Lysine analogue use during cancer surgery: a survey from a Canadian tertiary care centre

Background

When used during surgery, antifibrinolytic hemostatic agents such as lysine analogues are effective at reducing blood loss and the need for transfusions. Despite proven efficacy, use of hemostatic agents remains low during some surgeries. Our objective was to explore surgeon opinions about, and use of lysine analogues in, oncologic surgeries at a large tertiary care academic institution.

Methods

We administered a survey to surgeons who perform high-transfusion-risk oncologic surgeries at a large academic hospital in Ottawa, Ontario. Design and distribution of the survey followed a modified Dillman method. To ensure that the survey questionnaire was relevant, clear, and concise, we performed informant interviews, cognitive interviews, and pilot-testing. The final survey consisted of 19 questions divided into 3 sections: respondent demographics, use of hemostatic agents, and potential clinical trial opinions.

Results

Of 28 surgeons, 24 (86%) participated. When asked to indicate the frequency of lysine analogue use, "never" accounted for 46% of the responses, and "rarely" (<10% of the time) accounted for 23% of the responses. Reasons for never using included "unfamiliar with benefits" and "prefer alternatives." Fifteen surgeons (63%) felt that a trial was needed to demonstrate the efficacy and safety of lysine analogues in their cancer field.

Conclusions

Our survey found that lysine analogues are infrequently used during oncologic surgeries at our institution. Many surgeons are unfamiliar with the benefits and side effects of lysine analogues and, alternatively, use topical hemostatic agents. Our results demonstrate that future trials exploring the efficacy and safety of lysine analogues in oncologic surgery are needed.

A randomized trial of individualized versus standard of care antiemetic therapy for breast cancer patients at high risk for chemotherapy-induced nausea and vomiting

Purpose

Despite triple antiemetic therapy use for breast cancer patients receiving emetogenic chemotherapy, nausea remains a clinical challenge. We evaluated adding olanzapine (5 mg) to triple therapy on nausea control in patients at high personal risk of chemotherapy-induced nausea and vomiting (CINV).

Methods

This multi-centre, placebo-controlled, double-blind trial randomized breast cancer patients scheduled to receive neo/adjuvant chemotherapy with anthracycline-cyclophosphamide or platinum-based chemotherapy to olanzapine (5 mg, days 1–4) or placebo. Primary endpoint was frequency of self-reported significant nausea, repeated for all cycles of chemotherapy. Secondary endpoints included: duration of nausea, overall total control of CINV, Health Related Quality of Life (HRQoL) using FLIE questionnaire, use of rescue mediation and treatment-related adverse events.

Results

218 eligible patients were randomised to placebo (105) or olanzapine (113). From days 0–5 following each cycle of chemotherapy, 41.3% (95%CI: 36.1–46.7%) of patients in the placebo group reported significant nausea compared to 27.7% (95%CI: 23.2–32.4%) in the olanzapine group (p = 0.001). Across all cycles of chemotherapy, patients receiving olanzapine experienced a statistically significant improvement in HRQoL (p < 0.001). Grade 1/2 sedation was the most commonly side effect reported at 40.8% in the placebo group vs. 54.1% with olanzapine (p < 0.001).

Conclusion

In patients at high personal risk of CINV, the addition of olanzapine 5 mg daily to standard antiemetic therapy significantly improves the control of nausea, HRQoL, with no unexpected toxicities.

•

Double-blind trial evaluated the addition of olanzapine to triple therapy in patients at high personal risk of CINV.

•

Adding 5 mg olanzapine was associated with significantly improved nausea control with no unexpected toxicities.

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Olanzapine plus triple therapy should be considered standard of care for breast cancer patients at high risk of CINV.

Psychosocial and pharmacologic interventions for methamphetamine addiction: protocol for a scoping review of the literature

BACKGROUND

Methamphetamine use and harms are rising rapidly. Management of patients with methamphetamine use disorder (MUD) and problematic methamphetamine use (PMU) is challenging, with no clearly established best approach; both psychosocial and pharmacologic interventions have been described. Furthermore, given the diversity of individuals that use methamphetamines, there is a need to assess evidence for treatments for subgroups including youths; gay, bisexual, and other men who have sex with men; individuals with mental health comorbidities; and individuals in correction services. Establishing awareness of the messages regarding treatment from recent clinical practice guidelines (CPG) in the field is also of value. The first study objective will be to establish a greater understanding of the methods, populations, and findings of controlled studies for psychosocial and pharmacologic treatments for MUD and PMU. Investigation of this information can help establish the potential for advanced syntheses of the evidence (such as network meta-analysis) to compare therapies for this condition and to identify gaps related to key populations where more primary research is needed. Summarizing the recommendations regarding treatment of MUD/PMU from recent CPGs and systematic reviews will be an important secondary objective.

METHODS

A scoping review will be performed. Using the OVID platform, MEDLINE, Embase, PsycINFO, and relevant Cochrane databases from EBM Reviews will be searched (from databases' inception onwards). Eligibility criteria will include individuals described as having MUD or PMU, with designs of interest including randomized trials, non-randomized trials, and controlled cohort studies with three or more months of follow-up; systematic reviews and CPGs will also be sought. Two reviewers (with support from automation tools) will independently screen all citations, full-text articles, and chart data. Different approaches to handling and summarizing the data will be implemented for each type of study design. Tables and graphics will be used to map evidence sources and identify evidence gaps.

