Xanthoula Kostaras

Information needs and sources of information for patients during cancer follow-up

BACKGROUND Now more than ever, cancer patients want health information. Little has been published to characterize the information needs and preferred sources of that information for patients who have completed cancer treatment. METHODS We used a nationally validated instrument to prospectively survey patients attending a cancer clinic for a post-treatment follow-up visit. All patients who came to the designated clinics between December 2011 and June 2012 were approached (N = 648), and information was collected only from those who agreed to proceed. RESULTS The 411 patients who completed the instrument included individuals with a wide range of primary malignancies. Their doctor or health professional was overwhelmingly the most trusted source of cancer information, followed by the Internet, family, and friends. The least trusted sources of information included radio, newspaper, and television. Patients most preferred to receive personalized written information from their health care provider. CONCLUSIONS Cancer survivors are keenly interested in receiving information about cancer, despite having undergone or finished active therapy. The data indicate that, for patients, their health care provider is the most trusted source of cancer information. Cancer providers should ask patients about the information they want and should direct them to trusted sources.

Use of dexamethasone in patients with high-grade glioma: a clinical practice guideline.

BACKGROUND Dexamethasone is the corticosteroid most commonly used for the management of vasogenic edema and increased intracranial pressure in patients with brain tumours. It is also used after surgery (before embarking on radiotherapy), particularly in patients whose tumours exert significant mass effect. Few prospective clinical trials have set out to determine the optimal dose and schedule for dexamethasone in patients with primary brain tumours, and subsequently, fewer clinical practice guideline recommendations have been formulated. METHODS A review of the scientific literature published to November 2012 considered all publications that addressed dexamethasone use in adult patients with brain tumours. Evidence was selected and reviewed by a working group comprising 3 clinicians and 1 methodologist. The resulting draft guideline underwent internal review by members of the Alberta Provincial cns Tumour Team, and feedback was incorporated into the final version of the guideline. RECOMMENDATIONS Based on the evidence available to date, the Alberta Provincial cns Tumour Team makes these recommendations: Treatment with dexamethasone is recommended for symptom relief in adult patients with primary high-grade glioma and cerebral edema.After surgery, a maximum dose of 16 mg daily, administered in 4 equal doses, is recommended for symptomatic patients. This protocol should ideally be started by the neurosurgeon.A rapid dexamethasone tapering schedule should be considered where appropriate.Patients who have high-grade tumours, are symptomatic, or have poor life expectancy, can be maintained on a 0.5-1.0 mg dose of dexamethasone daily.Side effects with dexamethasone are common, and they increase in frequency and severity with increased dose and duration of therapy. Patients should be carefully monitored for endocrine, muscular, skeletal, gastrointestinal, psychiatric, and hematologic complications, and for infections and other general side effects.

Recommendations for the referral of patients for proton-beam therapy, an Alberta Health Services report: a model for Canada?

BACKGROUND Compared with photon therapy, proton-beam therapy (pbt) offers compelling advantages in physical dose distribution. Worldwide, gantry-based proton facilities are increasing in number, but no such facilities exist in Canada. To access pbt, Canadian patients must travel abroad for treatment at high cost. In the face of limited access, this report seeks to provide recommendations for the selection of patients most likely to benefit from pbt and suggests an out-of-country referral process. METHODS The medline, embase, PubMed, and Cochrane databases were systematically searched for studies published between January 1990 and May 2014 that evaluated clinical outcomes after pbt. A draft report developed through a review of evidence was externally reviewed and then approved by the Alberta Health Services Cancer Care Proton Therapy Guidelines steering committee. RESULTS Proton therapy is often used to treat tumours close to radiosensitive tissues and to treat children at risk of developing significant late effects of radiation therapy (rt). In uncontrolled and retrospective studies, local control rates with pbt appear similar to, or in some cases higher than, photon rt. Randomized trials comparing equivalent doses of pbt and photon rt are not available. SUMMARY Referral for pbt is recommended for patients who are being treated with curative intent and with an expectation for long-term survival, and who are able and willing to travel abroad to a proton facility. Commonly accepted indications for referral include chordoma and chondrosarcoma, intraocular melanoma, and solid tumours in children and adolescents who have the greatest risk for long-term sequelae. Current data do not provide sufficient evidence to recommend routine referral of patients with most head-and-neck, breast, lung, gastrointestinal tract, and pelvic cancers, including prostate cancer. It is recommended that all referrals be considered by a multidisciplinary team to select appropriate cases.

