Cancer Centers In Ontario Research Articles

Communicating with Emotional Patients: Thoughts, Skills and Influencing Factors for Ontario Radiation Therapists

Patients receiving radiation therapy are subject to very high anxiety levels. Therapists are uniquely positioned to support patients as they progress through treatment, but little is known about therapists’ ability to perform this important task. Therefore, this research was designed to describe radiation therapists’ ability to communicate with cancer patients during emotional interactions and to determine what intrinsic and extrinsic factors influence that ability. A two-phase consecutive mixed methods design was used. Single centre focus groups were used to develop themes for a questionnaire. That questionnaire was then distributed throughout 13 Ontario cancer centres. Themes evaluated included intrinsic factors (demographics, value, support education etc) and extrinsic factors (work environment and resources etc). A validated clinical vignette evaluated actual respondent communication ability. Inferential statistics were used to identify factors that influenced a respondent’s ability to correctly answer the vignette, and their overall satisfaction with provision of support to emotional patients. 199 responses were received from 13 large and small cancer centres, distributed broadly across Ontario. Response rate was low (31%) but wave analysis indicated a lack of non-response bias. Therapists showed a high degree of ability to effectively engage with emotional patients, with minimal use of blocking or controlling behaviors. 84% became radiation therapists to provide care and emotional support, and felt that this should be the focus of the profession. 63% of respondents felt satisfied with the quality of support they provide for emotional patients. Factors shown to significantly influence ability to communicate with emotional patients include personal sociability and experience, organizational provision of time, private space and support (p<0.05). This study demonstrates that radiation therapists are effective at communicating with emotional patients. That ability is significantly influenced by both personal and organizational factors. Most importantly these are experience and time. These findings are congruent with the literature for other professions and are likely generalisable throughout Canada and similar international practice environments.

Image-Guided Radiation Therapy Education Template

Purpose behind Practice InnovationIn November 2011, the Radiation Therapy Community of Practice (RT CoP) was formed as an initiative of Cancer Care Ontario. Radiation therapists representing each of the 14 Ontario Cancer Centres brainstormed areas of interest to improve radiation therapist practice province-wide.Image-guided radiation therapy (IGRT) education was unanimously identified as a subject that varied greatly between cancer centres. Whether the centre was changing to newer technology or simply hiring new or reintegrating staff, it was recognized that IGRT training for radiation therapists had become a high priority in providing quality care to patients. Therefore, as a commitment to best practice, the RT CoP developed an IGRT Education Template.Technique/Process UsedThe IGRT Education Template is designed to serve as a starting point for each centre to adapt centre specific policies and procedures. Major categories that are included in the template are: Cross Sectional Anatomy, Linear Accelerator Hardware/Software Overview, Site Specific IGRT Learning Modules, IGRT Quality Assurance Rounds & Additional Resources.Benefits/ChallengesEach centre will have an IGRT Education Template in place to ensure best practice and equal knowledge across the province. Radiation therapists can (re)develop IGRT skills by following the centre’s completed template. The challenge was to create the framework that could be adaptable to each cancer centres policies and procedures. The upcoming challenge is to maintain equal knowledge amongst the provinces’ cancer centres with the future advances in technology.Future Work/ImplicationsOntario is the first province in Canada to attempt to standardize a therapist driven process to create best practice across the province. The next step is to implement the IGRT Education Template and evaluate its effectiveness in the workplace. Purpose behind Practice InnovationIn November 2011, the Radiation Therapy Community of Practice (RT CoP) was formed as an initiative of Cancer Care Ontario. Radiation therapists representing each of the 14 Ontario Cancer Centres brainstormed areas of interest to improve radiation therapist practice province-wide.Image-guided radiation therapy (IGRT) education was unanimously identified as a subject that varied greatly between cancer centres. Whether the centre was changing to newer technology or simply hiring new or reintegrating staff, it was recognized that IGRT training for radiation therapists had become a high priority in providing quality care to patients. Therefore, as a commitment to best practice, the RT CoP developed an IGRT Education Template. In November 2011, the Radiation Therapy Community of Practice (RT CoP) was formed as an initiative of Cancer Care Ontario. Radiation therapists representing each of the 14 Ontario Cancer Centres brainstormed areas of interest to improve radiation therapist practice province-wide. Image-guided radiation therapy (IGRT) education was unanimously identified as a subject that varied greatly between cancer centres. Whether the centre was changing to newer technology or simply hiring new or reintegrating staff, it was recognized that IGRT training for radiation therapists had become a high priority in providing quality care to patients. Therefore, as a commitment to best practice, the RT CoP developed an IGRT Education Template. Technique/Process UsedThe IGRT Education Template is designed to serve as a starting point for each centre to adapt centre specific policies and procedures. Major categories that are included in the template are: Cross Sectional Anatomy, Linear Accelerator Hardware/Software Overview, Site Specific IGRT Learning Modules, IGRT Quality Assurance Rounds & Additional Resources. The IGRT Education Template is designed to serve as a starting point for each centre to adapt centre specific policies and procedures. Major categories that are included in the template are: Cross Sectional Anatomy, Linear Accelerator Hardware/Software Overview, Site Specific IGRT Learning Modules, IGRT Quality Assurance Rounds & Additional Resources. Benefits/ChallengesEach centre will have an IGRT Education Template in place to ensure best practice and equal knowledge across the province. Radiation therapists can (re)develop IGRT skills by following the centre’s completed template. The challenge was to create the framework that could be adaptable to each cancer centres policies and procedures. The upcoming challenge is to maintain equal knowledge amongst the provinces’ cancer centres with the future advances in technology. Each centre will have an IGRT Education Template in place to ensure best practice and equal knowledge across the province. Radiation therapists can (re)develop IGRT skills by following the centre’s completed template. The challenge was to create the framework that could be adaptable to each cancer centres policies and procedures. The upcoming challenge is to maintain equal knowledge amongst the provinces’ cancer centres with the future advances in technology. Future Work/ImplicationsOntario is the first province in Canada to attempt to standardize a therapist driven process to create best practice across the province. The next step is to implement the IGRT Education Template and evaluate its effectiveness in the workplace. Ontario is the first province in Canada to attempt to standardize a therapist driven process to create best practice across the province. The next step is to implement the IGRT Education Template and evaluate its effectiveness in the workplace.

