Oncology Research Articles

Association of Palliative Care With Readmission and Resource Utilization in Patients With Ovarian Cancer: A National Perspective.

Palliative care (PC) utilization in cancer care has been shown to alleviate symptoms, increase goals of care discussions, and reduce invasive end of life measures. This study examined the association of inpatient PC consultation with readmission and hospitalization costs among patients with ovarian cancer. All records for women (≥18years) hospitalized with a diagnosis of ovarian cancer were tabulated from the 2010-2020 Nationwide Readmissions Database. Multivariable logistic, Poisson, and linear regressions were used to evaluate the association of PC consultation during index hospitalization with length of stay, rates of 30-day non-elective readmission, time to readmission, as well as overall number of readmissions and hospitalization costs. Of an estimated 285,487 patients included, 25,957 (9.0%) received a PC consultation, with an increase from 5.1 to 11.7% (P < 0.001) across the period. Factors associated with use of PC included: increasing age (AOR 1.03/yr, 95% CI 1.03-1.03, P < 0.001) and Elixhauser comorbidity index (AOR 1.19/point, 95% CI 1.17-1.21). PC was associated with lower risk adjusted rates of 30 day (11.63%, 95% CI 11.0-12.3 vs 20.25%, 95% CI 20.0-20.6) non-elective readmission (P < 0.001). The adjusted incident rate ratio of readmission after PC consultation was 0.41 [0.38-0.43], P < 0.001. Patients receiving PC additionally had less cost associated with their index hospital stay; -$2,407 [-$2,669.86- -$2,144.43], P < 0.001). Inpatient PC consults appear to be associated with reduced medical readmissions for patients with ovarian cancer, as well as decreased hospital resource use, however disparities exist. Continued increase in access and early PC referral should be considered.

How organ-on-a-chip is advancing cancer research and oncology - a cancer hallmarks’ perspective

Despite significant improvements in methodologies behind the development of new anticancer therapies, the path from early-stage drug development through preclinical and clinical development pipeline is still arduous. Further refinement of the current preclinical models and the development of complementing alternative techniques that enable more reliable studies are paramount. The emerging organ-on-a-chip (OoC) technologies are physiological-like organ biomimetic systems built on a microfluidic chip, capable of enabling precise control over various physicochemical and biomechanical parameters and helping recreate the natural physiology and mechanical forces that cells experience in the human body. In oncology research, especially, since cancer has been understood to be a dynamic disease featured by complex interactions between cancer cells and their environment, this technology offers added advantage as it is able to provide a dynamic platform to simulate cancer-on-a-chip emulating the biological context of tumor microenvironment (TME); demonstrating progression to metastases to multiorgans; and helping to unravel complex information that other current in vitro methods are otherwise not able to provide. In this contribution, we provide a biological perspective on the recent advances in the field of OoC models in cancer biology studies from a cancer hallmark perspective. We also discuss current prospects and funding opportunities in this space, as well as a possible future outlook from a biology perspective, including major challenges and new opportunities as a way forward to OoC technologies.

Targeted anti-cancer agents and risk of venous thromboembolism.

The incidence of one-year venous thromboembolism (VTE) after cancer diagnosis is reported to be increasing for several types of cancer. The introduction of targeted anti-cancer therapies and immunotherapy into the therapeutic armamentarium of medical oncologists contributed to the significantly improved response rates and survival times of cancer patients. In recent years, a potential prothrombotic effect of several targeted anti-cancer agents and immunotherapy drugs has been suggested; however, the methodological limitations of clinical trials evaluating the possible role of these classes of drugs on the VTE risk often make the interpretation of their results difficult. It is still not clear whether the increased risk of VTE is more closely correlated to the expression of specific oncogenic profiles than to the administration of specific therapies against these mutations. Furthermore, the increased survival rates observed with these agents could influence the prevalence of VTE events in cancer patients by the competing risk mortality on the risk of VTE. To date, the available data have suggested that the risk of VTE varies among different categories of targeted therapy, being most reported for anti-vascular endothelial growth factor receptor (VEGFR), epidermal growth factor receptor (EGFR), monoclonal antibodies and immune checkpoint inhibitors, and less reported for tyrosine kinase inhibitors (TKI). The risk of VTE seems to significantly increase when targeted therapy is administered in combination with traditional anti-cancer agents. Considering the uncertainties in estimating the rate of thrombotic complications associated with targeted therapy, the need for antithrombotic prophylaxis in cancer patients receiving targeted therapies still needs to be specifically assessed. In this review, we examine available evidence of the literature and the methodological limitations of clinical trials, and we discuss the potential future perspectives.

