Patients Undergoing Cancer Therapy Research Articles

The Minneapolis-Manchester Quality of Life Instrument (MMQL): Reliability and validity of the Adult Form (AF).

9570 Background: Cancer survivors are at risk for deficits in health-related quality of life (HRQL). Youth (8-12y) and adolescent (13-20y) versions of the MMQL have been developed to address survivor-specific issues and are currently in use; the MMQL-AF has now been developed to assess HRQL in cancer survivors aged 21-55y, enabling cross-sectional and longitudinal assessment of childhood cancer survivors as they age. Methods: The MMQL-AF was administered to 499 adults: 65 patients undergoing cancer therapy, 107 off therapy, 327 healthy controls (matched on sex, age, education). Factor analysis was performed; items with factor loadings ≥0.40 were retained. The following psychometric properties were evaluated: internal consistency reliability (Cronbach’s alpha), construct validity (concurrent administration of SF-36), known-groups validity (score comparisons across the 3 groups), and stability (intraclass correlations from patients completing MMQL-AF twice, 2 weeks apart). Results: Among patients, 46% had hematological malignancies, 33% were males, 64% were non-Hispanic whites; median age was 40y. Factor analysis resulted in retention of 44 items across 6 scales: social functioning (n=9), physical functioning (n=12), cognitive functioning (n=7), outlook on life (n=4), body image (n=5), and psychological functioning (n=7).Internal consistency was 0.8-0.9 for scales and 0.95 overall.The MMQL-AF distinguished between known groups; healthy controls scored significantly higher (better HRQL) than patients on 4 of 6 scales. Off-therapy patients scored higher than on-therapy patients on physical functioning.The MMQL-AF scales correlated highly with SF-36 scales hypothesized to tap similar domains (all P values <0.001), demonstrating construct validity.Intraclass correlations were 0.82-0.95 for scales and 0.98 overall (all P values <0.001), indicating high stability. Conclusions: MMQL-AF is a reliable and valid self-report instrument for measuring multi-dimensional HRQL in cancer survivors aged 21-55y. Development of this instrument ensures availability of a tool that can assess HRQL from 8-55y, thus addressing needs of childhood cancer survivors as they age.

Water–fat MRI for assessing changes in bone marrow composition due to radiation and chemotherapy in gynecologic cancer patients

To assess the feasibility of using fat-fraction imaging for measuring marrow composition changes over large regions in patients undergoing cancer therapy. Thirteen women with gynecologic malignancies who were to receive radiation and/or chemotherapy were recruited for this study. Subjects were imaged on a 3T magnetic resonance (MR) scanner at baseline (after surgery but before radiation or chemotherapy), 6 months, and 12 months after treatment. Water-fat imaging was used to generate high-resolution, 3D signal fat fraction (sFF) maps extending from mid-femur to L3. Treatment changes were assessed by measuring marrow sFF in the L4 vertebra, femoral necks, and control tissues. Pretreatment and 6-month scans were compared in nine women. sFF increased significantly in both the L4 vertebral marrow (P = 0.04) and the femoral necks (P = 0.03), while no significant change was observed in control regions. Qualitatively, chemotherapy changes were more uniform in space, whereas the radiation-induced changes were largest in marrow regions inside and close to the target radiation field. Water-fat MRI is sensitive to changes in red/yellow marrow composition, and can be used for quantitative and qualitative assessment of treatment-induced marrow damage.

