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ABSTRACT: STUDY OBJECTIVE: Since 2007 in Ontario, Canada, the Edmonton Symptom Assessment System has been routinely used for cancer outpatients. The purpose of this study is to determine the relationship between individual patient symptoms and symptom severity, with the likelihood of an emergency department (ED) visit. METHODS: The cohort included all cancer patients in Ontario who completed an Edmonton Symptom Assessment System between January 2007 and March 2009. Using multiple linked provincial health databases, we examined the adjusted association between symptom scores and the likelihood of an ED visit within 7 days of assessment. RESULTS: The cohort included 45,118 patients whose first assessment contributed to the study, of whom 3.8% made a subsequent ED visit. A severe well-being score was associated with the highest odds of a subsequent ED visit (adjusted odds ratio [OR] 1.9; 95% confidence interval 1.5 to 2.4). Nausea, drowsiness, and shortness of breath with moderate or severe scores were associated with ED visits (adjusted OR 1.2 to 1.5), whereas pain, tiredness, poor appetite, and well-being had a significant association for mild scores (adjusted OR 1.2, 1.3, 1.2, and 1.3, respectively), moderate scores (adjusted OR 1.3, 1.5, 1.5, and 1.7, respectively), and severe scores (adjusted OR 1.4, 1.7, 1.7, and 1.9, respectively). Anxiety and depression were not associated with ED visits. CONCLUSION: Worsening symptoms contribute to emergency visits in cancer patients. Specific symptoms such as pain are obvious management targets, but constitutional symptoms were associated with even higher odds of ED usage and therefore warrant detailed assessment to optimize both patient outcomes and resource use.
Annals of emergency medicine 01/2013; · 4.23 Impact Factor
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ABSTRACT: As cancer care becomes increasingly complex, the ability to coordinate this care is more difficult for health care providers, patients and their caregivers alike. Despite the widely recognized need for improving continuity and coordination of care, the relationship of continuity of care with patient outcomes has yet to be elucidated. Our study's main finding is that the Continuity and Coordination subscale of the widely used Picker System of Ambulatory Cancer Care Survey is able to distinguish between lung cancer patients with unmet supportive care needs and those without. Specifically, this study shows a new association between this widely implemented continuity and coordination survey and the 'psychological needs' domain, as well as the 'health system and information' domains of supportive care needs. The finding provides support for the idea that interventions to improve continuity may impact tangible indicators of patient care such as supportive care needs being met. The study focuses attention on continuity of care as an important aspect of optimizing outcomes in cancer care.
Supportive Care in Cancer 12/2012; · 2.09 Impact Factor
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ABSTRACT: Abstract Background: Previous studies have reported survival estimates in palliative populations using the Palliative Performance Scale (PPS) (where 100=best status, 0=death). However, little research has examined the association of the PPS with hazard of death in ambulatory populations. Objective: We examined the association between performance status and the instantaneous hazard of death in ambulatory cancer patients, using longitudinal PPS scores. Methods: This retrospective, population-based cohort study included cancer outpatients who had at least one PPS assessment completed between 2007 and 2009. PPS scores were recorded opportunistically by health care providers at clinic or home care visits. We used a Cox proportional hazards model to determine the relative hazard of death based on repeated measures of PPS score, while controlling for other covariates. Results: Among 11,342 qualifying cancer patients, there were 54,207 PPS assessments. The distribution of PPS scores at first assessment were 23%, 56%, 20%, and 1% for PPS scores of 100, 90-70, 60-40, and ≤30, respectively. A quarter of the cohort died within 6 months of the first assessment. The relative hazard of death increases by a factor of 1.69 (95% confidence interval [CI]: 1.72-1.67) for each 10-point decrease in PPS score. Thus the hazard of death increases by 8.2 (1.69(4)) times for a person with PPS score of 30 compared with a person with a score of 70. Conclusion: The PPS was significantly associated with hazard of death in ambulatory cancer patients; the relative hazard of death increased based on lowered PPS scores. Providers should consider broadening its use to include patients throughout their disease trajectory.
