Curr. Oncol., Volume 26, Issue 3 (June 2019) – 33 articles

Combination immune checkpoint blockade with concurrent administration of the anti-CTLA4 antibody ipilimumab and the anti–PD-1 antibody nivolumab has demonstrated impressive responses in patients with advanced melanoma and other diseases. That combination has also been associated with increased toxicity, including rare immune-related adverse events. Here we describe a case of fatal steroid-refractory myocarditis and panmyositis associated with the use of this combination in a patient with metastatic melanoma. Correlative studies indicated increased levels of serum interleukin 6 in this patient at the onset of toxicity, suggesting a possible role for anti–interleukin 6 receptor antibodies in the treatment of subsequent cases of this rare, but fatal, toxicity. Full article

Introduction: The number of survivors of breast cancer (bca) in Canada has steadily increased thanks to major advances in cancer care. But the resulting clientele face new challenges related to survivorship. The lack of continuity of care and the side effects of treatment affect the resumption of active life by survivors of bca, including return to work (rtw). The goal of the present article was to outline gaps and delay in survivorship care in the rtw pathway of survivors of bca. Methods: This qualitative interpretative descriptive study recruited 9 survivors of bca in the province of Quebec. Interviews were conducted at the end of cancer treatments (n = 9), 1 month before rtw (n = 9), and after rtw (n = 5). In an iterative process, a content analysis was performed. Results: The interviews highlighted gaps in survivorship care and the paucity of dedicated resources for cancer survivors. Participants received neither a survivorship care plan nor information about cancer survivorship (for example, transition to a new normal, side effects, rtw). Conclusions: Support for survivors of bca resuming their active lives has to be optimized. We suggest that health professionals have to intervene at 1, 3, and 6 months after cancer treatment. At those points, survivors of bca need support for side-effects management, the rtw decision, resource navigation, and reintegration of daily activities. Also, delay in clinical pathways seems to be longer, and much attention is needed to accompany the transition to a “normal life” after cancer. Full article

Two guidelines about opioid use in chronic pain management were published in 2017: the Canadian Guideline for Opioids for Chronic Non-Cancer Pain and the European Pain Federation position paper on appropriate opioid use in chronic pain management. Though the target populations for the guidelines are the same, their recommendations differ depending on their purpose. The intent of the Canadian guideline is to reduce the incidence of serious adverse effects. Its goal was therefore to set limits on the use of opioids. In contrast, the European Pain Federation position paper is meant to promote safe and appropriate opioid use for chronic pain. The content of the two guidelines could have unintentional consequences on other populations that receive opioid therapy for symptom management, such as patients with cancer. In this article, we present expert opinion about those chronic pain management guidelines and their impact on patients with cancer diagnoses, especially those with histories of substance use disorder and psychiatric conditions. Though some principles of chronic pain management can be extrapolated, we recommend that guidelines for cancer pain management should be developed using empirical data primarily from patients with cancer who are receiving opioid therapy. Full article

Although mastectomy is an effective procedure, it can have a negative effect on body image, sense of attractiveness, and sexuality. As opposed to the combination of breast oncologic surgery and plastic surgery, whose primary focus is on replacing lost volume, breast-conserving oncoplastic surgery (OPS) redistributes remaining breast tissue in a manner that requires vision, anatomic knowledge, and an appreciation of esthetics, symmetry, and breast function. Modern surgical treatment of breast cancer can be realized only with breast and plastic surgeons working together using oncoplastic techniques to deliver superior cosmetic and cancer outcomes alike. Using this collaborative approach, oncologic and plastic surgeons in Canada have a significant opportunity to improve the care of their breast cancer patients. We propose a tri-level classification for volume displacement procedures to act as a rubric for the training of general surgeons and oncologic breast surgeons in oncoplastic breast-conserving therapy techniques. It is our position that OPS enhances outcomes for many women with breast cancer and should become part of the standard repertoire of procedures used by Canadian oncologic surgeons treating breast cancer. Full article

Background: Chemoradiation with curative intent is considered the standard of care in patients with locally advanced, stage III non-small-cell lung cancer (NSCLC). However, some patients with stage III (N2 or N3, excluding T4) NSCLC might be eligible for surgery. The objective of the present systematic review was to investigate the efficacy of surgery after chemoradiotherapy compared with chemoradiotherapy alone in patients with potentially resectable locally advanced NSCLC. Methods: A search of the MEDLINE, EMBASE, and PubMed databases sought randomized controlled trials (RCTS) comparing surgery after chemoradiotherapy with chemoradiotherapy alone in patients with stage III (N2 or N3, excluding T4) NSCLC. Results: Three included RCTS consistently found no statistically significant difference in overall survival between patients with locally advanced NSCLC who received surgery and chemoradiotherapy or chemoradiotherapy alone. Only one rct found that progression-free survival was significantly longer in patients treated with chemoradiation and surgery (hazard ratio: 0.77; 95% confidence interval: 0.62 to 0.96). In a post hoc analysis of the same trial, the overall survival rate was higher in the surgical group than in matched patients in a chemoradiation-only group if a lobectomy was performed (p = 0.002), but not if a pneumonectomy was performed. Furthermore, fewer treatment-related deaths occurred in patients who underwent lobectomy than in those who underwent pneumonectomy. Conclusions: For patients with locally advanced NSCLC, the benefits of surgery after chemoradiation are uncertain. Surgery after chemoradiation for patients who do not require a pneumonectomy might be an option. Full article

