Lymphedema in Canada : a qualitative study to help develop a clinical , research , and education strategy

Lymphedema is an under-recognized and undertreated condition that affects many cancer survivors, but that lacks a national voice. In 2009, the Canadian Lymphedema Framework was formed to fill that need (Table i). With medical improvements in cancer treatment leading to increased rates of survival and longer survival times, cancer rehabilitation is needed to address the physical, emotional, and social consequences of treatment, and to improve overall quality of life 1. Lymphedema is reported to be the most debilitating complication of treatment for breast cancer, affecting body image and social, family, ABSTRACT

Five priority areas for development were articulated: education of health care professionals, standards, research, reimbursement and access to treatment, and advocacy.
Conclusions: Data from stakeholders were obtained to solidly define priority areas for lymphedema development at a national level.The Canadian Lymphedema Framework has now developed a 3-year strategic roadmap to raise the profile of lymphedema in Canada; to develop a national coordinated patient advocacy strategy; to gain consensus and adoption of best-practice guidelines; and to promote the development of research networks.
A volunteer Advisory Board and three volunteer working groups (Education, Research, and Partnership Development) are now working with the executive to identify key partners, to gather data, and to take action to influence lymphedema practice, inform policy, and educate health professionals as first priorities.Valuable data on the current status of lymphedema management in Canada have been assembled through a lymphedema landscape study, undertaken in April 2010.Results were reported at the 3rd International Lymphedema Conference held in Toronto in June 2011 and will be used to inform the work of the committees and to measure progress; it will also be shared with government.Educational, translational, and research initiatives are in development.Through these volunteer efforts and in conjunction with stakeholders, the Canadian Lymphedema Framework is establishing a long-term national strategy and campaign for improved lymphedema management in Canada.

inter-rater Reliability Between musculoskeletal Radiologists and Orthopedic Surgeons on Computed tomography imaging Features of Spinal metastases
L. Khan md, G. Mitera mba, L. Probyn md, M. Ford md, M. Christakis md, J. Finkelstein md, A. Donovan md, L. Zhang phd, L. Zeng, J. Rubenstein md, A. Yee md, L. Holden mrtt, and E. Chow mbbs.Bone Metastases Site Group, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario.

Introduction:
The purpose of the present study was to assess the inter-rater reliability in scoring the computed tomography (ct) imaging features of spinal metastases in patients referred for radiotherapy (rt) for bone pain.This was an early investigational step in the process of determining the need for a prognostic tool to evaluate metastatic tumours to the spine.

Methods:
The available ct imaging for 41 patients who had confirmed spinal metastases and who, from January 2007 to October 2008, were receiving rt in an outpatient palliative clinic at a tertiary care hospital were retrospectively reviewed.Given the retrospective nature of the study, the review used the ct images routinely obtained for rt simulation.The 3 musculoskeletal radiologists and 2 orthopedic surgeons participating in the study independently evaluated the ct imaging features using in-house spinal assessment criteria including radiated site; extent of tumour involvement; type of lesion (that is, sclerotic, lytic, mixed); presence of pathologic fracture; height loss; column involvement; soft-tissue component; nerve-root compression; and kyphosis.The musculoskeletal scoring was considered the clinical standard.Cohen kappa coefficients were calculated between the two specialties.

Conclusions:
The range of agreement between musculoskeletal radiologists and orthopedic surgeons for most spinal assessment criteria was moderate to poor.The identified areas of poor agreement are central to clinical decision-making, highlighting the need to establish objective measures for validating clinical outcome, the efficiency of clinical trials, and the degree of certainty for clinicians correlating interval change with true change in the clinical status of patients.Our study may serve as an early investigational step in determining the need for a prognostic tool to evaluate metastases to the spine.Such a tool would be important in formulating consensus-based protocols for a multidisciplinary approach to managing challenging vertebral injuries secondary to spinal metastases.Background: Systemic treatment options in hepatocellular carcinoma (hcc) are limited.Sorafenib, a multikinase inhibitor, has been shown to improve survival in patients with advanced hcc and adequate hepatic reserve.Currently, the proportion of referred patients with hcc that would be eligible for sorafenib therapy is unclear.We reviewed patterns in the presentation and management of referred patients with hcc at the BC Cancer Agency (bcca) before the availability of sorafenib.
Methods: Records of patients with hcc referred to the bcca from January 1, 2003, to December 31, 2007, were reviewed.Distributions were analyzed using frequency statistics.

