Industry Funding of Oncology Randomised Controlled Trials: Implications for Design, Results and Interpretation

AIMS

Most randomised controlled trials (RCTs) in oncology are now funded by the pharmaceutical industry. We explore the extent to which RCT design, results and interpretation differ between industry-funded and non-industry-funded RCTs.

MATERIALS AND METHODS

In this cross-sectional analysis, a structured literature search was used to identify all oncology RCTs published globally during 2014-2017. Industry funding was identified based on explicit statements in the publication. Descriptive statistics were used to compare elements of trial methodology and output between industry- and non-industry-funded RCTs.

RESULTS

The study sample included 694 RCTs; 71% were funded by industry. Industry-funded trials were more likely to test systemic therapy (97% versus 62%; P < 0.001), palliative-intent therapy (71% versus 41%; P < 0.001) and study breast cancer (20% versus 12%; P < 0.001). Industry-funded trials were larger (median sample size 474 versus 375; P < 0.001) and more likely to meet their primary end point (49% versus 41%; P < 0.001). Among positive trials, there were no differences in the magnitude of benefit between industry- and non-industry-funded RCTs. Trials funded by industry were published in journals that had a significantly higher median impact factor (21, interquartile range 7, 28) than non-industry-funded trials (impact factor 12, interquartile range 5, 24; P = 0.005); this persisted when adjusted for whether a trial was positive or negative.

CONCLUSIONS

The vast majority of oncology RCTs are now funded by industry. Industry-funded trials are larger, more likely to be positive, predominantly test systemic therapies in the palliative setting and are published in higher impact journals than trials without industry support.

A Canadian single institution real-world experience using the CROSS trial regimen in the treatment of Esophageal and Gastroesophageal Junction Carcinoma

BACKGROUND

Trimodality therapy using the CROSS trial protocol is an accepted standard of care for locally advanced esophageal and gastroesophageal junction cancers. For medically inoperable patients, chemoradiation (CRT) has been a therapeutic option. This single institution review aimed to assess the real-world application of the CROSS trial protocol.

METHODS

This is a retrospective review of 83 patients who underwent CRT with carboplatin and paclitaxel with trimodality or definitive intent between June 2012 and June 2018. 65 patients underwent neoadjuvant CRT (NCRT); 40 had surgery. 18 had definitive CRT (DCRT). Patients' demographics, clinical, pathological, treatment and surgical characteristics were assessed. The data was analyzed in exploratory analyses and Kaplan-Meier curves.

RESULTS

For the 83 patients, the following median values were seen: RT dose 50.4 Gy, chemotherapy doses 5, time from CRT to surgery 62 days. 23% NCRT and 72% DCRT patients were ≥ 75 yrs and 49%, and 33% of these respectively had no interruptions to CRT. Patients ≥75 yrs were more likely to have DCRT (p = 0.001). Patients who underwent surgery were younger (p = 0.04). For NCRT and surgery, NCRT only, and DCRT respectively, median overall survival was 35.5, 12.1 and 17.1 months (log rank p=0.008); progression free survival was 32.2, 10 and 9.6 months (log rank p=0.001).

CONCLUSIONS

Despite broadening of the CROSS trial eligibility criteria in our real-world data, there appears to be a survival benefit with trimodality therapy. The use of carboplatin and paclitaxel in DCRT may be of value and requires further study. This article is protected by copyright. All rights reserved.

Longitudinal assessment of health-related quality of life in osteoporosis: data from the population-based Canadian Multicentre Osteoporosis Study

Little is known about the association between health-related quality of life (HRQOL) and osteoporosis in the absence of fracture, and how HRQOL may change over time. This study provides evidence of substantially reduced HRQOL in women and men with self-reported and/or BMD-confirmed osteoporosis, even in the absence of fragility fracture.

INTRODUCTION

Fragility fractures have a detrimental effect on the health-related quality of life (HRQOL) of those with osteoporosis. Less is known about the association between HRQOL and osteoporosis in the absence of fracture.

METHODS

Canadian Multicentre Osteoporosis Study participants completed the SF-36, a detailed health questionnaire and measures of bone mineral density (BMD) at baseline and follow-up. We report the results of participants ≥ 50 years with 10-year follow-up. Self-reported osteoporosis at baseline and BMD-based osteoporosis at follow-up were ascertained. Multivariable linear regression models were developed for baseline SF-36 domains, component summaries, and change over time, adjusting for relevant baseline information.

RESULTS

Baseline data were available for 5266 women and 2112 men. Women in the osteoporosis group had substantially lower SF-36 baseline scores, particularly in the physically oriented domains, than those without osteoporosis. A similar but attenuated pattern was evident for the men. After 10-year follow-up (2797 women and 1023 men), most domain scores dropped for women and men regardless of osteoporosis status, with the exception of mentally-oriented ones. In general, a fragility fracture was associated with lower SF-36 scores and larger declines over time.

CONCLUSIONS

This study provides evidence of substantially reduced HRQOL in women and men with self-reported and/or BMD-confirmed osteoporosis, even in the absence of fragility fracture. HRQOL should be thoroughly investigated even prior to fracture, to develop appropriate interventions for all stages of the disease.

Adjuvant treatment in older patients with rectal cancer: a population-based review

Background

Little is known about the benefits of adjuvant chemotherapy (adj) in the older population with locally advanced rectal cancer (larc). We evaluated use of adj, survival outcomes, and adj-related toxicity in older patients with larc.

Methods

Our retrospective review included 286 patients with larc (stages ii and iii) diagnosed between January 2010 and December 2013 in Nova Scotia who underwent curative-intent surgery. Baseline patient, tumour, and treatment characteristics were collected. The survival analysis used the Kaplan-Meier method and Cox regression statistics.