Background: Clinical practice guidelines recommend a multidisciplinary approach to cancer care that brings together all relevant disciplines to discuss optimal disease management. However, the literature is characterized by heterogeneous definitions and few reviews about the processes and outcomes of multidisciplinary care. The objective of this scoping review was to identify and classify the definitions and characteristics of multidisciplinary care, as well as outcomes and interventions for patients with breast cancer. Methods: A systematic search for quantitative and qualitative studies about multidisciplinary care for patients with breast cancer was conducted for January 2001 to December 2017 in the following electronic databases: MEDLINE, EMBASE, PsycInfo, and CINAH. Two reviewers independently applied our eligibility criteria at level 1 (title/abstract) and level 2 (full-text) screening. Data were extracted and synthesized descriptively. Results: The search yielded 9537 unique results, of which 191 were included in the final analysis. Two main types of multidisciplinary care were identified: conferences and clinics. Most studies focused on outcomes of multidisciplinary care that could be variously grouped at the patient, provider, and system levels. Research into processes tended to focus on processes that facilitate implementation: team-working, meeting logistics, infrastructure, quality audit, and barriers and facilitators. Summary: Approaches to multidisciplinary care using conferences and clinics are well described. However, studies vary by design, clinical context, patient population, and study outcome. The heterogeneity of the literature, including the patient populations studied, warrants further specification of multidisciplinary care practice and systematic reviews of the processes or contexts that make the implementation and operation of multidisciplinary care effective. Full article

Background: Patients with limited-stage (LS) or extensive-stage (ES) small-cell lung cancer (SCLC) are commonly given platinum-based chemotherapy as first-line treatment. Standard chemotherapy for patients with LS SCLC includes a platinum agent such as cisplatin combined with the non-platinum agent etoposide. The objective of the present systematic review was to investigate the efficacy of adding radiotherapy to chemotherapy in patients with ES SCLC and to determine the appropriate timing, dose, and schedule of chemotherapy or radiation for patients with SCLC. Methods: The MEDLINE and EMBASE databases were searched for randomized controlled trials (RCTS) comparing treatment with radiotherapy plus chemotherapy against treatment with chemotherapy alone in patients with ES SCLC. Identified rcts were also included if they compared various timings, doses, and schedules of treatment for patients with ES SCLC or LS SCLC. Results: Sixty-four RCTSwere included. In patients with LS SCLC, overall survival was greatest with platinum–etoposide compared with other chemotherapy regimens. In patients with ES SCLC, overall survival was greatest with chemotherapy containing platinum–irinotecan than with chemotherapy containing platinum–etoposide (hazard ratio: 0.84; 95% confidence interval: 0.74 to 0.95; p = 0.006). The addition of radiation to chemotherapy for patients with ES SCLC showed mixed results. There was no conclusive evidence that the timing, dose, or schedule of thoracic radiation affected treatment outcomes in SCLC. Conclusions: In patients with LS SCLC, cisplatin–etoposide plus radiotherapy should remain the standard therapy. In patients with ES SCLC, the evidence is insufficient to recommend the addition of radiotherapy to chemotherapy as standard practice to improve overall survival. However, on a case-by-case basis, radiotherapy might be added to reduce local recurrence. The most commonly used chemotherapy is platinum–etoposide; however, platinum–irinotecan can be considered. Full article