Integrating Dietary Supplements Into Cancer Care

Many studies confirm that a majority of patients undergoing cancer therapy use self-selected forms of complementary therapies, mainly dietary supplements. Unfortunately, patients often do not report their use of supplements to their providers. The failure of physicians to communicate effectively with patients on this use may result in a loss of trust within the therapeutic relationship and in the selection by patients of harmful, useless, or ineffective and costly nonconventional therapies when effective integrative interventions may exist. Poor communication may also lead to diminishment of patient autonomy and self-efficacy and thereby interfere with the healing response. To be open to the patient's perspective, and sensitive to his or her need for autonomy and empowerment, physicians may need a shift in their own perspectives. Perhaps the optimal approach is to discuss both the facts and the uncertainty with the patient, in order to reach a mutually informed decision. Today's informed patients truly value physicians who appreciate them as equal participants in making their own health care choices. To reach a mutually informed decision about the use of these supplements, the Clinical Practice Committee of The Society of Integrative Oncology undertook the challenge of providing basic information to physicians who wish to discuss these issues with their patients. A list of leading supplements that have the best suggestions of benefit was constructed by leading researchers and clinicians who have experience in using these supplements. This list includes curcumin, glutamine, vitamin D, Maitake mushrooms, fish oil, green tea, milk thistle, Astragalus, melatonin, and probiotics. The list includes basic information on each supplement, such as evidence on effectiveness and clinical trials, adverse effects, and interactions with medications. The information was constructed to provide an up-to-date base of knowledge, so that physicians and other health care providers would be aware of the supplements and be able to discuss realistic expectations and potential benefits and risks.

Clinical and Demographic Characteristics of Seasonal Influenza in Pediatric Patients With Cancer

Changes in oncology care and the diagnosis and management of influenza over the past several decades may have altered the epidemiology and outcomes of influenza in pediatric oncology patients. The clinical features and outcomes of 102 pediatric patients undergoing cancer therapy during 107 episodes of influenza between January 2002 and April 2009 were retrospectively ascertained. Median age at the time of influenza was 7.2 years (interquartile range: 3.8-11.2 years); 46% of patients were male. Nineteen patients (18%) were recipients of hematopoietic stem cell transplants. Patients' median absolute neutrophil and lymphocyte counts were 1300/μL (interquartile range: 500-2967/μL) and 360/μL (interquartile range: 180-836/μL), respectively. Twelve patients (11%) had coinfections with influenza and one or more other respiratory pathogens. Influenza prompted patients' hospitalization during 64% of episodes, and 75% received antiviral therapy. Complications occurred in 30% of infections and serious complications occurred in 7%. Three patients died, but no deaths were directly attributable to influenza. Most patients had delays in cancer therapy; the median delay was 5 days. Neutropenia, concurrent infection, increasing age and having received hematopoietic stem cell transplant increased the risk of serious complications. Advances in the management of pediatric cancer and influenza have not altered the epidemiology and outcome of influenza in oncology patients. Clinical features identify subgroups of patients with influenza who are at risk of poor outcomes and those with a good prognosis.

Oral health-related quality of life among children undergoing cancer therapy.

e12006 Background: Despite much interest in oral complications in cancer patients and studies reporting their prevalence, aetiology and management, there has been little understanding of how they affect the patients and the family. The aim of this study was, therefore, to assess the impact of oral complications on life quality for children undergoing cancer therapy. Methods: Seventy 6 - 14 years old paediatric patients undergoing cancer therapy in the Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong participated in this study. A clinical examination of the dentition and oral soft tissues was performed using criteria suggested by the World Health Organization. Clinical examination evaluated the status of: i) dental caries (DMFT/dmft Index), ii) periodontal health (CPI Index), iii) infection, such as herpes and candidiasis, iv) thrombocytopathy in the form of oral petechiae and spontaneous gingival bleeding, v) xerostomia, and vi) mucositis (WHO Mucositis Scale). Two questionnaires were filled by the children and their parents: i) the Child Perceptions Questionnaire (CPQ), and ii) a questionnaire contained simple closed questions to collect the information of oral health habits of children and demographic data from the parents. Results: Higher CPQ scores were found in children with mucositis (p < 0.001), dental caries (p < 0.001), children who were born in mainland China (p < 0.05), or parents of lower education or income level (p < 0.05). In multiple regression analyses, mucositis and dental caries were the significant predictors (p < 0.001) of the higher CPQ scores among the various parents and children characteristics collected in this survey. Conclusions: The findings of this study showed that paediatric cancer patients with mucositis and dental caries had poorer oral health-related quality of life.