A multicenter, phase IV study of the effectiveness of palliative gemcitabine in patients with advanced pancreatic cancer.

46 Background: Randomized controlled trials (RCTs) have shown that palliative gemcitabine provides clinical benefit and prolongs survival in patients with advanced pancreatic cancer. The purpose of this study was to determine if the efficacy of palliative gemcitabine demonstrated in RCTs has translated into effectiveness in routine clinical practice in Ontario. Methods: This was a retrospective cohort study of all patients with exocrine cancer of the pancreas treated with first line, single agent, palliative gemcitabine at all 13 provincial cancer centres in Ontario between 2008 and 2011. These patients were identified by linking electronic records of treatment from all cancer centres and hospitals in Ontario to the Ontario Cancer Registry. Patient-reported well-being and symptoms were captured by the Edmonton Symptom Assessment System, which has been in routine use at these centres since 2008. The effectiveness of gemcitabine was measured in terms of clinical benefit at two months and overall survival. Patients were classified as having achieved clinical benefit if they had not discontinued gemcitabine and their self-reported well-being was stable or improved at two months. Results: The study population included 423 patients. Their median age was 65 and 50% were women. Fifty-seven percent had stage IV disease, 17% had stage III disease, and 10% had recurrence after earlier treatment for stage I or II disease. Patients included in this study were older than, but otherwise similar to, patients enrolled in four relevant RCTs that used gemcitabine in the experimental or control arm. At two months, 36.9% (95% CI 29.6-44.2%) of patients in this study achieved clinical benefit, which was within the range of 24% to 56% observed in patients in these trials. Median overall survival was 5.7 months (95% CI 4.7-6.1), which was within the range of 5.4 to 6.9 months reported in the trials. Conclusions: The efficacy of gemcitabine demonstrated in RCTs has translated into effectiveness in routine clinical practice in Ontario. The approach described above could readily be used to study the effectiveness of other palliative interventions.

Peer-review of radiation treatment planning in a provincial radiation oncology program: A survey of current practice.