Background: Diagnosis and treatment of renal cell carcinoma (RCC) might be different in Indigenous Canadians than in non-Indigenous Canadians. In this cohort study, we compared RCC presentation and treatments in Indigenous and non-Indigenous Canadians. Methods: Patients registered in the Canadian Kidney Cancer Information System treated at 16 institutions between 2011 and 2018 were included. Baseline patient, tumour, and treatment characteristics were compared between Indigenous and non-Indigenous Canadians. The primary objective was to determine if differences in RCC stage at diagnosis were evident between the groups. The secondary objective was to determine if treatments and outcomes were different between the groups. Results: During the study period, 105 of the 4529 registered patients self-identified as Indigenous. Those patients were significantly younger at the time of clinical diagnosis (57.9 ± 11.3 years vs. 62.0 ± 12.1 years, p = 0.0006) and had a family history prevalence of RCC that was double the prevalence in the non-Indigenous patients (14% vs. 7%, p = 0.004). Clinical stage at diagnosis was similar in the two groups (p = 0.61). The disease was metastatic at presentation in 11 Indigenous Canadians (10%) and in 355 non-Indigenous Canadians (8%). Comorbid conditions that could affect the management of RCC—such as obesity, renal disease, diabetes mellitus, and smoking—were more common in Indigenous Canadians (p < 0.05). Indigenous Canadians experienced a lower rate of active surveillance (p = 0.01). Treatments and median time to treatments were similar in the two groups. Conclusions: Compared with their non-Indigenous counterparts, Indigenous Canadian patients with RCC are diagnosed at an earlier age and at a similar clinical stage. Despite higher baseline comorbid conditions, clinical outcomes are not worse for Indigenous Canadians than for non-Indigenous Canadians. Full article

Background: We investigated whether preoperative anemia and perioperative blood transfusion (PBT) are associated with overall survival and recurrence-free survival in patients with nonmetastatic colorectal cancer. Methods: From 1 January 2009 to 31 December 2014, 1003 patients with primary colorectal cancer were enrolled in the study. Perioperative clinical and oncologic outcomes were analyzed based on the presence of preoperative anemia and PBT. Results: Preoperative anemia was found in 468 patients (46.7%). In the anemia and no-anemia groups, PBT was performed in 44% and 15% of patients respectively. Independent predictors for PBT were preoperative anemia, higher American Society of Anesthesiologists score, laparotomy, lengthy operative time, advanced TNM stage, T4 stage, and 30-day morbidity. The use of PBT, but not preoperative anemia, was found to be an independent adverse prognostic factor for overall survival. In terms of recurrence-free survival, the presence of preoperative anemia was similarly not a significant prognostic factor, but the use of PBT was an independent factor for an unfavourable prognosis. Conclusions: The use of PBT, but not preoperative anemia, was independently associated with worse overall and recurrence-free survival in nonmetastatic colorectal cancer. For better oncologic outcomes, our findings indicate a need to reduce the use of blood transfusion during the perioperative period. Full article

Introduction: Total pancreatectomy for pancreatic ductal adenocarcinoma has historically been associated with substantial patient morbidity and mortality. Given advancements in perioperative and postoperative care, evaluation of the surgical treatment options for pancreatic adenocarcinoma should consider patient outcomes and long-term survival for total pancreatectomy compared with partial pancreatectomy. Methods: The U.S. National Cancer Database was queried for patients undergoing total pancreatectomy or partial pancreatectomy for pancreatic adenocarcinoma during 1998–2006. Demographics, tumour characteristics, operative outcomes, 30-day mortality, 30-day readmission, additional treatment, and Kaplan–Meier survival curves were compared. Results: The database query returned 807 patients who underwent total pancreatectomy and 5840 who underwent partial pancreatectomy. More patients who underwent total pancreatectomy than a partial pancreatectomy had a margin-negative resection (p < 0.0001). Mortality and readmission rates were similar in the two groups, as was long-term survival on Kaplan–Meier curves (p = 0.377). A statistically significant difference in the rate of surgery only (without additional treatment) was observed for patients in the total pancreatectomy group (p = 0.0003). Conclusions: Although total compared with partial pancreatectomy was associated with a higher rate of margin-negative resection, median survival was not significantly different for patients undergoing either procedure. Patients who underwent total pancreatectomy were significantly less likely to receive adjuvant therapy. Full article

Background: Isolated abdominal lymphadenopathy is frequently detected, but often challenging to diagnose. To obtain a tissue diagnosis, percutaneous biopsy (PB) or laparoscopic biopsy (LB) is often undertaken. The safety profiles and diagnostic accuracy of PB and LB within the abdomen are both poorly defined. Methods: In this retrospective analysis, we identified all patients who underwent LB or PB for isolated abdominal lymphadenopathy at our institute during 2008–2016. Results: Of 62 patients who underwent nodal biopsy for isolated abdominal lymphadenopathy, 33 underwent LB and 29 underwent PB. For the 33 patients who underwent LB, the procedure was diagnostic in 100% of cases; for the 29 who underwent PB, the procedure was diagnostic in 18 cases (62.1%). Both procedures were safe, with similar complication rates (6.0% for LB; 7.0% for PB). Conclusions: Our results establish that LB and PB are both safe and reliable in the setting of isolated abdominal lymphadenopathy. We also demonstrate that each procedure has situational advantages. A PB should be considered to be the upfront diagnostic modality, particularly when anatomic or disease factors favour its success. In situations in which it is felt that PB cannot safely access the lymphadenopathy or in disease states in which the yield of a core biopsy will be insufficient, LB should be strongly considered. Examples include extra-retroperitoneal lymphadenopathy and cases of suspected lymphoma. Full article

