may be accomplished through required clerkships or other similar programs.

Comparison of the FACT-C, EORTC QLQ-CR38, and QLQ-CR29 quality of life questionnaires for patients with colorectal cancer: a literature review

PurposeThe purpose of this review was to compare the development, characteristics, validity, and reliability of three widely used quality of life (QOL) assessment tools used in colorectal cancer (CRC) patients: the Functional Assessment of Cancer Therapy-Colorectal (FACT-C), the European Organization for Research and Treatment of Cancer Quality of Life (EORTC) Quality of Life Questionnaire Colorectal Cancer Module (QLQ-CR38) and its successor, the QLQ-CR29.MethodsA literature search was conducted using Ovid EMBASE and EMBASE Classic (1996–2015 Week 39), Ovid MEDLINE and OLDMEDLINE (1996 September Week 4 2015), and the Cochrane Central Register of Controlled Trials (up to August 2015) to identify studies that discussed the FACT-C, EORTC QLQ-CR38, and QLQ-CR29 including, but not limited to, their development, characteristics, validity, and reliability.ResultsThe FACT-C consists of 36 items, presented on a 5-point Likert scale, in four domains of well-being (physical, emotional, social, and functional), and the Colorectal Cancer Subscale (CCS). The physical and social well-being scales showed reasonable internal consistency (Cronbach’s alpha coefficient > 60) in all studied populations. The EORTC QLQ-CR38 (38 items) and the QLQ-CR29 (29 items) are implemented in conjunction with the core QLQ-C30 (30 items); all are presented in 4-point Likert scales. Seven scales in the QLQ-CR38 demonstrated good internal consistency (Cronbach’s alpha coefficient > 0.70). In the QLQ-CR29, three scales had a Cronbach’s alpha coefficient of less than 0.70.ConclusionThe FACT-C, QLQ-CR38, and QLQ-CR29 have been extensively validated. However, analysis of their characteristics, validity, and reliability suggest differing suitability in assessing QOL in specific clinical situations.

Solitary brain metastasis from prostate cancer: a case report

Brain metastases arising from prostate cancer are exceedingly rare and typically occur late in the course of the disease. Most patients have widespread metastatic disease before developing brain metastases from prostate cancer. We report the case of a 67-year-old male with prostate cancer presenting with an isolated symptomatic brain metastasis. Aggressive treatment of the metastatic site included tumor resection and adjuvant stereotactic radiation treatment (RT) to the surgical bed, resulting in a favorable outcome.

The impact of psychosocial intervention on survival in cancer: a meta-analysis.

BACKGROUND The impact of psychosocial interventions on survival remains controversial in patients with cancer. A meta-analysis of the recent literature was conducted to evaluate the potential survival benefit associated with psychosocial interventions for cancer patients. METHODS MEDLINE, EMBASE, and Cochrane Central were searched from January 2004 to May 2015 for all randomized controlled trials (RCTs) that compared survival outcomes between cancer patients receiving a psychosocial intervention and those receiving other, or no interventions. Endpoints included one-, two-, and four-year overall survival. Subgroup analyses were performed to compare group-versus individually-delivered interventions, and to assess breast cancer-only trials. RESULTS Of 5,080 identified articles, thirteen trials were included for analysis. There was a significant survival benefit for the intervention group at one year [risk ratio (RR) =0.82; 95% confidence interval (CI), 0.67-1.00; P=0.04] and two years (RR =0.86; 95% CI, 0.78-0.95; P=0.003). However, no significant difference was detected at four years (RR =0.94; 95% CI, 0.85-1.04; P=0.24). Among patients with breast cancer, there was a significant survival benefit of psychosocial interventions at one year (RR =0.59; 95% CI, 0.42-0.82; P=0.002), but no difference at two years (RR =0.82; 95% CI, 0.67-1.02; P=0.07) or four years (RR =0.95; 95% CI, 0.73-1.23; P=0.68). Group-delivered interventions had a significant survival benefit favouring the intervention group at one year (RR =0.57; 95% CI, 0.41-0.79; P=0.0008), but no difference at two years (RR =0.84; 95% CI, 0.68-1.02; P=0.08) or four years (RR =0.94; 95% CI, 0.75-1.20; P=0.64). Individually-delivered interventions had no significant survival benefit at one year (RR =0.92; 95% CI, 0.79-1.08; P=0.32), two years (RR =0.87; 95% CI, 0.75-1.00; P=0.05), or four years (RR =0.93; 95% CI, 0.84-1.04; P=0.21). CONCLUSIONS For the main analysis and group-delivered treatments, psychosocial interventions demonstrated only short-term improvements in survival. Individually-delivered interventions failed to show any survival benefit. Future studies with longer follow-up are warranted to investigate long-term survival outcomes.

Radiological changes on CT after stereotactic body radiation therapy to non-spine bone metastases: a descriptive series

BACKGROUND In recent years, stereotactic body radiation therapy (SBRT) has become increasingly used for the management of non-spine bone metastases. Few studies have examined the radiological changes in bone metastases after treatment with SBRT and there is no consensus about what constitutes radiologic response to therapy. This article describes various changes on CT after SBRT to non-spine bone metastases in eight selected cases. METHODS A retrospective review was conducted for patients treated with SBRT to non-spine bone metastases between November 2011 and April 2014 at Sunnybrook Health Sciences Centre. A musculoskeletal radiologist identified eight illustrative cases of interest and provided a description of the findings. RESULTS Different radiological changes following SBRT were described, including: remineralization of lytic bone metastases, demineralization of sclerotic bone metastases, pathologic fracture, size progression and response in different lesions, as well as lung fibrosis after SBRT to a rib metastasis. CONCLUSIONS We reviewed the radiological images of eight selected cases after SBRT to nonspine bone metastases and a number of characteristic findings were highlighted. We recommend future studies to correlate radiologic changes with clinical outcomes including pain relief, toxicity and long-term local control.