Australian Cancer Centre Research Articles

Establishing a cancer nutrition rehabilitation program (CNRP) for ambulatory patients attending an Australian cancer center

To establish a multidisciplinary Cancer Nutrition Rehabilitation Program (CNRP) for the management of the anorexia-cachexia syndrome (ACS) in an Australian cancer center and to evaluate outcomes of 2 months participation in the CNRP METHOD: Patients were eligible if they had significant anorexia/weight loss, identified by their oncologist or the Malnutrition Screening Tool. In the 9 months that funding was available, 54 participants (37 males, 17 females; median age, 62 years) enrolled. They had mainly lung or gastrointestinal cancers, with 67% receiving chemotherapy concomitantly. Baseline assessments of nutrition and physical status were: median weight 62.7 kg, median weight loss 10.2%, median BMI 21.2 kg/m(2), and 78% malnourished according to PG-SGA. Median baseline Karnofsky performance score (KPS) was 70%, with reduced right-hand grip strength (RGHS; median, 27 kg) and endurance (median, 6 min walk test 6MWT 442 m). Patients received individualized nutritional interventions, exercise programs, and symptom management and were followed prospectively for up to 6 months. Twenty-five (58%) of 41 evaluable CNRP participants attended the 2-month follow-up. Median weight (63.4 kg), KPS (80%), endurance (6MWT 570 m), and strength (RGHS 28 kg) were all improved. Edmonton symptom assessment scores (36 vs 27) and C-reactive protein levels (39 vs 22) fell. Participants were significantly more likely to return for re-evaluation if at baseline they were having anticancer therapy (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.3-16.2) or could walk >420 m in 6 min (OR 21, 95% CI 1.9-227). A CNRP may be beneficial for patients with advanced cancer and the ACS, but identification of patients who are likely to stay on the program is needed.

Clinician–Patient Communication: Evidence-Based Recommendations to Guide Practice in Cancer

To develop recommendations for effective communication between cancer health care providers and patients based on a systematic review of methods of clinician-patient communication that may affect patient outcomes associated with distress at critical points in the course of cancer care. A systematic review of the literature was conducted, and evidence-based recommendations were formulated to guide clinician-patient communication in cancer care. A formal external review was conducted to validate the relevance of these recommendations. Recommendations for communication in cancer care are presented, based on guidelines from the Australian National Breast Cancer Centre and the Australian National Cancer Control Initiative,an updated systematic review of the research evidence, and a consensus by the Clinician-Patient Communications Working Panel of the Program in Evidence-Based Care of Cancer Care Ontario. The recommendations were sent to 110 Ontario practitioners for external review: 33 responded (30% response rate). Most of these respondents (87%) agreed with the draft recommendations and approved of their use as a practice guideline (90%). A condensed version of the recommendations, including 10 key points, was also created. There is evidence to support general clinician-patient communication approaches, although the preferences of cancer patients regarding such communication exhibit individual and cultural variability. Recommendations are provided, based on evidence, the consensus of an expert panel, and feedback from a survey of external practitioners. Evidence evaluating the role of decision aids and strategies to facilitate better communication is inconsistent, although such tools may be of value for some patients.

A randomized controlled trial of the effect of intercessory prayer on the spiritual wellbeing and quality of life of patients with cancer

e20708 Background: A number of scientific trials assessing the positive impact of intercessory prayer attest to centuries of anecdotal evidence, despite debate of its mechanism. However, little attention has been afforded to patients with cancer and the effect such intervention has on quality of life, including spiritual wellbeing. This study aimed to assess the effect of remote, Christian intercessory prayer on cancer patients’ quality of life, specifically their spiritual wellbeing, including their search for meaning, peace, and faith. Methods: New, consecutive patients with cancer attending an Australian cancer centre, aged 18 years or above, able to read English, and give consent were recruited. With Ethics Committee approval, this prospective, double blinded randomized controlled trial only partially divulged the nature of the study to patients who were informed of the measurements but not the inclusion of randomization to an intervention. Specifically, patients were blindly, randomly allocated to receive distant, intercessory prayer from an established Christian prayer chain (intervention) or not to receive prayer (control). All patients completed the Mental Adjustment to Cancer (MAC) scale and the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being (FACIT-Sp) at baseline. The FACIT-Sp was re-administered six months later to assess the primary endpoint, a change in spiritual wellbeing. It was anticipated that 1000 patients were needed (allowing for 20% drop out) to achieve 80% power to detect hypothesized small differences (Cohen's d .20-.50) between groups (alpha = .05). Results: A total of 1003 eligible, consenting patients were accrued between June 2003 and May 2008. Intervention (n = 509) and control (n = 494) groups will be compared across baseline characteristics to identify any pre-existing differences. Between-within subject analyses of covariance (ANCOVAs) will be used to assess whether any differences were evident between groups across measures of spiritual wellbeing and other facets of quality of life. Conclusions: The results of these analyses will be presented. It is hoped this research will provide further empirical support for the biopsychosocialspiritual model of health. No significant financial relationships to disclose.