Results:
Of 518 patients reviewed, 77% were men and 45% were of Asian ethnicity; median age was 64 years.Histology confirmation was available in only 34% of the patients; 64% had an elevated level of alpha-fetoprotein at diagnosis.The Child-Pugh score at presentation could not be determined in 56%; the most common missing variable was albumin (44%).Among the 226 evaluable patients, the Child-Pugh classification was A in 140 (62%), B in 64 (28%), and C in 22 (10%).Eastern Cooperative Oncology Group performance status was not documented in 40% of patients.The TNM staging was recorded per agency protocol; however, it was incompletely documented in most patients.Distant metastases were recorded in 12% of patients, and 75 patients (15%) underwent hepatic resection before referral.After bcca referral, no further therapy was offered to 287 patients (54%), Background: The adoption of a chemotherapeutic regimen in oncologic practice is a function of both its clinical and its economic impacts on cancer management.For breast cancer, U.S. Oncology trial 9735 reported significant improvements in disease-free and overall survival favoring adjuvant tc (docetaxel 75 mg/ m 2 and cyclophosphamide 600 mg/m 2 every 3 weeks for 4 cycles) compared with ac (doxorubicin 60 mg/m 2 and cyclophosphamide 600 mg/m 2 every 3 weeks for 4 cycles).We carried out an economic evaluation to examine the cost-utility of adjuvant tc relative to ac, in terms of cost per quality-adjusted life year (qaly) gained, given the improved breast cancer outcomes and higher costs associated with the tc regimen.
Methods: A Markov model was developed to calculate the cumulative costs and qalys gained over a 10-year horizon for hypothetical cohorts of women with breast cancer treated with ac or with tc.Event rates, costs, and utilities were derived from the literature and local resources.Efficacy and adverse events were based on results reported from U.S. Oncology trial 9735.The model takes a thirdparty direct payer perspective and reports its results in 2008 Canadian dollars.Costs and benefits were both discounted at 3%.Deterministic and probabilistic sensitivity analyses were conducted and a costeffectiveness acceptability curve was conducted to test the plausibility of the cost-utility results over a reasonable range of parameters uncertainty.The impact of using granulocyte colony-stimulating factor (g-csf) as prophylaxis for febrile neutropenia with adjuvant tc chemotherapy was also examined.
Results: Compared with ac, tc was associated with $3,960 in incremental costs and a 0.24 qaly gain at a 10-year horizon, for a favorable cost-utility of $16,753 per qaly gained.The likelihood of the tc regimen being cost-effective at the $50,000-per-qalygained willingness-to-pay threshold was 91%.The cost-utility estimate increased to $21,333 and $33,510 per qaly gained assuming that the tc regimen was associated with febrile neutropenia rates of 10% and 20% respectively.Moreover, the cost-utility reached $43,693 per qaly if primary prophylaxis with g-csf was used in all patients undergoing tc chemotherapy.The cost-utility results were robust to all other model assumptions and input parameters.

Conclusions:
Adjuvant chemotherapy with tc is both more effective and more costly than that with ac; it also has favorable cost-utility estimates that fall well below commonly used cost-effectiveness thresholds.Based on its favorable clinical and economic evaluations, the tc regimen is an acceptable adjuvant chemotherapy option for women with breast cancer.

KEY WORDS
Non-small-cell lung cancer, nsclc, clinical practice guideline, mediastinal staging Current OnCOlOgy-VOlume 18, number 6 Copyright © 2011 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

URL http://www.current-oncology.com/index. php/oncology/article/view/820/ E-JOURNAL LINKED ABSTRACT
Introduction: Lung cancer remains the leading cause of cancer death for both men and women in Ontario, with almost 8000 new cases expected to be diagnosed each year in the province.In non-smallcell lung cancer (nsclc), invasive mediastinal staging is typically used to guide treatment decisionmaking.Here, we present clinical practice guideline recommendations for invasive mediastinal staging in nsclc patients who have been staged T1-4, N0-3, with no distant metastases.Staging techniques are also addressed.
Methods: Draft recommendations were formulated based on the best available evidence gathered by a systematic review and a consensus of expert opinion.The draft recommendations underwent an internal review by clinical and methodology experts, and an external review by clinical practitioners through a survey assessing the clinical relevance and overall quality of the guideline.Feedback from the internal and external reviews was into the clinical practice guideline.

Results:
A previously published guideline by the American College of Chest Physicians (accp) was identified.The guideline's methods were reviewed and found to be systematic and rigorous, and therefore its evidence base, which was current to June 2006, was adopted and updated to August 2010.In general, the clinical experts who participated in the review process agreed with the guideline.They approved its methodologic rigour, and more than 80% of the surveyed practitioners gave it a high quality rating.The expert reviewers who participated in the external review provided written comments, which were incorporated into the final version of the guideline.