Trend in incidence and clinicopathological characteristics of prostate cancer in Northern Tanzania: analysis from a population based cancer registry data 2015-2021.

Globally, prostate cancer is a common disease among men. However, limited epidemiological data exists regarding prostate cancer in Tanzania. Consequently, there is insufficient evidence to convince policymakers of the need to combat this health issue. The study aimed to assess the prevalence, trends and clinicopathological characteristics of prostate cancer in northern Tanzania. This cross-sectional study with chart review utilised data from the Kilimanjaro cancer registry, identifying all adult men diagnosed with cancer from January 2015- December 2021. The study recorded variables such as subject age, symptoms, Gleason score, prostate specific antigen (PSA) and metastatic statuses at presentation. Risk stratification followed American Society of Medical Oncology criteria, including low, intermediate and high-risk categories. The analysis was conducted using STATA version 17. Over the study period, 5164 adult men were registered, with prostate cancer accounting for 1619(31.4%) and showing an increase trend in incidence. The mean age at presentation was 73.9(± 10.1) years, and the majority of study subjects were from Kilimanjaro region 1200(74.1%). After applying exclusion criteria, 714 subjects with histologically confirmed diagnoses of prostate cancer remained. Of these, 710(99.4%) were symptomatic at presentation, with lower urinary tract symptoms being the most common symptoms in 548(76.8%). The median PSA at presentation was 109(36.2-263) ng/mL with 349(51.1%) having a PSA of > 100ng/mL. Gleason group grades 4 and 5 accounted for 207(29.5%) and 219(31.2%), respectively. A total of 178(43.6%) subjects had metastatic disease at presentation. The treatment of choice for a large proportion of subject 440(94.6%) was androgen deprivation therapy. The burden of prostate cancer in northern Tanzania is high and the majority of subjects present with symptoms. A large proportion of subjects have metastatic disease at initial presentation, emphasizing the need for prostate cancer screening.

Topical use of chicory root extract gel on the incidence and severity of radiodermatitis in breast cancer patients: a randomized controled trial.

Nearly 95% of women treated with radiotherapy for breast cancer experience some degree of radiodermatitis. Radiation therapy's most frequent side effect is skin damage. Managing radiation-induced skin reactions while maintaining treatment continuity is a challenging issue. The chicory plant has known anti-inflammatory properties. This study aimed to assess the effect of chicory root extract gel on the incidence and severity of radiodermatitis in breast cancer patients. This three-blind clinical trial was conducted in the radiation therapy department of Ayatollah Yasrebi Hospital in Kashan from September 2022 to February 2023. Forty-four breast cancer patients undergoing radiation therapy with a linear accelerator were randomly assigned to either the intervention group (n = 21) or the placebo group (n = 20). Participants applied topically chicory root extract gel or placebo twice daily, starting with their radiation therapy. The incidence and severity of dermatitis were assessed using the Radiation Therapy Oncology Group (RTOG) scale. Participants' characteristics were collected through a researcher-designed questionnaire. Data analysis was performed using chi-square tests, Fisher's exact test, independent t-tests, Mann-Whitney U tests, and generalized linear models with a Poisson distribution, using SPSS version 16 software. No significant differences were found between the two groups regarding individual and clinical characteristics at the beginning of the study. The results indicated that the number of patients who did not develop dermatitis in later weeks was higher in the intervention group compared to the placebo group (P < 0.001). In the second and third weeks, grade 1 and 2 dermatitis incidence was higher in the placebo group than in the intervention group (P < 0.001). A comparison of the incidence of dermatitis between the two groups, in terms of the number of days to develop grade 1 dermatitis, showed that the average duration was longer in the intervention group than in the placebo group (P > 0.05). This comparison was insignificant for grade 3 dermatitis in either group. Additionally, when considering body mass index (BMI) as a confounding variable and adjusting for its effect, the results revealed that the intervention group developed grade 1 dermatitis significantly later than the placebo group (P < 0.001). Chicory root extract gel offers an effective, low-risk option for managing radiodermatitis in breast cancer patients. This aligns with the goals of supportive cancer care, which emphasize minimizing side effects, maintaining treatment efficacy, and improving the patient's quality of life. The study was registered in the Clinical Trials Center of Iran ( https://irct.behdasht.gov.ir ) with the number cod: IRCT20220601055055N1 on July 2, 2023.