Effects of HMG on revascularization and follicular survival in heterotopic autotransplants of mouse ovarian tissue

Ovarian tissue transplantation is now considered as a procedure to preserve the fertility of young women patients undergoing cancer therapy. The present study investigated the effects and mechanism of human menopausal gonadotrophin (HMG) intervention on vascular remoulding in ovarian heterotopic autotransplantation. Ovaries of 8-week-old mice were cultured in vitro with different concentrations of HMG for 3h for measuring the expression of vascular endothelial growth factor (VEGF). The cultured ovaries were implanted under the kidney capsule and removed 24, 36, 48h or 1month after transplantation. Revascularization, fluid exudation and the number of surviving ovarian follicles were observed. The results showed that VEGF was increased 1.6–6.5 times in the HMG intervention groups. Revascularization appeared 24–36h after transplantation and was earlier than that of the control. Fluid exudation increased incrementally with increasing HMG concentrations. The total number of surviving ovarian follicles was increased by 1.2–1.5 times in the HMG 0.15IU/ml group as compared with the other groups 1month after transplantation. It is concluded that intervention with HMG in vitro before transplantation could improve the blood supply reconstruction and survival of the autotransplanted ovarian follicles, which might be associated with increased VEGF expression.Early diagnosis and effective therapy have been improving the long-term survival rate of children, adolescents and young women suffering from malignant tumours. Chemotherapy and/or radiation therapy commonly compromise the ovary functions. Cryopreservation of cortical fragments of ovarian tissue before cancer therapy, followed by later transplantation, is an emerging technique, but ischaemia after transplantation appears to be one of the main obstacles to successful transplantation. The aim of the present study was to investigate the effects of human menopausal gonadotrophin (HMG) on revascularization and follicular survival of autotransplanted ovary. Half ovaries of 8-week-old mice were cultured in vitro with different concentrations of HMG (0.00, 0.15, 0.30 and 0.60IU/ml) for 3h and transplanted back to the mice. The expression of vascular endothelial growth factor (VEGF), blood vessel repatency and survival ovarian follicles were observed. We found that the in vitro intervention of HMG could improve expression of VEGF in ovarian tissue, shorten the blood supply reconstruction time and increase the number of survival ovarian follicles. The starting date of the oestrous cycle was significantly earlier in the HMG 0.60IU/ml treatment group than the HMG 0.00IU/ml group. We also found that treatment with HMG 0.15IU/ml was better in preserving ovarian follicle numbers than HMG 0.30 or 0.60IU/ml. We concluded the intervention of HMG in vitro before transplantation could improve the blood supply reconstruction and survival of the autotransplanted ovarian follicles, which might be associated with increased VEGF expression. This method may have the potential for clinical usage.

Use of Rasch Analysis in the Evaluation of the Oropharyngeal Mucositis Quality of Life Scale

Oropharyngeal mucositis (OM) is a significant clinical problem causing profound impairment of health-related quality of life (HQoL) for patients undergoing cancer therapy. The Oropharyngeal Mucositis-Specific Health-Related Quality of Life Measure (OMQoL) was developed using classical test theory to measure the self-perceived HQoL of patients with mucositis. The aim of this study was to analyze the OMQoL according to the Rasch model and, on the basis of results, determine whether improvements could be made. A multicenter approach was used, and 210 patients treated with stomatotoxic chemotherapy (36%), high-dose myeloablative chemotherapy ± total body irradiation (10%), or head and neck irradiation ± chemotherapy (54%) completed the OMQoL. The Partial Credit Model of Rasch analysis was applied to evaluate the 31-item OMQoL using WINSTEPS and R software. Unidimensionality (measurement of a single construct), item fit, response category performance, person separation reliability, targeting of item difficulty to person ability, and differential item functioning (DIF) were examined. Of 31 items, 5 were removed due to misfit; the OMQoL was reduced to 26 items with acceptable information weighted fit/outlier-sensitive fit indices (within 0.7-1.3) and eigenvalue units (≤2.0), confirming the unidimensionality of the reduced OMQoL. The OMQoL and its four subscales showed ordered category thresholds, and the person separation reliability was high (person separation index >0.2 with reliability >.8). Nevertheless, some of the items in the OMQoL might not be targeted effectively to patients with low levels of OM. Significant uniform and nonuniform DIFs were not found for gender (uniform DIF, p = .26; nonuniform DIF, p= .24) and age (uniform DIF, p = .95; nonuniform DIF, p = .65). Rasch analysis reveals that the reduced 26-item OMQoL is unidimensional and is adequate to measure HQoL for patients with OM regardless of gender and age group. This improved version can provide a common platform for nurses to use in their assessment, caring, and treatment of patients with OM.