Background and Purpose: Adjuvant whole-breast irradiation after breast-conserving surgery, typically delivered over several weeks, is the traditional standard of care for low-risk breast cancer. More recently, hypofractionated, partial-breast irradiation has increasingly become established. Neoadjuvant single-fraction radiotherapy (RT) is an uncommon approach wherein the unresected lesion is irradiated preoperatively in a single fraction. We developed the SIGNAL (Stereotactic Image-Guided Neoadjuvant Ablative Radiation Then Lumpectomy) trial, a prospective single-arm trial to test our hypothesis that, for low-risk carcinoma of the breast, the preoperative single-fraction approach would be feasible and safe. Methods: Patients presenting with early-stage (T < 3 cm), estrogen-positive, clinically node-negative invasive carcinoma of the breast with tumours at least 2 cm away from skin and chest wall were enrolled. All patients received prone breast magnetic resonance imaging (MRI) and prone computed tomography simulation. Treatable patients received a single 21 Gy fraction of external-beam rt (as volumetric-modulated arc therapy) to the primary lesion in the breast, followed by definitive surgery 1 week later. The primary endpoints at 3 weeks, 6 months, and 1 year were toxicity and cosmesis (that is, safety) and feasibility (defined as the proportion of mri-appropriate patients receiving RT). Results: Of 52 patients accrued, 27 were successfully treated. The initial dosimetric constraints resulted in a feasibility failure, because only 57% of eligible patients were successfully treated. Revised dosimetric constraints were developed, after which 100% of patients meeting mri criteria were treated according to protocol. At 3 weeks, 6 months, and 1 year after the operation, toxicity, patient- and physician-rated cosmesis, and quality of life were not significantly different from baseline. Conclusions: The SIGNAL trial presents a feasible method of implementing single-dose preoperative rt in early-stage breast cancer. This pilot study did not identify any significant toxicity and demonstrated excellent cosmetic and quality-of-life outcomes. Future randomized multi-arm studies are required to corroborate these findings. Full article

Introduction: RIntroductionadiation-induced brain necrosis [“radionecrosis” (RN)] is a relatively uncommon but potentially severe adverse effect of stereotactic radiosurgery (SRS) for brain metastasis. Although dose, volume, and hypofractionation have been suggested to affect RN rates, patient and treatment variability in this population make it difficult to clearly delineate the risk. We set out to establish the effect of fractionation on RN rates by reviewing patients receiving simultaneous multi-fraction and single-fraction treatment at our centre. Methods: Patients receiving simultaneous (within 1 month) 1-fraction (SSRS) and 3-fraction (FSRS) radiosurgery treatments during 2012–2015 were identified in our institution’s database. Serial post-srs magnetic resonance imaging (MRI) was reviewed to determine RN and local recurrence. The effect of maximum dose, volume, whole-brain radiotherapy (WBRT), and fractionation on RN development was assessed using logistic regression for paired data. Results are reported using odds ratios (ORS) and corresponding 95% confidence intervals (CIS). Results: Of 90 patients identified, 22 had at least a 6-month mri follow-up. Median follow-up was 320 days. The most common primary tumour type was non-small-cell lung cancer, followed by breast and rectal cancer. Radionecrosis developed in 16 patients [21 of 62 lesions (34%), with 4 being symptomatic (20%)]. Of the 21 lesions in which RN developed, 11 received 3 fractions, and 10 received 1 fraction. The or for the association between the incidence of RN and maximum dose was 1.0 (95% CI: 0.9 to 1.1); for fractionation it was 1.0 (95% CI: 0.3 to 3.6); for previous wbrt, it was 0.4 (95% CI: 0.2 to 1.2); and for a 10-unit increase in volume, it was 3.1 (95% CI: 1.0 to 9.6). Local recurrence developed in 8 patients (12%), 6 of whom belonged to the ssrs group. Conclusions: Our results indicate that patients receiving srs for multiple brain metastases experience a higher rate of RN than is reported in the literature and poorer survival despite having equivalent local control. Maximum dose did not appear to be associated with RN risk in our cohort, but volume was significantly associated with RN risk. Although fractionated treatment did not directly lower the rate of RN in this population, it might have played a role in reducing the magnitude of the RN risk in large-volume lesions. Further investigation will help to delineate optimal dose and fractionation so as to minimize RN while maintaining local control in this group. Full article