Conclusions:
Invasive mediastinal staging of nsclc is recommended in all cases except those involving patients with normal-sized lymph nodes, negative combined positron-emission tomography and computed tomography (pet-ct), and peripheral clinical stage 1A tumour.By contrast, the accp guideline does not recommend invasive staging in the case of normal computed tomography imaging, negative pet-ct, and peripheral clinical stage 1 tumour.This distinction was made because, in the opinion of the guideline working group, the probability of nodal metastasis is greater with larger tumours.In other respects, the results of the updated systematic review largely accord with the findings of the accp.In a mediastinoscopy, 5 nodal stations (2R/L, 4R/L, 7) should routinely be examined.Further discussion of staging techniques is included in the full text of the guideline.Mediastinoscopy continues to be the standard technique for invasive mediastinal staging, but newer techniques are emerging, and therefore ongoing monitoring of the literature in this field is recommended.Methods: Articles were selected for inclusion as evidence in the systematic review if they reported on organizational system components or care delivery models for survivors cancer, or on psychosocial or supportive care interventions designed for survivors of cancer.Articles were excluded from the systematic review if they focused only on pediatric cancer survivor populations or on populations that transitioned from pediatric cancer to adult services; if they addressed only pharmacologic interventions or diagnostic testing and follow-up of cancer survivors; if they were systematic reviews with inadequately described methods; if they were qualitative or descriptive studies; and if they were opinion papers, letters, or editorials.

Data Extraction and Synthesis of the Evidence:
Evidence was selected and reviewed by three members of the Cancer Journey Survivorship Expert Panel (SM, TC, TKO).The resulting summary of the evidence was guided further and reviewed by the members of Cancer Journey Survivorship Expert Panel.Fourteen practice guidelines, eight systematic reviews, and sixty-thee randomized controlled trials form the evidence base for the guidance document.The final recommendations were reviewed by a purposively selected national expert interdisciplinary group.Most of the trials examined were of low quality and focused mainly on breast cancer populations, but overall, the evidence suggested that survivors can benefit from organized survivorship services and transition planning and from interventions designed to reduce the persistent effects of cancer and lead to adoption of health lifestyle behaviours.

Conclusions:
A publication that provides guidance to organizations developing survivorship services and that sets out best practices for the effective management of persistent side effects of cancer treatment is clearly warranted given the burgeoning survivorship population in Canada.However, high-quality trials investigating effective models of care delivery and specific components of care are lacking.To facilitate the standardization of approaches, further research into interventions for persistent effects and high-quality trials investigating the effectiveness of various care services models that can optimize health and quality of life for the post-treatment cancer population are urgently required across cancer populations.

G
.E. Darling md, A.J. Dickie md, R.A. Malthaner md, E.B. Kennedy mhsc, and R. Tey msc.Division of Thoracic Surgery, Toronto General Hospital, Toronto; Department of Surgery, Lakeridge Health Oshawa, Oshawa; Division of Thoracic Surgery, London Health Sciences Centre, London; and Cancer Care Ontario, Program in Evidence-Based Care, McMaster University, Hamilton, Ontario.

patterns of presentation, Referral, and treatment of Hepatocellular Carcinoma in a pre-Sorafenib Era: Experience of a Canadian provincial Cancer Agency
. Sundaralingam md and S. Gill md.University of British Columbia and Department of Medical Oncology, BC Cancer Agency, Vancouver, British Columbia. T

/www.current-oncology.com/index. php/oncology/article/view/956/ E-JOURNAL LINKED ABSTRACT Objective:
Cancer Journey Survivorship Expert Panel: D. Howell rn phd, T.F.Hack phd, T.K. Oliver ba, T. Chulak msc, S. Mayo rn mn, M. Aubin md phd, M. Chasen mb chb mphil (pall med), C.C. Earle md msc, A.J. Friedman msw rsw, E. Green rn bscn msc (t), G.W. Jones md msc, J.M. Jones phd, M. Parkinson med, N. Payeur msw rsw, C.M. Sabiston phd, and S. Sinclair phd.Faculty of Nursing, Cancer Patient Education and Survivorship, and Cancer Survivorship Program, University Health Network, Toronto, Ontario; Faculty of Nursing and Manitoba Palliative Care Research Unit, University of Manitoba, and Patient and Family Support Services, CancerCare Manitoba, Winnipeg, Manitoba; Department of Oncology, McMaster University, Hamilton, Ontario; Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Quebec; Palliative Care Program, University of Ottawa, Palliative Rehabilitation and Survivorship, Our goal was to develop evidence-based recommendations for the organization and structure of cancer survivorship services, and best-care practices to optimize the health and well-being of post-primary treatment survivors in the Canadian health care system.This systematic review sought to determine the

Current OnCOlOgy-VOlume 18, number 6
Copyright © 2011 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).optimalorganization and care delivery structure for cancer survivorship services, and the specific clinical practices and interventions that would improve or maximize the psychosocial health and overall wellbeing of adult cancer survivors.