Novel small molecules for the treatment of infections caused by Candida albicans: a patent review (2002 – 2010)

Introduction: The fungal pathogen Candida albicans is one of the leading causes of infections affecting immunodeficient individuals, including those HIV-infected and patients undergoing cancer therapy. Emerging problems in terms of therapeutic efficacy and drug resistance have highlighted the need to consider new therapeutic approaches, based on the exploitation of virulence factors as alternatives to conventional drug targets.Areas covered: Advances in the development of anti-Candida drugs are examined in this review, as reflected by the patent literature since 2002 along with selected peer-reviewed publications. Taking into account a total of 26 patents, the discussion encompasses several therapeutic approaches, including azoles as ergosterol biosynthesis inhibitors, glucan and chitin synthase inhibitors, and secreted aspartyl protease inhibitors.Expert opinion: New analogs of existing drugs are being developed as broad spectrum antifungals to improve efficacy and circumvent drug resistance. Also, candidate drugs targeting new virulence factors are promising to overcome limitations due to poor efficacy and the rising of drug resistance observed for several available drugs. Efforts for the discovery and development of antifungal agents should be equivalent to other therapeutic areas, and advances in the generation of therapeutic agents with fungus-specific mechanisms of action are of highest priority.

Quality-of-life outcomes of patients with breast cancer in an integrative cancer treatment setting.

1107 Background: There is evidence in the literature to suggest that patients undergoing cancer therapy experience an initial deterioration in their quality of life (QoL). We longitudinally investigated the impact of an integrative care model characterized by conventional cancer treatment in combination with a comprehensive, complementary program on QoL outcomes of patients with breast cancer. Methods: We examined a random sample of 689 breast cancer patients treated at two single-system cancer centers from January 2001 to December 2008 who were available for a minimum follow-up of 3 months. QoL was evaluated using the validated survey instrument European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) at baseline and after 3 months of treatment. The QLQ-C30 provides a global score as well as five functional and nine symptom scores. Higher scores in the global and functional scales and lower scores in the symptom scales indicate better QoL. The mean QoL scores were compared using paired sample t-test. Results: QoL scores for all patients together were well maintained from baseline to 3 months for both global scores (63.6 vs. 61.7, p=0.11) and across scales, excluding emotional functioning (66.6 vs. 71.3, p<0.001) and insomnia (36.7 vs. 32, p=0.003), both of which actually improved at 3 months. There were 257 analytic and 432 non-analytic patients whose mean global QoL scores were 67 and 61.5 at baseline (p=0.005) and 65 and 59.7 at 3 months (p=0.006). There was no significant difference in mean global scores at baseline as compared with 3 months for either analytic or non-analytic patients. Patient's stage of disease at diagnosis was I, 133; II, 282; III, 145; and IV, 85. Mean global QoL scores for locoregional (stages I-III) and metastatic (stage IV) disease patients were 63.4 and 65.2 at baseline (p=0.53) and 61.9 and 59.8 at 3 months (p=0.45); there was no significant difference in mean global scores at baseline as compared with 3 months for either loco-regional or metastatic disease patients. Conclusions: This study suggests that the QoL outcomes of patients with breast cancer are maintained and may even be improved while undergoing therapy in an integrative cancer treatment setting. No significant financial relationships to disclose.