Journal of palliative medicine 12/2012; · 1.84 Impact Factor
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ABSTRACT: Standardized, electronic, symptom assessment is purported to help identify symptom needs. However, little research examines clinical processes related to symptom management, such as whether patients with worsening symptoms receive clinical actions more often. This study examined whether patient visits with higher symptom scores are associated with higher rates of symptom documentation in the chart and symptom-specific actions being taken.
Retrospective chart reviews on cancer patient visits at a regional cancer center. An electronic Edmonton Symptom Assessment Scale (ESAS), a validated tool to measure symptoms, was implemented center-wide to standardize symptom screening at every patient visit. The independent variable was ESAS scores for pain and shortness of breath, categorized by severity: 0 (none), 1-3, 4-6, 7-10 (severe). Outcomes included symptom documentation in the chart on the visit date and symptom-related action(s) taken within 1 week.
Nine hundred twelve visits were identified. Pain and shortness of breath were documented in 51.8% and 29.7% of charts, and a related-action occurred in 16.9% and 3.9% of charts, respectively. As ESAS severity score category increased from none to severe, the proportion of visits with pain documented increased significantly (36.9%, 49.2%, 55.2%, and 71.4%; P < .001). Likewise, as ESAS score severity increased, the proportion of visits with a pain-related action increased significantly (4.2%, 10.6%, 21.3%, and 37.0%; P < .001). Trends were similar for shortness of breath.
Results show a positive association between higher symptom scores and higher rates of documentation and clinical actions taken. However, symptom-related actions were documented in a minority of visits in which symptoms were noted as severe.
Journal of Oncology Practice 11/2012; 8(6):e142-e148.
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ABSTRACT: CONTEXT: Understanding the longitudinal transitions of performance status among persons with cancer can assist providers in determining the appropriate time to initiate palliative care support. OBJECTIVES: To model longitudinal transitions of the performance status in cancer outpatients, to determine the probabilities of improvement and deterioration in performance status over time, and to evaluate the factors associated with rates of transitions. METHODS: This population-based, retrospective, cohort study comprised adult outpatients diagnosed with any type of cancer and assessed for performance status throughout their observation period using the Palliative Performance Scale (PPS; scale 0-100; 0 indicates death). At every PPS assessment, patients were assigned to one of four states: stable state (PPS score 70-100), transitional state (PPS score 40-60), end-of-life state (PPS score 10-30), or dead. A Markov multistate model under the presence of interval censoring was used to examine the rate of state-to-state transitions. RESULTS: There were 11,374 patients representing nearly 71,000 assessments. Patients with lung cancer in the transitional state had a 27.7% chance of being dead at the end of one month vs. 17.5% in patients with breast cancer. The average time spent in the transitional state was 6.6 weeks for patients diagnosed with gastrointestinal cancer vs. 8.8 weeks for patients with breast cancer. The rate at which one moves from the transitional state to death was higher for patients with lung cancer than those with breast cancer. CONCLUSION: We estimated the probability and direction of change in performance status in cancer outpatients. Entry into the transitional state may serve as an indicator for referral for palliative care support. Mean end-of-life sojourn times are too short to allow meaningful integration of palliative care.
Journal of pain and symptom management 08/2012; · 2.42 Impact Factor
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ABSTRACT: Cluster identification has emerged as a priority for symptom research. Variation in statistical approaches has hampered the identification of common clusters that should be targeted for intervention. The purpose of this study was to identify and validate common symptom clusters in a large population-based cohort of ambulatory cancer subjects.
This descriptive, factor analysis study used bootstrap methods to derive a stable factor structure to identify symptom clusters in a population-based sample of cancer patients. Subjects were identified from a provincial symptom database and linked to other provincial databases. Symptom clusters were validated using confirmatory factor analysis in a randomly selected portion of the sample and model fit examined using common goodness of fit criteria.