DISCUSSION

This research will enhance awareness of evidence addressing the effects of psychosocial and pharmacologic interventions for MUD/PMU overall and in sub-populations, both in terms of recent CPGs/reviews and primary studies; inspection of the latter will also help establish the feasibility of future syntheses to compare treatments, such as network meta-analysis. SYSTEMATIC REVIEW PROTOCOL REGISTRATION: Open Science Framework ( https://osf.io/9wy8p ).

A multicentre, randomised trial comparing schedules of G-CSF (filgrastim) administration for primary prophylaxis of chemotherapy-induced febrile neutropenia in early stage breast cancer

BACKGROUND

The optimal duration of filgrastim as primary febrile neutropenia (FN) prophylaxis in early breast cancer patients is unknown, with 5, 7 or 10 days being commonly prescribed. This trial evaluates whether 5 days of filgrastim was non-inferior to 7/10 days.

PATIENTS AND METHODS

In this randomised, open-label trial, early breast cancer patients who were to receive filgrastim as primary FN prophylaxis were randomly allocated to 5 versus 7 versus 10 days of filgrastim for all chemotherapy cycles. A protocol amendment in November 2017 allowed subsequent patients (N = 324) to be randomised to either 5 or 7/10 days. The primary outcome was a composite of either FN or treatment-related hospitalisations. Secondary outcomes included chemotherapy dose reductions, delays and discontinuations. Analyses were carried out by per protocol (primary) and intention-to-treat, and the non-inferiority margin was set at 3% for the risk of having FN and/or hospitalisation per cycle of chemotherapy.

RESULTS

Patients (N = 466) were randomised to receive 5 (184, 39.5%), or 7/10 (282, 60.5%) days of filgrastim. In our primary analysis, the difference in risk of either FN or treatment-related hospitalisation per cycle was -1.52% [95% confidence interval (CI): -3.22% to 0.19%] suggesting non-inferiority of a 5-day filgrastim schedule compared with 7/10-days. The difference in events per cycle for FN was 0.11% (95% CI: -1.05 to 1.27) while for treatment-related hospitalisations it was -1.68% (95% CI: -2.73% to -0.63%). The overall proportions of patients having at least one occurrence of either FN or treatment-related hospitalisation were 11.8% and 14.96% for the 5- and 7/10-day groups, respectively (risk difference: -3.17%, 95% CI: -9.51% to 3.18%).

CONCLUSION

Five days of filgrastim was non-inferior to 7/10 days. Given the cost and toxicity of this agent, 5 days should be considered standard of care. CLINICALTRIALS.

GOV REGISTRATION

NCT02428114 and NCT02816164.

Knowledge Synthesis in Evidence-Based Medicine

Systematic reviews are the most common form of knowledge synthesis and remain a cornerstone of the practice of evidence-based medicine. They offer enhanced rigor and validity relative to traditional narrative review articles by reducing bias and increasing objectivity. In answering focused research questions, systematic reviews are directly applicable to clinical practice as well as the development of clinical guidelines and the identification of knowledge gaps, which may drive future primary research directions. Typically, such a rigorous process necessarily requires substantive time to carefully and systematically identify, screen, and synthesize all relevant available primary research on a topic. Further, other knowledge synthesis methods have emerged to address the varying needs of decision makers with respect to condensed timelines and more diverse research questions, as well as to allow incorporation of already synthesized evidence into reviews. These alternative methods include rapid reviews, scoping reviews, and overviews of systematic reviews, which are being used with increasing frequency by clinicians, decision-makers, and researchers. We encourage clinicians and researchers in nuclear medicine and other imaging sciences to acquire a greater familiarity with these methods and to consider them in clinical decision making, the development of clinical guidelines, and the planning of future research activities.

Guselkumab for the Treatment of Moderate-to-Severe Plaque Psoriasis During Induction Phase: A Systematic Review and Network Meta-Analysis

Background:

Guselkumab is an interleukin-23 inhibitor indicated for treatment of moderate-to-severe plaque psoriasis.

Objective:

The objective was to determine the relative efficacy and safety of guselkumab compared to other biologics.

Methods:

A systematic review was performed to identify randomized controlled trials (RCTs). Bayesian network meta-analyses (NMAs) were conducted using meta-regression analyses that adjusted for cross-trial differences and risk differences. The primary outcome was Psoriasis Area and Severity Index (PASI) 90 response. Other efficacy and safety outcomes were considered. Several meta-regressions were performed to account for variations in patient and study characteristics: baseline risk adjustment (ie, control group response), prior biologic use, duration of psoriasis, weight, age, race, and baseline PASI/dermatology life quality index scores. The best-fitting model using predefined criteria was selected.

Results:

Forty-five RCTs were identified. Patient and study characteristics differed between RCTs as reflected in variations in control group response. Both the baseline risk-adjusted NMA and the risk-difference NMA fit the data best and suggested guselkumab has one of the highest PASI 90 responses. Pairwise comparisons from the baseline risk-adjusted PASI 90 NMA suggested guselkumab has comparable efficacy with ixekizumab (relative risk [RR]: 0.999, 95% credible intervals [CrIs]: 0.89-1.13) and brodalumab (RR: 1.04, 95% CrIs: 0.91-1.17) and superior efficacy versus all other treatments in the network (RR range, 1.20 to 43.22). Guselkumab was superior or comparable to other therapies for other efficacy outcomes and had a more favorable safety profile than most.

