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Falkson CB, Vella ET, Ellis PM, Maziak DE, Ung YC, Yu E. Surgical, Radiation, and Systemic Treatments of Patients With Thymic Epithelial Tumors: A Systematic Review. J Thorac Oncol 2023; 18:299-312. [PMID: 36343922 DOI: 10.1016/j.jtho.2022.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/14/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Thymic epithelial tumors are rare and are classified as thymoma, thymic carcinoma, and thymic neuroendocrine tumors. The objective of this systematic review was to evaluate the treatment options for patients with thymic epithelial tumors. METHODS This systematic review was developed by Ontario Health (Cancer Care Ontario)'s Program in Evidence-Based Care and by the Lung Cancer Disease Site Group. MEDLINE, EMBASE, and the Cochrane Library were searched for studies comparing surgical, radiotherapy, or systemic treatments against any combination of these treatments in patients with thymic epithelial tumors. Meta-analyses were conducted with clinically homogenous studies. RESULTS A total of 106 studies were included, mainly from observational studies. There was an overall survival benefit with postoperative radiotherapy for patients with thymic carcinoma (hazard ratio = 0.65, 95% confidence interval: 0.47-0.89) and for patients with thymoma (hazard ratio = 0.70, 95% confidence interval: 0.59-0.82), especially for those with a high risk for mortality. Patients with thymic carcinoma or thymoma had a response to chemotherapy. Selection bias affected the results for studies that evaluated neoadjuvant chemotherapy or minimally invasive surgical techniques. Furthermore, the overall survival benefit found for adjuvant chemotherapy may have been confounded by the administration of postoperative radiotherapy. CONCLUSIONS For patients with thymoma or thymic carcinoma, the literature is of low quality and subject to bias. There were overall survival benefits with postoperative radiotherapy. The results of this systematic review were used to inform treatment recommendations in a clinical practice guideline. Future large-scale prospective studies that control for confounders are needed.
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Affiliation(s)
- Conrad B Falkson
- Radiation Oncology, Cancer Centre of Southeastern Ontario, Kingston General Hospital and Queen's University, Kingston, Ontario, Canada
| | - Emily T Vella
- Program in Evidence-Based Care, McMaster University, Hamilton, Ontario, Canada.
| | - Peter M Ellis
- Medical Oncology, Juravinski Cancer Centre and Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Donna E Maziak
- Thoracic Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Yee C Ung
- Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Edward Yu
- Radiation Oncology, London Regional Cancer Centre and Western University, London, Ontario, Canada
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Falkson CB, Vella ET, Ellis PM, Maziak DE, Ung YC, Yu E. Surgical, Radiation, and Systemic Treatments of Patients with Thymic Epithelial Tumours: A Clinical Practice Guideline. J Thorac Oncol 2022; 17:1258-1275. [PMID: 36031176 DOI: 10.1016/j.jtho.2022.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/05/2022] [Accepted: 08/17/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The aim of this guideline was to provide recommendations for the most effective therapy for patients with thymic epithelial tumours, including thymoma, thymic carcinoma, and thymic neuroendocrine tumours. This guideline is intended to be used by all healthcare professionals managing patients with thymic epithelial tumours. METHODS The guideline was developed by Ontario Health (Cancer Care Ontario)'s Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a systematic review of the evidence, expert consensus, and formal internal and external reviews. RESULTS Evidence-based recommendations were developed to improve the management of patients with thymic epithelial tumours. The guideline includes recommendations for surgical, radiation, and systemic treatments for patients with thymoma, thymic carcinoma, and thymic neuroendocrine tumours separated by stage of disease using the TNM staging system. Recommendations for patients with thymic neuroendocrine tumours were endorsed from the 2021 National Comprehensive Cancer Network Neuroendocrine and Adrenal Tumors Guideline. CONCLUSION This guideline reflects the new staging system for patients with thymoma and thymic carcinoma and includes supporting evidence from the best available studies.
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Affiliation(s)
- Conrad B Falkson
- Radiation Oncology, Cancer Centre of Southeastern Ontario, Kingston General Hospital and Queen's University, Kingston, Ontario.
| | - Emily T Vella
- Program in Evidence-Based Care, McMaster University, Hamilton, Ontario
| | - Peter M Ellis
- Medical Oncology, Juravinski Cancer Centre, and Department of Oncology, McMaster University, Hamilton, Ontario
| | - Donna E Maziak
- The Ottawa Hospital, and University of Ottawa, Ottawa, Ontario
| | - Yee C Ung
- Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario
| | - Edward Yu
- Radiation Oncology, London Regional Cancer Centre and Western University, London, ON
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Yao X, Vella ET, Sussman J. More Thoughts than Answers: What Distinguishes Evidence-Based Clinical Practice Guidelines from Non-evidence-Based Clinical Practice Guidelines? J Gen Intern Med 2021; 36:207-208. [PMID: 32291722 PMCID: PMC7858728 DOI: 10.1007/s11606-020-05825-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 03/26/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Xiaomei Yao
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada. .,Center for Clinical Practice Guideline Conduction and Evaluation, Children's Hospital of Fudan University, Shanghai, China.
