Understanding the needs and preferences for cancer care among First Nations people: An integrative review

AIM

This systematic review aimed to identify the needs and preferences for cancer care services among Australian First Nations people.

DESIGN

Integrative review.

DATA SOURCES

An integrative review was conducted. A wide range of search terms were used to increase the sensitivity and specificity of the searches in electronic databases. Methodological quality assessment, data extraction, was conducted independently by two reviewers, and a narrative synthesis was conducted.

RESULTS

Forty-two studies were included. A total of 2965 Australian First Nations adults, both men and women of various ages across the lifespan, were represented; no First Nations children affected by cancer were represented in the studies. Three themes emerged which included: (1) discrimination, racism and trauma, resulting from colonization, directly impacted First National people's cancer care experience; (2) cultural ways of knowing, being and doing are fundamental to how First Nations people engage with cancer care services; and (3) First Nations people need culturally safe person-centred cancer care services that address practical needs.

CONCLUSION

Most participants represented in this review experienced discrimination, racism and trauma, resulting from colonization, which directly negatively impacted Aboriginal peoples' cancer care experience. While the Optimal Cancer Pathway (OCP) was launched in Australia several years ago, people with cancer may continue to experience distressing unmet care needs.

PATIENT OR PUBLIC CONTRIBUTION

Our team includes both First Nations people, non-First Nations researchers and healthcare professionals with expertise in cancer care. The researchers employed decolonizing restorative approaches to ensure voice, respect, accountability and reciprocity in this review work.

IMPLICATIONS FOR NURSING PRACTICE

Members of the multidisciplinary team including nurses and policymakers should reflect on these findings, ensure that they have up-to-date cultural safety training and stand together with Indigenous and non-Indigenous cancer leaders to take proactive steps to stamp out and dismantle oppression in health, and safely implement the OCP.

The UK Divide: Does Having a Pembrolizumab-Chemotherapy Option in Head and Neck Cancer Matter? Real-world Experience of First-line Palliative Pembrolizumab Monotherapy and Pembrolizumab-Chemotherapy Combination in Scotland

AIMS

The Scottish Medical Consortium recently approved first-line pembrolizumab monotherapy or in combination with chemotherapy for head and neck squamous cell carcinoma in the palliative setting, contrasting with the decision made by the National Institute for Health and Care Excellence, who approved monotherapy alone in England and Wales. The aim of this study was to provide real-world performance data for first-line pembrolizumab-containing treatments for head and neck squamous cell carcinoma in the palliative setting in Scotland.

MATERIALS AND METHODS

We analysed the electronic records of patients who started pembrolizumab-containing treatment between 1 March 2020 and 30 September 2021. Outcomes included overall survival, progression-free survival (PFS), the duration of response and the disease control rate. Data were compared with the KEYNOTE-048 study and clinical factors were evaluated for association with survival.

RESULTS

Our cohort included 91 patients (median follow-up 10.8 months). Patient characteristics were similar to those in the KEYNOTE-048 study, although our cohort had a higher proportion of patients with newly diagnosed, non-metastatic disease. For patients receiving monotherapy (n = 76), 12- and 24-month overall survival were 45% and 27%, respectively. For patients receiving pembrolizumab-chemotherapy (n = 15), 12-month overall survival was 60% (24-month overall survival had not yet been reached). Experiencing one or more immune-related adverse event (irAE; versus no irAEs), of any grade, was associated with favourable overall survival and PFS for patients receiving monotherapy in both univariable Log-rank analysis (median overall survival 17.4 months versus 8.6 months, respectively, P = 0.0033; median PFS 10.9 months versus 3.0 months, respectively, P < 0.0001) and multivariable analysis (Cox proportional hazards regression: overall survival hazard ratio 0.31, P = 0.0009; PFS hazard ratio 0.17, P < 0.0001).

CONCLUSION

Our real-world data support the KEYNOTE-048 study findings and the value of combination treatment options. Additionally, our data show that irAEs of any grade, as reported in routine clinical records, are associated with better outcomes in this patient group, adding to the growing body of evidence showing that irAEs are generally a positive marker of programmed death-ligand 1 (PD-L1) inhibitor response.

Identifying the unmet supportive care needs of individuals affected by testicular cancer: a systematic review

PURPOSE

To critically appraise studies to identify experiences of unmet supportive care needs of individuals affected by testicular cancer.

METHODS

A registered priori systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. CINAHL, PsycINFO, and MEDLINE were searched for quantitative, qualitative, and mixed methods studies using a wide range of search terms. All articles were double screened according to a pre-determined eligibility criterion. Reference lists of the final included studies were checked for further eligible studies. The review process was managed using Covidence systematic review software. Data from the studies were extracted, methodological quality appraisal conducted, and a narrative synthesis conducted.

RESULTS

Of the 72 papers identified, 36 studies were included. In descending order of frequency of need, psychological needs were identified in 26/36, physical needs 18/36, interpersonal/intimacy needs 19/36, health system/information needs 11/36, cognitive needs 9/36, social needs 7/36, and of equal frequencies counts of 4/36 for family, practical, and patient-clinician information needs. Only one study explored spiritual needs and no daily living needs were identified.

CONCLUSIONS

The experience of needs varied in terms of frequency and distress which were commonly influenced by the age of the individual across the cancer care continuum persisting after 1-year post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

When caring for individuals affected by testicular cancer, clinicians are encouraged to take a holistic lens to cancer care, particularly to explore issue or concerns that young men affected by testicular cancer might be embarrassed or reticent to discuss.