Longitudinal Results From the Nationwide Just ASK Initiative to Promote Routine Smoking Assessment in American College of Surgeons-Accredited Cancer Programs.

Persistent smoking after cancer diagnosis causes adverse outcomes while smoking cessation can improve survival. Thus, integration of smoking assessment and cessation assistance into routine cancer care is critical. Aiming for incremental practice change that could be sustained and built upon through future quality improvement (QI) projects, the American College of Surgeons initiated Just ASK in 2022 to increase implementation of smoking assessment among its accredited Cancer Programs. This manuscript describes outcomes from Just ASK. Seven hundred sixty-two programs enrolled in this cohort study, followed Plan Do Study Act methodology, and used local QI teams to facilitate practice change. The primary outcome was the ask rate (ie, patients asked/patients seen). Programs completed three surveys across the 1-year study (89.8% retention), answering questions about their program plus organizational readiness, implementation barriers, implementation strategies, and clinical practices related to assessing smoking among patients newly diagnosed with cancer. Data analysis involved descriptive statistics and analysis of change over time (eg, McNemar chi-squares). Programs (53.1% community-based) tended to report moderate organizational readiness, multiple implementation barriers, and adoption of 4.63 ± 1.49 of eight possible implementation strategies (eg, training staff/providers). Programs reported frequency of assessing smoking status, documenting it in the electronic health record, advising patients who smoke to quit, and documenting advice and treatment increased over time (all P < .001). The ask rate increased from baseline to mid to final survey (P < .01; 87.79% v 88.65% v 91.92%, respectively). Just ASK is the latest, and by far the largest, endeavor to improve assessment of cancer patients' smoking status. Participants reported significant advances within a short time span and study results underscore the potential for national accreditation organizations to transform oncology practice.

Repurposing colforsin daropate to treat MYC-driven high-grade serous ovarian carcinomas.

High-grade serous ovarian cancer (HGSOC) is one of the deadliest cancers for women, with a low survival rate, no early detection biomarkers, a high rate of recurrence, and few therapeutic options. Forskolin, an activator of cyclic AMP signaling, has several anticancer activities, including against HGSOC, but has limited use in vivo. Its water-soluble derivative, colforsin daropate, has the same mechanism of action as forskolin and is used to treat acute heart failure. Here, we investigated the potential of colforsin daropate as a treatment for HGSOC. We found that colforsin daropate induced cell cycle arrest and apoptosis in cultured HGSOC cells and spheroids but had negligible cytotoxicity in immortalized, nontumorigenic fallopian tube secretory cells and ovarian surface epithelial cells. Colforsin daropate also prevented HGSOC cells from invading ovarian surface epithelial cell layers in culture. In vivo, colforsin daropate reduced tumor growth, synergized with cisplatin (a standard chemotherapy in ovarian cancer care), and improved host survival in subcutaneous and intraperitoneal xenograft models. These antitumor effects of colforsin daropate were mediated in part by its reduction in the abundance and transcriptional activity of the oncoprotein c-MYC, which is often increased in HGSOC. Our findings demonstrate that colforsin daropate may be a promising therapeutic that could be combined with conventional therapies to treat HGSOC.