| | - Emily T Vella
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sussman
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Swaminath A, Vella ET, Ramchandar K, Robinson A, Simone C, Sun A, Ung YC, Yasufuku K, Ellis PM. Surgery after chemoradiotherapy in patients with stage III (N2 or N3, excluding T4) non-small-cell lung cancer: a systematic review. ACTA ACUST UNITED AC 2019; 26:e398-e404. [PMID: 31285684 DOI: 10.3747/co.26.4549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Chemoradiation with curative intent is considered the standard of care in patients with locally advanced, stage iii non-small-cell lung cancer (nsclc). However, some patients with stage iii (N2 or N3, excluding T4) nsclc might be eligible for surgery. The objective of the present systematic review was to investigate the efficacy of surgery after chemoradiotherapy compared with chemoradiotherapy alone in patients with potentially resectable locally advanced nsclc. Methods A search of the medline, embase, and PubMed databases sought randomized controlled trials (rcts) comparing surgery after chemoradiotherapy with chemoradiotherapy alone in patients with stage iii (N2 or N3, excluding T4) nsclc. Results Three included rcts consistently found no statistically significant difference in overall survival between patients with locally advanced nsclc who received surgery and chemoradiotherapy or chemoradiotherapy alone. Only one rct found that progression-free survival was significantly longer in patients treated with chemoradiation and surgery (hazard ratio: 0.77; 95% confidence interval: 0.62 to 0.96). In a post hoc analysis of the same trial, the overall survival rate was higher in the surgical group than in matched patients in a chemoradiation-only group if a lobectomy was performed (p = 0.002), but not if a pneumonectomy was performed. Furthermore, fewer treatment-related deaths occurred in patients who underwent lobectomy than in those who underwent pneumonectomy. Conclusions For patients with locally advanced nsclc, the benefits of surgery after chemoradiation are uncertain. Surgery after chemoradiation for patients who do not require a pneumonectomy might be an option.
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Affiliation(s)
- A Swaminath
- Radiation Oncology, Juravinski Cancer Centre, and Department of Oncology, McMaster University, Hamilton, ON
| | - E T Vella
- Program in Evidence-Based Care, McMaster University, Hamilton, ON
| | - K Ramchandar
- Radiation Oncology, Thunder Bay Regional Health Sciences Centre-Cancer Care, Thunder Bay, ON
| | - A Robinson
- Medical Oncology, Kingston General Hospital, Kingston
| | - C Simone
- Department of Surgery, Michael Garron Hospital, Toronto, ON
| | - A Sun
- Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON
| | - Y C Ung
- Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, ON
| | - K Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON
| | - P M Ellis
- Medical Oncology, Juravinski Cancer Centre, and Department of Oncology, McMaster University, Hamilton, ON
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Abstract
Clinical practice guidelines (CPGs) are systematically-developed statements aimed to assist decision-making relevant to the clinical encounter, to inform clinical policy, and to strengthen health care systems. The development of a CPG begins with the identification of a problem for which evidence-informed guidance is required. Interdisciplinary panels work to craft - and then execute - a protocol that will serve as a blueprint for the development process. It includes the scope of the project; who is involved and how they will function; the specific systematic review and consensus methods that will be used to ensure quality recommendations and to mitigate bias. CPGs should undergo a formal review of relevant stakeholders and results of this review, actions taken by the panel, and the final recommendations should be documented in the final CPG report. Dissemination activities, including the use of social media platforms, and more purposefully designed implementation activities are required to optimize the adoption of recommendations. Methods to keep recommendations current are required to ensure on-going validity and credibility of the recommendations. Two tools, AGREE II, and the AGREE REX, provide quality criteria related to the whole CPG development process and the CPG recommendations, respectively. The AGREE II is comprised of 23 items within 6 CPG quality domains: scope and purpose, stakeholder involvement, rigor, clarity of presentation, applicability, and editorial independence. The AGREE REX is comprised of 9 items within 3 CPG Recommendation quality domains: clinical applicability, values and preferences, and implementability. CPGs are important tools to an overall quality agenda.