The cluster cohort included 14,247 subjects. Three symptom clusters were identified: fatigue-sickness symptoms (tiredness, nausea, drowsiness and shortness of breath), emotional distress (depression and anxiety), and a poor sense of well-being (appetite and well-being). These clusters were stable across most sub-populations in the cohort.
The identification of common symptom clusters using robust statistical methods will help to yield targets to improve symptom management and identify populations at risk for worse disease outcomes.
European journal of cancer (Oxford, England: 1990) 05/2012; 48(16):3073-81. · 4.12 Impact Factor
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ABSTRACT: Goal of WorkThe goal of this work was to identify methods of clinician–patient cancer-related communication that may impact patient outcomes
associated with distress at critical points in the course of cancer care.
Materials and methodsA systematic review of practice guidelines, systematic reviews, or randomized trials on this topic was conducted. Guidelines
for quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Instrument, and the contributive value
for recommendations was assessed. Systematic reviews and randomized trials were also evaluated for methodological rigor.
ResultsFour existing guidelines, eight systematic reviews and nine randomized trials were identified. Two of the guidelines were
of high quality, and all systematic reviews reported clear search criteria and support for their conclusions; the randomized
trials were of modest or low quality. For all situations and disease stages, guidelines consistently identified open, honest,
and timely communication as important; specifically, there was evidence for a reduction in anxiety when discussions of life
expectancy and prognosis were included in consultations. Techniques to increase patient participation in decision-making were
associated with greater satisfaction but did not necessarily decrease distress. Few studies took cultural and religious diversity
into account.
ConclusionsThere is little definitive evidence supporting the superiority of one specific method for communicating information compared
to another. Evidence regarding the benefit of decision aids or other strategies to facilitate better communication is inconsistent.
Since patients vary in their communication preferences and desire for active participation in decision making, there is a
need to individualize communication style.
Supportive Care Cancer 04/2012; 17(6):627-644. · 2.60 Impact Factor
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ABSTRACT: GoalThis study assessed the degree to which services in south–central Ontario, Canada, were coordinated to meet the supportive
care needs of palliative cancer patients and their families.
Participants and methodPrograms within the region that were identified as providing supportive care to palliative cancer patients and their families
were eligible to participate in the study. Program administrators participated in a semi-structured interview and direct-care
providers completed a survey instrument.
Main resultsAdministrators from 37 (97%) of 38 eligible programs and 109 direct-care providers representing 26 (70%) programs participated
in the study. Most administrator and direct-care respondents felt that existing services in the community were responsive
to palliative care patients’ individual needs. However, at a system level, most respondents in both groups felt that required
services were not available and that resources were inadequate. The most frequently reported unmet supportive care need identified
by both respondent groups was psychological/social support. Most administrator (69%) and direct-care (64%) respondents felt
that palliative care services were not available when needed. The majority of administrator and direct-care respondents were
satisfied with the exchange of patient information within and between programs, although direct-care staff identified a deficit
in information transferred on palliative care patients’ social/psychological status.
ConclusionsThe study demonstrated the value of a theory-based approach to evaluate the coordination of palliative cancer care services.
The findings revealed that service programs faced significant challenges in their efforts to provide coordinated care.
Supportive Care Cancer 04/2012; 17(7):819-828. · 2.60 Impact Factor
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ABSTRACT: The purpose of this study was to measure opioid prescription (OP) rates in elderly cancer outpatients around the time of assessment for pain and to evaluate factors associated with receiving OPs for those with severe pain.
The cross-sectional cohort includes all patients with cancer in Ontario older than age 65 years who completed a pain assessment as part of a provincial initiative of systematic symptom screening. Patients were assigned to mutually exclusive categories by pain score severity: 0, 1 to 3 (mild), 4 to 6 (moderate), and 7 to 10 (severe). We linked multiple provincial health databases to examine the proportion of patients with an OP within 7 days after or 30 days before the assessment date. We examined factors associated with OPs for patients with pain scores of 7 to 10.