Conclusions:

Guselkumab has one of the highest PASI 90 responses among psoriasis treatments; similar findings were observed for other efficacy outcomes. Guselkumab has a favorable benefit–risk balance compared to moderate-to-severe psoriasis therapies.

Perceptions of vascular access for intravenous systemic therapy and risk factors for lymphedema in early-stage breast cancer-a patient survey

Background

The choice of vascular access for systemic therapy administration in breast cancer remains an area of clinical equipoise, and patient preference is not consistently acknowledged. Using a patient survey, we evaluated the patient experience with vascular access during treatment for early-stage breast cancer and explored perceived risk factors for lymphedema.

Methods

Patients who had received systemic therapy for early-stage breast cancer were surveyed at 2 Canadian cancer centres.

Results

Responses were received from 187 patients (94%). The route of vascular access was peripheral intravenous line (IV) in 24%, a peripherally inserted central catheter (picc) in 42%, and a surgically inserted central catheter (port) in 34%. Anthracycline-based regimens were associated with a greater use of central vascular access devices (cvads- that is, a picc or port; 86/97, 89%). Trastuzumab use was associated with greater use of ports (49/64, 77%). Although few patients (7%) reported being involved in the decisions about vascular access, most were satisfied or very satisfied (88%) with their access type. Patient preference centred mainly on avoiding delays in the initiation of chemotherapy. Self-reported rates of complications (183 evaluable responses) were infiltration with peripheral IVs (9/44, 20%), local skin infections with piccs (7/77, 9%), and thrombosis with ports (4/62, 6%). Perceived risk factors for lymphedema included use of the surgical arm for blood draws (117/156, 75%) and blood pressure measurement (115/156, 74%).

Conclusions

Most patients reported being satisfied with the vascular access used for their treatment. Improved education and understanding about the evidence-based requirements for vascular access are needed. Perceived risk factors for lymphedema remain variable and are not evidence-based.

Optimizing vascular access for patients receiving intravenous systemic therapy for early-stage breast cancer-a survey of oncology nurses and physicians

Background

Despite advances in systemic therapy choices for patients with early-stage breast cancer, optimal practices for intravenous (IV) access remain unknown. That lack of knowledge holds particularly true for the use of central venous access devices (cvads) such as peripherally inserted central catheters (piccs) and implanted vascular access devices (ports).

Methods

Using a survey of Canadian oncologists and oncology nurses responsible for the care of breast cancer patients, we evaluated current access practices, perceptions of complications, and perceptions of risk, and we estimated complication rates and evaluated perceived risk factors for lymphedema.

Results

Survey responses were received from 25 physicians and 57 oncology nurses. Administration of trastuzumab or an anthracycline was associated with a higher likelihood of a cvad being recommended. Other factors associated with recommendation of a cvad included prior difficult IV access and a recommendation from the chemotherapy nurse. Although the complication rates perceived to be associated with the use of piccs and ports remained high, respondents felt that cvads might improve patient quality of life. Risk factors perceived to be associated with the risk of lymphedema were axillary lymph node dissection, radiation to the axilla, and line-associated infection. Factors known to be unrelated to lymphedema risk (specifically, blood draws and blood pressure measurement) continue to be perceived as posing a higher risk.

Conclusions

Despite widespread use of chemotherapy for patients with breast cancer, the type of venous access used for treatment varies significantly, as do perceptions about the risks of cvad use and the risk for lymphedema development. Further prospective studies are needed to identify best-practice strategies.

Optimal sequence of adjuvant endocrine and radiation therapy in early-stage breast cancer - A systematic review

IMPORTANCE

Clinical equipoise exists around the optimal time to start adjuvant endocrine therapy in patients who will receive post-operative radiotherapy for breast cancer. Concerns continue to exist regarding potential reduced efficacy, or increased toxicity, when radiation, and endocrine therapy are administered concurrently.

OBJECTIVE

To perform a systematic review of studies comparing outcomes between sequential and concurrent adjuvant radiation and endocrine therapy in early-stage breast cancer. All modalities of radiation therapy were considered, and endocrine therapy could be either tamoxifen or an aromatase inhibitor. Outcomes of interest included; local, regional or distant recurrence, overall survival and treatment-related toxicities.

EVIDENCE REVIEWED

PubMed, Ovid Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from 1946 to December 2017. Two reviewers independently assessed each citation using the criteria outlined above. Study quality was assessed using the Cochrane Collaboration's tool for prospective studies, and the Newcastle-Ottawa scale for retrospective studies.

FINDINGS

Of 2137 unique citations identified, 13 met eligibility criteria. Eleven were unique studies (7569 patients), while 2 of the studies were updated analyses of previous studies. Studies evaluated the timing of adjuvant radiation, and tamoxifen (5 studies, 1550 patients), or aromatase inhibitors (6 studies, 6019 patients). We identified 1 complete randomized clinical trial (150 patients), and 5 retrospective studies (1580 patients), in addition to conference abstracts (5 studies, 5839 patients). Overall, none of the studies showed a significant difference in efficacy, or toxicity, with concurrent versus sequential treatment. However, given the significant heterogeneity of the study populations, it was not possible to conduct a meta-analysis.