A systematic review of dental disease in patients undergoing cancer therapy

IntroductionThis purpose of this systematic review was to evaluate the literature and update our current understanding of the impact of present cancer therapies on the dental apparatus (teeth and periodontium) since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies.Review methodA systematic literature search was conducted with assistance from a research librarian in the databases MEDLINE/PubMed and EMBASE for articles published between 1 January 1990 and 31 December 2008. Each study was independently assessed by two reviewers. Taking into account predetermined quality measures, a weighted prevalence was calculated for the prevalence of dental caries, severe gingival disease, and dental infection. Data on DMFT/dmft, DMFS/dmfs, plaque, and gingival indexes were also gathered. The level of evidence, recommendation, and guideline (if possible) were given for published preventive and management strategies.ResultsSixty-four published papers between 1990 and 2008 were reviewed. The weighted overall prevalence of dental caries was 28.1%. The overall DMFT for patients who were post-antineoplastic therapy was 9.19 (SD, 7.98; n = 457). The overall plaque index for patients who were post-antineoplastic therapy was 1.38 (SD, 0.25; n = 189). The GI for patients who were post-chemotherapy was 1.02 (SD, 0.15; n = 162). The weighted prevalence of dental infections/abscess during chemotherapy was reported in three studies and was 5.8%.ConclusionsPatients who were post-radiotherapy had the highest DMFT. The use of fluoride products and chlorhexidine rinses are beneficial in patients who are post-radiotherapy. There continues to be lack of clinical studies on the extent and severity of dental disease that are associated with infectious complications during cancer therapy.

Systematic reviews of oral complications from cancer therapies, Oral Care Study Group, MASCC/ISOO: methodology and quality of the literature

Oral complications are commonly experienced by patients undergoing cancer therapies. The Oral Care Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) has completed nine systematic reviews including Bisphosphonate Osteonecrosis of the Jaw, Odontogenic/Periodontal Infection, Dysgeusia, Oral Fungal Infection, Osteoradionecrosis, Trismus, Oral Pain, Oral Viral Infection, and Xerostomia. The aims of these reviews were to determine the prevalence of each oral complication, relationship with quality of life, economic impact, and formulation of guidelines based on the quality of the literature. The present article described the details of the methodology and statistical analysis utilized in these nine systematic reviews. Additionally, a summary of the quality of the literature from these oral complications is presented. Oral complications associated with cancer therapies are common among cancer patients. The systematic reviews by the Oral Care Study Group of MASCC/ISOO provide a thorough assessment of the available literature for these oral complications.

Microbial influences on the small intestinal response to radiation injury

Injury to the small bowel from ionizing radiation occurs commonly in patients undergoing cancer therapy and less commonly in instances of accidental radiation overexposure. Several lines of evidence now suggest that dynamic interactions between the host's enteric microbiota and innate immune system are important in modulating the intestinal response to radiation. Here, we will review recent developments in the area of acute radiation enteropathy and examine the current state of knowledge regarding the impact of host-microbial interactions in the process. There is promise in the development and testing of new clinical biomarkers including serum citrulline. Toll-like receptor agonists and innate immune system signaling pathways including nuclear factor-kappa B profoundly alter intestinal epithelial cell apoptosis and crypt survival after radiation exposure. Germ-free conditions, probiotics and antibiotics are each identified as modifiers of disease development and course. A human study suggested that luminal microbiota composition may influence the host's intestinal response to radiation and may change in those developing postradiation diarrhea. New knowledge implies that investigations aimed at deciphering the microbiome-host interactions before and after small bowl radiation injury may eventually allow prediction of disease course and offer opportunities for the development of novel therapeutic or prophylactic strategies.