Sense of coherence moderates job demand-resources and impact on burnout among nurses and midwives in the context of the COVID-19 pandemic: A cross-sectional survey

AIM

This study aimed to test the propositions using the job demands-resources (JD-R) model for main/moderation/mediation effects of a sense of coherence and practice environment support on mental well-being (anxiety, depression and burnout) outcomes in nurses and midwives in Australia during the COVID-19 pandemic.

DESIGN

Cross-sectional quantitative survey.

DATA SOURCES

The study was a cross-sectional design using self-report questionnaires reported as per the Reporting of Observational Studies in Epidemiology Guidelines. Following human research ethics approval (2020.ETH.00121) participants were recruited to take part in an online anonymous survey using self-report instruments to test the JD-R model in Australia.

RESULTS

156 participant nurses and midwives experienced anxiety, depression and emotional burnout during COVID-19. While a considerable proportion of participants indicated high levels of emotional exhaustion, their responses showed low levels of depersonalization (detached response to other people) and high levels of personal accomplishment (high levels of work performance and competence). A sense of coherence was a significant protective factor for mental health well-being for the participants, which is to say, high levels of sense of coherence were predictive of lower levels of anxiety, depression and burnout in this study sample.

CONCLUSION

It is evident that both nursing and midwifery professions require psychosocial support to preserve their health both in the short and long term. Ensuring individualized tailored support will require a layered response within organizations aimed at individual self-care and collegial peer support.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution in this study, as the focus was on nurses and midwives.

To understand the experiences, needs, and preferences for supportive care, among children and adolescents (0-19 years) diagnosed with cancer: a systematic review of qualitative studies

PURPOSE

This study aimed to understand the experiences, needs, and preferences for supportive care, among children and adolescents (0-19 years) diagnosed with cancer.

METHODS

A qualitative systematic review has been reported according to PRISMA guidelines. A comprehensive search was conducted across multiple databases (APA PsycINFO, CINAHL, and Medline) and citation searches. Studies were screened according to pre-determined inclusion and exclusion criteria. Methodological quality was evaluated. Findings were extracted in relation to the context of interest of experiences, needs, and preferences of supportive care. Each finding was accompanied by a qualitative verbatim illustration representing the participant's voice.

RESULTS

4449 publications were screened, and 44 studies were included. Cancer populations represented in the included studies included lymphoma, leukaemia, brain cancer, sarcomas, and neuroblastoma. Two overarching synthesised findings were identified as (1) coping, caring relationships, communication, and impact of the clinical environment, and (2) experiences of isolation, fear of the unknown, restricted information, and changing self. Children and adolescents articulated that cancer care would be enhanced by developing a sense of control over their body and healthcare, being involved in communication and shared decision-making, and ensuring the clinical environment is age-appropriate. Many experienced a sense of disconnection from the rest of the world (including peers, school, and experiences of prejudice and bullying), and a lack of tailored support and information were identified as key unmet care needs that require further intervention.

CONCLUSIONS

Children and adolescent who are diagnosed with cancer are a unique and understudied group in oncological survivorship research, with the slowest progress in improvement of care over time. This review will facilitate the development of future interventions and promote the importance of tailored support for children and adolescents at all stages of the cancer journey.

IMPLICATIONS FOR CANCER SURVIVORS

Children and adolescents continue to experience a range of difficulties despite routine contact with cancer healthcare professionals. Children and adolescents should be carefully assessed about their individual circumstances and preferences for support given the clear implications from this review that "one size" does not fit all.

Identifying experiences of supportive care of children and young people affected by kidney failure: A qualitative systematic review

BACKGROUND

Children and young people affected by kidney failure experience complexities in their care. Little is known about the unique needs of this young patient population group living with a long-term condition.

OBJECTIVE

A meta-aggregation of all qualitative studies was conducted to identify experiences of supportive care among children and young people living with kidney failure.

METHODS

A systematic review of qualitative studies was conducted following the Joanna Briggs Institute meta-aggregation method. This review has been reported according to the PRISMA statement guidelines. Six electronic databases (CINAHL, Cochrane Library, MEDLINE, Proquest, PsycINFO, and Scopus) were comprehensively searched by an expert systematic review librarian using keywords and subject headings, from inception to September 2022. All studies were accessed using a predetermined inclusion and exclusion criteria. Methodological quality assessment and data extraction performed. Qualitative findings accompanied by illustrative quotes from included studies were extracted and grouped into categories which created the overall synthesised findings.

RESULTS

A total of 34 studies were included in this review representing a total of 613 children and young people affected by kidney failure. There was a total of 190 findings which created 13 categories representing experiences of supportive care. The meta-aggregation developed five synthesised findings namely: 'physical needs', 'information and technology', 'treatment and healthcare', 'social needs' and 'psychological impacts'.

CONCLUSION

This systematic review identified that children and young people affected by kidney failure can experience a range of unmet supportive care needs in routine clinical services. Kidney failure impacted children and young people's self-identify, social and peer networks, introduced daily practical needs because of inherent physical and psychological burden due to the failure and associated treatments. Despite improvements in the medical management of kidney failure in children and young people, further attention is needed to optimise supported self-management in this young patient group.

