Rebecca Verity

Enhancing the experience of carers in the chemotherapy outpatient setting: an exploratory randomised controlled trial to test impact, acceptability and feasibility of a complex intervention co-designed by carers and staff

PurposeSupporting someone through chemotherapy can be emotionally and physically demanding. However, research has yet to establish the type of support carers require or the best way to provide this. This study tested the feasibility and acceptability of a complex intervention for carers that was co-designed by staff and carers of patients starting chemotherapy.MethodsForty-seven carers were recruited, randomised between the intervention (n = 24) and control (n = 23) groups. A questionnaire was completed pre- and post-intervention measuring knowledge of chemotherapy and its side effects, experience of care, satisfaction with outpatient services, coping and emotional wellbeing. The intervention process was evaluated by carers and healthcare professionals (HCPs) in focus groups.ResultsRecruitment to the study was unproblematic and attrition from it was low, suggesting the intervention and study processes were acceptable to patients and carers. Carers in receipt of the ‘Take Care’ intervention reported statistically significantly better understanding of symptoms and side effects and their information needs being more frequently met than carers in the control. Confidence in coping improved between baseline and follow-up for the intervention group and declined for the control although differences were insufficient to achieve statistical significance. There was no significant difference between the two groups’ emotional wellbeing. HCP and carer focus groups confirmed the feasibility and acceptability of the intervention.ConclusionsThe ‘Take Care’ intervention proved acceptable to carers and HCPs and demonstrates considerable promise and utility in practice. Study findings support the conduct of a fully powered RCT to determine the intervention’s effectiveness and cost-effectiveness.

A longitudinal qualitative interview study tounderstand need for support in family members ofpeople having chemotherapy

BACKGROUND: The World Health Organisation reports that cancer mortality rates in developing African countries are rising because late diagnosis limits treatment options. In the UK there is evidence of inequalities in the delivery of cancer services to black and minority ethnic groups contributing to deaths from late diagnoses. UK studies of the African population are limited and focus on the African Caribbean community. Hence, UK cancer prevention strategies may not account for the African population’s cultural beliefs or attitudes towards cancer; this may affect awareness of the signs and symptoms. AIM: To identify evidence-based information about African immigrants’ views regarding cancer. METHODS: Six databases were searched: Academic Search Complete, AMED, CINAHL, MEDLINE, PsycInfo, and Soc Index. The literature search was extended to include grey literature and a search of reference lists of relevant studies. Publications not written in English were excluded. RESULTS: Six qualitative, nine quantitative, and one mixed method study were identified; all except two were conducted in the USA. The majority indicated that African people had low levels of knowledge about cancer risk factors, signs and symptoms. Misconceptions, cultural and religious belief and fear appear to influence African people’s views towards cancer; this may affects their behaviour in terms of seeking treatment. CONCLUSION: This review demonstrates a need for UK based studies to determine the relevance of review findings towards, and fill the gaps in knowledge about, the growing UK based African population.

EXPLORING THE WORK OF NURSES WHO ADMINISTER CHEMOTHERAPY TO CHILDREN AND YOUNG PEOPLE

Purpose: Langerhans Cell Histiocytosis (LCH) is a rare disease characterized by heterogeneous lesions containing CD207þ Langerhans cells and lymphocytes that can arise in almost any tissue and may cause significant morbidity and mortality. After decades of research, the pathogenesis of LCH remains speculative. This study was performed to test the prevailing model of LCH pathogenesis that lesions arise due to malignant transformation of epidermal Langerhans cells (LCs). Method: LCH CD207þ cells were isolated from LCH lesions, control LCs were isolated from normal skin, and gene expression was compared. Similarly, gene expression in LCH lesion CD3þ cells was compared to gene expression in peripheral blood CD3þ cells from LCH patients with active disease. Results: Compared to control epidermal CD207þ cells, the LCH CD207þ cells yielded 2900 differentially-expressed probes. Expression of many genes previously associated with LCH, including cell-cycle regulators, pro-inflammatory cytokines and chemokines were not significantly different from control LCs in our study. The study also identified several interesting genes not previously associated with increased expression in LCH including genes involved in regulation of cell cycle (CDC2A, AFF3, SMYD3, HOXB7), apoptosis (BAX, BCL2L1, CFLAR) signal transduction (DUSP4, JAK3, PRKCA, TLR2, TLR4, SOCS3, JAG2), tumor invasion and metastasis/tissue invasion (CEACAM6, MMP1, TGFB1), myeloid cell maturation (CD1d, CD13, CD14, CD33, ITGA2B, ITGAX, ITGAM, CD300LF) and lymphocyte trafficking (SPP1, VNN1, NRP1, CCR1). A large number of the cells with decreased or absent expression in the LCH-CD207 cells are involved in cell-cell adhesion, including TACSTD1. Compared to the peripheral CD3þ cells from LCH patients, the LCH lesion CD3þ cells yielded only 162 differentially-regulated probes, and the expression profile of the LCH lesion CD3þ cells was consistent with an activated regulatory T cell phenotype, including increased expression of FOXP3 and CTLA4. SPP1 had the highest relative expression in both LCH lesion CD207þ and CD3þ cells. IL-17 is a proinflammatory cytokine recently associated with LCH pathogenesis. In this study, IL-17 expression was absent from control and LCH CD207þ cells. Very little IL-17 expression was detected in T cells from LCH lesions, but abundant message was detected from tonsil lymphocytes. Conclusion: We propose a revised model of LCH pathogenesis in which lesions do not arise from epidermal Langerhans cells, but from accumulation of bone-marrow derived immature myeloid dendritic cells that recruit activated lymphocytes. Until the cell of origin can be identified, perhaps ‘‘LCH’’ should return to ‘‘Histiocytosis X’’.Purpose: The SIOP WT 2001 trial introduced a new ‘high risk’ entity: ‘blastemal type’ WT. However, the largest absolute number of relapses among localised tumours emanates from the ‘intermediate risk’ histology subgroup. We therefore investigated whether different thresholds for percentage necrosis/blastema might improve risk stratification based on histological response to pre-operative chemotherapy. Method: Data on 2,071 patients with localised unilateral WT treated with preoperative chemotherapy in the SIOP 2001 trial (to Sept 2009) were analysed. Martingale plots of excess risk of relapse versus overall% necrosis or%blastema in the viable residue were interrogated for thresholds at which risk altered. Event free survival was analysed by Kaplan-Meier methods and subgroups compared by log rank. Results: For the entire group, 2yr EFS was 88.2% (95%CI:86.6–89.8) and 5yr OS: 93.7% (95% CI:92.2–95.2). Histological risk group was a better discriminator of outcome than tumour stage (2yr EFS low risk:95.9%, intermediate risk:89.8% and high risk:76.9%, p<0.001; 2yr EFS stage I:91.0%, stage II:87.8% and stage III:83.2% p<0.001). Martingale plots showed no threshold effect for%necrosis but a reduced risk of relapse in those with <20% blastema in the viable tumour, with a small but steadily increasing risk of relapse with >50% blastema. For intermediate risk tumours, there was a significant decrease in EFS with increasing% blastema (comparing 0–10%, 10–90%, 90–100%). This persisted in the regressive subtype but was at the borderline for statistical significance in the mixed subtype (p¼0.05). The worst outcome group had 2 yr EFS of 79%. Conclusion: Survival of blastema after pre-operative chemotherapy in Wilms tumour is a better prognostic factor than% necrosis. Improved definition of chemoresistant blastema requires molecular characterisation of the disrupted biological pathways to improve risk stratification and inform discussions of new therapeutic approaches for these higher risk tumours.