Introduction: Cardiovascular disease is the 2nd leading cause of long-term morbidity and mortality in cancer survivors. Cardio-oncology clinics (COCS) have emerged to address the issue; however, there is a paucity of data about the demographics and clinical outcomes of patients seen in the COC setting. Methods: Cancer patients referred to The Ottawa Hospital COC were included in this retrospective observational study. Data collected were patient demographics, cancer type and stage, reason for referral, cardiac risk factors, cardiac assessments and treatment, and clinical outcomes. Results:Between 2008 and 2015, 779 patients (516 women, 66%; 263 men, 34%) were referred to the COC. Median age of the patients at cancer diagnosis was 60 years (range: 18–90 years). The most frequent reasons for referral were decreased left ventricular ejection fraction (33%), pre-chemotherapy assessment (14%), and arrhythmia (14%). Treatment with cardiac medication was given in 322 patients (41%), 181 (56%) of whom received more than 2 cardiac medications, with 57 (18%) receiving an angiotensin-converting enzyme inhibitor (ACEi), 46 (14%) receiving an acei and a beta-blocker, and 38 (12%) receiving a beta-blocker. Of 163 breast cancer patients, 129 (79%) were able to complete targeted therapy with COC co-management. Most of the 779 patients (n = 643, 83%) were alive at the time of the last data collection. Conclusions: This cohort study is one of the largest to report characteristics and clinical outcomes of patients referred to a COC. Collaboration between oncologists and cardiologists resulted in completion of cancer therapy in most patients. Ongoing analysis of referral patterns, management plans, and patient outcomes will help to guide the cardiac care of oncology patients, ultimately optimizing cancer and cardiac outcomes alike. Full article

Background: Clinical trials have demonstrated an increased risk of cardiotoxicity in patients with breast cancer (BCA) receiving trastuzumab-based therapy. Diabetes, dyslipidemia, and obesity are known risk factors for cardiovascular disease. Studies have yielded conflicting results about whether those factors increase the risk of cardiotoxicity in patients with BCA receiving trastuzumab. Methods: In this retrospective cohort study, data were collected for 243 patients with BCA positive for HER2 (the human epidermal growth factor receptor 2) who were receiving trastuzumab and who were referred to The Ottawa Hospital Cardio-oncology Referral Clinic between 2008 and 2013. The data collected included patient demographics, reason for referral, cardiac function, chemotherapy regimen (including anthracycline use), and 3 comorbidities (diabetes, dyslipidemia, obesity). Rates of symptomatic cancer treatment–related cardiac dysfunction (SCTCD) and asymptomatic decline in left ventricular ejection fraction (adLVEF) were calculated for patients with and without the comorbidities of interest. Results: Of the 243 identified patients, 104 had either diabetes, dyslipidemia, or obesity. In that population, the most likely reason for referral to the cardio-oncology clinic was adLVEF. Conclusions: The combination of 2 or 3 comorbidities significantly increased the incidence of sctcd in our population, reaching a rate of 67% for patients with obesity and dyslipidemia [relative risk (RR): 2.2; p = 0.04], 69% for patients with obesity and diabetes (RR: 2.3; p = 0.02), and 72% for patients with all 3 risk factors (RR: 2.4; p = 0.08). The combination of 2 or 3 comorbidities significantly increases the incidence of symptomatic cancer treatment–related cardiotoxicity. Patients with BCA experiencing cancer treatment–related cardiotoxicity who have a history of diabetes, dyslipidemia, and obesity might require more proactive strategies for prevention, detection, and treatment of cardiotoxicity while receiving trastuzumab-based treatment. Full article

Introduction: Patients with metastatic cancer have a decreased life expectancy, and with screening and surveillance for new primary cancers, they run the risk of immediate harm with little chance of any benefit. Choosing Wisely Canada therefore recommends that such investigations be avoided in patients with metastatic disease. Methods: We examined cancer screening practices in a subset of patients with metastatic cancer in Newfoundland and Labrador. Patients with metastatic breast cancer seen at the provincial cancer clinic during 2014–2016 were identified from the Newfoundland and Labrador Cancer Registry. For each patient, we assessed whether any one or a combination of screening mammography, Pap (Papanicolaou) test, flexible sigmoidoscopy or colonoscopy, or fecal immunohistochemical test were performed at any point after the diagnosis of metastatic disease. Results: Of 305 patients with metastatic breast cancer, 114 (37.4%) underwent at least 1 screening investigation (mean: 2.92 investigations per screened patient). The most common screening investigations were mammography (n = 197) and Pap test (n = 107). Primary care providers ordered most of the screening investigations (70%); oncology specialists ordered 14%, and other specialists, 12%. Median overall survival for patients with breast cancer after a diagnosis of metastatic disease was 42 months, with a 5-year overall survival of 35.9%. Conclusion: A significant proportion of patients with metastatic breast cancer in Newfoundland and Labrador are still undergoing screening for new primary malignancies, which is discordant with oncology guidelines from Choosing Wisely Canada. Increased education strategies are needed if the Choosing Wisely Canada recommendations are to be implemented into routine clinical practice. Full article