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Affiliation(s)
- Melissa C Brouwers
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Program in Evidence-based Care, Cancer Care Ontario, Hamilton, Ontario, Canada.
| | - Ivan D Florez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Pediatrics, University of Antioquia, Colombia
| | - Sheila A McNair
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Program in Evidence-based Care, Cancer Care Ontario, Hamilton, Ontario, Canada
| | - Emily T Vella
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Program in Evidence-based Care, Cancer Care Ontario, Hamilton, Ontario, Canada
| | - Xioamei Yao
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Program in Evidence-based Care, Cancer Care Ontario, Hamilton, Ontario, Canada
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Falkson CB, Vella ET, Yu E, El-Mallah M, Mackenzie R, Ellis PM, Ung YC. Radiotherapy With Curative Intent in Patients With Early-stage, Medically Inoperable, Non–Small-cell Lung Cancer: A Systematic Review. Clin Lung Cancer 2017; 18:105-121.e5. [DOI: 10.1016/j.cllc.2016.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 12/23/2022]
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Falkson CB, Vella ET, Yu E, El-Mallah M, Mackenzie R, Ellis PM, Ung YC. Guideline for radiotherapy with curative intent in patients with early-stage medically inoperable non-small-cell lung cancer. ACTA ACUST UNITED AC 2017; 24:e44-e49. [PMID: 28270731 DOI: 10.3747/co.24.3358] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES For this guideline, we investigated the effectiveness of radiotherapy with curative intent in medically inoperable patients with early-stage non-small-cell lung cancer (nsclc). METHODS The guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a systematic review of mainly retrospective studies, expert consensus, and formal internal and external reviews. RECOMMENDATIONS ■ Stereotactic body radiation therapy (sbrt) with curative intent is an option that should be considered for patients with early-stage, node-negative, medically inoperable nsclc. Qualifying Statements■ Because of the high dose per fraction, the planning process and treatment delivery for sbrt require the use of advanced technology to maintain an appropriate level of safety. Consistent patient positioning and 4-dimensional analysis of tumour and critical structure motion during simulation and treatment delivery are essential.■ Preliminary results for proton-beam therapy have been promising, but the technique requires further clinical study.■ Recommended fractionation schemes for sbrt should result in a biologically effective dose of 100 or greater by the linear quadric model, choosing an α/β value of 10 [bed10(LQ) ≥ 100]. Qualifying Statements■ Because of the increased risk of treatment-related adverse events associated with centrally located tumours, consideration of tumour size and proximity to critical central structures is required when determining the dose and fractionation.■ Examples of dose-fractionation schemes used in the included studies have been provided.■ Based on the current evidence and the opinion of the authors, radiation doses at bed10(LQ) greater than 146 might significantly increase toxicity and should be avoided.■ Determination of the radiation bed by the linear quadratic model has limitations for the extreme hypofractionated schemes used in sbrt.
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Affiliation(s)
- C B Falkson
- Radiation Oncology, Cancer Centre of Southeastern Ontario, Kingston General Hospital and Queen's University, Kingston
| | - E T Vella
- Cancer Care Ontario, Program in Evidence-Based Care, McMaster University, Hamilton
| | - E Yu
- Radiation Oncology, London Regional Cancer Centre and Western University, London
| | - M El-Mallah
- Radiation Oncology, Durham Regional Cancer Centre, Oshawa
| | - R Mackenzie
- Cancer Care Ontario, Program in Evidence-Based Care, McMaster University, Hamilton
| | - P M Ellis
- Medical Oncology, Juravinski Cancer Centre, and Department of Oncology, McMaster University, Hamilton; and
| | - Y C Ung
- Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, ON
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Ellis PM, Vella ET, Ung YC. Immune Checkpoint Inhibitors for Patients With Advanced Non-Small-Cell Lung Cancer: A Systematic Review. Clin Lung Cancer 2017; 18:444-459.e1. [PMID: 28416123 DOI: 10.1016/j.cllc.2017.02.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 02/01/2017] [Accepted: 02/07/2017] [Indexed: 11/28/2022]
Abstract
Second-line treatment options are limited for patients with advanced non-small-cell lung cancer (NSCLC). Standard therapy includes the cytotoxic agents docetaxel and pemetrexed, and the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib. Immune checkpoint inhibitors are a new class of treatment that have shown durable overall radiologic response rates and have been well tolerated. The objective of this systematic review was to investigate the efficacy of immune checkpoint inhibitors compared with other chemotherapies in patients with advanced NSCLC. Medline, Embase, and PubMed were searched for randomized controlled trials comparing treatment with immune checkpoint inhibitors against treatment with chemotherapy in patients with stage IIIB or IV NSCLC. Nine randomized controlled trials with 15 publications were included. A significant overall survival benefit of second-line nivolumab (nonsquamous: hazard ratio [HR] = 0.72, 95% confidence interval [CI], 0.60-0.77; P < .001; squamous: HR = 0.59, 95% CI, 0.44-0.79; P < .001) or second-line atezolizumab (HR = 0.73, 95% CI, 0.62-0.87; P = .0003) or second-line pembrolizumab (in patients with programmed cell death ligand 1 [PD-L1]-positive tumors) (pembrolizumab 2 mg/kg HR = 0.71, 95% CI, 0.58-0.88; P = .0008; pembrolizumab 10 mg/kg HR = 0.61, 95% CI, 0.49-0.75; P < .0001) or first-line pembrolizumab (HR = 0.60, 95% CI, 0.41-0.89; P = .005) compared with chemotherapy was found. The adverse effects were mainly higher in the chemotherapy arms. For patients with advanced stage IIIB/IV NSCLC, the improvement in overall survival outweighed the harms and supported the use of first-line pembrolizumab (in patients with ≥ 50% PD-L1-positive tumors) or second-line nivolumab, atezolizumab, or pembrolizumab (in patients with PD-L1-positive tumors).