The proportion of patients with an OP increased as pain score severity increased: 10% of those with no pain, 24% of those with mild pain, 45% of those with moderate pain, and 67% of those with severe pain. More specifically, for those with severe pain, 41% filled an OP within 7 days of assessment for pain, and 26% had an OP from the 30 days before assessment for pain, leaving 33% without an OP. In multivariable analysis, factors associated with OPs are younger age, male sex, comorbid illness, cancer type, and assessment at home.
Despite a generous time window for capturing OPs, the proportion of patients without an OP seems high. Further knowledge translation is required to maximize the impact of the symptom screening initiative in Ontario and to optimize management of cancer-related pain.
Journal of Clinical Oncology 02/2012; 30(10):1095-9. · 18.37 Impact Factor
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Eva Grunfeld,
Jim A Julian,
Gregory Pond,
Elizabeth Maunsell,
Douglas Coyle,
Amy Folkes,
Anil A Joy,
Louise Provencher,
Daniel Rayson,
Dorianne E Rheaume,
Geoffrey A Porter,
Lawrence F Paszat,
Kathleen I Pritchard,
André Robidoux,
Sally Smith, Jonathan Sussman,
Susan Dent,
Jeffrey Sisler,
Jennifer Wiernikowski,
Mark N Levine
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ABSTRACT: An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes.
Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures.
Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005).
The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer.
Journal of Clinical Oncology 12/2011; 29(36):4755-62. · 18.37 Impact Factor
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ABSTRACT: Patient involvement in care practice has many and diverse proponents. It is endorsed by health care institutions and promoted by community agencies representing people with illness. A vast literature documents the benefits of patient involvement and describes ways to enable it. This article contributes to a critical literature on patient involvement by documenting the work done by women with cancer in relation to care timelines and in responding to troubles with care. We highlight continuities and disjunctures between this work, and discourses of patient involvement as they manifest in documents circulating at an Ontario cancer centre. In making visible the social and material resources that underpin successful involvement, the study shows how initiatives that endorse and promote 'the involved patient' can function to exacerbate health care and social disparities. As well, the study extends analysis of the individualization and privatization of health by showing how contemporary discourses of involvement enlist patients to monitor and sustain not only their own health, but also the health care they receive.
Health 08/2011; 16(4):400-17. · 2.10 Impact Factor
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ABSTRACT: A number of palliative care delivery models have been proposed to address the structural and process gaps in this care. However, the specific elements required to form competent systems are often vaguely described.
The purpose of this study was to explore whether a set of modifiable health system factors could be identified that are associated with population palliative care outcomes, including less acute care use and more home deaths.
A comparative case study evaluation was conducted of 'palliative care' in four health regions in Ontario, Canada. Regions were selected as exemplars of high and low acute care utilization patterns, representing both urban and rural settings. A theory-based approach to data collection was taken using the System Competency Model, comprised of structural features known to be essential indicators of palliative care system performance. Key informants in each region completed study instruments. Data were summarized using qualitative techniques and an exploratory factor pattern analysis was completed.
43 participants (10+ from each region) were recruited, representing clinical and administrative perspectives. Pattern analysis revealed six factors that discriminated between regions: overall palliative care planning and needs assessment; a common chart; standardized patient assessments; 24/7 palliative care team access; advanced practice nursing presence; and designated roles for the provision of palliative care services.
The four palliative care regional 'systems' examined using our model were found to be in different stages of development. This research further informs health system planners on important features to incorporate into evolving palliative care systems.