Background: Commonly used first-line (1L) chemotherapies for patients with advanced squamous-cell lung cancer (SCC) include gemcitabine–platinum (GP), nab-paclitaxel–carboplatin (nabpc), and sb-paclitaxel–carboplatin (sbpc) regimens. However, no head-to-head trials have compared those treatments. In the present study, we compared the efficacy of 1L GP, nabpc, and sbpc in patients with SCC and in patients with SCC who subsequently received second-line (2L) immunotherapy. Methods: Medical records of patients who initiated the 1L treatments of interest between June 2014 and October 2015 were reviewed by 132 participating physicians. Kaplan–Meier curves were used to evaluate overall survival (os), progression-free survival (PFS), and treatment discontinuation (TD), and then Cox proportional hazards regression was used to compare the results between the cohorts. Results: Medical records of 458 patients with SCC receiving GP (n = 139), nabpc (n = 159), or sbpc (n = 160) as 1L therapy were reviewed. Median os was longer with nabpc (23.9 months) than with GP (16.9 months; adjusted hazard ratio vs. nabpc: 1.55; p < 0.05) and with sbpc (18.3 months; adjusted hazard ratio: 1.42; p = 0.10). No differences were observed in PFS (median PFS: 8.8, 8.0, and 7.6 months for GP, nabpc, and sbpc respectively; log-rank p = 0.76) or in TD (median TD: 5.5, 5.7, and 4.6 months respectively; p = 0.65). For patients who subsequently received 2L immunotherapy, no differences in os were observed (median os: 27.3, 25.0, and 23.0 months respectively; p = 0.59). Conclusions: In a nationwide sample of SCC patients, longer median os was associated with 1L nabpc than with GP and sbpc. Median os for all 1L agents considered was similar in the subgroup of patients who sequenced to a 2L immunotherapy. Full article

Background: Literature suggests that factors such as rural residence and low socioeconomic status (SES) might contribute to disparities in survival for Canadian cancer patients because of inequities in access to care. However, evidence specific to brain cancer is limited. The present research estimates the effects of rural or urban residence and SES on survival for Canadian patients diagnosed with brain cancer. Methods: Adults diagnosed with primary malignant brain tumours during 1996–2008 were identified through the Canadian Cancer Registry. Brain tumours were classified using International Classification of Diseases for Oncology (3rd edition) site and histology codes. Hazard ratios (HRS) and 95% confidence intervals (CIS) were estimated using Cox proportional hazards models. Events were restricted to individuals whose underlying cause of death was cancer-related. Postal codes were used to match patient records with Statistics Canada data for rural or urban residence and neighbourhood income as a surrogate measure of SES. Results: Of 25,700 patients included in the analysis, 78% died during the study period, 21% lived in rural areas, and 19% were in the lowest income group. A modest variation in survival by rural compared with urban residence was observed for patients with glioblastoma (first 5 weeks after diagnosis hr: 0.86; 95% CI: 0.79 to 0.99) and oligoastrocytoma (first 3 years after diagnosis hr: 1.41; 95% CI: 1.03 to 1.93). Small effects of low compared with high income were seen for patients with glioblastoma (first 1.5 years after diagnosis hr: 1.15; 95% CI: 1.08 to 1.22) and diffuse astrocytoma (first 6 months after diagnosis hr: 1.17; 95% CI: 1.00 to 1.36). Conclusions: Our analysis did not yield evidence of strong effects of rural compared with urban residence or ses strata on survival in brain cancer. However, some variation in survival for patients with specific histologies warrants further research into the mechanisms by which rural or urban residence and income stratum influences survival. Full article

Background: Colposcopy is a key part of cervical cancer control. As cervical cancer screening and prevention strategies evolve, monitoring colposcopy performance will become even more critical. In the present paper, we describe population-based colposcopy quality indicators that are recommended for ongoing measurement by cervical cancer screening programs in Canada. Methods: The Pan-Canadian Cervical Cancer Screening Network established a multidisciplinary expert working group to identify population-based colposcopy quality indicators. A systematic literature review was conducted to ascertain existing population and program-level colposcopy quality indicators. A systems-level cervical cancer screening pathway describing each step from an abnormal screening test, to colposcopy, and back to screening was developed. Indicators from the literature were assigned a place on the pathway to ensure that all steps were measured. A prioritization matrix scoring system was used to score each indicator based on predetermined criteria. Proposed colposcopy quality indicators were shared with provincial and territorial screening programs and subsequently revised. Results: The 10 population-based colposcopy quality indicators identified as priorities were colposcopy uptake, histologic investigation (biopsy) rate, colposcopy referral rate, failure to attend colposcopy, treatment frequency in women 18–24 years of age, re-treatment proportion, colposcopy exit-test proportion, histologic investigation (biopsy) frequency after low-grade Pap test results, length of colposcopy episode of care, and operating room treatment rate. Two descriptive indicators were also identified: colposcopist volume and number of colposcopists per capita. Summary: High-quality colposcopy services are an essential component of provincial cervical cancer screening programs. The proposed quality and descriptive indicators will permit colposcopy outcomes to be compared between provinces and across Canada so as to identify opportunities for improving colposcopy services. Full article