CONCLUSIONS AND RELEVANCE

In the absence of high quality data, adequately powered randomized trials are required to answer this important clinical question.

Taxane acute pain syndrome (TAPS) in patients receiving chemotherapy for breast or prostate cancer: a prospective multi-center study

BACKGROUND

Taxane acute pain syndrome (TAPS) is characterized by myalgias and arthralgias starting 2-3 days after taxane-based chemotherapy and lasting up to 7 days. In the absence of validated tools, many studies use the presence of both the myalgia and arthralgia components of the Common Terminology Criteria for Adverse Events (CTCAE) to define TAPS. The present study prospectively evaluated the frequency, severity, and impact of TAPS in patients with breast or prostate cancer.

PATIENTS AND METHODS

In this prospective, non-randomized study, patients with breast or prostate cancer commencing taxane-based chemotherapy completed the CTCAE (version 4.03), the Functional Assessment of Cancer Therapy-Taxane (FACT-T), and Brief Pain Inventory (BPI) questionnaires at baseline and once between days 5 and 7 of each chemotherapy cycle.

RESULTS

From March 2015 to April 1, 2016, 75 patients (breast n = 66, prostate n = 9) were enrolled; 83% received docetaxel and 16% paclitaxel and 1% withdrew. After the first cycle of taxane, TAPS was reported by 25/69 (36.2%) patients; a further 8/69 (18.2%) reporting TAPS after a subsequent chemotherapy treatment. Overall incidence of TAPS was 33/75 (44%). While associated with detrimental scores on FACT-T and BPI as well as increased use of analgesics in 63% (21/33) of patients with TAPS, TAPS did not lead to alterations in chemotherapy dosing.

CONCLUSIONS

TAPS is common after taxane-based chemotherapy, and its presence is associated with reduced quality of life and increased analgesic requirements. Prospective patient-reported outcome assessments are crucial to help individualize treatment strategies and improve management of TAPS.

Network geometry of evidence from randomised controlled trials addressing donor selection and source of haematopoietic progenitor cells used in allogeneic transplantation: a systematic scoping review

BACKGROUND AND METHODS

A scoping review of randomised controlled trials (RCTs) addressing source of cells and choice of donor for allogeneic haematopoietic cell transplantation (HCT) was performed to create a network of best evidence that allows us to identify new potential indirect comparisons for the strategic development of future studies that connect to the existing evidence network.

RESULTS

A total of 19 eligible RCTs (2589 total patients) were identified. Nine studies (1566 patients) compared clinical outcomes following the use of peripheral blood progenitor cells (PBPCs) with bone marrow (BM) from matched related donors (eight studies) or matched unrelated donors (one study). The remaining studies compared BM or PBPCs with various methods of BM stimulation or manipulation (six studies), compared different methods of surface molecule-based selection and/or depletion of grafts (two studies) or compared the optimal number of units for paediatric cord blood transplantation (two studies). No published RCTs compared different types of donors. The geometry of the evidence network was analysed to identify opportunities for potential novel indirect comparisons and to identify opportunities to expand the network. Few indirect comparisons are currently feasible due to small sample size and heterogeneity in patient diagnoses and demographics between treatment nodes in the network.

CONCLUSION

More RCTs that enrol greater numbers of similar patients are needed to leverage the current evidence network concerning donor choice and source of cells used in allogeneic HCT.

Physician "out of office" alert: does it work?

The rapid expansion of electronic communication has aided in patient care, but it has also increased the amount of time that physicians spend reviewing and responding to e-mail messages. [...]

Estrogen, progesterone, and HER2/neu receptor discordance between primary and metastatic breast tumours-a review

Discordance in estrogen (ER), progesterone (PR), and HER2/neu status between primary breast tumours and metastatic disease is well recognized. In this review, we highlight how receptor discordance between primary tumours and paired metastasis can help elucidate the mechanism of metastasis but can also effect patient management and the design of future trials. Discordance rates and ranges were available from 47 studies (3384 matched primary and metastatic pairs) reporting ER, PR, and HER2/neu expression for both primary and metastatic sites. Median discordance rates for ER, PR, and HER2/neu were 14 % (range 0-67 %, IQR 9-25 %), 21 % (range 0-62 %, IQR 15-41 %), and 10 % (range 0-44 %, IQR 4-17 %), respectively. Loss of receptor expression was more common (9.17 %) than gain (4.51 %). Discordance rates varied amongst site of metastasis with ER discordance being highest in bone metastases suggesting that discordance is a true biological phenomenon. Discordance rates vary for both the biomarker and the metastatic site. Loss of expression is more common than gain. This can affect patient management as it can lead to a reduction in both the efficacy and availability of potential therapeutic agents. Future studies are recommended to explore both the mechanisms of discordance as well as its impact on patient outcome and management.

