Remote, proactive, telephone based management of toxicity in outpatients during adjuvant or neoadjuvant chemotherapy for early stage breast cancer: pragmatic, cluster randomised trial

OBJECTIVE

To evaluate the effectiveness of remote proactive management of toxicities during chemotherapy for early stage breast cancer.

DESIGN

Pragmatic, cluster randomised trial.

SETTING

20 cancer centres in Ontario, Canada, allocated by covariate constrained randomisation to remote management of toxicities or routine care.

PARTICIPANTS

All patients starting adjuvant or neoadjuvant chemotherapy for early stage breast cancer at each centre. 25 patients from each centre completed patient reported outcome questionnaires.

INTERVENTIONS

Proactive, standardised, nurse led telephone management of common toxicities at two time points after each chemotherapy cycle.

MAIN OUTCOME MEASURES

The primary outcome, cluster level mean number of visits to the emergency department or admissions to hospital per patient during the whole course of chemotherapy treatment, was evaluated with routinely available administrative healthcare data. Secondary patient reported outcomes included toxicity, self-efficacy, and quality of life.

RESULTS

Baseline characteristics of participants were similar in the intervention (n=944) and control arms (n=1214); 22% were older than 65 years. Penetration (that is, the percentage of patients who received the intervention at each centre) was 50-86%. Mean number of visits to the emergency department or admissions to hospital per patient was 0.91 (standard deviation 0.28) in the intervention arm and 0.94 (0.40) in the control arm (P=0.94); 47% (1014 of 2158 patients) had at least one visit to the emergency department or a hospital admission during chemotherapy. Among 580 participants who completed the patient reported outcome questionnaires, at least one grade 3 toxicity was reported by 48% (134 of 278 patients) in the intervention arm and by 58% (163 of 283) in the control arm. No differences in self-efficacy, anxiety, or depression were found. Compared with baseline, the functional assessment of cancer therapy trial outcome index decreased by 6.1 and 9.0 points in the intervention and control participants, respectively.

CONCLUSIONS

Proactive, telephone based management of toxicities during chemotherapy did not result in fewer visits to the emergency department or hospital admissions. With the rapid rise in remote care because of the covid-19 pandemic, identifying scalable strategies for remote management of patients during cancer treatment is particularly relevant.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02485678.

Adherence to surveillance guidelines after curative resection for stage II/III colorectal cancer

PURPOSE

Our aims were to determine adherence to American Society of Clinical Oncology (ASCO) guidelines on colorectal cancer (CRC) surveillance and to evaluate differences in practice patterns and clinical outcomes between an academic institution (Princess Margaret Hospital [PMH]) and a community cancer hospital (Credit Valley Hospital [CVH]).

PATIENTS AND METHODS

Patients with stage II/III CRC who were diagnosed between January 1, 1999, and December 31, 2001, were identified, and their records were retrospectively reviewed.

RESULTS

A total of 244 and 97 patients were eligible at PMH and CVH, respectively. Surveillance patterns, including blood tests, imaging studies, and colonoscopies, were inconsistent with ASCO recommendations in a significant proportion of patients. Clinic visits occurred more frequently and imaging studies were more commonly ordered at PMH than at CVH (P < .001). In contrast, CVH performed a higher median number of blood count and liver function tests (P = .001) per patient than PMH. The rates of carcinoembryonic antigen monitoring and surveillance colonoscopies were not statistically different between centers (P = .67 and P = .43, respectively). There were a total of 70 CRC recurrences: 53 (75.7%) were detected by surveillance (44 at PMH and 9 at CVH) and 17 (24.3%) by patient symptoms (9 at PMH and 8 at CVH). For recurrences detected by surveillance, 38% were resectable, whereas only 18% of those detected by symptoms were resectable.

CONCLUSION

Colorectal cancer surveillance revealed noticeable departures from ASCO guidelines, with the academic institution using a more intensive surveillance strategy with imaging studies than the community cancer center. Surveillance was associated with a higher proportion of resectable tumor recurrences than was detection by patient symptoms.