Background: Cervical cancer is the 2nd most common malignant tumour in women worldwide. Previous research studies have given little attention to its prognostic factors in the rapidly growing Asian American population. In the present study, we explored prognostic factors in Asian and white American patients with cervical cancer, considering competing risks. Methods: The study included 58,780 patients with cervical cancer, of whom 54,827 were white and 3953 were Asian American, and for all of whom complete clinical information was available in the U.S. Surveillance, Epidemiology, and End Results database. Death from cervical cancer was considered to be the event of interest, and deaths from other causes were defined as competing risks. The cumulative incidence function and the Fine–Gray method were applied for univariate and multivariate analysis respectively. Results: We found that, for all patients (white and Asian American combined), the cumulative incidence function was associated with several factors, such as age at diagnosis, FIGO (Fédération internationale de Gynécologie et d’Obstétrique) stage, registry area, and lymph node metastasis. Similar results were found when considering white patients only. However, for Asian American patients, registry area was not associated with the cumulative incidence function, but the other factors (for example, FIGO stage) remained statistically significant. Similarly, in multivariate analyses, we found that age at diagnosis, figo stage, lymph node metastasis, tumour histology, treatment method, and race were all associated with prognosis. Conclusions: Survival status differs for white and Asian American patients with cervical cancer. Our results could guide the treatment of, and facilitate prognostic judgments about, white and Asian American patients with cervical cancer. Full article

Background: In Ontario, an online audit and feedback tool that provides primary care physicians with detailed information about patients who are overdue for cancer screening is underused. In the present study, we aimed to examine the effect of messages operationalizing 3 behaviour change techniques on access to the audit and feedback tool and on cancer screening rates. Methods: During May–September 2017, a pragmatic 2×2×2 factorial experiment tested 3 behaviour change techniques: anticipated regret, material incentive, and problem-solving. Outcomes were assessed using routinely collected administrative data. A qualitative process evaluation explored how and why the e-mail messages did or did not support Screening Activity Report access. Results: Of 5449 primary care physicians randomly allocated to 1 of 8 e-mail messages, fewer than half opened the messages and fewer than 1 in 10 clicked through the messages. Messages with problem-solving content were associated with a 12.9% relative reduction in access to the tool (risk ratio: 0.871; 95% confidence interval: 0.791 to 0.958; p = 0.005), but a 0.3% increase in cervical cancer screening (rate ratio: 1.003; 95% confidence interval: 1.001 to 1.006; p = 0.003). If true, that association would represent 7568 more patients being screened. No other significant effects were observed. Conclusions: For audit and feedback to work, recipients must engage with the data; for e-mail messages to prompt activity, recipients must open and review the message content. This large factorial experiment demonstrated that small changes in the content of such e-mail messages might influence clinical behaviour. Future research should focus on strategies to make cancer screening more user-centred. Full article

Background: In relation to the general Canadian population, Inuit face increased cancer risks and barriers to health services use. In shared decision-making (SDM), health care providers and patients make health care decisions together. Enhanced participation in cancer care decisions is a need for Inuit. Integrated knowledge translation (KT) supports the development of research evidence that is likely to be patient-centred and applied in practice. Objective: Using an integrated KT approach, we set out to promote the use of SDM by Inuit in cancer care. Methods: An integrated KT study involving researchers with a Steering Committee of cancer care system partners who support Inuit in cancer care (“the team”) consisted of 2 theory-driven phases: (1) using consensus-building methods to tailor a previously developed SDM strategy and developing training in the SDM strategy; and (2) training community support workers (CSWS) in the SDM strategy and testing the SDM strategy with community members. Results: The team developed a SDM strategy that included a workshop and a booklet with 6 questions for use by CSWS with patients. The SDM strategy (training and booklet) was finalized based on feedback from 5 urban-based Inuit CSWS who were recruited and trained in using the strategy. Trained CSWS were matched with 8 community members, and use of the SDM strategy was assessed during interviews, reported as 6 themes. Participants found the SDM strategy to be useful and feasible for use. Conclusions: An integrated KT approach of structured research processes with partners developed a SDM strategy for use by Inuit in cancer care. Further work is needed to test the SDM strategy. Full article