Comparison of pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a protocol for a systematic review incorporating network meta-analyses

BACKGROUND

Delirium is characterized by acute changes in mental status including inattention, disorganized thinking, and altered level of consciousness, and is highly prevalent in critically ill adults. Delirium has adverse consequences for both patients and the healthcare system; however, at this time, no effective treatment exists. The identification of effective prevention strategies is therefore a clinical and research imperative. An important limitation of previous reviews of delirium prevention is that interventions were considered in isolation and only direct evidence was used. Our systematic review will synthesize all existing data using network meta-analysis, a powerful statistical approach that enables synthesis of both direct and indirect evidence.

METHODS

We will search Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science from 1980 to March 2016. We will search the PROSPERO registry for protocols and the Cochrane Library for published systematic reviews. We will examine reference lists of pertinent reviews and search grey literature and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We will include randomized and quasi-randomized trials of critically ill adults evaluating any pharmacological, non-pharmacological, or multi-component intervention for delirium prevention, administered in or prior to (i.e., peri-operatively) transfer to the ICU. Two authors will independently screen search results and extract data from eligible studies. Risk of bias assessments will be completed on all included studies. To inform our network meta-analysis, we will first conduct conventional pair-wise meta-analyses for primary and secondary outcomes using random-effects models. We will generate our network meta-analysis using a Bayesian framework, assuming a common heterogeneity parameter across all comparisons, and accounting for correlations in multi-arm studies. We will perform analyses using WinBUGS software.

DISCUSSION

This systematic review will address the existing knowledge gap regarding best practices for delirium prevention in critically ill adults by synthesizing evidence from trials of pharmacological, non-pharmacological, and multi-component interventions administered in or prior to transfer to the ICU. Use of network meta-analysis will clarify which delirium prevention strategies are most effective in improving clinical outcomes while causing least harm. The network meta-analysis is a novel approach and will provide knowledge users and decision makers with comparisons of multiple interventions of delirium prevention strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016036313.

Should de-escalation of bone-targeting agents be standard of care for patients with bone metastases from breast cancer? A systematic review and meta-analysis

BACKGROUND

De-escalation of bone-targeted agents, such as bisphosphonates and denosumab, from 4- to 12-weekly dosing is an increasingly used strategy in patients with bone metastases from breast cancer. It is unclear whether there is sufficient evidence to support de-escalation as a standard of care.

METHODS

A systematic review of randomized trials comparing standard 4-weekly administration of bone-targeted agents with de-escalated (Q12-weekly) dosing in breast cancer patients was carried out. Medline, PubMed and the Cochrane Register of Controlled Trials were searched from inception until November 2014 for relevant studies. Outcomes of interest included skeletal-related event (SRE) rates, bone pain, adverse events (AEs) and bone turnover biomarkers. Random-effects meta-analyses were carried out.

RESULTS

A total of nine citations representing seven unique studies were eligible. One study is ongoing with no reported data. Six studies reported data for at least one outcome of interest. Data were available comparing standard versus de-escalated therapy for pamidronate (1 study, 38 patients), zoledronate (3 studies, 1117 patients) and denosumab (2 studies, 284 patients). Meta-analysis of five trials reporting data for on-study SRE rates between standard (61/443 patients) and de-escalated (49/392 patients) arms produced a summary risk ratio of 0.90 (95% confidence interval 0.63-1.29). Meta-analyses of data for AEs and bone turnover biomarkers also showed no statistically significant differences between standard and de-escalated arms, though only limited numbers of patients and events were present for most analyses.

CONCLUSION

In this systematic review of studies of bisphosphonates and denosumab, there appears to be no difference in SREs or pain with de-escalated therapy. While a large, hopefully definitive study is ongoing, the data presented so far are consistent with de-escalation of bone-targeting agents becoming a standard of care for patients with bone metastases from breast cancer.

Abstract P6-07-01: Are patient perceptions and expectations about peri-operative imaging for metastatic breast cancer in keeping with current guidelines?

Background: The probability of detecting radiologically evident distant metastatic disease in asymptomatic women with primary operable breast cancer is low. Because of this, evidence-based guidelines have been developed to guide physicians on whom to image. Despite these guidelines, peri-operative staging imaging is frequently over-utilized. Relatively little is known about what patients’ perceptions and expectations are regarding peri-operative imaging and whether or not their views are in concordance with the guidelines. We undertook this study in an attempt to answer this question.

Methods: A questionnaire on peri-operative imaging to look for distant metastatic disease was given to women with early stage breast cancer who had completed their surgery. The survey questions were developed in a collaborative effort amongst oncologists, epidemiologists and knowledge translation experts.

Results: Over a 3 month period, 234 surveys were completed at a large Canadian academic cancer centre. The use of peri-operative imaging to assess the skeleton (e.g. bone scan), thorax (e.g. CT, xray), and abdomen (e.g. CT, MRI or ultrasound) is summarized in Table 1 for the 187 patients (80%) who identified their disease stage.