The Effects of Human Papillomavirus Status and Treatment on the Positive Predictive Value of Post-radiotherapy 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Advanced Head and Neck Squamous Cell Carcinoma

AIMS

The high negative predictive value of post-chemoradiation (CRT) positron emission tomography-computed tomography (PET-CT) is well established in head and neck squamous cell cancers (HNSCC). The positive predictive value (PPV) remains under scrutiny, with increasing evidence that it is affected by several factors. The aim of this study was to assess the PPV of post-treatment PET-CT for residual nodal disease when stratified by treatment modality and tumour human papillomavirus (HPV) status.

MATERIALS AND METHODS

This was a retrospective cohort study in a tertiary oncology centre carried out between January 2013 and December 2019. Patients were radically treated with radiotherapy only/CRT for node-positive HNSCC. PET-CT nodal responses were categorised as complete, equivocal (EQR) or incomplete (ICR), and outcomes extracted from electronic records.

RESULTS

In total, 480 patients were evaluated, all had a minimum potential follow-up of 2 years, with a median of 39.2 months. The PPV of 12-week PET-CT was significantly different between HPV-positive (22.5%) and HPV-unrelated (52.7%) disease, P < 0.001. It was also significantly different between the CRT (24.8%) and radiotherapy-only (51.1%) groups, P = 0.001. The PPV of an EQR was significantly less than an ICR, irrespective of HPV status and primary treatment modality. In HPV-positive disease, the PPV of an EQR was 9.0% for the CRT group compared with 21.4% for radiotherapy only, P = 0.278. The PPV in those who achieved an ICR was 34.2% in the CRT group, significantly lower than 70.0% in the radiotherapy-only group, P = 0.03.

CONCLUSION

The PPV of 12-week PET-CT is significantly lower for HPV-positive compared with HPV-unrelated HNSCC. It is poorer in patients with HPV-positive disease treated with CRT compared with radiotherapy alone.

Current Landscape of Ecological Momentary Assessment (Real-Time Data) Methodology in Cancer Research: A Systematic Review

OBJECTIVE

To critically synthesize and describe the use and methods of ecological momentary assessment (EMA) in cancer research.

DATA SOURCES

A systematic review was conducted and has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Guideline. Electronic databases (APA PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, and Web of Science Core Collection) were searched using a variety of keywords and subject headings by an expert systematic review librarian. All publications were double screened by two reviewers using predetermined exclusion and inclusion criteria throughout the full review process. The review used Covidence Systematic Review Software. Methodological quality assessment and data extraction were performed. A narrative synthesis was conducted to examine the aim for EMA, the characteristics of the study samples, the EMA sampling procedures, EMA completion rates, outcome measures, and any implications of findings for survivorship care.

CONCLUSION

A total of 42 EMA studies in cancer were included. Most studies used an electronic mobile device to capture EMA data apart from several that used paper diaries. Existing studies were found to have significant heterogeneity in methods and widely varying approaches to design and self-report measurements. While EMA in cancer research holds significant promise to advance cancer care research into the future by increasing ecological validity and reducing retrospective bias and can capture the unique idiographic within-person change over time, in real-time, further research is needed to develop standardized EMA self-report questionnaires.

IMPLICATIONS FOR NURSING PRACTICE

This is the first comprehensive systematic review to describe the use and methods of EMA in cancer research. There is significant heterogeneity in methods and widely varying approaches to design and self-report measurements in EMA cancer research. People affected by cancer found taking part in EMA studies reported benefit from the experience. However, researchers must engage with cancer survivors in the development and co-design of future EMA questionnaires to ensure relevant and acceptability of EMA data collection protocols.

Exploring Experiences Among People Diagnosed With Cancer During the COVID-19 Pandemic: A Qualitative Descriptive Study

OBJECTIVES

To describe the experiences of people diagnosed with cancer during the COVID-19 pandemic.

DATA SOURCES

Qualitative data were collected through semistructured interviews conducted with people affected by cancer in the Australian context. Following institutional ethical approval, interviews were conducted over Microsoft Teams and Zoom platforms and complied with confidentiality requirements. Data were transcribed verbatim and analyzed, and emergent themes were developed using thematic analysis to understand patient experiences of cancer care during the COVID-19 pandemic.

CONCLUSIONS

The COVID-19 pandemic was disruptive to the daily experiences of supportive care. Four overarching themes were identified related to: 1) the impact on accessing healthcare services, 2) encounters with healthcare professionals, 3) the impact on daily living, and 4) the impact of COVID on psychological well-being.

IMPLICATIONS FOR NURSING PRACTICE

As the COVID-19 pandemic held global consequences on cancer practices, it is recommended that nursing and other multidisciplinary healthcare professionals reflect upon these findings, in the context of planning for future pandemics. We encourage further exploration into the sustainability of telehealth services universally, given the issues highlighted in this study.

Scan-Associated Distress in People Affected by Cancer: A Qualitative Systematic Review

OBJECTIVE

The term "scanxiety" has been coined to describe the anxiety commonly associated with individuals undergoing cancer-related imaging. Despite the prevalence and severity of scanxiety across various clinical and demographic populations, there remains a significant lack of qualitative insights from existing studies that effectively capture patients' experiences of scanxiety in their own words. Therefore, this review addresses the following research question: What are the experiences of scanxiety distress among people affected by cancer across the cancer care continuum?

DATA SOURCES

Following the PRISMA methodology, a meta-aggregation of qualitative studies was performed, encompassing patients of all age groups who had been diagnosed with cancer or were indicated for a cancer-related scan. Of the 556 articles screened, 15 were deemed eligible for inclusion in the analysis.