Palliative Medicine 08/2011; 26(4):322-35. · 2.38 Impact Factor
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Laurie H Sehn,
David MacDonald,
Sheldon Rubin,
Guy Cantin,
Morel Rubinger,
Bernard Lemieux,
Sanraj Basi,
Kevin Imrie,
Randy D Gascoyne, Jonathan Sussman,
Bingshu E Chen,
Marina Djurfeldt,
Lois Shepherd,
Stephen Couban,
Michael Crump
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ABSTRACT: Bortezomib has demonstrated promising activity in patients with follicular lymphoma (FL). This is the first study to evaluate the safety and efficacy of bortezomib added to rituximab, cyclophosphamide, vincristine, and prednisone (R-CVP) in previously untreated advanced-stage FL.
This is a phase II multicenter trial adding bortezomib (1.3 mg/m(2) days 1 and 8) to standard-dose R-CVP (BR-CVP) for up to eight cycles in patients with newly diagnosed stage III/IV FL requiring therapy. Two co-primary end points, complete response rate (complete response [CR]/CR unconfirmed [CRu]) and incidence of grade 3 or 4 neurotoxicity, were assessed.
Between December 2006 and March 2009, 94 patients were treated with BR-CVP. Median patient age was 57 years (range, 29 to 84 years), and the majority had a high (47%) or intermediate (43%) Follicular Lymphoma International Prognostic Index score. BR-CVP was extremely well tolerated, with 90% of patients completing the intended eight cycles. No patients developed grade 4 neurotoxicity, and only five of 94 patients (5%; 95% CI, 0.8% to 9.9%) developed grade 3 neurotoxicity, which was largely reversible. On the basis of an intention-to-treat analysis, 46 of 94 patients (49%; 95% CI, 38.8% to 59.0%) achieved a CR/CRu, and 32 of 94 patients (34%) achieved a partial response, for an overall response rate of 83% (95% CI, 75.4% to 90.6%).
The addition of bortezomib to standard-dose R-CVP for advanced-stage FL is feasible and well tolerated with minimal additional toxicity. The complete response rate in this high-risk population compares favorably to historical results of patients receiving R-CVP. Given these results, a phase III trial comparing BR-CVP with R-CVP is planned.
Journal of Clinical Oncology 08/2011; 29(25):3396-401. · 18.37 Impact Factor
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ABSTRACT: Meeting the supportive care needs of cancer patients remains a challenge to cancer care systems around the world. Despite significant improvements in the organization of medical care of patients with cancer, numerous surveys of cancer populations demonstrate that significant proportions of patients fail to have their supportive care needs met. One possible solution is the introduction of a care coordinator role using oncology nursing to help ensure that patients' physical, psychological, and social support needs are addressed. Although having face validity, there is little empirical evidence on the effects of nurse-led supportive care coordinator roles on patient reported supportive care outcomes. In this article the authors present the results of a prospective longitudinal cohort study of 113 patients referred to a community-based specialist oncology nursing program. Using validated instruments they found significant improvements in patient-reported outcomes in key supportive care domains: unmet needs, quality of life, and continuity of care, as well as a shift in patterns of health resource utilization from acute care settings to the community over the course of the intervention. The results of this study are important in supporting the design and development of controlled trials to examine provider roles in the coordination of supportive cancer care.
Journal of Psychosocial Oncology 05/2011; 29(3):286-307. · 0.98 Impact Factor
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ABSTRACT: Ontario's cancer system is unique because it has implemented two standardized assessment tools population-wide to improve care: the Edmonton Symptom Assessment System (ESAS) measures severity of nine symptoms (scale 0 to 10; 10 indicates the worst) and the Palliative Performance Scale (PPS) measures performance status (scale 0 to 100; 0 indicates death). This article describes the trajectory of ESAS and PPS scores 6 months before death.
Observational cohort study of cancer decedents between 2007 and 2009. Decedents required ≥1 ESAS or PPS assessment in the 6 months before death for inclusion. Outcomes were the decedents' average ESAS and PPS scores per week before death.