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Affiliation(s)
- Peter M Ellis
- Medical Oncology, Juravinski Cancer Centre, and Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Emily T Vella
- Program in Evidence-Based Care, McMaster University, Hamilton, Ontario, Canada.
| | - Yee C Ung
- Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
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Tinmouth J, Vella ET, Baxter NN, Dubé C, Gould M, Hey A, Ismaila N, McCurdy BR, Paszat L. Colorectal Cancer Screening in Average Risk Populations: Evidence Summary. Can J Gastroenterol Hepatol 2016; 2016:2878149. [PMID: 27597935 PMCID: PMC5002289 DOI: 10.1155/2016/2878149] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Introduction. The objectives of this systematic review were to evaluate the evidence for different CRC screening tests and to determine the most appropriate ages of initiation and cessation for CRC screening and the most appropriate screening intervals for selected CRC screening tests in people at average risk for CRC. Methods. Electronic databases were searched for studies that addressed the research objectives. Meta-analyses were conducted with clinically homogenous trials. A working group reviewed the evidence to develop conclusions. Results. Thirty RCTs and 29 observational studies were included. Flexible sigmoidoscopy (FS) prevented CRC and led to the largest reduction in CRC mortality with a smaller but significant reduction in CRC mortality with the use of guaiac fecal occult blood tests (gFOBTs). There was insufficient or low quality evidence to support the use of other screening tests, including colonoscopy, as well as changing the ages of initiation and cessation for CRC screening with gFOBTs in Ontario. Either annual or biennial screening using gFOBT reduces CRC-related mortality. Conclusion. The evidentiary base supports the use of FS or FOBT (either annual or biennial) to screen patients at average risk for CRC. This work will guide the development of the provincial CRC screening program.
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Affiliation(s)
- Jill Tinmouth
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emily T. Vella
- Program in Evidence-Based Care, Cancer Care Ontario, Hamilton, ON, Canada
| | - Nancy N. Baxter
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Catherine Dubé
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
- Department of Medicine, Division of Gastroenterology, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michael Gould
- William Osler Health Centre, Etobicoke, ON, Canada
- Vaughan Endoscopy Clinic, Vaughan, ON, Canada
| | - Amanda Hey
- Northeast Cancer Centre Health Sciences North/Horizon Santé-Nord, Sudbury Outpatient Centre, Sudbury, ON, Canada
| | | | | | - Lawrence Paszat
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Kulkarni S, Vella ET, Coakley N, Cheng S, Gregg R, Ung YC, Ellis PM. The Use of Systemic Treatment in the Maintenance of Patients with Non–Small Cell Lung Cancer: A Systematic Review. J Thorac Oncol 2016; 11:989-1002. [DOI: 10.1016/j.jtho.2016.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/04/2016] [Accepted: 03/10/2016] [Indexed: 12/09/2022]
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Covens A, Vella ET, Kennedy EB, Reade CJ, Jimenez W, Le T. Sentinel lymph node biopsy in vulvar cancer: Systematic review, meta-analysis and guideline recommendations. Gynecol Oncol 2015; 137:351-61. [DOI: 10.1016/j.ygyno.2015.02.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/13/2015] [Indexed: 01/08/2023]
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Kennedy E, Vella ET, Blair Macdonald D, Wong CS, McLeod R. Optimisation of preoperative assessment in patients diagnosed with rectal cancer. Clin Oncol (R Coll Radiol) 2015; 27:225-45. [PMID: 25656631 DOI: 10.1016/j.clon.2015.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 11/18/2014] [Accepted: 01/06/2015] [Indexed: 12/14/2022]
Abstract
AIMS Treatment decision making for patients with rectal cancer is complex and optimal preoperative assessment is important to ensure patients receive appropriate and high-quality care. Therefore, our objective was to develop an evidence-based, multidisciplinary guideline to assist physicians treating rectal cancer to ensure that preoperative assessment is optimal. MATERIALS AND METHODS A multidisciplinary expert panel of physicians who treat rectal cancer was selected as members of the Cancer Care Ontario Preoperative Assessment for Rectal Cancer Guideline Development Group (GDG). This group initially met to identify important clinical questions with respect to optimisation of preoperative assessment in patients diagnosed with rectal cancer. A systematic review, specific to each of these clinical questions, was then conducted using MEDLINE, EMBASE and the Cochrane Library databases. The GDG met at regular intervals to review the evidence and to develop guidelines to address each of the clinical questions. RESULTS The GDG identified seven important clinical questions with respect to the optimisation of preoperative assessment in patients diagnosed with rectal cancer. The clinical questions pertained to: (i) investigations required to assess distant metastasis (one question); (ii) imaging for local staging of rectal cancer (five questions); (iii) multidisciplinary cancer conference (MCC) (one question); (iv) restaging-magnetic resonance imaging (one question). The systematic reviews related to these clinical questions yielded 31 articles that were abstracted and reviewed by the GDG. Based on the systematic reviews, a guideline was developed containing seven recommendations that were either adapted from existing guidelines, based on review of the evidence or by consensus when evidence was limited. CONCLUSIONS A set of seven recommendations have been developed in order to optimise pretreatment assessment in patients with rectal cancer by promoting evidence-based practice. These guidelines are based on the best available evidence and have been peer reviewed by two independent multidisciplinary expert panels for relevance and validity.