Photodynamic therapy for early and recurrent oral cancers and pre-malignant lesions. Need of the hour for India

Oral cancer rates in India surpass those in any other nation, with patients manifesting varied disease stages, including pre-malignant phases. Tobacco chewing promotes field cancerization, and related surgical interventions can be remarkably morbid. Advanced-stage patients with frequent recurrences undergo treatments that significantly degrade their quality of life. In such instances, Photodynamic Therapy (PDT) emerges as an invaluable tool, enhancing both the longevity and quality of life. This paper elucidates two such cases benefiting from PDT, spotlighting its potential in transforming cancer care in India.

Centrality in Collaboration: Community Detection for Oncology Researchers

Background: Cancer patients who do not respond to standard treatments often become candidates for clinical trials. It is known that the collaboration networks between oncologists is a primary factor for further engagement in subsequent trial enrollment. Social network analysis (SNA) and community detection algorithms can be used to explore collaboration patterns using data from the Princess Margaret Clinical Research Record and Cancer Registry. Objectives: The data consists of 2970 patients in 515 clinical trials between January 2016 to December 2018. We are interested in the referral patterns among patients enrolled in multiple trials. Among 389 patients enrolled in more than one of 288 trials, we aim to identify collaboration networks based on intervention type. Methods: We applied community detection algorithms, including Girvan-Newman and Louvain, and compared them to an author-developed algorithm that utilizes degree centrality and directionality in participant enrollments to identify influential interventions. Community detection was assessed by superimposing sociograms and visualizing the contrast between the in-degree/out-degree distribution of participant enrollments. Results: Application of Girvan Newman, which incorporates edge betweenness but not degree centrality, and Louvain, which does not consider directionality, did not yield informative structure for oncology collaboration networks. The algorithm developed by the authors found intuitively descriptive communities that were supported by the sociograms and visualized in-degree/out-degree distribution. Conclusions: SNA approaches utilizing a combination of degree centrality and edge betweenness can interpret oncology collaboration networks. With this perspective, it is possible to delve deeper into patient engagement and improve the organizational design of clinical trial referrals.

Integration of palliative rehabilitation in cancer care: a multinational mixed method study

BackgroundIncurable cancer is a major contributor to societal suffering and disability, and palliative rehabilitation is recommended to be integrated within and between cancer services at all healthcare levels. However, little knowledge exists on how integration of palliative rehabilitation in cancer is understood and achieved in clinical practice. INSPIRE (Integrated short-term palliative rehabilitation to improve quality of life and equitable care access in incurable cancer) is a large European-funded project that aims to promote quality of life through a novel rehabilitation model for people disabled by advanced cancer.AimTo compare the existing integration of palliative rehabilitation in cancer within official documents and in clinical practice across five European countries including United Kingdom, France, Denmark, Norway, and Italy.MethodsMixed methods study with a concurrent research design, comprising a document analysis (N = 23), stakeholder interviews (N = 22), and an online survey (N = 225). Data from each sub-study were analysed separately before results were merged.ResultsThere was limited integration of palliative rehabilitation in cancer in official documents and in clinical practice, though some indicators of integration, including participation in multidisciplinary teams and adherence to standardised pathways, were identified in the survey. Notably, integration of palliative rehabilitation in cancer in clinical practice was observed within limited organisations in secondary healthcare systems, without widespread adoption. Although palliative rehabilitation in cancer as a concept was sparingly used by stakeholders, they recognised the need for a comprehensive approach including multidisciplinary teams that aligns with the individual patient’s needs and goals. Moreover, the ambiguous distinction between the terms ‘palliative rehabilitation’ and ‘palliative care’, insufficient funding, lack of well-defined care pathways and competence gaps among healthcare professionals represented barriers to integration of palliative rehabilitation in cancer into clinical practice.ConclusionIntegration of palliative rehabilitation in cancer was limited in the five EU partnership countries investigated. Clarifying the concept of palliative rehabilitation, including adoption of the concept into official documents and delineating it from palliative care, is essential for more successful integration. This can possibly be achieved by addressing the barriers identified and fostering close collaboration across disciplines.