Is There a Role for Clinical Practice Guidelines in Multidisciplinary Tumor Board Meetings? A Descriptive Study of Knowledge Transfer Between Research and Practice

The aim of this study was to characterize practice patterns and decision-making processes of healthcare providers attending weekly neuro-oncology tumor board meetings, and to assess their familiarity with clinical practice guidelines (CPGs) in neuro-oncology. Members of the Neuro-Oncology Tumor Team at two tertiary cancer centers completed a web-based questionnaire assessing characteristics of weekly tumor board meetings and perceptions of CPGs. Twenty-three (66%) tumor team members responded. Diagnostic imaging results and interpretation, medical, surgical, and/or radiation treatment planning, and pathology results and interpretation were the most commonly identified aspects of patient care discussed at tumor board meetings, and almost all respondents indicated that these meetings were “very beneficial” to their own practice. When deciding on a treatment plan, respondents rely most on the clinical expertise of colleagues, medical literature, personal experience, active clinical trial protocols, and published CPGs. Opinions of the local CPGs varied considerably, and while 56% of respondents supported regular discussion of them during meetings, only 32% indicated that they were routinely reviewed. Updating the literature more frequently, implementing a formal grading system for the evidence, and incorporating clinical care pathways were the most frequently cited methods to improve the CPGs. Tumor board meetings are beneficial to the treatment planning process for neuro-oncology patients.

Management of recurrent medulloblastoma in adult patients: a systematic review and recommendations

Medulloblastoma accounts for almost one-third of pediatric central nervous system (CNS) cancers, but is very rare in the adult population. As a result, adult patients with medulloblastoma are often treated according to therapies developed for children with similarly staged disease at diagnosis, based on the assumption that adult and pediatric tumors have similar properties. The purpose of this review was to summarize the evidence and to make recommendations for the management of recurrent disease in adult patients with medulloblastoma. We conducted a systematic literature search to find publications addressing treatment of recurrent medulloblastoma in adults. Current treatment strategies for adult patients with relapsed medulloblastoma are based on the results of retrospective case series and published consensus recommendations, and include maximal safe re-resection where possible, combined with chemotherapy and/or re-irradiation. We describe the results of 13 publications involving 66 adult patients treated with high-dose chemotherapy (HDCT) plus stem cell transplantation for recurrent medulloblastoma. HDCT with stem cell transplantation may be a treatment option for a small proportion of adult patients who are unlikely to benefit from conventional chemotherapy and who are fit and have their disease recurrence contained within the CNS. Potential cases in which stem cell transplantation is being considered should be discussed at a multidisciplinary tumor board which includes involvement by hematologic oncologists and transplant specialists.

Comparative effectiveness analysis of different salvage therapy intensities used for diffuse large B-cell lymphoma in Northern or Southern Alberta: an instrumental variable analysis

Abstract To date, no clinical trial has addressed salvage therapy intensity for relapsed/refractory diffuse large B-cell lymphoma (DLBCL). We sought to determine whether the more intensive salvage chemotherapy approach used in Southern Alberta (SAB) compared to the conventional dose salvage approach used in Northern Alberta (NAB) affects the rates of autologous stem cell transplant (ASCT) and survival in patients with relapsed DLBCL. Using instrumental variable analysis, we examined 147 consecutive patients with relapsed/refractory DLBCL from 2004 to 2010 who received salvage therapy in SAB (n = 70) or NAB (n = 77). Patients treated in SAB had higher rates of: salvage chemotherapy response (85.0% vs. 54.0%, p = 0.001), ASCT (61.4% vs. 41.6%, p = 0.016) and 4-year overall survival (41% vs. 20%, p = 0.002) than those in NAB, respectively. This study supports the hypothesis that selective use of intensive salvage chemotherapy leads to higher rates of ASCT and survival in this population.

A population-based assessment of melanoma: Does treatment in a regional cancer center make a difference?

Regionalization of care to specialized centers has improved outcomes for several cancer types. We sought to determine if treatment in a regional cancer center (RCC) impacts guideline adherence and outcomes for patients with melanoma.

Real-world adjuvant TAC or FEC-D for HER2-negative node-positive breast cancer in women less than 50 years of age