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Affiliation(s)
- E Kennedy
- Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - E T Vella
- Program in Evidence-based Care, Cancer Care Ontario, McMaster University, Juravinski Hospital Site, Hamilton, Ontario, Canada
| | | | - C S Wong
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - R McLeod
- Mount Sinai Hospital, Toronto, Ontario, Canada
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Young SM, Bansal P, Vella ET, Finelli A, Levitt C, Loblaw A. Systematic review of clinical features of suspected prostate cancer in primary care. Can Fam Physician 2015; 61:e26-e35. [PMID: 25756146 PMCID: PMC4301783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To systematically review the literature and provide an update and integration of existing peer-reviewed guidelines with recent systematic reviews and with primary studies related to the early recognition and management of prostate cancer in primary care. DATA SOURCES We searched MEDLINE and EMBASE for relevant articles. The quality of the evidence to support existing guideline recommendations and the consistency of recommendations with updated evidence were assessed. Applicability in a Canadian primary care setting was also evaluated. STUDY SELECTION All studies conducted in the primary care setting that provided information on clinical features predictive of prostate cancer were included. Also, studies that assessed the accuracy of nomograms to predict prostate cancer were reviewed. SYNTHESIS The findings suggest that lower urinary tract symptoms are not highly predictive of prostate cancer. However, evidence suggests that FPs might be good at discriminating between patients with and without prostate cancer using digital rectal examination and prostate-specific antigen testing. Nomograms might also be useful in assessing patients for aggressive prostate cancers. CONCLUSION The results of this review can be used to inform recommendations for referral for suspected prostate cancer in the primary care setting. They could also inform development of prostate cancer diagnostic assessment programs.
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Del Giudice ME, Young SM, Vella ET, Ash M, Bansal P, Robinson A, Skrastins R, Ung Y, Zeldin R, Levitt C. Systematic review of guidelines for the management of suspected lung cancer in primary care. Can Fam Physician 2014; 60:e395-e404. [PMID: 25122830 PMCID: PMC4131976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To systematically review the literature and provide an update and integration of existing peer-reviewed guidelines with recent systematic reviews and with primary studies related to the early recognition and management of lung cancer in primary care. DATA SOURCES MEDLINE and EMBASE were searched for relevant articles. The quality of the evidence to support existing guideline recommendations, and the consistency of recommendations with updated evidence, were assessed. Applicability in a Canadian primary care setting was also evaluated. STUDY SELECTION All studies that explored signs or symptoms of or risk factors for lung cancer in the primary care setting were included. All diagnostic studies in which symptomatic primary care patients underwent 1 or more investigations were also searched. SYNTHESIS Recommendations were consistent among guidelines despite a paucity of supporting evidence. Updated evidence provided further support for the recommendations. Recommendations for identifying signs and symptoms of lung cancer presenting in primary care and for initial management can be adopted and applied within a Canadian primary care setting. CONCLUSION This updated review of recommendations might help promote evidence-based practice and, ultimately, more timely management and improved prognosis for lung cancer patients. It might also assist in the development of lung cancer diagnostic assessment programs.
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Affiliation(s)
- M Elisabeth Del Giudice
- Physician with the Sunnybrook Academic Family Health Team in Toronto, Ont, and is Regional Primary Care Cancer Lead for the Toronto Central Local Health Integration Network.
| | | | - Emily T Vella
- Health Research Methodologist in the Department of Oncology at McMaster University in Hamilton, Ont, and for Cancer Care Ontario's Program in Evidence-based Care.