CONCLUSION

The three overarching themes of 1) experience of "scan-itis," 2) experience of "patient-clinician support," and 3) development of self-management strategies reveal the complex and interconnected factors that influence scanxiety in individuals undergoing cancer-related imaging. These findings emphasized distress experienced by patients during the waiting period for scan results, the act of viewing the results, and even the delivery of "bad" news. Consequently, patients expressed a strong desire for increased information, communication, and empathy from attending healthcare providers. Patients also report a myriad of self-coping strategies to manage their scanxiety well before, during, and after their scan appointment.

IMPLICATIONS FOR NURSING PRACTICE

The study highlights the need for targeted interventions for those undergoing cancer-related scans, including increased awareness and education for health professionals regarding scanxiety.

A Multicenter Study of Clinician and Patient Reported Acute and Late Toxicity after Radical (Chemo)Radiotherapy for Non-Endemic Nasopharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Curative (chemo)radiotherapy ((CT)RT) for Nasopharyngeal cancers (NPC) achieves excellent disease control but is associated with significant late toxicities despite modern treatment delivery. Contemporary late toxicity data, including patient reported outcomes (PROs), is limited in the non-endemic population; we present a large contemporary series of toxicity outcomes and late PROs following treatment of non-endemic NPC.

MATERIALS/METHODS

Adult patients completing radical (CT)RT for primary NPC between February 2016 and 2020 at 7 large UK cancer centers were identified on institutional databases. Patients were excluded if they had prior head and neck cancer or prior therapeutic head and neck surgery (except neck dissection). Patients with an active other cancer were excluded from PRO assessment. Demographic, treatment, acute toxicity and outcome data were collected retrospectively from patient records. Disease-free patients were invited to complete an M.D. Anderson Dysphagia Index (MDADI) and University of Washington (UoW) Quality of Life (QoL) PROs questionnaires.

RESULTS

A total of 180 eligible patients were identified: 68% male, median age 54 years, 11% ≥70 years. EBV status was positive in 61% (unknown 12%). Patients had stage I (5%), II (22%), III (37%), IV (36%) disease; 95% were performance status ≤1 at baseline. Median follow-up was 31.2 months (range 0-68). A total of 54% received 70Gy in 33-35# and 43% received 65-66 Gy in 30-33#. 66% received induction and 65% received concurrent chemotherapy. 9.5% had residual disease at the first follow-up scan. Subsequent locoregional or distant recurrence occurred in 5% and 12% respectively. At last assessment, 84% patients were alive, 16% had died (of which 70% had active disease). Acute treatment toxicity included: 63% of patients required enteral support (median duration 98 days) with 9% a feeding tube at 1 year post treatment. 18% G3 dermatitis, 53% G3 mucositis. 82% requiring opioids and 40% admitted for symptom management. 90 patients completed the PROs (76% response rate) at a median of 37.8 months post treatment (Table 1). These demonstrate significant QoL detriment: 28% report significant pain, 24% require regular analgesia, and 59% report significant impact on daily activity. This was found to persist at different timepoints (not shown).

CONCLUSION

Excellent cancer survival outcomes are seen in a non-selected, non-endemic NPC population. However significant acute and late toxicity following radical treatment is identified which can profoundly negatively impact QoL in a relatively young cohort. This highlights the importance of ongoing efforts to reduce toxicity and supports the prospective evaluation of potential toxicity sparing technologies, such as proton beam radiotherapy.

Role of Adjuvant Radiotherapy in Acinic Cell Carcinoma of the Salivary Glands: A Systematic Review

A systematic review was carried out to evaluate if adjuvant radiotherapy for acinic cell carcinomas (ACCs) of salivary glands improves survival. Twelve retrospective studies published between 2000 and 2020 that analysed the effect of radiotherapy on salivary gland neoplasms and ACCs of salivary glands and met the inclusion criteria were included in the review. The overall quality of the studies was moderate to low. There was no high-quality evidence for improved survival with radiotherapy for ACCs of the salivary gland. Some evidence suggests that there may be an advantage for patients with high-grade tumours, but these data should be interpreted with caution due to the small number of patients and low-quality evidence. Good quality of evidence is lacking. Recommendation for adjuvant radiotherapy for tumours with poor prognostic factors will require discussion and shared decision-making with the patients.

What are the holistic care impacts among individuals living through the COVID-19 pandemic in residential or community care settings? An integrative systematic review

INTRODUCTION

To critically synthesise evidence in relation to the holistic care impacts (physical, psychological, social, spiritual, and environmental well-being) among individuals living in residential aged care facilities (RACFs) with restrictions during the COVID-19 pandemic.

METHODS

An integrative systematic review followed a pre-registered protocol and has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Guidelines. Electronic databases were searched from inception to June 2022. Qualitative, quantitative, and mixed methods studies were included. All articles were double screened according to a pre-determined eligibility criterion. The review process was managed using Covidence systematic review software. Data from the studies were extracted, methodological quality appraisal conducted, and a narrative synthesis conducted.

RESULTS

18 studies were included. The impact of restrictive practices and periods of lockdown impacted older people on all levels of individual quality-of-life. With or without COVID-19, residents experienced functional decline and many experienced malnutrition, increased incontinence, increased pain, and poorer general health and significant psychological distress. Depression increased with reduced social contact, as did anxiety and loneliness. Some residents spoke of suicidal ideation.