Whose Responsibility Is It? Implementing Patient-Prioritized Healthcare System Change in Oncology.

This brief commentary describes the reflections on a fundamental question by the Public Interest Group on Cancer Research, a successful academic-community partnership focused on cancer research, education, public engagement, and advocacy in Canada's Eastern province of Newfoundland and Labrador. Our Group has achieved some success in a short time with very limited funding. It has successfully created public spaces for conversations about cancer care and priorities for research and regularly advocated for health service change prioritized by input from patients and family members. However, we remain challenged in our understanding of how to truly implement change within oncology care contexts that is informed by patients and families affected by cancer. In this short reflection, we hope to raise awareness of this important issue and question whose responsibility it is to work with patients and families and follow through on prioritized healthcare issues and services. We suggest this may be a matter of integrated knowledge translation and a better understanding of where patients and families fit in this space. We hope to encourage reflection and conversation among all relevant stakeholders about how best to implement patient-prioritized change in oncology care and policy.

Global disparities in cancer care: Bridging the gap in affordability and access to medications between high and low‐income countries

AbstractBackgroundCancer remains a significant challenge for health care systems, despite notable progress in the field. These advancements have significant financial implications that disproportionately affect low‐income countries. This review article aims to explore the present state of drug development, assessing the availability of drugs in different income countries, and proposing potential solutions to address the inequality in access to new cancer treatments.MethodsA search was conducted on MEDLINE and PubMed on October 2, 2023 and updated on December 14, 2023, limited to English language articles.ResultsThere is a projected rise in cancer cases worldwide, particularly in low‐income countries where most cancer‐related deaths are expected. Although the approval rate of cancer treatments has risen, their excessive cost and lack of affordability pose significant barriers to widespread access. Disparities in the costs of crucial cancer medications are influenced by geographic location and procurement connections. Potential solutions to address the inequity in drug distribution include sharing production secrets, implementing price discrimination, international funding, improved primary health care measures, and the implementation of cost‐effective screening methods.ConclusionPreventing, screening for, and treating cancer should be a global priority with minimal differences in access to therapy among various countries.

What is the Standard of Care For Multifocal Low-Grade Bladder Cancer?

What is the Standard of Care For Multifocal Low-Grade Bladder Cancer?

Group medical visits in cancer survivorship care: a scoping review

Abstract Background More than 60% of cancer survivors report unmet physical, psychosocial, and informational needs. The care of cancer survivors includes surveillance, health maintenance monitoring, referral for long-term adverse effects of cancer treatment, and coordination of care. Group medical visits (GMV) include medical care, education, and peer support and can be used to facilitate the delivery of multidisciplinary survivorship care. We aimed to characterize the current state of related research describing the role of GMV in cancer survivorship care. Methods For this scoping review, we searched for published literature using PubMed, Embase, and other resources. We included intervention studies of multidisciplinary care involving GMVs of adult patients with a history of cancer requiring the presence of medical personnel, physicians, advanced practitioners, or oncology nurses. We included studies that focused on broad cancer survivorship care, rather than those using specific modalities, such as yoga, or limited to specific aspects of cancer survivorship care, such as weight loss. We characterized the studies by cancer type, structure of GMVs, and reported outcomes. Results We identified 2311 studies (2122 from PubMed and 189 from Embase). We excluded 1524 duplicates and screened 787 studies for title and abstract review. Finally, 63 studies were retrieved for full-text review, and six were included in this scoping review. Of the included studies, four were non-randomized, and two were randomized. Breast cancer was the most common site (4); other studies included breast and other cancers (1) and hematopoietic transplant cancer survivors (1). There was heterogeneity in the structure and frequency of sessions and the survivorship domains addressed. The outcomes studied included quality of life, healthcare utilization, and costs. Conclusions Limited high-quality research exists on the role of GMV in cancer survivorship. Though shown to be effective in chronic disease, the evidence for the effectiveness of this important and widely used approach in multidisciplinary survivorship care remains inconsistent and preliminary; the literature to date provides a starting point for larger-scale studies of GMV in cancer survivorship care. Implications for Cancer Survivors While Group medical visits are a promising intervention to provide multidisciplinary care, larger studies are needed to support their benefit in the care of cancer survivors.