Perceived importance of evidence-based psychosocial clinical guidelines for Hong Kong Chinese women with breast cancer: opinions of patients and health care providers

The aim of this study was to assess Chinese breast cancer patients' and health care providers' (HCPs) perceptions of psychosocial clinical guidelines developed by the Australian National Health and Medical Research Council's National Breast Cancer Centre. A convenience sample of Hong Kong Chinese women diagnosed with breast cancer was recruited. In addition, all surgeons and clinical/medical oncologists registered with the Hong Kong Medical Council were invited to complete a mailed survey. Both women and HCPs were asked to rate the importance of the 55 psychosocial clinical guideline items. HCPs also rated the feasibility of implementing each item in their practice. Overall, 344 of 362 (95%) women completed the face-to-face interview. Of 490 eligible HCPs, 75 (15%) completed the mailed survey. At least 50% of the women rated 16 of the 55 psychosocial issues as an essential part of psychosocial care in clinical practice. The top ten ranked items rated essential by patients addressed disease and treatment information provision and question opportunity. HCPs also placed high priority on the scope and opportunities for information giving. Emotional care was intermediately valued. Practical issues and providing social support were rated by both patients and HCPs as the least important aspect of psychosocial care in clinical practice. Fewer than half of the HCPs rated any psychosocial item as feasible to implement in their practice. Chinese women value information provision and question opportunities, highlighting the need of HCPs to address these issues. Interventions that facilitate HCP's provision of psychosocial support in breast cancer should be set as a high priority.

Experience with docetaxel in hormone‐refractory prostate cancer (HRPC) at three Australian cancer centers: A retrospective study

AbstractBackground: Hormone‐refractory prostate cancer (HRPC) is associated with a poor prognosis and has historically been considered relatively chemoresistant. Emerging data demonstrate clinical benefit with the use of docetaxel in HRPC, culminating in two recent published phase III studies demonstrating survival benefit. Currently, docetaxel is registered but not reimbursed for HRPC in Australia.Aim: To retrospectively review prostate‐specific antigen (PSA) response rate, and survival following the use of docetaxel for metastatic HRPC.Methods: Retrospective audit of the use of docetaxel for HRPC from 1 January 2001 to 1 April 2004 in three medical oncology practices. Demographic data, baseline PSA, ECOG (Eastern Cooperative Oncology Group) Performance Status, sites of disease, number of cycles received and PSA response rates were collected.Results: Thirty five patients (median age, 71 years; range, 50–88) had an ECOG status of 0 (eight), 1 (20) and 2 (seven). The mean duration from initial prostate cancer diagnosis to start of docetaxel was 5.4 years (range, 0.2–13.5 years). The mean baseline PSA doubling time, available for 29/35 patients, was 1.9 months (range, 0.4–4.9). The median number of metastatic sites was 1 (range, 1–4): bone (34 patients), lymph nodes (10), liver (seven) and lung (seven). Twelve patients were chemotherapy naive; 23 had received prior chemotherapy (21/23 received mitoxantrone). Twenty patients received docetaxel three times weekly; 15 were on weekly schedules. Their mean dose density was 23 mg/m2/week. Patients received an average of 3.2 months of treatment (range, 0.2–11.8). There were 170 recorded toxicities, 13 of which were grade 3–4, and two likely treatment‐related deaths (sepsis). Twelve patients (34%) had >50% PSA response (four were chemotherapy naive); of these 12 responders, seven patients had a >75% PSA response (four chemotherapy naive). Median survival from start of docetaxel was 8 months with 37% alive at 12 months and 23% alive at 24 months.Conclusion: Docetaxel is active in HRPC (in both chemotherapy naive and exposed patients) with a predictable toxicity profile. More research is warranted to identify predictors of response and toxicity.

Fludarabine, Idarubicin and High Dose Cytarabine (FLAG-IDA) Followed by Allogeneic Transplantation: A Successful Strategy for Remission Re-Induction in High Risk Pediatric Patients with Relapsed, Refractory and Secondary Acute Leukemias.