Effectiveness of triclosan in the management of radiation-induced oral mucositis: A randomized clinical trial

Oral care in cancer patients is an important aspect in the quality of life of patients undergoing cancer therapy. Mucositis, trismus, salivary gland dysfunction are the main complications of the cancer therapy, which lead to long-term complications such as radiation caries, poor oral hygiene and osteoradionecrosis. A timely oral evaluation and intervention in these patients can reduce the severity of the potential complications. Triclosan is an antibacterial agent widely used in periodontal therapy, the effectiveness of triclosan in the management of radiation induced oral mucositis is evaluated here. 1) To determine the effectiveness of triclosan in the management of radiation-induced oral mucositis. 2) To compare the effectiveness of triclosan mouth rinse with conventional sodium bicarbonate mouth rinse. Twenty-four patients who underwent radiation therapy for oral cancer and subsequently developed oral mucositis were included in the study. They were randomly allocated into two groups on noticing grade I mucositis (erythema). The study group was advised to use triclosan mouthwash containing triclosan 0.03% W/V and sodium bicarbonate 2 mg mouth wash for the control group. A weekly follow-up evaluation of body weight, food intake, pain and grading of mucositis were made during the radiation treatment period and post radiation treatment period. Both the groups were statistically identical. All the 24 patients in both the groups passed through grade 3 mucositis on the last day of radiotherapy. However, 10 patients in the control group and only one patient in the study group entered to grade 4 mucositis. A definite change was noticed in the severity of the mucositis, food intake and weight loss. The control group took more than 45 days to resolve while the study group took only less than 28 days. The results of the study were evaluated and tried to formulate a hypothesis so as to explain the less severity and early resolution of mucositis in the study group. Triclosan mouthwash was found to be effective in reducing the severity of radiation- induced oral mucositis and helped in early reversal of symptoms during post treatment period. However, further studies are necessary to confirm this observation.

Clinical and virological factors associated with hepatitis B virus reactivation in HBsAg-negative and anti-HBc antibodies-positive patients undergoing chemotherapy and/or autologous stem cell transplantation for cancer

We studied clinical outcome and clinico-virological factors associated with hepatitis B virus reactivation (HBV-R) following cancer treatment in hepatitis B virus surface antigen (HBsAg)-negative/anti-hepatitis B core antibodies (anti-HBcAb)-positive patients. Between 11/2003 and 12/2005, HBV-R occurred in 7/84 HBsAg-negative/anti-HBcAb-positive patients treated for haematological or solid cancer. Virological factors including HBV genotype, core promoter, precore, and HBsAg genotypic and amino acid (aa) patterns were studied. Patients presenting with reactivation were men, had an hepatitis B virus surface antibody (HBsAb) titre <100 IU/L and underwent >1 line of chemotherapy (CT) significantly more frequently than controls. All were treated for haematological cancer, 3/7 received haematopoietic stem cell transplantation (HSCT), and 4/7 received rituximab. Using multivariate analysis, receiving >1 line of CT was an independent risk factor for HBV-R. Fatal outcome occurred in 3/7 patients (despite lamivudine therapy in two), whereas 2/4 survivors had an HBsAg seroconversion. HBV-R involved non-A HBV genotypes and core promoter and/or precore HBV mutants in all cases. Mutations known to impair HBsAg antigenicity were detected in HBV DNA from all seven patients. HBV DNA could be retrospectively detected in two patients prior cancer treatment and despite HBsAg negativity. HBV-R is a concern in HBsAg-negative/anti-HBcAb-positive patients undergoing cancer therapy, especially in males presenting with haematological cancer, a low anti-HBsAb titre and more than one chemotherapeutic agent. HBV DNA testing is mandatory to improve diagnosis and management of HBV-R in these patients. The role of specific therapies such as rituximab or HSCT as well as of HBV aa variability deserves further studies.

Predictors of distress and quality of life in patients undergoing cancer therapy: impact of treatment type and decisional role

The purpose of this secondary investigation was to examine the impact of the type of treatment received and the perceived role in treatment decision making in predicting distress and cancer-specific quality of life in patients newly diagnosed with breast or prostate cancer. Participants included 1057 newly diagnosed breast and prostate cancer patients from four Canadian cancer centers who partook in a randomized controlled trial examining the utility of providing patients with an audio-recording of their treatment planning consultation. A MANCOVA was performed to predict distress and cancer-specific quality of life at 12 weeks post-consultation based on control variables (patient age, education, residence, tumor size (breast sample), gleason score (prostate sample), and receipt of an initial treatment consultation recording), predictor variables (treatment type--chemotherapy, hormone therapy, radiation therapy; decisional role--active, collaborative, passive), and interactions between these predictors. Women who received chemotherapy and reported having played a more passive role in treatment decision making had significantly greater distress and lower cancer-specific quality of life at 12-week post-consultation. There were no statistically significant predictors of these outcomes identified for men with prostate cancer. Receipt of chemotherapy places women with breast cancer at risk for distress and reduced quality of life, but only for the subset of women who report playing a passive role in treatment decision making. Prospective, longitudinal studies are needed to confirm the present findings and to explicate the antecedents, composition, and consequences of the 'passive' decisional role during the treatment phase of the cancer trajectory.