| | - Marla Ash
- Family physician with the North York Family Health Team in Ontario
| | | | - Andrew Robinson
- Assistant Professor in the Department of Oncology at Queen's University in Kingston, Ont
| | | | - Yee Ung
- Associate Professor in the Department of Radiation Oncology at the University of Toronto and a staff radiation oncologist at Sunnybrook Odette Cancer Centre
| | - Robert Zeldin
- Associate Professor in the Division of Thoracic Surgery at the University of Toronto and Medical Director of Surgical Oncology at the Toronto East General Hospital
| | - Cheryl Levitt
- Professor in the Department of Family Medicine at McMaster University and Past Provincial Primary Care Lead at Cancer Care Ontario
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Del Giudice ME, Young SM, Vella ET, Ash M, Bansal P, Robinson A, Skrastins R, Ung Y, Zeldin R, Levitt C. Guideline for referral of patients with suspected lung cancer by family physicians and other primary care providers. Can Fam Physician 2014; 60:711-e382. [PMID: 25122814 PMCID: PMC4131959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The aim of this guideline is to assist FPs and other primary care providers with recognizing features that should raise their suspicions about the presence of lung cancer in their patients. COMPOSITION OF THE COMMITTEE Committee members were selected from among the regional primary care leads from the Cancer Care Ontario Provincial Primary Care and Cancer Network and from among the members of the Cancer Care Ontario Lung Cancer Disease Site Group. METHODS This guideline was developed through systematic review of the evidence base, synthesis of the evidence, and formal external review involving Canadian stakeholders to validate the relevance of recommendations. REPORT Evidence-based guidelines were developed to improve the management of patients presenting with clinical features of lung cancer within the Canadian context. CONCLUSION Earlier identification and referral of patients with lung cancer might ultimately help improve lung cancer morbidity and mortality. These guidelines might also be of value for informing the development of lung cancer diagnostic programs and for helping policy makers to ensure appropriate resources are in place.
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Affiliation(s)
- M Elisabeth Del Giudice
- Physician with the Sunnybrook Academic Family Health Team in Toronto, Ont, and is Regional Primary Care Cancer Lead for the Toronto Central Local Health Integration Network.
| | | | - Emily T Vella
- Health Research Methodologist in the Department of Oncology at McMaster University in Hamilton, Ont, and for Cancer Care Ontario's Program in Evidence-based Care.
| | - Marla Ash
- Family physician with the North York Family Health Team in Ontario
| | | | - Andrew Robinson
- Assistant Professor in the Department of Oncology at Queen's University in Kingston, Ont
| | | | - Yee Ung
- Associate Professor in the Department of Radiation Oncology at the University of Toronto and a staff radiation oncologist at Sunnybrook Odette Cancer Centre
| | - Robert Zeldin
- Associate Professor in the Division of Thoracic Surgery at the University of Toronto and Medical Director of Surgical Oncology at the Toronto East General Hospital
| | - Cheryl Levitt
- Professor in the Department of Family Medicine at McMaster University and Past Provincial Primary Care Lead at Cancer Care Ontario
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Del Giudice ME, Vella ET, Hey A, Simunovic M, Harris W, Levitt C. Guideline for referral of patients with suspected colorectal cancer by family physicians and other primary care providers. Can Fam Physician 2014; 60:717-23, e383-90. [PMID: 25122815 PMCID: PMC4131960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The aim of this guideline is to assist FPs and other primary care providers with recognizing features that should raise their suspicions about the presence of colorectal cancer (CRC) in their patients. COMPOSITION OF THE COMMITTEE Committee members were selected from among the regional primary care leads from the Cancer Care Ontario Provincial Primary Care and Cancer Network, the members of the Ontario Colorectal Cancer Screening Advisory Committee, and the members of the Cancer Care Ontario Gastrointestinal Cancer Disease Site Group. METHODS This guideline was developed through systematic review of the evidence base, synthesis of the evidence, and formal external review involving Canadian stakeholders to validate the relevance of recommendations. REPORT Evidence-based guidelines were developed to improve the management of patients presenting with clinical features of CRC within the Canadian context. CONCLUSION The judicious balancing of suspicion of CRC and level of risk of CRC should encourage timely referral by FPs and primary care providers. This guideline might also inform indications for referral to CRC diagnostic assessment programs.
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Affiliation(s)
- M Elisabeth Del Giudice
- Physician with the Sunnybrook Academic Family Health Team in Toronto, Ont, and is Regional Primary Care Cancer Lead for the Toronto Central Local Health Integration Network.
| | - Emily T Vella
- Health Research Methodologist in the Department of Oncology at McMaster University in Hamilton, Ont, and for Cancer Care Ontario's Program in Evidence-based Care.
| | - Amanda Hey
- Regional Primary Care Lead at the Northeast Cancer Centre in Sudbury, Ont
| | - Marko Simunovic
- Surgical oncologist at the Juravinski Cancer Centre in Hamilton
| | - William Harris
- Surgeon at Thunder Bay Regional Health Sciences Centre in Ontario
| | - Cheryl Levitt
- Professor in the Department of Family Medicine at McMaster University and Past Provincial Primary Care Lead at Cancer Care Ontario
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Del Giudice ME, Vella ET, Hey A, Simunovic M, Harris W, Levitt C. Systematic review of clinical features of suspected colorectal cancer in primary care. Can Fam Physician 2014; 60:e405-e415. [PMID: 25122831 PMCID: PMC4131977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To systematically review the diagnostic accuracy of clinical features associated with colorectal cancer (CRC) presenting in primary care. DATA SOURCES MEDLINE and EMBASE were searched for studies in primary care that provided information on clinical features predictive of CRC. Positive predictive values were used to guide the determination of clinical features associated with increased risk of CRC. STUDY SELECTION Systematic reviews or primary studies that provided possible clinical features predictive of CRC were included. SYNTHESIS Clinical features of patients presenting in primary care that are associated with increased risk of CRC, listed in descending order of association, included palpable rectal or abdominal mass; rectal bleeding combined with weight loss; iron deficiency anemia; rectal bleeding mixed with stool; rectal bleeding in the absence of perianal symptoms; rectal bleeding combined with change in bowel habits; dark rectal bleeding; rectal bleeding and diarrhea; and change in bowel habits. Being male and increasing age were also, in general, associated with increased risk of CRC. CONCLUSION Recognition of clinical features associated with increased risk of CRC by FPs might help with earlier identification and referral among patients presenting in primary care. This review might help inform providers and CRC diagnostic assessment programs about indications for assessment and further investigation.