211 Background: The use of peer-review activities in oncology is not well described as a quality improvement process. We sought to describe current patterns of practice of radiation oncology peer-review across a large Provincial Cancer program and to identifiy barriers to its use. Methods: Ontario cancer centres were surveyed. Survey item responses were typically scored using a 10-point Likert scale. The survey was administered electronically with follow-up reminders as required. The use of free-text for comments elaborating on responses was encouraged. Results: Fourteen (100%) centres responded. All rated the importance of peer-review as at least 8/10 (10=extremely important). Detection of medical error and improvement of planning processes were the highest-rated benefits of peer-review (each median 9/10). Four centres (29%) conducted peer-review in more than 80% of cases treated with curative intent; six (43%) peer-reviewed at least 50% of curative cases. Five centres (36%) reported “always” or “almost always” conducting peer-review prior to the initiation of treatment. Variation was seen in which aspects of a case were typically reviewed (e.g., GTV “almost always” reviewed in 67%; contouring of organs at risk in 50%). Five centres (46% of those with regular peer-review) reported that 5% to 9% of peer-reviewed cases were flagged as requiring a change, whereas 3 centres (27%) reported that &lt; 2% of peer-reviewed cases required a change to be made. Five centres (36%) recorded the outcomes of peer-review on the medical record. Thirteen centres (93%) planned to expand peer-review activities; the two factors rated as most limiting to expanding peer-review were a critical mass of radiation oncologists (median score 6/10), and prioritization of peer review by the program overall (median 5/10). Conclusions: Peer review in radiation oncology practices it is now widely used as a quality assurance activity in Ontario, identifies changes to improve quality in the individual case, and improves departmental process. The development of guidelines and standards for peer-review activities, coupled with effective knowledge translation activities are recommended.

A Multi-institutional Study of Factors Influencing the Use of Stereotactic Radiosurgery for Brain Metastases

Stereotactic radiosurgery (SRS) for brain metastases is a relatively well-studied technology with established guidelines regarding patient selection, although its implementation is technically complex. We evaluated the extent to which local availability of SRS affected the treatment of patients with brain metastases. We identified 3030 patients who received whole-brain radiation therapy (WBRT) for brain metastases in 1 of 7 cancer centers in Ontario. Clinical data were abstracted for a random sample of 973 patients. Logistic regression analyses were performed to identify factors associated with the use of SRS as a boost within 4 months following WBRT or at any time following WBRT. Of 898 patients eligible for analysis, SRS was provided to 70 (7.8%) patients at some time during the course of their disease and to 34 (3.8%) patients as a boost following WBRT. In multivariable analyses, factors significantly associated with the use of SRS boost following WBRT were fewer brain metastases (odds ratio [OR] = 6.50), controlled extracranial disease (OR = 3.49), age (OR = 0.97 per year of advancing age), and the presence of an on-site SRS program at the hospital where WBRT was given (OR = 12.34; all P values were <.05). Similarly, availability of on-site SRS was the factor most predictive of the use of SRS at any time following WBRT (OR = 5.98). Among patients with 1-3 brain metastases, good/fair performance status, and no evidence of active extracranial disease, SRS was provided to 40.3% of patients who received WBRT in a hospital that had an on-site SRS program vs 3.0% of patients who received WBRT at a hospital without SRS (P<.01). The availability of on-site SRS is the factor most strongly associated with the provision of this treatment to patients with brain metastases and appears to be more influential than accepted clinical eligibility factors.

Bevacizumab in combination with FOLFIRI in metastatic colorectal cancer: A retrospective study of adverse events and their correlation with clinical outcome.

426 Background: Bevacizumab is a monoclonal antibody against the VEGF ligand that disrupts vascularization of solid tumors and is part of first-line therapy for metastatic colorectal cancer (mCRC) in Ontario. The current study is intended to assess the rate of adverse events in general practice and to explore the relationship of adverse events to clinical outcomes in patients (pts) receiving bevacizumab. Methods: Patients with mCRC from one Ontario cancer centre who received FOLFIRI with bevacizumab (BEV-FOLFIRI) as first-line treatment were retrospectively reviewed. Data collected included demographics, adverse events, radiographic response, and survival times. Results: 57 patients were included in the study with a median age of 61 years, all with ECOG ≤1, and received a median of 5.5 cycles of BEV-FOLFIRI. Median follow-up was 5.8 months. Progression-free survival (PFS) was 9.8 months (95% CI 8.2-11.0) and overall survival (OS) was 13.1 months (95% CI 12.0-15.0). The most common bevacizumab-related adverse event was proteinuria with 11 (19.3%) pts developing any grade. Other adverse events included venous thromboembolism (VTE) in 9 (15.8%) pts, hypertension (NCI-CTCAE v3) in 7 (12.3%) pts, and GI perforation in 2 (3.5%) pts. 15 (26.3%) pts had a favorable radiographic response with 40% of pts who developed significant hypertension considered responders, compared with only 25% of those without hypertension. When using NCI-CTCAE v4.03, 19 (33.3%) pts developed grade ≥2 hypertension and had significantly longer PFS (13.5 vs 8.9 months, p=0.005) and OS (16.3 vs 11.0 months, p=0.015). Finally, developing a VTE was associated with increased PFS (14.8 vs 9.6 months, p=0.012), whereas proteinuria was associated with a significantly reduced OS (6.6 vs 14.0 months, p=0.001). Conclusions: Use of NCI-CTCAE v4.03 criteria for hypertension identifies more patients with significant hypertension. Patients with hypertension according to these criteria appear to have a better treatment response, suggesting hypertension may be a useful biomarker. Conversely, new or worse proteinuria related to therapy was associated with a poor treatment response.