Transforming the landscape of liver cancer detection and care.

Transforming the landscape of liver cancer detection and care.

Late-line options for patients with metastatic colorectal cancer: a review and evidence-based algorithm.

Over the past few years, several novel systemic treatments have emerged for patients with treatment-refractory metastatic colorectal cancer, thus making selection of the most effective later-line therapy a challenge for medical oncologists. Over the past decade, regorafenib and trifluridine-tipiracil were the only available drugs and often provided limited clinical benefit compared to best supportive care. Results from subsequent practice-changing trials opened several novel therapeutic avenues, both for unselected patients (such as trifluridine-tipiracil plus bevacizumab or fruquintinib) and for subgroups defined by the presence of actionable alterations in their tumours (such as HER2-targeted therapies or KRASG12C inhibitors) or with no acquired mechanisms of resistance to the previously received targeted agents in circulating tumour DNA (such as retreatment with anti-EGFR antibodies). In this Review, we provide a comprehensive overview of advances in the field over the past few years and offer a practical perspective on translation of the most relevant results into the daily management of patients with metastatic colorectal cancer using an evidence-based algorithm. Finally, we discuss some of the most appealing ongoing areas of research and highlight approaches with the potential to further expand the therapeutic armamentarium.

Risk Factors of Colorectal Cancer Other than Genetic Factors at Jinnah Post Graduate Medical Center

Objective: To determine the association of different risk factors other than genetic factors in patients having colorectal carcinoma. Study Design: Case control study. Place and Duration of Study: Medical Oncology Department, Jinnah Postgraduate Medical Center, Karachi Pakistan, from Jan 2019 to Jan 2020. Methodology: A total of 200 patients of age more than 10 years of either gender were included in the study. Hundred were cases of newly diagnosed colorectal cancer and 100 were healthy controls. The data regarding socio-demographics and risk factors other than genetic risk factors was collected through pre-designed questionnaire. Results: The mean age of the cases was 42.76±15.02 &amp; the controls were 39.42±14.03 years. After adjusting odds in multivariate analysis, physically inactive (OR=0.40; 95% CI: 0.16-0.98, p&lt;0.05), low fruits and vegetable intake (OR=0.42; 95% CI: 0.22-0.82, p&lt;0.05), processed meat intake (OR=2.00; 95% CI: 1.01-3.96, p&lt;0.05) and fats intake (OR=5.12; 95% CI: 2.68-9.76, p&lt;0.05) remained positively associated with colorectal carcinoma. Conclusion: Higher risk of developing colorectal carcinoma is associated with obesity, low fruits and vegetables intake, high red meat consumption, processed meat consumption, fats intake, physical inactivity and working during night. The initiative for screening would be helpful in determining the colorectal carcinoma at an early stage. Early diagnosis will increase the survival rate and help increasing long term prognosis of the colorectal carcinoma.

Factors associated with work engagement of nurses in the radiology department, Japan: a cross-sectional study.

Radiology departments present unique challenges compared to other departments due to exposure to radiation and the specialized nature of the work. Nurses must not only manage typical nursing duties but also adhere to strict safety protocols to minimize radiation exposure. These additional responsibilities can significantly impact their work engagement and overall job satisfaction. This study aimed to identify the factors associated with work engagement among nurses working at prefectural designated cancer care hospitals in Japan. Identifying these factors may lead to improvements in future work environments and educational systems. This was a cross-sectional study using an internet-based survey. A questionnaire using the Utrecht Work Engagement Scale (UWES) was conducted among 317 nurses; 140 responded (response rate: 44.2%). Significant associations were found between work engagement and several factors. The mean UWES score was 54.3 (Standard deviation (SD): 18.4). Work engagement was positively associated with age (B = 0.179, p = 0.03), being male (B = 0.19, p = 0.015), higher position (B = 0.199, p = 0.012), desire for radiology assignments (B = 0.223, p = 0.003), and presence of a radiation exposure consultation system (B = 0.214, p = 0.034). This study identified several factors associated with work engagement among radiology nurses, highlighting the importance of specialized support systems to address radiation-related concerns. These findings can inform interventions to enhance work engagement and well-being in this field.