Despite significant advances in the treatment of childhood acute lymphoblastic (ALL) and acute myeloid (AML) leukemias, the prognosis of those with primary refractory, secondary and early relapsed disease remains extremely poor with survival reported in most studies at less than 20%. Salvage rates are particularly poor in children with ALL who relapse on therapy and in children with AML who relapse post autologous bone marrow transplant. Encouraging results using the re-induction combination regimen of Fludarabine, high dose Cytarabine and Idarubicin (FLAG-IDA) have been reported, however the majority of data is in adult patients. Here we report the largest series of pediatric patients with high risk acute leukemias receiving this regimen in combination with allogeneic hematopoietic cell transplantation as salvage therapy.Between 1999–2005 a toal of 32 patients at 2 Australian Pediatric Cancer Centers were given Fludarabine (30mg/m2 IV over 1 hour for 5 days); Idarubicin (8mg/m2 IV over 1 hour for 3 days); Cytarabine (2000mg/m2 IV over 4 hours for 5 days) and GCSF (5mcg/kg/day). There were 21 males and 11 females, with a median age of 10.4 years (range 1.7 to 15.5 years). All patients had high risk leukemias; relapsed ALL (n=13), primary refractory ALL (n=3), relapsed AML (n=13), primary refractory AML (n=1) and secondary AML (n=2). For the overall cohort median duration of first complete remission (CR1) was 16 months (range 2–34 months). Relapsed ALL patients were all considered extremely high risk with a CR1 duration of <36 months.Overall, 23 of 32 patients (71.9%) achieved a complete remission (defined as <5% blasts with evidence of marrow regeneration) following a single course of FLAG-IDA. For those with relapsed ALL, 10 of 13 patients (76.9%) achieved a remission. 2 out of the 3 patients with primary refractory ALL achieved a remission (both Philadelphia chromosome positive), 1 following a second course of FLAG-IDA. In the relapsed AML group, 9/13 (69.2%) achieved a remission, including 7 out of 10 patients who had relapsed post autologous BMT. 1 of the 2 patients with secondary AML achieved a remission. All of the 9 patients who did not achieve a remission died of progressive disease. The median time to neutrophil recovery following therapy was 26.5days (range 16–73). One patient remained aplastic and an attempt was made to transplant during this phase.22 of the 23 patients (10 AML and 12 ALL) who achieved remission proceeded to an allogeneic bone marrow transplant, following a further 2–3 courses of FLAG (without IDA) for consolidation. 70% of patients received an unrelated donor transplant. Stem cell source was MUD BM (n=9), unrelated UCB (n=6) and HLA-ID sibling donor (n=7). Overall 17 of the 22 (77.3%) remain alive and leukaemia free (9 AML and 8 ALL patients) with a median duration of 36.5 months (9–84 months). Cause of death in the transplanted patients was progressive disease (n=4) and Pneumocystis Carinii pneumonitis (n=1). In summary, for this group of high risk, early relapsed and heavily pretreated pediatiric patients, re-induction chemotherapy with FLAG-IDA followed by allogeneic transplantation has provided an excellent strategy in the achievement of long term cure.

Integrative Oncology in Australia

In Australia, use of complementary and alternative therapies for cancer is widespread and increasing. Recent government inquiries have recommended stronger controls on manufacturing quality of complementary medicines, better availability of evidence-based information about complementary therapies, and more research into such therapies for cancer. At present very few Australian cancer centers provide complementary therapies along with orthodox service, but if the government adopts the recommendations of its committees, there will be pressure and possibly funding for such provision.

From evidence to practice: Audit of adjuvant chemotherapy after complete resection of non‐small cell lung cancer in an Australian lung cancer center

AbstractObjective: To investigate patterns in the rate of referral and uptake of platinum‐based adjuvant chemotherapy following resection of non‐small cell lung cancer (NSCLC) after recent landmark evidence‐based publications.Design and setting: An audit of all patients who underwent complete resection of NSCLC by a specialist thoracic surgeon between 1 January 2002 and 31 December 2004. Results of several randomised trials of adjuvant therapy (including the largest ever multicentre trial) were reported during this period and confirmed an overall and disease‐free survival benefit.Patients: One hundred and twenty‐six adult patients who underwent complete resection of histologically confirmed NSCLC between 1 January 2002 and 31 December 2004.Main outcome measure: Percentage of patients referred, commencing and completing platinum‐based adjuvant chemotherapy between January and June 2002, July and December 2002, January and June 2003, July and December 2003, January and June 2004, and July and December 2004.Results: Of patients who underwent complete resection of NSCLC in each of the 6‐month intervals, 0.0%, 3.4%, 30.8%, 52.2%, 58.8% and 68.3% were referred for adjuvant chemotherapy, respectively. Treatment delivery rates were 0.0%, 3.4%, 7.7%, 30.4%, 29.4% and 36.8%, respectively. The most common reason for failing to receive adjuvant chemotherapy after referral was excessive risks compared with benefits of treatment as perceived by the medical oncologist and/or patient.Conclusion: Both rate of referral and utilization of platinum‐based adjuvant chemotherapy have increased with successive publications of evidence of survival benefit. Further improvements may be possible by routine referral policy, earlier timing and choice of regimen.