Patient reported perioperative imaging by disease stage Stage 1Stage 2Stage 3No. of patients (%)82/187 (44%)67/187 (36%)38/187 (20%)Median age (range)59 (29-80)57 (27-77)56 (49-65)Peri-operative imaging done for   Skeleton in (%)41/82 (50%)47/67 (70%)33/38 (87%)Thorax in (%)48/82 (59%)53/67 (79%)30/38 (79%)Abdomen in (%)34/82 (41%)42/67 (63%)27/38 (71%)

The relative proportion of patients undergoing imaging increased with advancing stage. Of the 187 patients, 66% indicated they would want imaging if the chance of finding metastatic disease was ≤10% and half of these patients (i.e. 33%) indicated they would want imaging if the chance was &lt;1%. The most common factors identified as being either extremely (EI) or very important (VI) by patients were: catching the spread of cancer to other parts of the body early (93%), reducing the chance of dying (90%), and providing peace of mind (77%). Avoiding inconvenience, exposure to scans, and extra imaging that will not change length or quality of life, and false alarms were EI or VI in ∼50%. Perceptions of these factors did not differ across disease stage. Although 85% indicated doing whatever their doctor recommended was either EI or VI to them, 72% indicated that they would feel very or somewhat uncomfortable if their physician did not order imaging to look for metastatic disease, even if this was in keeping with the guideline recommendation.

Conclusion: Irrespective of evidence-based guidelines, many patients undergo peri-operative imaging. While guidelines tend to address physician behaviour it is evident that patient perceptions and expectations are divergent from the evidence-based guidelines. If patient expectations are, in part, driving excessive imaging, new strategies targeting patient expectations and knowledge are required.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-07-01.

Abstract P3-09-02: Optimal anti-emetic choice for breast cancer patients receiving anthracycline and cyclophosphamide-based chemotherapy - A systematic review and network meta-analysis of randomized controlled trials

Background: International expert consensus groups such as ASCO (JCO 2011) and MASCC (Ann of Oncol. 2010) recommend that patients (pts) receiving anthracycline and cyclophosphamide-based chemotherapy (A&C-CT) regimens receive an anti-emetic combination of 5HT3 antagonist (day 1), NK1 receptor antagonist (day/s 1 or 1-3), and dexamethasone (days 1-3/4). Clinical experience would suggest that Total Control (no episodes of chemotherapy-induced nausea and vomiting [CINV] and no rescue anti-emetic use for 5 days after CT) is often not achieved. We therefore sought to use Network meta-analysis (NMA) to provide a quantitative summary of existing randomised controlled trials (RCTs) to identify the optimal anti-emetic regimen for these pts.

Methods: A peer reviewed search of RCTs assessing combination anti-emetic regimens in breast cancer pts on A&C-CT was performed using Medline, Embase and Cochrane CENTRAL. No additional restriction criteria were employed. Two individuals independently screened citations and full text articles to identify eligible RCTs. Pt and study characteristics, as well as, outcome data were collected to ensure studies were sufficiently similar to include in the NMA. The primary outcome was Total Control of CINV (no nausea, no vomiting, and no rescue anti-emetics for 5 days). Secondary outcomes included Complete Response (no vomiting and no rescue medications for 5 days), No Vomiting and No Nausea in the acute (0-24 hrs) and delayed (24-120 hrs) periods, respectively.

Results: From 962 citations identified, 152 were retained after abstract screening, and 20 retained after full-text screening. Trials were published from 1990 to 2012. There was limited reporting of pt characteristics and CINV outcomes beyond the first CT cycle. The majority of comparisons in the network of treatments were supported by only one RCT. The significant heterogeneity in anti-emetic regimens (n = 21) mandated combining treatment doses and durations to make NMA feasible. Six out of 20 studies reported Total Control, occurring in a mean proportion of 26.9% (23 - 65%) of pts. Complete Response was reported in 11/18 trials, occurring in a mean of 49.8% (31.2% - 79.3%) of pts.

Conclusions: Clinical experience suggests that despite best practice recommendations, many pts do not achieve Total Control of CINV. In preparing for a NMA, we identified marked heterogeneity between trials. This included variability in study design, sample size, treatment agents, duration of agents used, and in reporting of pt characteristics and outcome measures. Given these limitations, despite the recommendations of consensus groups, we have yet been able to make any firm decision on the optimal anti-emetic regimen based on the evidence at this time. We will present findings from our NMA, which will try to account for these limitations. However, if anti-emetic care is to be improved future pragmatic RCTs that include both nausea and vomiting outcomes are clearly required.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-02.

Incidence, consequences and treatment of bone metastases in breast cancer patients-Experience from a single cancer centre

Background

There is a paucity of literature about the benefits of bone-targeted agents for breast cancer patients with bone metastases treated in the non-trial setting. We explored the incidence, consequences, and treatment of bone metastases at a single cancer centre.

Methods

Electronic records of metastatic breast cancer patients were reviewed and pertinent information was extracted.

Results

Of 264 metastatic breast cancer patients, 195 (73%) developed bone metastases. Of these patients, 176 were eligible for analysis. Median age at bone metastases diagnosis was 56.9 years (IQR 48–67) and initial presentation of bone metastases included asymptomatic radiological findings (58%), bone pain (40%), or a SRE (12.5%). Most patients (88%) received a bone-targeted agent, starting a median of 1.5 months (IQR 0.8–3.30) after bone metastasis diagnosis. 62% of patients had ≥1 SRE. The median time from bone metastasis diagnosis to first SRE was 1.8 months (IQR 0.20–8.43 months). Median number of SREs per patient was 1.5 (IQR 0–3). Overall, 26.8% of all SREs were clinically asymptomatic. Within the entire cohort, 51% required opioids and 20% were hospitalized due to either an SRE or bone pain.