A descriptive study of functions, symptoms, and perceived health state after radiotherapy for prostate cancer

PurposeTo explore the impact of prostate cancer treatment on: (a) the experience of symptoms (i.e. sexual, urinary, and bowel), and (b) perceived health state of men with prostate cancer one month following their radiation treatment. MethodsA prospective pre-test–post-test descriptive survey was conducted on a convenience sample of 73 men with prostate cancer who were recruited from a Regional Cancer Centre in Southwestern Ontario, Canada. Participants receiving radiation treatment (brachy therapy, high dose radiation [HDR] and external beam radiation [EBR], or EBR alone) completed a questionnaire that elicited information pertaining to quality of life (QOL), symptom experiences, and perceived health state prior to, and one month after completion of their radiation treatment. ResultsPost-treatment scores showed increased problems with urinary bother (p<0.001) and function (p<0.001), bowel bother (p=0.002) and function (p=0.001), and sexual function (p<0.001). The results also suggested that urinary bother, sexual bother, and pain were independent predictors of the perceived health state of participants after radiation treatment. DiscussionOur findings suggest that prostate cancer treatment presents a challenge with regard to symptom experiences and perceived health state in men with prostate cancer. Therefore, strategies for patient education to assist men to cope with their symptoms and to provide them with support in the initial weeks following treatment are discussed.

Of time and troubles: Patient involvement and the production of health care disparities

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.

Factors affecting the implementation of complex and evolving technologies: multiple case study of intensity-modulated radiation therapy (IMRT) in Ontario, Canada

BackgroundResearch regarding the decision to adopt and implement technological innovations in radiation oncology is lacking. This is particularly problematic since these technologies are often complex and rapidly evolving, requiring ongoing revisiting of decisions regarding which technologies are the most appropriate to support. Variations in adoption and implementation decisions for new radiation technologies across cancer centres can impact patients' access to appropriate and innovative forms of radiation therapy. This study examines the key steps in the process of adopting and implementing intensity modulated radiation therapy (IMRT) in publicly funded cancer centres and identifies facilitating or impeding factors.MethodsA multiple case study design, utilizing document analysis and key informant interviews was employed. Four cancer centres in Ontario, Canada were selected and interviews were conducted with radiation oncologists, medical physicists, radiation therapists, and senior administrative leaders.ResultsEighteen key informants were interviewed. Overall, three centres made fair to excellent progress in the implementation of IMRT, while one centre achieved only limited implementation as of 2009. Key factors that influenced the extent of IMRT implementation were categorized as: 1) leadership, 2) training, expertise and standardization, 3) collaboration, 4) resources, and 5) resistance to change.ConclusionA framework for the adoption and implementation of complex and evolving technologies is presented. It identifies the key factors that should be addressed by decision-makers at specific stages of the adoption/implementation process.