CONCLUSION

It is highly plausible that further outbreaks may prompt knee-jerk reactions from public health departments and governing bodies to continue to restrict and lockdown facilities. Public health COVID-19 outbreak policy for aged care across the globe will need to consider the benefits verses risk debate given the findings uncovered in this review. These findings showed that it is vital that policy considers quality-of-life domains not solely survival rates.

What are the experiences of supportive care in people affected by brain cancer and their informal caregivers: A qualitative systematic review

PURPOSE

To critically synthesise qualitative research to understand experiences of supportive care in people affected by brain cancer and their informal caregivers.

METHODS

A qualitative systematic review was conducted according to the Joanna Briggs methodology and has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. Electronic databases were searched by an expert systematic review librarian for all qualitative studies irrespective of research design. All publications were double screened by two reviewers using a pre-determined exclusion and inclusion criteria. The review was managed using Covidence systematic review software. Methodological quality assessment and data extraction were performed. Qualitative findings accompanied by illustrative quotes from included studies were extracted and grouped into categories, which created the overall synthesised findings.

RESULTS

A total of 33 studies were included which represented a total sample of 671 participants inclusive of 303 patients and 368 informal caregivers. There was a total of 220 individual findings included in this review, which were synthesised into two findings (1) caregivers and patients perceived supports which would have been helpful and (2) caregiver and patient experiences of unmet supportive care needs.

CONCLUSION

This review highlighted the suffering and distress caused by brain cancer and associated treatments. Both patients and their informal caregivers experienced disconnect from themselves in renegotiating roles, and a profound sense of loneliness as the physical deterioration of the disease progressed. Both patients and informal caregivers reported similar unmet needs within the current service provision for brain cancer. However, what is apparent is that current cancer services are provided solely for patients, with little or no consideration to the support needs of both the patient and their informal caregiver. Service re-design is needed to improve care coordination with individualised informational support, implementation of holistic needs assessments for both the patients and their caregivers, better community support provision, improved opportunities for emotional care with early referral for palliative care services.

IMPLICATIONS FOR CANCER SURVIVORS

It is recommended that members of the multidisciplinary brain cancer team reflect on these findings to target holistic needs assessments and develop shared self-management care plans for both the patient and the informal caregiver.

POS0348 GENETIC SUSCEPTIBILITY VARIANTS FOR RHEUMATOID ARTHRITIS ARE NOT ASSOCIATED WITH EARLY REMISSION; A MULTI-COHORT STUDY

Background:

Patients who achieve remission promptly could have a specific genetic risk profile that supports regaining immune tolerance. The identification of these genes could provide novel drug targets.

Objectives:

To test the association between RA genetic risk variants with achieving remission at 6 months.

Methods:

We computed genetic risk scores (GRS) comprising of the RA susceptibility variants1 and HLA-SE status separately in 4425 patients across eight datasets from inception cohorts. Remission was defined as DAS28CRP<2.6 at 6 months. Missing DAS28CRP values in patients were imputed using predictive mean matching by MICE. We first tested whether baseline DAS28CRP changed with increasing GRS using linear regression. Next, we calculated odds ratios for GRS and HLA-SE on remission using logistic regression. Heterogeneity of the outcome between datasets was mitigated by running inverse variance meta-analysis.

Results:

Evaluation of the complete dataset, baseline clinical variables did not differ between patients achieving remission and those who did not (Table 1). Distribution of GRS was consistent between datasets. Neither GRS nor HLA-SE was associated with baseline DAS2DAS (OR1.01; 95% CI 0.99-1.04). A fixed effect meta-analysis (Figure 1.) showed no significant effect of the GRS (OR 0.99; 95% CI 0.94-1.03) or HLA-SE (OR 0.8CRP87; 95% CI 0.75-1.01) on remission at 6 months.

Table 1.

Summary of the data separated by disease activity after 6 months.

allRemission at 6 monthsNo remission at 6 monthsN4425*15582430Age, mean (sd)55.38 (13.87)5517 (14.09)55.62 (13.59)Female %68.98%65.43%70.73%ACPA+ %61.94%63.53%61.67%Baseline DAS28, mean (sd)4.76 (1.22)4.47 (1.23)5.1 (1.15)

*not all patients had 6 months data

Conclusion:

In these combined cohorts, RA genetics risk variants are not associated with early disease remission. At baseline there was no difference in genetic risk between patients achieving remission or not. Studies encompassing other genetic variants are needed to elucidate the genetics of RA remission.

References:

[1]Knevel R et al. Sci Transl Med. 2020;12(545):eaay1548.

Acknowledgements:

This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777357, RTCure.

This project has received funding from Pfizer Inc.

Disclosure of Interests:

Samantha Jurado Zapata: None declared, Marc Maurits: None declared, Yann Abraham Employee of: Pfizer, Erik van den Akker: None declared, Anne Barton: None declared, Philip Brown: None declared, Andrew Cope: None declared, Isidoro González-Álvaro: None declared, Carl Goodyear: None declared, Annette van der Helm - van Mil: None declared, Xinli Hu Employee of: Pfizer, Thomas Huizinga: None declared, Martina Johannesson: None declared, Lars Klareskog: None declared, Dennis Lendrem: None declared, Iain McInnes: None declared, Fraser Morton: None declared, Caron Paterson: None declared, Duncan Porter: None declared, Arthur Pratt: None declared, Luis Rodriguez Rodriguez: None declared, Daniela Sieghart: None declared, Paul Studenic: None declared, Suzanne Verstappen: None declared, Leonid Padyukov: None declared, Aaron Winkler Employee of: Pfizer, John D Isaacs: None declared, Rachel Knevel Grant/research support from: Pfizer

AB0265 OPIOIDS AND ANALGESIC USE IN EARLY RHEUMATOID ARTHRITIS: A LONGITUDINAL ANALYSIS OF LINKED REAL-WORLD PRESCRIPTION DATA

Background:

Large numbers of patients with rheumatoid arthritis (RA) receive regular opioids despite significant toxicity and a lack of evidence supporting their use in non-cancer pain. In order to address this situation, we need to understand when opioids are started in early RA where this has not been studied.