Hematopoietic stem-cell transplantation (HSCT) is a medical procedure that consists of infusing stem cells after a short course of chemotherapy or radiotherapy, or both. It can be used in the treatment of various cancers, as well as some benign conditions. In the present review, we discuss the various types of HSCT and their main indications. The principles of the transplant procedure itself and the basics of recipient selection are reviewed. Special attention is given to both the immediate and the long-term complications of HSCT and their management strategies. Hematopoietic stem-cell transplantation is a potentially life-saving procedure and often the only curative option for a variety of diseases; however, it is not without significant toxicities. Full article

Background: DICER1 syndrome is an autosomal dominant tumour predisposition syndrome associated with a wide variety of cancerous and noncancerous conditions, including ovarian sex cord–stromal tumours and thyroid conditions, including multinodular goiter. The most common ovarian sex cord–stromal tumour associated with DICER1 syndrome is Sertoli–Leydig cell tumour, with germline DICER1 mutations present in more than 50% of cases. We present a case in which a patient in her late 30s was diagnosed with a Sertoli–Leydig cell tumour in the background of a strong family history of multinodular goiter and Sertoli–Leydig cell tumour with a germline mutation in DICER1. Case Presentation: A 38-year-old woman with history of multinodular goiter was found to have stage iiic ovarian Sertoli–Leydig cell cancer after presenting with abdominal pain. She underwent multiple surgeries and chemotherapy. The patient developed rapid disease progression and died 7 months after diagnosis. Seven years earlier, a daughter had experienced the same disease and was found to have a germline DICER1 mutation. The mother had not undergone testing before her own diagnosis. Summary: The co-occurrence of Sertoli–Leydig cell tumour and multinodular goiter is highly suggestive of DICER1 syndrome. The recognition of DICER1 syndrome within a family is essential for increased awareness and potential early recognition of complications. Most conditions associated with DICER1 syndrome occur in childhood, and most of the current screening recommendations are specific for childhood and young adulthood. Cancer risks and findings for the adult population are not as well defined. Clinicians who encounter DICER1 syndrome should review recommendations for genetic testing and surveillance and enrol patients in the DICER1 registry. Full article

Introduction: The pan-Canadian Oncology Symptom Triage and Remote Support (costars) team is studying how to improve the quality and consistency of cancer symptom management. Methods: A 1-day invitational meeting was held 24 October 2017 in Ottawa, Ontario, to review the current evidence from costars projects and to establish research priorities for a future largescale implementation study. The meeting included 36 participants who were clinicians from adult oncology, pediatric oncology, and homecare; policymakers from national, provincial, and regional organizations; researchers; and a patient. Half the day involved summarizing evidence from four costars studies and experiences with implementing the costars symptom practice guides. The second half of the day used a modified nominal group technique to generate research questions within small groups, presentation of research questions to all participants, and two rounds of voting to reach consensus on research priorities. Results: Participants proposed 4 research categories: (1) User-centred augmentation to enhance usability (for example, designing a mobile costars solution); (2) Outcome measurement (for example, determining key competencies for clinicians); (3) Regular renewal of costars to keep pace with evolving evidence (for example, updates for novel therapies); (4) Integration into clinical practice (for example, meaningful engagement of patients and caregivers in study design). Conclusions: Across categories, the top 3 priorities were effect on health services use, competency development, and a mobile costars solution. Future research will address identified priorities, reflecting the needs and perspectives of diverse stakeholders. Stakeholder collaboration will continue to guide our approach to operationalizing this priority research agenda. Full article

Background: CervixCheck, Manitoba’s cervical cancer screening program, conducted a pilot study to assess whether screening participation could be improved in unscreened women by offering a mailed self-sampling kit for human papillomavirus (HPV) testing instead of a Pap test. Methods: In a prospective cohort study design, a sample of unscreened women (n = 1052) who had been sent an invitation letter from CervixCheck in the past but who did not respond were randomized to either an intervention group or a control group. The intervention group received a mailed HPV self-sampling kit; the control group received no additional communication. Returned HPV self-sampling swabs were analyzed by a provincial laboratory. After 6 months, screening participation in the two study groups was compared using a logistic regression model adjusted for age and area of residence (urban or rural). Secondary outcomes included HPV positivity, specimen inadequacy, compliance with follow-up, and time to colposcopy. Results: Screening participation was significantly higher in the intervention group than in the control group (n = 51, 9.6%, vs. n = 13, 2.5%; odds ratio: 4.7; 95% confidence interval: 2.56 to 8.77). Geographic area of residence (urban or rural) and age were not statistically significant. Conclusions: The study demonstrated that HPV self-sampling kits can enhance screening participation in unscreened non-responder women in the setting of an organized screening program. Next steps should include additional research to determine the best implementation strategy for HPV self-sampling in Manitoba. Full article