Ten thousand seven hundred fifty-two (ESAS) and 7,882 (PPS) decedents were included. The mean age was 65 years, half were female, and approximately 75% of assessments occurred in cancer clinics. Average PPS score declined slowly over the 6 months before death, starting at approximately 70 and ending at 40, declining more rapidly in the last month. For ESAS symptoms, average pain, nausea, anxiety, and depression scores remained relatively stable over the 6 months. Conversely, shortness of breath, drowsiness, well-being, lack of appetite, and tiredness increased in severity over time, particularly in the month before death. More than one third of the cohort reported moderate to severe scores (ie, 4 to 10) for most symptoms in the last month of life.
In this large outpatient cancer population, trajectories of mean ESAS scores followed two patterns: increasing versus generally flat. The latter was perhaps due to available treatment (eg, prescriptions) for those symptoms. Future research should prioritize addressing symptoms that worsen over time.
Journal of Clinical Oncology 02/2011; 29(9):1151-8. · 18.37 Impact Factor
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ABSTRACT: Despite growing implementation of electronic symptom assessment in oncology settings, few studies have described how standardized symptom assessment can enhance multidisciplinary care. The Edmonton Symptom Assessment System (ESAS) is a validated measure of symptom burden that has been adopted by Ontario's cancer centers to assess symptoms for patients with cancer. This study examines the perceived value of the ESAS among clinical teams and barriers to its use in enhancing multidisciplinary care.
Self-completed surveys were administered online to clinical teams at various disease-site clinics at a cancer center in Ontario, Canada.
One hundred twenty-eight nurses, oncology physicians, and allied health professions completed the survey. The majority of nurses (89%), physicians (55%), and other providers (57%) reported referring to ESAS in clinic either "always" or "most of the time." Many of those who either "never" or "rarely" looked at ESAS scores reported finding it more efficient to talk to the patient or do their own assessment to determine symptom issues. Although most of the nurses and allied health professions found the ESAS to enhance patient care, help patients to articulate their symptom issues, and facilitate follow-up with patients with past symptom issues, only approximately half of the physicians agreed with these statements.
Variable adoption of the ESAS by physicians may limit its potential to improve both interprofessional communication and comprehensive symptom control. To encourage consistent use, a symptom assessment system needs to be complementary to the perceived roles of all multidisciplinary team members, including physicians.
Journal of Oncology Practice 01/2011; 7(1):19-23.
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ABSTRACT: The objective of this study is to estimate the direct medical cost of end-of-life and palliative (EOL/PAL) care for cancer patients during the last six months of their lives--or, during the period from diagnosis to death, if briefer--in 2002 and 2003, in Ontario, Canada. A linkage of cancer registry and administrative data is used to determine the costs of health care resources used during the EOL/PAL care period. Costs are analyzed by cancer diagnosis, location of death, and type of service. The total Ontario Ministry of Health-funded cost of EOL/PAL care for cancer patients is estimated to be about CAD$544 million per year, with an average per patient cost of about $25,000 in 2002-2003. Our results suggest that acute care consumes 75 percent of EOL/PAL funding and that only a small proportion of health care services used by EOL/PAL care cancer patients is likely to be formal palliative care.
Journal of palliative care 01/2011; 27(2):79-88. · 0.93 Impact Factor
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ABSTRACT: For ambulatory cancer patients, Ontario has standardized symptom and performance status assessment population-wide, using the Edmonton Symptom Assessment System (ESAS) and Palliative Performance Scale (PPS). In a broad cross-section of cancer outpatients, the authors describe the ESAS and PPS scores and their relation to patient characteristics.
This is a descriptive study using administrative healthcare data.
The cohort included 45,118 and 23,802 patients' first ESAS and PPS, respectively. Fatigue was most prevalent (75%), and nausea least prevalent (25%) in the cohort. More than half of patients reported pain or shortness of breath; about half of those reported moderate to severe scores. Seventy-eight percent had stable performance status scores. On multivariate analysis, worse ESAS outcomes were consistently seen for women, those with comorbidity, and those with shorter survivals from assessment. Lung cancer patients had the worst burden of symptoms.