PURPOSE We compared the efficacy, toxicity, and use of granulocyte colony-stimulating factor (g-csf) with tac (docetaxel-doxorubicin-cyclophosphamide) and fec-d (5-fluorouracil-epirubicin-cyclophosphamide followed by docetaxel) in women less than 50 years of age. METHODS The study included all women more than 18 years but less than 50 years of age with her2-negative, node-positive, stage ii or iii breast cancer diagnosed in Alberta between 2008 and 2012 who received tac (n = 198) or fec-d (n = 274). RESULTS The patient groups were well-balanced, except that radiotherapy use was higher in the tac group (91.9% vs. 79.9%, p < 0.001). At a median follow-up of 49.6 months, disease-free survival was 91.4% for tac and 92.0% for fec-d (p = 0.76). Overall survival (os) was 96% with tac and 95.3% with fec-d (p = 0.86).The incidences of grades 3 and 4 toxicities were similar in the two groups (all p > 0.05). Overall, febrile neutropenia (fn) was reported in 11.6% of tac patients and 15.7% of fec-d patients (p = 0.26). However, use of g-csf was higher in the tac group than in the fec-d group (96.4% vs. 71.5%, p < 0.001). Hospitalization for fn was required in 10.5% of tac patients and 13.0% of fec-d patients (p = 0.41). In g-csf-supported and -unsupported patients receiving tac, fn occurred at rates of 11.1% and 33.3% respectively (p = 0.08); in patients receiving the fec portion of fec-d, those proportions were 2.9% and 8.1% respectively (p = 0.24); and in patients receiving docetaxel after fec, the proportions were 4.1% and 17.6% respectively (p < 0.001). CONCLUSIONS In women less than 50 years of age receiving adjuvant tac or fec-d, we observed no differences in efficacy or other nonhematologic toxicities. Based on the timing and rates of fn, use of prophylactic g-csf should be routine for the docetaxel-containing portion of treatment; however, prophylactic g-csf could potentially be avoided during the fec portion of fec-d treatment.

Improving access to cancer guidelines: feedback from health care professionals.

PURPOSE We examined access to locally developed and other available clinical practice guidelines (cpgs) for the management of cancer and evaluated how to improve uptake. METHODS A 12-question online survey was administered to 772 members of 12 multidisciplinary tumour teams in a Canadian provincial oncology program. The teams are composed of physicians, surgeons, nurses, allied health professionals, and researchers involved in the provision of cancer care across the province. Many of these individuals construct or provide input into the provincial cpgs. The questionnaires were administered online and were completed voluntarily. RESULTS Responses were received from 232 individuals, a response rate of 30.1%. Most respondents (75.1%) indicated they actively referenced cpgs for cancer treatment. Of the 177 respondents who identified barriers to cpg access, 24.9% said that the cause was being too busy; 24.3% and 22.6% cited the user-unfriendliness of the Web site and a lack of awareness about the cpgs. When asked about innovative changes that could be made to improve access, the creation of cpg summary documents was identified as the most effective change (46.3%). The creation of summary documents was ranked highest by physicians, surgeons, and nurses. CONCLUSIONS Clinical practice guidelines are important tools for standardizing treatment protocols and improving outcomes in health care systems, but support for their use is variable among health care professionals. We have identified barriers to-and potential mitigating strategies for-more widespread access to cpgs by the various health professions involved in cancer care. Local creation of succinct and easily accessible cpgs was identified as the single most effective way to enhance access by health care professionals.

An audit of referral and treatment patterns of high-risk prostate cancer patients in Alberta

INTRODUCTION We aimed to determine the impact of clinical practice guidelines (CPG) on rates of radiation oncologist (RO) referral, androgen-deprivation therapy (ADT), radiation therapy (RT), and radical prostatectomy (RP) in patients with high-risk prostate cancer (HR-PCa). METHODS All men >18 years, diagnosed with PCa in 2005 and 2012 were identified from the Alberta Cancer Registry. Patient age, aggregated clinical risk group (ACRG) score, Gleason score (GS), pre-treatment prostate-specific antigen (PSA), RO referral, and treatment received were extracted from electronic medical records. Logistic regression modelling was used to examine associations between RO referral rates and relevant factors. RESULTS HR-PCa was diagnosed in 261 of 1792 patients in 2005 and 435 of 2148 in 2012. Median age and ACRG scores were similar in both years (p>0.05). The rate of patients with PSA >20 were 67% and 57% in 2005 and 2012, respectively (p=0.004). GS ≤6 was found in 13% vs. 5% of patients, GS 7 in 27% vs. 24%, and GS ≥8 in 59% vs. 71% in 2005 and 2012, respectively (p<0.001). In 2005, RO referral rate was 68% compared to 56% in 2012 (p=0.001), use of RT + ADT was 53% compared to 32% (p<0.001), and RP rate was 9% vs. 17% (p=0.002). On regression analysis, older age, 2012 year of diagnosis and higher PSA were associated with decreased RO referral rates (odds ratios [OR] 0.49, 95% confidence interval [CI] 0.39-0.61; OR 0.51, 95% CI 0.34-0.76; and OR 0.64, 95% CI 0.39-0.61), respectively [p<0.001]). CONCLUSIONS Since CPG creation in 2005, RO referral rates and ADT + RT use declined and RP rates increased, which demonstrates a need to improve adherence to CPG in the HR-PCa population.