Experience with docetaxel in hormone-refractory prostate cancer (HRPC) at three Australian cancer centers: A retrospective study

4786 Aim: To retrospectively review PSA response rate, and survival following the use of docetaxel (D) for metastatic HRPC. Background: HRPC is associated with poor prognosis and has historically been considered relatively chemo-resistant. Emerging data demonstrate clinical benefit with the use of D in HRPC, culminating in 2 recent published Phase III studies demonstrating survival benefit. Currently, D is not registered or reimbursed through Medicare (Pharmaceutical Benefits Scheme) for the treatment of HRPC in Australia. Methods: Retrospective audit (commenced September 2003) of the use of D for HRPC from January 2001- January 2004 in 3 Medical Oncology practices. Demographic data, baseline PSA, ECOG status, sites of disease, number of cycles received and PSA response rate were collected. Results: 35 patients (pts); median age 71yrs (50–88yrs). ECOG status: 0 (8pts), 1 (20pts), 2 (7pts). Mean duration from initial prostate cancer diagnosis to start of D 5.4yrs (0.2–13.5yrs). Mean baseline PSA doubling time, available for 18/35 pts, was 3.91 months (1–15). Median number of metastatic sites 1 (range 1–4): bone-34 pts, lymph nodes-10, liver-7 and lung-7. Twelve pts were chemo-naïve; 23 pts had received prior chemotherapy (21/23 received mitoxantrone). Twenty pts received D 3 weekly; 15 pts were on weekly schedules. Mean dose density was 23mg/m2/week. Pts received an average of 3.2 months of treatment (0.2–11.8). There were 170 recorded toxicities, of which 13 were grade 3–4, and two likely treatment-related deaths (sepsis). Twelve pts (34%) had >50% PSA response (4 chemo-naïve); of these 12 responders, 7 pts had a >75% PSA response (4 chemo-naïve). Median survival from start of D was 8 months with 37% alive at 12 months and 23% alive at 24 months. Conclusion: Docetaxel is active in HRPC (in both chemotherapy naïve and exposed pts) with a predictable toxicity profile.Our median survival of 8 months compared to a median survival of 18.9 months in the TAX-327 Phase III study is probably due to the fact that our patients on average were slightly older, more heavily pre-treated and more likely to have a poorer performance status. More research is warranted to identify predictors of response and toxicity. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Aventis

Evaluating key dimensions of the breast care nurse role in Australia.

A survey of women who had surgery for breast cancer during 1997-1998 at The St George Public and St George Private Hospitals identified substantial deficits in information provision, perceived support, and use of available services. Consequently, a breast care nurse (BCN) was appointed for a 12-month trial to assess women's needs and provide emotional support, education, and referral to appropriate services from diagnosis through to completion of treatment, according to evidence-based guidelines set out by the Australian National Breast Cancer Centre. A questionnaire regarding the role of the BCN was sent to 63 women who had surgery at either hospital from September 1999 to January 2000. Fifty women responded, for a 79% response rate. Ninety percent of respondents reported that it was helpful to talk to the BCN and rated verbal information given as helpful. Women accessed significantly more services than reported in 1998, and disparities in service use by age and public/private sector were eliminated. These results show strong consumer endorsement of service provision by the BCN. During this 12-month trial, consumer demand resulted in service expansion from 24 hours per week to 80. Ongoing evaluation of this developing role is required to ensure that women's needs are managed optimally.

Breast radiotherapy: an Australasian survey of current treatment techniques.

Prior to the dissemination of evidence-based quality assurance guidelines, the Australian National Breast Cancer Centre Radiation Oncology Group conducted a process survey of breast radiotherapy treatment delivery throughout Australia. A process survey was conducted in August/September 1998. This survey comprised questions enquiring about treatment positioning, immobilization devices used, planning strategies, simulation and dose computation methods, treatment prescribing and quality assurance. The survey was sent to 123 Australian fellows of the Royal Australian and New Zealand College of Radiologists (RANZCR) and to the six directors of New Zealand radiation oncology departments. Fifty-eight questionnaires were returned of which 38 were received from individuals and 20 represented a reply from a department with a routine breast radiotherapy protocol (representing an average of 4.5 radiation oncologists per reply). The study identified great consistency between departments with respect to dose and fractionation for breast tangents. The study also identified some areas of treatment planning and delivery that varied between individuals or departments. These mainly reflected a lack of evidence in some areas of radiotherapy treatment delivery. The circulation of quality assurance guidelines will perhaps improve consistency of radiotherapy techniques in which studies have identified that technique changes improve outcome. This study identified that these areas include the taking of simulation and port films and the use of off-axis dosimetry. Further studies are required for areas of radiotherapy treatment delivery that have little evidence for or against their implementation.