The NF-kappa B signal transduction pathway in aortic endothelial cells is primed for activation in regions predisposed to atherosclerotic lesion formation

Atherosclerotic lesions form at distinct sites in the arterial tree, suggesting that hemodynamic forces influence the initiation of atherogenesis. If NF-kappaB plays a role in atherogenesis, then the activation of this signal transduction pathway in arterial endothelium should show topographic variation. The expression of NF-kappaB/IkappaB components and NF-kappaB activation was evaluated by specific antibody staining, en face confocal microscopy, and image analysis of endothelium in regions of mouse proximal aorta with high and low probability (HP and LP) for atherosclerotic lesion development. In control C57BL/6 mice, expression levels of p65, IkappaBalpha, and IkappaBbeta were 5- to 18-fold higher in the HP region, yet NF-kappaB was activated in a minority of endothelial cells. This suggested that NF-kappaB signal transduction was primed for activation in HP regions on encountering an activation stimulus. Lipopolysaccharide treatment or feeding low-density lipoprotein receptor knockout mice an atherogenic diet resulted in NF-kappaB activation and up-regulated expression of NF-kappaB-inducible genes predominantly in HP region endothelium. Preferential regional activation of endothelial NF-kappaB by systemic stimuli, including hypercholesterolemia, may contribute to the localization of atherosclerotic lesions at sites with high steady-state expression levels of NF-kappaB/IkappaB components.

Leukocyte adhesion molecules in atherogenesis

Functions of mononuclear leukocytes and endothelial cell leukocyte adhesion molecules in the formation of early atherosclerotic lesions is discussed. The main transgenic mouse models developed to study cholesterol metabolism and atherosclerotic lesion formation, including apolipoprotein E knockout and low density lipoprotein receptor knockout (LDLR-/-) mice, are reviewed. Differences in their dependence on dietary cholesterol supplementation is emphasized and a new semi-purified, cholate-free mouse diet for LDLR-/- mice is described. This diet is highly reproducible, versatile (pellet, powder or liquid formulations), inexpensive and promotes hypercholesterolemia and atherosclerotic lesion development despite absence of sodium cholate. We describe the expression patterns of leukocyte adhesion molecules in rabbit and mouse models of atherosclerosis and compare them to humans. Finally, ongoing studies are summarized which utilize transgenic mice to assess the roles of individual adhesion molecules in atherosclerotic lesion formation.

Patterns of vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 expression in rabbit and mouse atherosclerotic lesions and at sites predisposed to lesion formation

The recruitment of mononuclear leukocytes and formation of intimal macrophage-rich lesions at specific sites of the arterial tree are key events in atherogenesis. Inducible endothelial cell adhesion molecules may participate in this process. In aortas of normal chow-fed wild-type mice and rabbits, vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1), but not E-selectin, were expressed by endothelial cells in regions predisposed to atherosclerotic lesion formation. En face confocal microscopy of the mouse ascending aorta and proximal arch demonstrated that VCAM-1 expression was increased on the endothelial cell surface in lesion-prone areas. ICAM-1 expression extended into areas protected from lesion formation. Hypercholesterolemia induced atherosclerotic lesion formation in rabbits, LDL receptor and apolipoprotein E knockout mice, and Northern blot analysis demonstrated increased steady-state mRNA levels of VCAM-1 and ICAM-1, but not of E-selectin. Immunohistochemical staining revealed that VCAM-1 and ICAM-1 were expressed predominantly by endothelium in early lesions and by intimal cells in more advanced lesions. In early and advanced lesions, staining was most intense in endothelial cells at and adjacent to lesion borders. ICAM-1 staining extended into the uninvolved aorta. These expression patterns were highly reproducible in both species. The only difference was that VCAM-1 expression in endothelium over the central portions of lesions was found frequently in rabbits and rarely in mice. The expression of VCAM-1 by arterial endothelium in normal animals may represent a pathogenic mechanism or a phenotypic marker of predisposition to atherogenesis.