Level of activity in children undergoing cancer treatment

The diagnosis of cancer bears severe implications for pediatric patients. One immense restriction consists in a reduced level of activity due to different factors. Physical activity affects various aspects of development and can be regarded as an essential part of a child's life. In the present study physical activity in patients undergoing cancer therapy was quantified in order to determine the extent of the restriction and to provide baseline information for the assessment of possible interventions. Physical activity in 80 patients and 45 healthy children matched for age and gender was measured using the StepWatch 3 Activity Monitor (SAM, OrthoCare Innovations). Pediatric cancer patients, at 2,787 gait cycles (gcs) per day, were significantly less active than their healthy counterparts (8,096 gcs). Patients were significantly more active at home than during inpatient stays (3,185 gcs compared to 1,830 gcs), and patients with bone tumors were less active than those with leukemia regarding both, the amount (1,849 gcs vs. 2,992 gcs) and the intensity of activity. The present study quantified an often observed but so far hardly assessable problem. Activity in cancer patients is considerably reduced and patients with bone tumors are at increased risk from the detrimental effects of prolonged inactivity. Both our findings and the accepted fact that activity is an essential element of child development confirm the need for interventions tailored to a patient's needs and abilities during the course of treatment.

Treatment of Osteoporosis/Osteopenia in Pediatric Leukemia and Lymphoma

To evaluate the efficacy and safety of various treatment options for osteopenia and osteoporosis secondary to cancer treatment in pediatric patients undergoing cancer therapy. A systematic search of PubMed (1949-November 2008) and International Pharmaceutical Abstracts (to November 2008) was conducted using the following search terms: osteoporosis, osteopenia, pediatrics, cancer, neoplasms, chemotherapy, bisphosphonates, calcium, vitamin D, calcitonin, and physical therapy. All prospective studies that evaluated various osteoporosis treatment options in pediatric patients undergoing chemotherapy were included. Results from studies evaluating bisphosphonates and other treatments in children with osteoporosis due to other causes were also included if important safety and efficacy data were provided. Most commonly reported primary efficacy endpoints included comparisons of bone density parameters measured before and after treatment. Four clinical studies and 2 case reports describing treatment with bisphosphonates, specifically alendronate and pamidronate, for osteoporosis or osteopenia in pediatric cancer patients were identified. Results from the trials showed that these medications were efficacious in reducing bone mineral density loss during cancer therapy and were well tolerated in this special population. Primary efficacy endpoints included improvements in Z-scores measured by dual-energy X-ray absorptiometry scans. The most commonly reported adverse effects included hypocalcemia, mild stomach upset, and infusion-related hyperpyrexia. Four additional clinical trials involving the treatment of osteoporosis or osteopenia in children and adolescents who developed bone degeneration after chronic steroid therapy are also included. In these trials, treatment options such as calcitonin, and calcium and vitamin D supplementation were also shown to be beneficial. The clinical trials published to date are limited to only a few conducted in small populations of patients diagnosed with lymphoblastic leukemia or non-Hodgkin's lymphoma. However, alendronate and pamidronate both appeared to be effective options in improving bone mineral density scores with minimal adverse effects.