Real-World Experience with Adjuvant FEC-D Chemotherapy in Four Ontario Regional Cancer Centres

The efficacy of adjuvant chemotherapy with fec-d (5-fluorouracil-epirubicin-cyclophosphamide followed by docetaxel) is superior to that with fec-100 alone in women with early-stage breast cancer. As the use of fec-d increased in clinical practice, health care providers anecdotally noted higher-than-expected toxicity rates and frequent early treatment discontinuations because of toxicity. In the present study, we compared the rates of serious adverse events in patients who received adjuvant fec-d chemotherapy in routine clinical practice with the rates reported in the pacs-01 trial. We retrospectively reviewed all patients prescribed adjuvant fec-d for early-stage breast cancer at 4 regional cancer centres in Ontario. Information was collected from electronic and paper charts by a physician investigator from each centre. Data were analyzed using chi-square tests, independent samples t-tests, one-way analysis of variance, and univariate regression. The 671 electronic and paper patient records reviewed showed a median patient age of 52.2 years, 229 patients (34.1%) with N0 disease, 508 patients (75.7%) with estrogen or progesterone receptor-positive disease (or both), and 113 patients (26%) with her2/neu-overexpressing breast cancer. Febrile neutropenia occurred in 152 patients (22.7%), most frequently at cycle 4, coincident with the initiation of docetaxel [78/152 (51.3%)]. Primary prophylaxis with hematopoietic growth factor support was used in 235 patients (35%), and the rate of febrile neutropenia was significantly lower in those who received prophylaxis than in those who did not [15/235 (6.4%) vs. 137/436 (31.4%); p < 0.001; risk ratio: 0.20]. In routine clinical practice, treatment with fec-d is associated with a higher-than-expected rate of febrile neutropenia, in light of which, primary prophylaxis with growth factor should be considered, per international guidelines. Adoption based on clinical trial reports of new therapies into mainstream practice must be done carefully and with scrutiny.

Results of an Ontario Clinical Oncology Group (OCOG) prospective cohort study on the use of FDG PET/CT to predict the need for neck dissection following radiation therapy of head and neck cancer (HNC).

5504 Background: A significant proportion of node-positive HNC patients will have residual nodes visible on CT following curative radiation therapy +/- concurrent chemotherapy (RT+/-Chemo). A third of these will harbor residual cancer and can be cured by neck dissection (ND). This study examines the ability of PET/CT to detect residual nodal cancer following RT+/-Chemo in HNC patients. Methods: This prospective multi-center study was conducted at 4 regional cancer centers in Ontario. Eligible patients had squamous cell carcinomas with N2 or N3 neck disease. They were treated curatively with RT+/-Chemo to include full radiation dose to nodes deemed involved by tumor. Contrast enhanced CT scans and PET/CT were performed prior to and 8-10 weeks following RT+/-Chemo. Patients with residual nodes >1cm axial dimension on CT were mandated to undergo ND within 4 weeks of imaging. The pathologic results of ND were correlated with post treatment imaging. Patients were followed for neck recurrence for 2 years. Resul...

Do high symptom scores trigger clinical actions by providers? Assessing the effect of standardized symptom screening.

9127 Background: Standardized cancer symptom screening is being used increasingly in cancer care systems. It is assumed that by using a standardized approach to symptom screening, the quality of care will be improved. Since 2007, Ontario cancer centres have implemented an electronic version of the Edmonton Symptom Assessment Scale (ESAS) at every patient visit. To date, there is little research documenting the relationship between screening and resultant clinical actions. This study examines how ESAS scores are associated with rates of symptom documentation in the patient chart and clinical actions taken. Methods: Retrospective chart reviews on a random stratified sample of visits by ambulatory lung and breast cancer patients at a large regional cancer centre. The dependent variable was ESAS symptom scores for pain and shortness of breath, categorized by severity: 0=none, 1-3, 4-6, and 7-10=severe. Outcomes included symptom documentation in the chart on the visit date and symptom-related action(s) taken within a week. Chart reviewers were blinded to ESAS scores. Results: 912 unique visits were reviewed, 25% from each score category. 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. The proportion of visits that had pain documented increased significantly (36.9%, 49.2%, 55.2%, and 71.4%; p<0.001) as ESAS score category increased. Likewise, from low to high ESAS score category, the proportion of visits that had a pain-related action increased significantly (4.2%, 10.6%, 21.3%, and 37.0%; p<0.001). Similar trends were found for shortness of breath but at much lower rates with overall only 11.1% having evidence of actions taken when the symptom was documented in the chart. Conclusions: Our results illustrate the link between standardized symptom screening and clinical actions. However, substantial opportunities for improvement remain as symptom-related actions were documented infrequently, even when symptoms were reported as severe. Future research that addresses this apparant gap between screening and actions is important to support the concept of routine screening to improve quality of care.