Conclusions

Despite extensive use of bone-targeted agents, the incidence of SREs remains high. Nearly half of SREs occur prior to starting a bone-targeted agent. Use of opioids and hospitalizations secondary to bone metastases remain common. More effective treatment options are clearly needed.

Monte Carlo simulations of clinical PET and SPECT scans: impact of the input data on the simulated images

Monte Carlo simulations of emission tomography have proven useful to assist detector design and optimize acquisition and processing protocols. The more realistic the simulations, the more straightforward the extrapolation of conclusions to clinical situations. In emission tomography, accurate numerical models of tomographs have been described and well validated under specific operating conditions (collimator, radionuclide, acquisition parameters, count rates, etc). When using these models under these operating conditions, the realism of simulations mostly depends on the activity distribution used as an input for the simulations. It has been proposed to derive the input activity distribution directly from reconstructed clinical images, so as to properly model the heterogeneity of the activity distribution between and within organs. However, reconstructed patient images include noise and have limited spatial resolution. In this study, we analyse the properties of the simulated images as a function of the properties of the reconstructed images used to define the input activity distributions in (18)F-FDG PET and (131)I SPECT simulations. The propagation through the simulation/reconstruction process of the noise and spatial resolution in the input activity distribution was studied using simulations. We found that the noise properties of the images reconstructed from the simulated data were almost independent of the noise in the input activity distribution. The spatial resolution in the images reconstructed from the simulations was slightly poorer than that in the input activity distribution. However, using high-noise but high-resolution patient images as an input activity distribution yielded reconstructed images that could not be distinguished from clinical images. These findings were confirmed by simulated highly realistic (131)I SPECT and (18)F-FDG PET images from patient data. In conclusion, we demonstrated that (131)I SPECT and (18)F-FDG PET images indistinguishable from real scans can be simulated using activity maps with spatial resolution higher than that used in routine clinical applications.

Home telehealth for diabetes management: a systematic review and meta-analysis

AIM

It is estimated that more than 180 million people worldwide have diabetes. Health-care providers can remotely deliver health services to this patient population using information and communication technology, also known as home telehealth. Home telehealth may be classified into two subtypes: home telemonitoring (HTM) and telephone support (TS). The research objective was to systematically review the literature and perform meta-analyses to assess the potential benefits of home telehealth compared with usual care (UC) for patients with diabetes.

METHODS

An electronic literature search was conducted to identify studies on home telehealth and patients with diabetes that were published between 1998 and 2008 using Medline, Medline In-Process & Other Non-Indexed Citations, BIOSIS Previews and EMBASE.

RESULTS

Twenty-six studies (n = 5069 patients) on home telehealth for diabetes were selected. Twenty-one studies evaluated HTM and 5 randomized controlled trials assessed TS. HTM had a positive effect on glycaemic control [as measured by lower glycated haemoglobin level] compared with UC (weighted mean difference =-0.21; 95% confidence interval -0.35 to -0.08), but the results were mixed for TS. Study results indicated that home telehealth helps to reduce the number of patients hospitalized, hospitalizations and bed days of care. Home telehealth was similar or favourable to UC across studies for quality-of-life and patient satisfaction outcomes.

CONCLUSIONS

In general, home telehealth had a positive impact on the use of numerous health services and glycaemic control. More studies of higher methodological quality are required to give more precise insights into the potential clinical effectiveness of home telehealth interventions.

Use of intravenous immunoglobulin for treatment of recurrent miscarriage: a systematic review

BACKGROUND

Intravenous immunoglobulin (IVIG) is a fractionated blood product whose off-label use for treating a variety of conditions, including spontaneous recurrent miscarriage, has continued to grow in recent years. Its high costs and short supply necessitate improved guidance on its appropriate applications.

OBJECTIVE

We conducted a systematic review of randomised controlled trials evaluating IVIG for treatment of spontaneous recurrent miscarriage.

SEARCH STRATEGY

A systematic search strategy was applied to Medline (1966 to June 2005) and the Cochrane Register of Controlled Trials (June 2005).

SELECTION CRITERIA

We included all randomised controlled trials comparing all dosages of IVIG to placebo or an active control.

DATA COLLECTION AND ANALYSIS

Two investigators independently extracted data using a standardised data collection form. Measures of effect were derived for each trial independently, and studies were pooled based on clinical and methodologic appropriateness.

MAIN RESULTS

We identified eight trials involving 442 women that evaluated IVIG therapy used to treat recurrent miscarriage. Overall, IVIG did not significantly increase the odds ratio (OR) of live birth when compared with placebo for treatment of recurrent miscarriage (OR 1.28, 95% CI 0.78-2.10). There was, however, a significant increase in live births following IVIG use in women with secondary recurrent miscarriage (OR 2.71, 95% CI 1.09-6.73), while those with primary miscarriage did not experience the same benefit (OR 0.66, 95% CI 0.35-1.26).

AUTHOR'S CONCLUSIONS

IVIG increased the rates of live birth in secondary recurrent miscarriage, but there was insufficient evidence for its use in primary recurrent miscarriage.

