Rajiv Samant

Barriers to palliative radiotherapy referral: A Canadian perspective

Radiotherapy is an effective but underutilized treatment modality for cancer patients. We decided to investigate the factors influencing radiotherapy referral among family physicians in our region. A 30-item survey was developed to determine palliative radiotherapy knowledge and factors influencing referral. It was sent to 400 physicians in eastern Ontario (Canada) and the completed surveys were evaluated. The overall response rate was 50% with almost all physicians seeing cancer patients recently (97%) and the majority (80%) providing palliative care. Approximately 56% had referred patients for radiotherapy previously and 59% were aware of the regional community oncology program. Factors influencing radiotherapy referral included the following: waiting times for radiotherapy consultation and treatment, uncertainty about the benefits of radiotherapy, patient age, and perceived patient inconvenience. Physicians who referred patients for radiotherapy were more than likely to provide palliative care, work outside of urban centres, have hospital privileges and had sought advice from a radiation oncologist in the past. A variety of factors influence the referral of cancer patients for radiotherapy by family physicians and addressing issues such as long waiting times, lack of palliative radiotherapy knowledge and awareness of Cancer Centre services could increase the rate of appropriate radiotherapy patient referral.

Radiotherapy education among family physicians and residents

BACKGROUND This study was performed to assess radiotherapy education among family physicians. METHODS A questionnaire evaluating radiotherapy training and knowledge was given to participants of a palliative care conference. RESULTS Thirty-four physicians completed the survey (71% response rate). Major deficiencies in radiotherapy education were identified and 88% of respondents stated that they did not have adequate knowledge. Only 33% had received formal training in radiotherapy and the majority (77%) thought that they would benefit considerably from continuing medical education. CONCLUSIONS Better education about radiotherapy is required for family physicians and could lead to increased patient referral for such treatment.

On-line rapid palliation using helical tomotherapy : A prospective feasibility study

Rapid delivery of radiation therapy is expected to benefit patients requiring palliation. We investigated the feasibility of employing a helical tomotherapy unit to scan, plan, and deliver a radiation treatment in a single radiation therapy appointment. Eleven patients each had an MVCT scan acquired, a plan created, and delivery completed while the patient was on the treatment couch. Timelines for each step of the process were recorded for each patient, and compared with the conventional process for similar patients. Preliminary results show that patients routinely can be treated within a 1 hour appointment for the first fraction.

Analysis of Cigarette Smoking Habits of Cancer Patients Referred to the Northeastern Ontario Regional Cancer Centre

PURPOSE To review cigarette smoking among patients referred to the Northeastern Ontario Regional Cancer Centre (NEORCC). METHODS Database analysis of the smoking history information for patients referred to the NEORCC from 1991-1999 was performed. RESULTS Data was available for 15,850 patients and 72.7% reported being either current or previous smokers. Approximately 24.5% of patients were still smoking and 7.8% had quit within the last year. Smoking rates and total consumption were highest among those patients with cancers arising in the lung, bladder, esophagus and head & neck regions. The percentage of patients reporting a history of smoking remained consistently high over the time period studied. CONCLUSIONS Cigarette smoking rates are high among NEORCC patients and strategies to improve the situation are required.

Oncology Residents’ Perspectives on Communication Skills and Shared Decision Making

Shared decision making (SDM) and effective communication are essential components of cancer care. Residents in oncology-related specialties were surveyed about communication skills and SDM. The response rate was 77% (17/22), and 93% stated that communication skills were very important for their specialty. Most (76%) thought their communication skills were adequate, but areas of difficulty included discussing end-of-life issues, giving hope when the prognosis was bleak and dealing with hostile patients. Only 58% of respondents had heard the term SDM, and 29% were aware of its meaning. More SDM and communication training are required for future oncology physicians.

Palliative Radiotherapy Knowledge Among Community Family Physicians and Nurses

Background. Primary care physicians and nurses care for patients with advanced cancer and need to be aware of the role for palliative radiotherapy (PR). Methods. We surveyed 250 family physicians, family medicine residents, and nurses attending oncology educational symposia to determine their knowledge of PR. Results. The survey response rate was 59%, and most respondents (77%) were involved with the care of cancer patients. Many (58%) thought that their knowledge of PR was insufficient for their needs. Although bone metastasis and spinal cord compression were frequently recognized indications for PR, only 50% of other assessed indications for PR were correctly identified. Almost all respondents stated that they wanted to learn more about PR. Conclusions. More education regarding PR is required for primary care physicians and nurses caring for cancer patients.Background. Primary care physicians and nurses care for patients with advanced cancer and need to be aware of the role for palliative radiotherapy (PR). Methods. We surveyed 250 family physicians, family medicine residents, and nurses attending oncology educational symposia to determine their knowledge of PR. Results. The survey response rate was 59%, and most respondents (77%) were involved with the care of cancer patients. Many (58%) thought that their knowledge of PR was insufficient for their needs. Although bone metastasis and spinal cord compression were frequently recognized indications for PR, only 50% of other assessed indications for PR were correctly identified. Almost all respondents stated that they wanted to learn more about PR. Conclusions. More education regarding PR is required for primary care physicians and nurses caring for cancer patients.