The Supportive Care Needs of Men With Advanced Prostate Cancer

To better understand the priority supportive care needs of men with advanced prostate cancer. Qualitative, descriptive study. Outpatient cancer center and urology clinics in central western Ontario, Canada. 12 men with hormone-sensitive prostate cancer and 17 men with hormone-refractory prostate cancer. Patients participated in focus groups and interviews that examined their supportive care needs, their priority needs, and suggestions for improvements to the delivery of care. Tape-recorded focus group discussions and interviews were organized using NVivo software. Patients' supportive care needs. Participants identified prostate cancer-specific information and support to maintain their ability "to do what they want to do" as priority needs. Both hormone-sensitive and hormone-refractory groups cited problems with urinary function, the side effects of treatment, fatigue, and sexual concerns as major functional issues. Participants experienced emotional distress related to diagnosis and treatment. A priority health need for men with advanced prostate cancer is to improve or maintain functional abilities. In addition, men require support to meet their stage-specific information needs and to address concerns about the diagnosis and ambivalent feelings about past treatment decisions. Nurses could play an important role in addressing men's information needs and providing emotional support. The complex care needs of men with advanced prostate cancer provide opportunity for the development of advanced practice nurse roles that would use the clinical and nonclinical aspects of the role.

Temsirolimus in VEGF-refractory metastatic renal cell carcinoma

Background: Temsirolimus is an i.v. administered inhibitor of mammalian target of rapamycin with activity in the first-line setting in poor-prognosis patients with metastatic renal cell carcinoma (RCC). The efficacy of this agent after failure of prior inhibitors of vascular endothelial growth factor (VEGF) is unknown.Methods: A retrospective review of patients with metastatic RCC treated at the Cleveland Clinic Taussig Cancer Institute and three regional cancer centers in Ontario, Canada, through the Torisel (temsirolimus) Compassionate Use Program was conducted. Demographic, toxicity and response data were collected.Results: A total of 87 patients with metastatic RCC were identified who had previously been treated with inhibitors of VEGF subsequently treated with temsirolimus. The majority of patients had either intermediate or poor-prognosis disease at baseline. Expected toxic effects including hyperglycemia and noninfectious pneumonitis were observed. The RECIST-defined objective response rate was 5% and the stable disease rate was 65%. The median time to progression (TTP) was 3.9 months (95% confidence interval 2.8–4.8 months), and median overall survival was 11.2 months.Conclusions: In a cohort of pre-treated intermediate to poor-prognosis patients with metastatic RCC, weekly i.v. temsirolimus is associated with predictable, but manageable toxicity, and a TTP approaching 4 months.

Multidisciplinary Health Care Professionals' Perceptions of the Use and Utility of a Symptom Assessment System for Oncology Patients

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.

Laryngeal Cancer Treatment and Survival Differences across Regional Cancer Centres in Ontario, Canada

Aims We conducted a population-based study of practice patterns and outcome across the regional cancer centres providing care to patients with laryngeal cancer in the Province of Ontario, Canada. Materials and methods : This was a retrospective cohort study of 1547 patients with cancers of the glottic or supraglottic larynx diagnosed between 1982 and 1995. Data were collected via chart review, including: patient and disease characteristics, treatment, waiting times and treatment volumes. Vital status was obtained from the Ontario Cancer Registry. Variations across the nine regional cancer centres are described and their effect on outcome explored. All analyses were stratified by stage I and II separately from stage III and IV. Results Treatments differed across centres ( P < 0.0001); for instance, in the stage I and II group, use of a daily dose of >2.54 Gy varied from 0 to 87.6% and in the stage III and IV group, total laryngectomy rates varied from a low of 6% to a high of 53%. The percentage of patients waiting more than 6 weeks from diagnosis to first treatment varied from 17 to 49% ( P < 0.0001). Multivariate analysis revealed cause-specific survival differences that were not explained by control for case mix, treatment or waiting times. Differences ranged from an 82% risk reduction in one centre compared with the reference (stage I and II group, P = 0.008) to a 153% increase in risk (stage III and IV group, P = 0.02). Centre case volumes were not associated with cause-specific survival. Conclusions This study quantifies the degree of variation that can occur in the treatment and outcome of people with cancer. We cannot properly assess whether care delivery is of high quality until we have a better understanding of the factors that drive such variations.