Validation of fully automatic brain SPET to MR co-registration

Fully automatic co-registration of functional to anatomical brain images using information intrinsic to the scans has been validated in a clinical setting for positron emission tomography (PET), but not for single-photon emission tomography (SPET). In this paper we evaluate technetium-99m hexamethylpropylene amine oxime to magnetic resonance (MR) co-registration for five fully automatic methods. We attached six small fiducial markers, visible in both SPET and MR, to the skin of 13 subjects. No increase in the radius of SPET acquisition was necessary. Distortion of the fiducial marker distribution observed in the SPET and MR studies was characterised by a measure independent of registration and three subjects were excluded on the basis of excessive distortion. The location of each fiducial marker was determined in each modality to sub-pixel precision and the inter-modality distance was averaged over all markers to give a fiducial registration error (FRE). The component of FRE excluding the variability inherent in the validation method was estimated by computing the error transformation between the arrays of MR marker locations and registered SPET marker locations. When applied to the fiducial marker locations this yielded the surface registration error (SRE), and when applied to a representative set of locations within the brain it yielded the intrinsic registration error (IRE). For the best method, mean IRE was 1.2 mm, SRE 1.5 mm and FRE 2.4 mm (with corresponding maxima of 3.3, 4.3 and 5.0 mm). All methods yielded a mean IRE <3 mm. The accuracy of the most accurate fully automatic SPET to MR co-registration was comparable with that published for PET to MR. With high standards of calibration and instrumentation, intra-subject cerebral SPET to MR registration accuracy of <2 mm is attainable.

Mercaptoacetate-induced feeding is impaired by central nucleus of the amygdala lesions

Systemic administration of mercaptoacetate (MA) blocks beta oxidation of fatty acids and stimulates food intake. The present experiment examined MA-induced feeding in rats with bilateral lesions of the central nucleus of the amygdala (CNA) and sham-operated controls. Food intake was measured for 6 h immediately following i.p. injection of 400, 600, or 800 mumol/kg of MA or saline. Feeding was also measured in these rats in response to 2-deoxy-D-glucose (2DG) (100, 200, and 300 mg/kg, SC), a glucose analogue that competitively inhibits glucose utilization. We found that CNA lesions blocked feeding in response to all three doses of MA. Feeding in response to 2DG was significantly reduced, but not abolished, by the lesion. These findings suggest that the CNA is a crucial component of the neural pathway for feeding in response to MA and may also participate in 2DG-induced feeding.

Infant apnoea: a home monitoring programme

A home monitoring programme for infants, thought to be at high risk of cot death, has been conducted in Auckland for the past five years. It has included infants who have experienced an apnoea thought to have been a life-threatening event, infants of very low birth weight, and siblings of infants who died of cot death. The supervision of the 84 infants referred to the programme in 1985 are discussed. The 77 referrals for presumed apnoea resembled the population of cot deaths in Auckland, being predominantly Maori--of low birth weight--between one and four months of age and being identified in the winter months. The mean age of occurrence of the last apnoea was 4 months. There were no deaths, but in 60% of the infants further apnoea was considered to occur and half of these infants required stimulation to recommence breathing. In 11 infants an underlying pathology was later identified as the cause of the initial apnoeic events. Hospital facilities for the investigation and supervision of these infants are inadequate in Auckland at present. The establishment of a fully integrated service for the care of infants at high risk of dying from a cot death is an urgent priority.

Endometrial blood flow measured by xenon 133 clearance in women with normal menstrual cycles and dysfunctional uterine bleeding

Endometrial blood flow was measured through the menstrual cycle in nonpregnant women (28 studies of 17 women with normal menstrual cycles and 32 studies of 20 women with dysfunctional uterine bleeding) with use of a clearance technique in which 100 to 400 microCi of the gamma-emitting isotope, xenon 133 in saline solution was instilled into the uterine cavity. The mean (+/- SEM) endometrial blood flow in normal cycles was 27.7 +/- 2.6 ml/100 gm/min, with a significant elevation in the middle to late follicular phase, followed by a substantial fall and a secondary slow luteal phase rise that was maintained until the onset of menstruation. There was a significant correlation between plasma estradiol levels and endometrial blood flow in the follicular but not the luteal phase. Blood flow patterns in women with ovulatory dysfunctional bleeding were similar to normal, except for a significantly lower middle follicular rate. Women with anovulatory dysfunctional bleeding exhibited exceedingly variable flow rates.

An evaluation of two inert gas clearance techniques for measurement of endometrial blood flow in women

Two methods utilizing inert gas clearance for the measurement of endometrial blood flow in non-pregnant women have been assessed and compared. A Krypton-85 rebreathing technique allowed measurement of superficial flow by means of an intrauterine semiconductor beta-detector probe. Intrauterine instillation of high specific activity Xenon-133 in small volumes of saline allowed endometrial flow measurement by gamma camera recording of the rate of clearance. Both these methods permitted calculation of absolute rates of flow and comparison of cyclical changes. Direct comparison of the techniques in the same women, and repeatability studies have shown good agreement, with calculated rates of absolute endometrial blood flow varying within the range 14-60 ml per 100 g tissue per minute. Vaginal blood flow measured simultaneously was always significantly lower (36-64%) than endometrial flow.