This is the first study to report ESAS and PPS scores in a large, geographically based cohort with a full scope of cancer diagnoses, including patients seen earlier in the cancer trajectory (ie, treated for cure). In this ambulatory cancer population, the high prevalence of numerous symptoms parallels those reported in palliative populations and represents a target for improved clinical care. Differences in outcomes for subgroups require further investigation. This research sets the groundwork for future research on patient and provider outcomes using linked administrative healthcare data.
Cancer 12/2010; 116(24):5767-76. · 4.77 Impact Factor
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Tanya S Berrang,
Ivo Olivotto,
Do-Hoon Kim,
Alan Nichol,
B C John Cho,
Islam G Mohamed,
Tarnjit Parhar,
J R Wright,
Pauline Truong,
Scott Tyldesley, Jonathan Sussman,
Elaine Wai,
Tim Whelan
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ABSTRACT: To report 3-year toxicity, cosmesis, and efficacy of a multicenter study of external beam, accelerated partial breast irradiation (APBI) for early-stage breast cancer.
Between March 2005 and August 2006, 127 women aged ≥40 years with ductal carcinoma in situ or node-negative invasive breast cancer ≤3 cm in diameter, treated with breast-conserving surgery achieving negative margins, were accrued to a prospective study involving five Canadian cancer centers. Women meeting predefined dose constraints were treated with APBI using 3 to 5 photon beams, delivering 35 to 38.5 Gy in 10 fractions, twice a day, over 1 week. Patients were assessed for treatment-related toxicities, cosmesis, and efficacy before APBI and at specified time points for as long as 3 years after APBI.
104 women had planning computed tomography scans showing visible seromas, met dosimetric constraints, and were treated with APBI to doses of 35 Gy (n=9), 36 Gy (n=33), or 38.5 Gy (n=62). Eighty-seven patients were evaluated with minimum 3-year follow-up after APBI. Radiation dermatitis, breast edema, breast induration, and fatigue decreased from baseline levels or stabilized by the 3-year follow-up. Hypopigmentation, hyperpigmentation, breast pain, and telangiectasia slightly increased from baseline levels. Most toxicities at 3 years were Grade 1. Only 1 patient had a Grade 3 toxicity with telangiectasia in a skin fold inside the 95% isodose. Cosmesis was good to excellent in 86% (89/104) of women at baseline and 82% (70/85) at 3 years. The 3-year disease-free survival was 97%, with only one local recurrence that occurred in a different quadrant away from the treated site and two distant recurrences.
At 3 years, toxicity and cosmesis were acceptable, and local control and disease-free survival were excellent, supporting continued accrual to randomized APBI trials.
International journal of radiation oncology, biology, physics 10/2010; 81(5):1220-7. · 4.59 Impact Factor
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ABSTRACT: The risk of cardiac hospitalization (CH) in Hodgkin lymphoma (HL) patients with preexisting heart disease was evaluated. Patients with HL were identified from a population-based registry (N = 3964). Data were abstracted from records of a randomly selected subcohort (N = 1096). A population-based registry was used to identify CH. Factors associated with CH and the incidence of CH after HL were estimated with competing risk models. Preexisting heart disease was the strongest predictor of posttreatment CH (hazard ratio = 3.98, P < .001) and significantly modified (P = .01) the effect of treatment on the risk of CH. Among patients with preexisting heart disease, treatment with mediastinal radiation therapy plus doxorubicin-based chemotherapy was associated with a 10-year incidence of CH more than 20% higher than treatment with chemotherapy alone. There is a high risk of CH after mediastinal radiation therapy plus doxorubicin-based chemotherapy among patients with preexisting heart disease; this is an important consideration when weighing treatment options, and in the follow-up of these patients.
Blood 09/2010; 116(13):2237-40. · 9.90 Impact Factor