Phase I/II trial of metronomic chemotherapy with daily dalteparin and cyclophosphamide, twice-weekly methothrexate, and daily prednisone (DalCMP) as therapy for metastatic breast cancer (MBC).

1152 Background: We recently published data on 41 patients (pts) treated with DalCMP (JCO 2009). We have now accrued additional pts to further compare responses in pts treated or not with prior anthracycline (A) and taxane (T) based regimens. Methods: Pts with measurable MBC received daily sc dalteparin (5,000UI), po cyclophosphamide (50mg), twice weekly po methothrexate (2.5mg BID) and daily po prednisone (5mg). Primary study endpoint was clinical benefit rate (CBR) (i.e., complete response [CR] + partial response [PR] + prolonged stable disease for ≥ 24 weeks [pSD]). Secondary endpoints included time to progression (TTP), duration of response (DOR), and overall survival (OS). Pts were in group 1 (no prior chemotherapy for metastatic disease) or group 2 (prior A and T for metastatic disease, or prior adjuvant A and T if relapse < 1 year, or prior adjuvant A and prior T for metastatic disease). Adverse events were assessed by common toxicity criteria version 2 (CTCAE). Kaplan-Meier methods and log rank test were used for time to event outcomes. Exact confidence intervals (CI) and Fisher's Exact test were used for proportions. Results: Between Oct 2003 and Sept 2008, 92 eligible pts were recruited from two cancer centers in Ontario, Canada, 44 in group 1 and 48 in group 2. There were 2 cases of grade (G) 4 toxicity (anemia, leukopenia). G3 toxicity included transient elevation of liver transaminases in 21 pts and fatigue in 7. Efficacy results are shown in the Table. Conclusions: Metronomic DalCMP is safe, well tolerated, and clinically active in MBC. Group 1 (no prior A/T) n=44 Group 2 (prior A/T) n=48 p value Response CR- 1 (2.2%) CR- none 0.15 PR-5 (11.4%) PR-3 (6.2%) D-14 (31.8%) SD-8 (16.7%) pSD-5 (11.4%) SD-5 (10.4%) D-19 (43.2%) PD-32 (66.7%) CBR (%) 25 (CI 95%: 13.2-40.3) 16.7 (CI 95%: 7.5-30.2) 0.44 TTP (median, wks) 15.7 (CI 95%: 7.4-22.1) 7.8 (CI 95%: 7.0-14.7) 0.16 OS (median, wks) 73.5 (CI 95%: 48.0- 86.8) 31.7 (CI 95%: 26.4- 57.0) 0.051 Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Pfizer

Incidence of Febrile Neutropenia with Taxane-Based Systemic Therapy in Women with Early Stage Breast Cancer.

Abstract Background: Febrile neutropenia (FN) is one of the most significant toxicities experienced by patients treated with systemic therapy. Taxanes now play an integral role in the systemic therapy for women with early stage breast cancer. The most common taxane-containing regimen utilized in Ontario, Canada is 5-Fluorouracil/Epirubicin/Cyclophosphamide x 3 followed by Docetaxel x 3 (FEC-D). PACS 01 reported a febrile neutropenia (FN) rate of 11.2% in the FEC-D arm. In our clinical practice, clinicians have noted a much higher rate of FN. We report the FN rate with the use of FEC-D in women with early stage breast cancer treated at tertiary care centers in Ontario.Methods: All women with early stage breast cancer who were treated with FEC-D from three tertiary care cancer centers in Ontario, Canada (London, Sudbury, Ottawa) between June 2006 and December 2008 were included in this retrospective analysis. Data included: demographics, staging, hormone receptor status, primary prophylaxis use with growth factors, FN rate, admission to hospital and duration of hospital admission.Results: Median age of 630 women is 52 years (r: 24-77). Staging was: I (88), IIA (243), IIB (159), IIIA (94), IIIB (23), IIIC (14) and 9 unknown. A total of 474 (75.2%) were ER positive. Primary prophylaxis with growth factor support was given to 222 patients (35%) and 408 patients (65%) did not have upfront prophylaxis. Of the 222 patients who were given primary prophylaxis, 14 patients (6.3%) were diagnosed with FN. Of the 408 patients who did not receive primary prophylaxis, 120 patients (29.4%) were diagnosed with FN. All patients (n=120) diagnosed with FN received secondary prophylaxis with growth factor support. A total of 126 patients (20%) were admitted to hospital for FN. The median duration of hospital admission was 3.9 days (r: 1-65 days). The impact of risk factors, the use of filgastrim versus pegylated filgastrim on FN rates and the clinical ramifications of febrile neutropenia (ICU admissions/deaths) will be reported.Conclusions: The results of this retrospective analysis demonstrate a much higher risk of FN (29.4%) with FEC-D than has been previously reported. More complete reporting of primary prophylaxis is required. This rate of FN would warrant use of primary prophylaxis for patients prescribed FEC-D, particularly in high risk subgroups. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2087.