Objectives:

To examine the temporal trend of opioid prescriptions before and after RA symptom onset and to compare this with DMARD and NSAID prescriptions.

Methods:

RA participants (cases) were recruited as part of the Scottish Early Rheumatoid Arthritis (SERA) inception cohort1. Controls without RA (five per case), matched for sex, age and post code over the same time period, were obtained through routine data linkage. Prescription data between Jan 2009 to Nov 2019 of cases and matched controls were compared using date of RA symptom onset as reference point. The Prescriptions Per Participant (PPP) for each three-month block was estimated by dividing the number of prescribed drugs in the selected drug classes (assigned using the British National Formulary) in that time block by the number of participants in each group. The differences between mean PPP of the RA cases and controls in each time block were tested by t-test for independent groups and subsequent adjustment for multiple testing.

Results:

1,720,335 prescriptions were available for analysis with 421,961 items for 950 RA cases and 1,299,374 items for 4,558 matched controls. As expected, DMARD prescriptions in the SERA cases increased after the symptom onset period and were then sustained (Figure 1: top left panel). NSAID prescriptions in RA cases peaked during the 3 months after symptom onset and then reduced progressively (top right panel). Opioid analgesic prescriptions for the RA cases increased two-fold during the reference period and then reduced 6-9 months post-symptom onset. However, unlike NSAIDs, after this there was no further significant reduction in opioid prescriptions in the RA cases, which remained stable and significantly higher than in the controls for the remaining study period. The non-opioid analgesic mean PPP increased sharply at the time of symptom onset, with a steady gradual upward trend over time (lower right panel).

Conclusion:

Opioid prescriptions increase significantly at the time of RA symptoms onset. Despite rapid introduction of DMARDs and resultant reductions in NSAIDs, analgesic use remains significantly higher than in controls. Further research is required to identify the factors associated with persistent opioid use in early RA with interventions aimed at the first 6 months.

References:

[1]Dale et al. BMC Musculoskelet Disord. 2016;17:461.

Acknowledgements:

The work was supported by Health Data Research UK which receives its funding from HDR UK Ltd funded by the UKRI MRC, EPSRC, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientists Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust.

The SERA study was jointly funded by the Chief Scientists Office Scotland and Pfizer Ltd.

Disclosure of Interests:

None declared

Functional Imaging to Predict Treatment Response in Head and Neck Cancer: How Close are We to Biologically Adaptive Radiotherapy?

It is increasingly recognised that head and neck cancer represents a spectrum of disease with a differential response to standard treatments. Although prognostic factors are well established, they do not reliably predict response. The ability to predict response early during radiotherapy would allow adaptation of treatment: intensifying treatment for those not responding adequately or de-intensifying remaining therapy for those likely to achieve a complete response. Functional imaging offers such an opportunity. Changes in parameters obtained with functional magnetic resonance imaging or positron emission tomography-computed tomography during treatment have been found to be predictive of disease control in head and neck cancer. Although many questions remain unanswered regarding the optimal implementation of these techniques, current, maturing and future studies may provide the much-needed homogeneous cohorts with larger sample sizes and external validation of parameters. With a stepwise and collaborative approach, we may be able to develop imaging biomarkers that allow us to deliver personalised, biologically adaptive radiotherapy for head and neck cancer.

Positron Emission Tomography-Computed Tomography Surveillance after (Chemo)Radiotherapy in Advanced Head and Neck Squamous Cell Cancer: Beyond the PET-NECK Protocol

AIMS

To evaluate the implementation of 18-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) surveillance after (chemo)radiotherapy, to compare outcomes for those who achieved a complete (CR), equivocal (EQR) and incomplete (ICR) nodal response on 12-week PET-CT according to their human papillomavirus (HPV) status, and to assess the safety of ongoing surveillance beyond 12 weeks in the HPV-positive EQR group.

MATERIALS AND METHODS

All patients with node-positive head and neck squamous cell carcinoma (HNSCC) treated with (chemo)radiotherapy between January 2013 and September 2017 were identified. PET-CT responses were classified as CR, ICR or EQR. Patient outcomes were obtained from electronic records.

RESULTS

In total, 236 patients with a minimum of 2 years of follow-up were identified. The mean age was 59 years; 79.3% had N2 disease; 77.1% of patients had oropharyngeal cancer and 10.1% had squamous cell carcinoma of unknown primary, of whom 82.0% (169) were HPV positive; 78.0% received chemoradiotherapy. The median time from the end of radiotherapy to PET-CT was 91 days. Of the HPV-related HNSCC, 60.4% achieved CR, 29.0% EQR and 10.6% ICR. With a median follow-up of 41.7 months, there was no difference in survival between patients with HPV-related HNSCC achieving CR and EQR (median overall survival not reached for both, P = 0.67) despite the omission of immediate neck dissection in 98.0% of the EQR group.