Pain assessment during conscious sedation for cervical cancer high-dose-rate brachytherapy

BACKGROUND This observational study set out to evaluate the effectiveness of conscious sedation anesthesia for pain control during high-dose-rate (hdr) brachytherapy using a ring-and-tandem applicator system for patients with cervical cancer. METHODS At the time of initiation of the hdr cervical cancer brachytherapy program at our institution, patients received a detailed symptom assessment during the procedures. Brachytherapy was carried out using a Smit sleeve, together with a ring-and-tandem applicator. Midazolam and an opioid-hydromorphone, morphine, or fentanyl-were the main agents used to achieve conscious sedation. RESULTS From January 2009 to October 2010, 20 patients (median age: 45 years) underwent 57 procedures. All patients received chemoradiation with curative intent. The median duration of the procedures was 1.4 hours, and no significant cardiovascular events were noted. The total dose of intravenous midazolam used ranged from 0.5 mg to 8.5 mg (median: 2.5 mg). The total dose of intravenous morphine equivalent used ranged from 2.5 mg to 60 mg (median: 8 mg). The mean and median pain scores during the procedures were 1.4 and 1.1 respectively. Brief moments of moderate to severe incidental pain were noted at the time of certain events during the procedure-specifically during insertion of the ring-and-tandem applicator. The maximal pain score during the entire procedure ranged from 0 to 10 (median: 4.7). The period of recovery from conscious sedation was relatively brief (median discharge time: 1 hour). CONCLUSIONS We were able to demonstrate that patients undergoing hdr brachytherapy for cervical cancer can achieve good pain control with conscious sedation.

Total Body Irradiation without Chemotherapy as Conditioning for an Allogeneic Hematopoietic Cell Transplantation for Adult Acute Myeloid Leukemia

Current therapies for acute myeloid leukemia (AML), failing induction, are rarely effective. We report our experience in 4 patients with AML who received 16 Gy TBI prior to allogeneic hematopoietic cell transplantation (alloHCT), between June 2010 and May 2011. Patients were 20 to 55 years of age, 2 with relapsed disease and 2 with AML failing induction. An HLA-matched graft from related or unrelated donor was infused on day 0. All but one, who received a CD34+-selected graft, received methotrexate and tacrolimus +/− antithymocyte globulin, as GVHD prophylaxis. The other patient received tacrolimus alone. Neutrophil and platelet engraftment occurred at a median of 18 and 14 days, respectively. Patients were discharged at a median of 28 days. There were no unexpected toxicities in the first 30 days. One patient had cytomegalovirus (CMV) viremia and anorexia, at two months. One patient had grade 2 acute GVHD of the skin. One patient developed chronic GVHD of the eyes, mouth, skin, joints, and lung at 4 months. Two patients died from relapse of their leukemia at days 65 and 125. Two patients remain in remission beyond day 1500. 16 Gy TBI followed by an alloHCT for AML, failing induction, is feasible and tolerable.

Evaluating contemporary radiotherapy approaches in the primary treatment of cervical cancer.

Purpose: Radiotherapy with concurrent cisplatinum-based chemotherapy became a standard recommendation for the management of advanced cervical cancer in 1999. We reviewed our experience with this approach to determine the impact on patient outcomes. Methods: A retrospective review of all cervical cancer patients treated with curative intent using radical radiotherapy ± chemotherapy from 1992 to 2005 was performed. Survival and relapse rates were analyzed using the Kaplan-Meier method and were compared using the log-rank test. Results: During this period, 224 treated patients were identified: 153 (68%) were treated between 1992 and 1999 (group 1) and 71 (32%) were treated after 1999 (group 2). The median age was 53 and 55 years with a median follow-up of 49 and 34 months for groups 1 and 2, respectively. Stage classification and histological diagnosis were similar for both groups. Treatment usually consisted of external beam pelvic radiotherapy (40-45 Gy in 20-25 fractions) followed by low-dose rate brachytherapy (35-40 Gy to point A). Chemotherapy consisted of weekly intravenous cisplatinum (40 mg/m2) given concurrently with pelvic radiation. The proportion of patients receiving chemotherapy increased significantly after 1999, 12% in group 1 compared with 79% in group 2 (P < 0.01). The 5-year overall survival (OS) and progression-free survival (PFS) rates were 53% and 54% for group 1 and 64% and 67% for group 2. The improvement in PFS for group 2 approached statistical significance (P = 0.06), but the difference in OS did not. Conclusions: There has been a significant increase in the use of concurrent chemoradiation for cervical cancer treatment after 1999, and this seems to have led to higher rates of PFS and OS, although these have yet to achieve statistical significance.

Assessing Patient Outcomes after Palliative Radiotherapy using Image-guided Intensity-modulated Radiotherapy

Sir d Radiotherapy is an effective tool for cancer palliation [1e3] and can relieve symptoms in 50e80% of patients with minimal toxicity. Typically, palliative radiotherapy planning is simple and involves one or two beams. However, as radiotherapy technology evolves, it is important to investigate more sophisticated approaches for palliation. We have investigated the use of image-guided intensitymodulated radiotherapy (IG-IMRT) using helical TomoTherapy for palliation and found it to be feasible [4]. It involves single-session scanning, planning and treatment of patients on a treatment machine and the process takes just 1 h. This is advantageous for palliative patients because they remain on the treatment couch for the entire procedure, do not have to move, and spend less time in the department. We have treated 40 cancer patients with palliative IG-IMRT. Themost common symptomswere pain (80%) and bleeding (12.5%). The doses prescribed ranged from 5 to 25 Gy in one to five fractions, with 8 Gy/one fraction used most often (35%). Most patients had follow-up 1 month after radiation and every 1e3 months afterwards, and 28 (70%) had documentation of their responses. Within 1 month after radiation, 75% had a partial decrease in symptoms, 7% had complete relief, 14% had no change and 4% had increasing symptoms. The response rates for pain and bleeding were similar, the average response duration was 25 weeks and side-effects were minor. Our experience suggests that IG-IMRT for palliation provides symptom relief that is at least comparable with palliative radiotherapy with more traditional approaches,