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Affiliation(s)
- M Elisabeth Del Giudice
- Physician with the Sunnybrook Academic Family Health Team in Toronto, Ont, and is Regional Primary Care Cancer Lead for the Toronto Central Local Health Integration Network.
| | - Emily T Vella
- Health Research Methodologist in the Department of Oncology at McMaster University in Hamilton, Ont, and for Cancer Care Ontario's Program in Evidence-based Care.
| | - Amanda Hey
- Regional Primary Care Lead at the Northeast Cancer Centre in Sudbury, Ont
| | - Marko Simunovic
- Surgical oncologist at the Juravinski Cancer Centre in Hamilton
| | - William Harris
- Surgeon at Thunder Bay Regional Health Sciences Centre in Ontario
| | - Cheryl Levitt
- Professor in the Department of Family Medicine at McMaster University and Past Provincial Primary Care Lead at Cancer Care Ontario
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Nofech-Mozes S, Vella ET, Dhesy-Thind S, Hanna WM. Cancer care Ontario guideline recommendations for hormone receptor testing in breast cancer. Clin Oncol (R Coll Radiol) 2012; 24:684-96. [PMID: 22608362 DOI: 10.1016/j.clon.2012.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 02/07/2012] [Accepted: 04/24/2012] [Indexed: 12/31/2022]
Abstract
Hormone receptor testing (oestrogen and progesterone) in breast cancer at the time of primary diagnosis is used to guide treatment decisions. Accurate and standardised testing methods are critical to ensure the proper classification of the patient's hormone receptor status. Recommendations were developed to improve the quality and accuracy of hormone receptor testing based on a systematic review conducted jointly by the American Society of Clinical Oncology/College of American Pathologists and Cancer Care Ontario's Program in Evidence-Based Care. Evidence-based recommendations were formulated to set standards for optimising immunohistochemistry in assessing hormone receptor status, as well as assuring quality and proficiency between and within laboratories. A formal external review was conducted to validate the relevance of these recommendations. It is anticipated that widespread adoption of these guidelines will further improve the accuracy of hormone receptor testing in Canada.
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Affiliation(s)
- S Nofech-Mozes
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Bond LJ, Vella ET, Kiparissis Y, Wynne-Edwards KE. Anthropometry and body composition do not predict bioavailable androgen or progesterone concentration in adolescent girls. Am J Hum Biol 2006; 18:639-53. [PMID: 16917896 DOI: 10.1002/ajhb.20534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Our objective was to test the hypothesis that anthropometry and body composition were independently associated with sex-steroid concentration in adolescent girls. Premenarcheal (age, mean +/- SD = 10.9 +/- 0.6, N = 51), perimenarcheal (age = 13.7 +/- 0.6, N = 74), and postmenarcheal (age = 16.7 +/- 0.6, N = 44) cohorts provided saliva at morning recess during the schoolday over 6 weeks. Estradiol, testosterone, progesterone, and dehydroepiandrosterone (DHEA) were quantified. Age, developmental cohort, self-reported Tanner stage of breast development and pubic-hair distribution, gynecological age, height, weight, waist/hip ratio, and percent body fat (by impedance) were assessed. Repeated measures were reduced to a mean. Data were hierarchically standardized for sexual maturation status, and then used to predict anthropometry/percent body fat. After intensive repeated sampling, individuals still varied widely in testosterone, progesterone, and DHEA concentrations within a developmental cohort (35.0 < or = coefficient of variation < or = 66.5%). Individual hormone concentration was repeatable across 2 years (0.51 < or = r(2) < or = 0.73). In spite of the variability within a cohort, there was no evidence for an association between the standardized hormone and body mass index, percent body fat, or waist/hip ratio, whether or not measures were age-adjusted (21 univariate tests; 0.19 < or = P < or = 0.96). Stratification by developmental cohort also did not reveal associations. Low estradiol assay precision precluded analyses. In conclusion, despite considerable population variation in hormone concentration after repeated sampling, no evidence supported an association between anthropometry or pecent body fat and testosterone, progesterone, or DHEA in adolescent girls.