CONCLUSION

Patients with HPV-positive HNSCC who have achieved EQR have comparable survival outcomes to those who achieved a CR despite the omission of immediate neck dissections; this shows the safety of ongoing surveillance beyond 12 weeks in this group of patients.

Prostate Cancer Prehabilitation and the Importance of Multimodal Interventions for Person-centred Care and Recovery

BACKGROUND

Prostate cancer is the second most commonly diagnosed cancer globally. Cancer prehabilitation is defined as a process on the continuum of care that occurs between the time of a cancer diagnosis and the beginning of acute treatment. This article will discuss the importance of prostate cancer prehabilitation interventions in optimising physical and psychological recovery to enhance person-centred care.

DATA SOURCES

Electronic databases including CINAHL, MEDLINE, PsychINFO, Scopus, professional websites, and grey literature were searched using Google Scholar.

CONCLUSION

Prehabilitation in cancer care aims to enhance perioperative care and recovery. An emerging field of research suggests that the preoperative period may be physically and psychologically salient to introduce modifiable self-management behaviours to optimise overall recovery.

IMPLICATIONS FOR NURSING PRACTICE

Prostate cancer specialist nurses provide the hub of person-centred care across the entire cancer care continuum embedded within the multidisciplinary team. Individually tailored interventions such as exercise and pelvic floor muscle training programmes, nutritional advice, anxiety and depression reduction, and sexual well-being interventions should be considered in the prehabilitation phase of the cancer care continuum.

Identifying the supportive care needs of men and women affected by chemotherapy-induced alopecia? A systematic review

PURPOSE

To systematically evaluate evidence regarding the unmet supportive care needs of men and women affected by chemotherapy-induced alopecia (CIA) to inform clinical practice guidelines.

METHODS

We performed a review of CINAHL, MEDLINE, PsychINFO, Scopus, the Cochrane Library (CCRT and CDSR) controlled trial databases and clinicaltrials.gov from January 1990 to June 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Twenty-seven publications were selected for inclusion in this analysis.

RESULTS

Included reports used qualitative (ten) and quantitative (17) studies. Across these studies men and women reported the major impact that CIA had on their psychological well-being, quality of life and body image. Hair loss had a negative impact irrespective of gender, which resulted in feelings of vulnerability and visibility of being a "cancer patient". Men and women described negative feelings, often similar, related to CIA with a range of unmet supportive care needs.

CONCLUSIONS

Some patients are not well-prepared for alopecia due to a lack of information and resources to reduce the psychological burden associated with CIA. Hair loss will affect each patient and their family differently, therefore, intervention and support must be tailored at an individual level of need to optimise psychological and physical well-being and recovery.

IMPLICATIONS FOR CANCER SURVIVORS

People affected by CIA may experience a range of unmet supportive care needs, and oncology doctors and nurses are urged to use these findings in their everyday consultations to ensure effective, person-centred care and timely intervention to minimise the sequalae associated with CIA.

An Exploration of the Rs of Radiobiology in Prostate Cancer

OBJECTIVES

To explore the four Rs of radiobiology (Repair, Reoxygenation, Reassortment, and Repopulation) as a means to understand the effects of ionising radiation on biological tissue and subsequently as the basis for conventional fractionated treatment schedules. These radiobiological principles will form a rationale for combined regimens in prostate cancer treatment involving androgen deprivation therapy and radiation therapy and the associated toxicities of this approach will be discussed.

DATA SOURCES

Electronic databases including CINAHL, MEDLINE, Scopus, professional websites, books and grey literature were searched using Google Scholar.

CONCLUSION

It is important for nurses to understand the four Rs of radiobiology to grasp the effects of ionising radiation on biological tissue as the basis for conventional fractionated treatment schedules in prostate cancer. Men can experience a sequalae of physical and psychological side effects of treatment that can negatively impact quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Men can experience a range of unmet supportive care needs particularly related to informational, sexual, and psychological needs. For men affected by prostate cancer opting for radiation therapy (+/-) androgen deprivation therapy, nurses should ask targeted questions based on the Common Terminology Criteria for Adverse Events related to urinary and bowel function, potency and fatigue, and sexual health. We also recommend the use of holistic needs assessments to tailor self-management care plans. Evidence-based self-management advice should be provided in response to each man's unique needs.

Immunotherapy in the management of squamous cell carcinoma of the head and neck

Despite many advances in surgery, radiotherapy, and systemic treatments, only modest improvements in survival, function, and quality of life have been achieved after treatment of squamous cell carcinoma (SCC) of the head and neck. With a better understanding of the biology and genetics of tumours, the emergence of a paradigm shift towards the further development of non-surgical treatments may result in less morbidity and better outcomes than are seen currently. SCC of the head and neck is known to be a complex disease that has a sophisticated interaction with the human immune system. At the forefront of emerging treatments is immunotherapy, which has already been established in many other areas of oncology. The rapidly evolving nature of immunotherapeutic agents and, sometimes, their complex mechanisms can make the understanding of these concepts challenging, and could discourage clinicians from engaging in clinical trials. The aim of this paper therefore was to review the current premise for immunotherapeutic approaches, and to provide a contemporary evidence-based rationale for their use.

Unmet informational and supportive care needs of patients with muscle invasive bladder cancer: A systematic review of the evidence

BACKGROUND

Little is known about the unmet supportive care needs of patients affected by muscle invasive bladder cancer (MIBC). We set out to determine the different domains of unmet supportive care needs for patients affected by MIBC.