Rurality and pediatric cancer survival in the United States: An analysis of SEER data from 2000 to 2021

BackgroundCancer is the leading cause of death by disease among children in the United States. Residing in rural areas may impact cancer outcomes as rural areas tend to have fewer available healthcare resources. Few population-based studies have investigated rural/urban disparities in pediatric cancer outcomes. The objective of this study was to examine rural/urban differences in (1) five-year relative survival and (2) cancer-specific survival among children in the United States. MethodsThe study is a population-based longitudinal study using data from the Surveillance, Epidemiology, and End Results (SEER) 17 registries database (2000–2021). We included data for individuals aged 0–19 with a first primary malignant cancer diagnosed from 2000 to 2016. Rurality was measured by Rural-Urban Continuum Codes (RUCCs). Five-year relative survival rates, Kaplan-Meier curves, and Cox regression analysis were used to determine the differences in pediatric cancer survivorship between rural and urban areas. ResultsBoth five-year relative survival rates and log-rank tests of survival probabilities over time by rurality showed no statistically significant difference between individuals living in urban versus rural counties. However, after adjusting for age, sex, race/ethnicity, cancer type, median household income, and region, children diagnosed in rural counties had a 9 % higher risk of death compared to children diagnosed in urban counties (95 % CI 1.02–1.17), with the highest increased risk observed for children with retinoblastoma (aHR: 6.12, 95 % CI 2.01–18.59). A higher increased risk of death was observed for children living in the most rural counties (aHR: 1.18, 95 % CI 1.07–1.32). ConclusionIn this study, residing in rural areas was associated with an increased risk of death from pediatric cancer, especially for children residing in rural areas not adjacent to urban areas. Our findings warrant further investigation to determine the rural/urban disparities in pediatric cancer outcomes and to develop interventions to deliver high-quality cancer care to rural children.

CarersCanADAPT: Study protocol of a stepped care pathway and hybrid type 1 effectiveness-implementation trial of an online cognitive behavioural therapy (iCBT) program for cancer carers with anxiety and depression

BackgroundFamily or friend carers of people with cancer report high levels of depression, anxiety, caregiving strain, and unmet needs. Limited strategies for identification and management of distress have been established among cancer carers. This paper describes the protocol of two linked studies: Study 1a, a distress screening and stepped care pathway feasibility study and Study 1b, a hybrid implementation-effectiveness Randomised Controlled Trial (RCT) to assess the benefit of a comprehensive, carer-centred online Cognitive Behavioural Therapy (iCBT) program for carers with anxiety and depression. MethodsFor Study 1a, 300 cancer carers will be screened for distress. Carers with low distress will be referred to publicly available carer resources. Carers scoring 4 and higher on the distress thermometer will complete depression and anxiety measures. Carers with high anxiety/depression will be recommended psychological therapy. Carers with mild/moderate anxiety and/or depression will be allocated to the Carers iCBT Program, evaluated via a RCT with waitlist control group (Study 1b). For Study 1b, intervention group carers will receive access to a 6-lesson self-directed online iCBT program. Waitlist-controls will access the intervention at 14 weeks. Intervention and control groups will complete baseline, 6 week, and 14 week self-report measures; controls will complete additional measures at 20 and 28 weeks. A sample size of n = 166 carers in the iCBT RCT is needed. ConclusionsIf acceptable, feasible and effective, this pathway and iCBT intervention could offer a sustainable, scalable and low-cost approach to identifying and managing distress in carers, and potentially improving patient and carer outcomes.Trial Registration: Australian and New Zealand Clinical Trial Registry number: ACTRN12623001341617p.