Assessing the Need for a Dietitian in Radiation Oncology

Nutritional care is an integral component of quality cancer treatment. Patients undergoing cancer therapy are at risk for developing a variety of side effects that impact their intake, absorption, and nutritional status. The issue becomes compounded in newly diagnosed patients who have preexisting poor nutritional status, comorbid diseases, mechanical obstruction, and metabolic abnormalities. Standards related to the role of dietitians are well defined in the literature and by the Joint Commission. The quality improvement project illustrated in this article clearly demonstrated the need for a dietitian in the radiation oncology clinic by using the Patient-Generated Subjective Global Assessment.

Measuring the Symptom Experience of Chinese Cancer Patients: A Validation of the Chinese Version of the Memorial Symptom Assessment Scale

The purpose of this study was to translate the Memorial Symptom Assessment Scale (MSAS) into Chinese and evaluate the psychometric properties of this version. The original MSAS is a 32-item, patient-rated measure that was developed to assess common cancer-related physical and psychological symptoms with respect to frequency, intensity, and distress. In this study, a two-phase design was used. Phase I involved iterative forward–backward translation, testing of content validity (CVI) and a pretest. Phase II established the psychometric properties of the Chinese version MSAS (MSAS-Ch). Results showed that the MSAS-Ch achieved content relevancy CVI of 0.94 and semantic equivalence CVI of 0.94. Pretesting was performed in 10 cancer patients, and the results revealed adequate content coverage and comprehensibility of the MSAS-Ch. A convenience sample of 370 patients undergoing cancer therapy or at the early post-treatment stage was recruited for psychometric evaluation. Confirmatory factor analysis confirmed the construct validity of the MSAS-Ch, with a good fit between the factor structure of the original version and our present sample data (goodness-of-fit indices all above 0.95). The internal consistency reliability of subscales and total MSAS-Ch was moderately high, with Cronbach alpha coefficients ranging from 0.79 to 0.87. The test–retest intraclass correlation results for the subscale and total MSAS-Ch ranged from 0.68 to 0.79. The subscale scores of MSAS-Ch were moderately correlated with the scores on various validation measurements that assessed psychological distress, pain, and health-related quality of life ( r = 0.46–0.65, P < 0.01), confirming that they were measurements of similar constructs. The validity of the construct validity was also supported by comparing the MSAS-Ch scores for subpopulations that varied clinically. Inpatients and patients with poorer performance status scored higher on the MSAS-Ch subscale and total scores than outpatients and patients with higher performance status ( P < 0.05). Our study shows that the MSAS-Ch has adequate psychometric properties of validity and reliability, and can be used to assess symptoms during cancer therapy and at the early post-treatment stage in Chinese-speaking patients.

Dangers of restocking T cells

Refilling an empty niche with proliferating CD8+ T cells can cause autoimmune disease, say Tajima et al. (page 1019). Figure 1 Autoimmune colitis (top) caused by homeostatically proliferating CD8+ T cells is resolved in mice injected with anti–IL-6 antibody (bottom). Infusion of naive T cells into an environment where there are few native T cells—such as in patients undergoing cancer therapy—spurs two kinds of proliferation. T cells activated by non-self-peptide/MHC complexes proliferate rapidly, whereas those activated by self-peptide/MHC in the presence of cytokines such as IL-7 and IL-15 proliferate slowly. CD4+ T cells that proliferate by these methods have previously been shown to drive the inflammation seen in several autoimmune diseases. Tajima et al. now find a new variation in homeostatic proliferation of CD8+ T cells that also induces autoimmunity. In gut lymph nodes of T cell–deficient mice, injected CD8+ T cells proliferated rapidly in response to IL-6. This inflammatory cytokine was found at high levels in these lymph nodes, perhaps due to their proximity to the bacterium-laden gut. The mice developed a thicker gut epithelium and lost weight—signs of an autoimmune disease called colitis. T cell–injected mice treated with an IL-6–blocking antibody or with bacterium-depleting drugs, however, remained healthy. The proliferating T cells secreted several inflammatory cytokines, including IL-17. The IL-17 alone seemed to be responsible for the colitis, as mice injected with T cells that were unable to produce IL-17 remained healthy. If these IL-17–producing CD8+ T cells are found in patients suffering from diseases such as colitis, the anti–IL-6 antibody might be a good therapeutic option.