LITERATURE SEARCH

A systematic review was conducted according to the PRISMA Statement Guidelines. A sensitive search was performed in electronic databases (DARE, Cochrane, MEDLINE, BNI, PsychINFO, EMBASE and CIHAHL) from the earliest date available to January 2017.

DATA EVALUATION

1405 references were retrieved, 8 articles met the eligibility criteria and were appraised and ranked by strength using the levels of evidence.

SYNTHESIS

Individual unmet needs were classified into the following domains: patient-clinician communication, daily living needs, health system/information needs, practical needs, family-related needs, social needs, psychological needs, physical needs and intimacy needs. Patients reported high unmet needs at diagnosis and into survivorship.

CONCLUSIONS

This review contributes to a greater understanding of the unmet supportive care needs of patients affected by MIBC. Findings reflect a paucity of research, but existing studies indicated needs commonly related to intimacy, informational, physical and psychological needs. Despite the emerging evidence-base, the current within study limitations precludes our understanding about how the needs of patients evolve over time.

Gamma-irradiated human amniotic membrane decellularised with sodium dodecyl sulfate is a more efficient substrate for the ex vivo expansion of limbal stem cells

The gold standard substrate for the ex vivo expansion of human limbal stem cells (LSCs) remains the human amniotic membrane (HAM) but this is not a defined substrate and is subject to biological variability and the potential to transmit disease. To better define HAM and mitigate the risk of disease transmission, we sought to determine if decellularisation and/or γ-irradiation have an adverse effect on culture growth and LSC phenotype. Ex vivo limbal explant cultures were set up on fresh HAM, HAM decellularised with 0.5M NaOH, and 0.5% (w/v) sodium dodecyl sulfate (SDS) with or without γ-irradiation. Explant growth rate was measured and LSC phenotype was characterised by histology, immunostaining and qRT-PCR (ABCG2, ΔNp63, Ki67, CK12, and CK13). Ƴ-irradiation marginally stiffened HAM, as measured by Brillouin spectromicroscopy. HAM stiffness and γ-irradiation did not significantly affect the LSC phenotype, however LSCs expanded significantly faster on Ƴ-irradiated SDS decellularised HAM (p<0.05) which was also corroborated by the highest expression of Ki67 and putative LSC marker, ABCG2. Colony forming efficiency assays showed a greater yield and proportion of holoclones in cells cultured on Ƴ-irradiated SDS decellularised HAM. Together our data indicate that SDS decellularised HAM may be a more efficacious substrate for the expansion of LSCs and the use of a γ-irradiated HAM allows the user to start the manufacturing process with a sterile substrate, potentially making it safer.

STATEMENT OF SIGNIFICANCE

Despite its disadvantages, including its biological variability and its ability to transfer disease, human amniotic membrane (HAM) remains the gold standard substrate for limbal stem cell (LSC) culture. To address these disadvantages, we used a decellularised HAM sterilised by gamma-irradiation for LSC culture. We cultured LSCs on fresh HAM, HAM decellularised with NaOH, HAM decellularised with sodium dodecyl sulfate (SDS) and HAM decellularised with SDS and sterilised with gamma-irradiation. We demonstrated that although HAM decellularised with SDS and sterilised with gamma-irradiation is significantly stiffer this does not affect LSC culture growth rate or the phenotype of cultured LSCs. We therefore recommend the use of SDS decellularised gamma-irradiated HAM in future LSC clinical trials.

Validation of a Magnetic Resonance Imaging-based Auto-contouring Software Tool for Gross Tumour Delineation in Head and Neck Cancer Radiotherapy Planning

AIMS

To carry out statistical validation of a newly developed magnetic resonance imaging (MRI) auto-contouring software tool for gross tumour volume (GTV) delineation in head and neck tumours to assist in radiotherapy planning.

MATERIALS AND METHODS

Axial MRI baseline scans were obtained for 10 oropharyngeal and laryngeal cancer patients. GTV was present on 102 axial slices and auto-contoured using the modified fuzzy c-means clustering integrated with the level set method (FCLSM). Peer-reviewed (C-gold) manual contours were used as the reference standard to validate auto-contoured GTVs (C-auto) and mean manual contours (C-manual) from two expert clinicians (C1 and C2). Multiple geometric metrics, including the Dice similarity coefficient (DSC), were used for quantitative validation. A DSC≥0.7 was deemed acceptable. Inter- and intra-variabilities among the manual contours were also validated. The two-dimensional contours were then reconstructed in three dimensions for GTV volume calculation, comparison and three-dimensional visualisation.

RESULTS

The mean DSC between C-gold and C-auto was 0.79. The mean DSC between C-gold and C-manual was 0.79 and that between C1 and C2 was 0.80. The average time for GTV auto-contouring per patient was 8 min (range 6-13 min; mean 45 s per axial slice) compared with 15 min (range 6-23 min; mean 88 s per axial slice) for C1. The average volume concordance between C-gold and C-auto volumes was 86.51% compared with 74.16% between C-gold and C-manual. The average volume concordance between C1 and C2 volumes was 86.82%.

CONCLUSIONS

This newly designed MRI-based auto-contouring software tool shows initial acceptable results in GTV delineation of oropharyngeal and laryngeal tumours using FCLSM. This auto-contouring software tool may help reduce inter- and intra-variability and can assist clinical oncologists with time-consuming, complex radiotherapy planning.