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Affiliation(s)
- Lea J Bond
- Department of Biology, Queen's University, Kingston, Ontario K7L 3N6, Canada
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Brooks PL, Vella ET, Wynne-Edwards KE. Dopamine agonist treatment before and after the birth reduces prolactin concentration but does not impair paternal responsiveness in Djungarian hamsters, Phodopus campbelli. Horm Behav 2005; 47:358-66. [PMID: 15708766 DOI: 10.1016/j.yhbeh.2004.10.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Revised: 10/07/2004] [Accepted: 10/11/2004] [Indexed: 11/16/2022]
Abstract
Male Djungarian hamsters, Phodopus campbelli, are highly parental and experience a late-afternoon prolactin surge before the birth that is not seen in a closely related species, P. sungorus, which lacks paternal care. At the same stage, female prolactin is needed for later maternal behavior. Male prolactin was suppressed in first-time fathers before the birth of the litter using two different dopamine agonists, bromocriptine mesylate and cabergoline. Plasma prolactin concentration confirmed the efficacy of each treatment. Paternal responsiveness was quantified using three variations on a pup-displacement paradigm. No adverse effects of either treatment were seen. Across four experiments, there was no decrease in paternal retrieval or in retrieval latency in response to male prolactin suppression. In addition, there was no decrease in litter growth or survival, nor was there an increase in maternal investment to compensate for a deficit in paternal care. As cabergoline suppression of prolactin persisted after the birth without behavioral deficits, prolactin after the birth was also not required for the expression of paternal behavior. In spite of an extensive literature supporting an association between prolactin and natural paternal behavior, we conclude that dopamine-mediated prolactin release into peripheral plasma is not essential for paternal responsiveness in P. campbelli.
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Affiliation(s)
- Patricia L Brooks
- Department of Biology, Queen's University, Kingston, Ontario, Canada K7L 3N6
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Vella ET, Evans CCD, Ng MWS, Wynne-Edwards KE. Ontogeny of the transition from killer to caregiver in dwarf hamsters (Phodopus campbelli) with biparental care. Dev Psychobiol 2005; 46:75-85. [PMID: 15732058 DOI: 10.1002/dev.20047] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Biparental Phodopus campbelli and uniparental P. sungorus juvenile litters (2 males, 2 females) both consumed amniotic fluid and placenta during the birth of younger siblings. Three days later, P. campbelli juveniles were most responsive to a displaced younger sibling. Thus, P. campbelli are responsive to pups as juvenile alloparents and as new parents; however, at intervening ages, infanticidal attack (bite) was seen. At 5, 7, 9, 11, or 13 weeks of age, male and female P. campbelli were given a 5-min test with an unrelated, 3-day-old, anesthetized pup. Females attacked more often than males, yet pup-retrieval rates did not differ. Female aggression increased with age and was replaced by retrieval behavior 3 days after parturition. Male attack ceased after a birth, but parental behavior did not increase, remaining below the rate for new fathers tested with their own awake pup. Over repeated testing, behavior in one test did not predict behavior in another. Transitions from caregiving alloparent to infanticidal adult and back to parental care were clear in females, but less discrete with this stimulus paradigm in these highly paternal males.
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Affiliation(s)
- Emily T Vella
- Department of Biology, Queen's University, Kingston Ontario, Canada K7L 3N6
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Vella ET, Evans CCD, Williams S, Wynne-Edwards KE. Neonatal anesthesia for studies of hamster parental behavior when infanticidal aggression is a possibility. Comp Med 2004; 54:202-8. [PMID: 15134367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Experiments involving investigation of the neuroendocrine basis for paternal care in rodents risk activation of aggressive behavior toward pups. To minimize pain and suffering during tests of parental responsiveness requiring retrieval of a displaced pup to its nest, a method of anesthetizing the pup was developed in Djungarian hamsters, Phodopus campbelli. A surgical plane of anesthesia, as measured by criteria, such as respiratory depression, loss of the pedal reflex, and failure to increase respiratory rate or to vocalize in response to handling, was achieved by use of intraperitoneal administration of a combination of ketamine and xylazine. Both parents (tested separately) expressed normal behavior toward anesthetized pups. In random order, a saline-injected or anesthetized pup was displaced from its nest in the home cage. There were no differences in pick-up or retrieval rates between saline and anesthetized pups for either parent. A third test using an unmanipulated pup confirmed that parental behavior was not reduced toward an anesthetized pup. However, if anesthetized pups were tested first among littermates, retrieval by males was less likely. This method will, therefore, underestimate retrieval behavior in males, but not females. Adult male hamsters that had never been parents also expressed expected behavior by attacking the pup in 45% of cases. This method provides an efficient and effective means of protecting pups while allowing adults to express a wide range of parental and infanticidal behaviors. It also has application in behavioral screening of transgenic strains toward unrelated young.
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Affiliation(s)
- Emily T Vella
- Department of Biology, Queen's University, Kingston, ON, Canada K7L 3N6
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