Canadian pattern of care for anemia: comparison of chemotherapies in adjuvant breast cancer setting.

Abstract Abstract #2118 Background: Anemia is a common side effect of chemotherapy in adjuvant breast cancer patients (pts) but its treatment may be inconsistent. Erythropoiesis-stimulating agents (ESAs) are the only alternative to blood transfusion in the treatment of chemotherapy-induced anemia, yet their appropriate use continues to be defined. The purpose of this study was to determine the frequency of anemia associated with adjuvant chemotherapy in Canadian breast cancer pts and to explore the corrective interventions which were undertaken.&amp;#x2028; Methods: A retrospective chart review was conducted at 11 cancer centres in Ontario, Canada. Beginning on September 1, 2004 data were collected for 60 consecutive cases of adjuvant breast cancer at each centre, giving a total of 620 patients. Chemotherapy consisted mainly of FEC100, AC-T, AC, CEF, FEC50, and AC-T Dose Dense. Overall, 8% of pts were enrolled in a clinical trial and 76% received adjuvant radiotherapy. Hemoglobin level (Hb), supportive therapy (antibiotics, GCSF, ESA, and transfusion) and type of chemotherapy were recorded at each cycle.&amp;#x2028; Results: The median pt age was 53. The mean baseline Hb was 132.8 (92.0-163) g/L, 11.6% of pts had Hb&amp;lt;120g/L. During the course of chemotherapy, the percentage of subjects with Hb&amp;lt;120 at least once was 55.8%, Hb&amp;lt;110 was 37.8%, Hb&amp;lt;100 was 21.2 % and Hb&amp;lt;90 was 11.5%, with a median of 36.0, 52.5, 71.0, and 75.0 days to develop anemia respectively. For pts whose Hb dropped below 100 g/L, 45.4% occurred after the 1st cycle, 68.8% after the 2nd, 83.7% after the 3rd, and 92.2% after the 4th chemotherapy cycle. Overall, 13.2% of subjects received prophylactic antibiotics, 26.3% were supported by G-CSF, 9.0% received an ESA (epoetin alfa) during their chemotherapy and 7.4% were transfused. The rates of anemia as well as means of intervention are summarized in Figure 1. ESAs were not used prophylactically in this setting.&amp;#x2028; Conclusions: In Canada, breast cancer patients receiving adjuvant chemotherapy commonly become anemic during their course of treatment. This retrospective study demonstrated that ESAs play an important role in the management of anemia in the adjuvant setting. Canadian treatment guidelines recommend that ESA therapy be initiated when Hb &amp;lt;100 g/L. Our finding shows that ∼42% of patients whose Hb dropped below 100g/L were treated with ESAs, suggesting that ESAs were not overused in Canadian practice.&amp;#x2028; &amp;#x2028; Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2118.

Supportive Care Needs of Women With Gynecologic Cancer

Gynecologic cancers often place a heavy emotional and physical burden on patients. However, there is a lack of information about the types of supportive care needs that these patients have, the services that are available, and whether patients want help with their needs. The aims of this cross-sectional, descriptive study were to (1) identify the supportive care needs (physical, emotional, social, spiritual, psychological, informational, and practical) of women with gynecologic cancer who attended a comprehensive, outpatient cancer center in Ontario, Canada, and (2) determine if patients wanted assistance in meeting those needs. A total of 103 patients participated in this study by completing a self-report questionnaire. Sixty-five of the women were no longer on treatment at the time of completing the survey. Eight of the top 10 most frequently reported needs were non physical, such as fears about the cancer returning or spreading. The data indicated that a range of needs remained unmet for this patient group. However, identifying the presence of a need did not necessarily mean that a patient wanted to have assistance with the need. Suggestions for practice and future research are offered to assist healthcare professionals in providing care to these patients.