Results

Of 286 identified patients, 152 were 65 years of age or older, and 92 were 70 years of age or older. Median follow-up was 46 months, and 163 patients (57%) received neoadjuvant chemoradiation. Although adj was given to 81% of patients (n = 109) less than 65 years of age, only 29% patients (n = 27) 70 years of age and older received adj. Kaplan-Meier analysis suggested a potential survival advantage for adj regardless of age. In multivariate Cox regression analysis, Eastern Cooperative Oncology Group performance status, T stage, and adj were significant predictors of overall survival (p < 0.04); age was not. Similarly, N stage, neoadjuvant chemoradiation, and adj were significant predictors of disease-free survival (p < 0.01). Poor Eastern Cooperative Oncology Group performance status was the most common cause of adj omission. In patients 70 years of age and older, grade 1 or greater chemotherapy-related toxicities were experienced significantly more often by those treated with adj (85% vs. 68% for those not treated with adj, p < 0.05).

Conclusions

Regardless of age, patients with larc seem to experience a survival benefit with adj. However, older patients are less likely to receive adj, and when they do, they experience more chemotherapy-related toxicities.

Medical oncology workload in Canada: infrastructure, supports, and delivery of clinical care

Background

In 2000, a Canadian task force recommended that medical oncologists (mos) meet a target of 160-175 new patient consultations per year. Here, we report the Canadian results of a global survey of mo workload compared with mo workload in other high-income countries (hics).

Methods

Using a snowball method, an online survey was distributed by national oncology societies to chemotherapy-prescribing physicians in 22 hics (World Bank criteria). The survey was distributed within Canada to all members of the Canadian Association of Medical Oncologists. Workload was measured as the annual number of new cancer patient consults per oncologist.

Results

The survey was completed by 782 oncologists from hics, including 58 from Canada. Median annual consults per mo were 175 in Canada compared with 125 in other hics. The proportions of mos having 100 or fewer consults or more than 300 consults per year were 3% (2/58) and 5% (3/58) in Canada compared with 31% (222/724) and 16% (116/724) in other hics (p < 0.001 and p = 0.023 respectively). The median number of patients seen in a full-day clinic was 15 in Canada and 25 in other hics (p = 0.220). Canadian mos reported spending a median of 55 minutes per new consultation; new consultations of 35 minutes were reported in other hics (p < 0.001). Median hours worked per week was 55 in Canada and 45 in other hics (p = 0.200).

Conclusions

Although the median annual clinical volume for Canadian mos aligns with recommended targets, half the respondents exceeded that level of activity. Health policymakers and educators have to consider mo workforce supply and alternative models of care in preparation for the anticipated surge in cancer incidence in the coming decade.

Toward improved goals-of-care documentation in advanced cancer: report on the development of a quality improvement initiative

Background

Documentation of advance care planning for patients with terminal cancer is known to be poor. Here, we describe a quality improvement initiative.

Methods

Patients receiving palliative chemotherapy for metastatic lung, pancreatic, colorectal, and breast cancer during 2010-2015 at the Cancer Centre of Southeastern Ontario were identified from electronic pharmacy records. Clinical notes were reviewed to identify documentation of care plans in the event of acute deterioration. After establishing baseline practice, we sought to improve documentation of goals of care and referral rates to palliative care. Using quality improvement methodology, we developed a guideline, a standardized documentation system, and a process to facilitate early referral to palliative care.

Results

During 2010-2015, 456 patients were included in the baseline cohort: 63% with lung cancer, 16% with colorectal cancer, 13% with pancreatic cancer, and 7% with breast cancer. Care goals in the event of an acute illness were documented by medical oncologists in 6% of cases (26 of 456). Of the 456 patients, 47% (n = 214) were seen by palliative care; care goals were documented by palliative care in 48% of the patients seen (103 of 214). With those baseline data in hand, a local practice guideline and process was developed to facilitate the identification of patients for whom advance care planning and early palliative care referral should be considered. A system was also established so that goals-of-care documentation will be supported with a written framework and broadly accessible in the electronic medical record.

Conclusions

Low rates of documentation of advance care planning and referral to palliative care persist and have stimulated a local quality improvement initiative.

Shifting practice in definitive chemoradiation for localized esophageal cancer

BACKGROUND

The efficacy of carboplatin-paclitaxel in the trimodality setting was demonstrated in the cross trial. Because of better tolerance, that regimen has been adopted as an alternative for patients receiving definitive chemoradiation (dcrt). The purpose of our study was to compare outcomes in patients with localized esophageal and gastroesophageal junction (gej) cancer who received dcrt using either platinum-5-fluorouracil (5fu) or carboplatin-paclitaxel.

METHODS

Medical records and outcomes for all patients diagnosed with localized carcinoma of the esophagus and gej at our centre between 2008 and 2015 were reviewed. All patients who underwent dcrt using cisplatin-5fu, carboplatin-5fu, or carboplatin-paclitaxel were included.

RESULTS

The 73 identified patients (34 cisplatin-5fu, 13 carboplatin-5fu, 26 carboplatin-paclitaxel) were all prescribed concomitant radiotherapy of 50 Gy in 25 daily fractions. The diagnosis was adenocarcinoma in 64% and squamous cell carcinoma in 36%. Median overall survival (os) duration for the cisplatin-5fu group was 28 months [95% confidence interval (ci): 19 to 41 months], with a 3-year os rate of 44%, in contrast to the 15 months (95% ci: 11 to 17 months) and 15% in the carboplatin-paclitaxel group (log-rank p = 0.0047). Median os duration for the carboplatin-5fu group was 17 months (95% ci: 11 to 68 months) with a 3-year os rate of 31%. Adjusting for patient and disease factors, better os durations and rates were associated with cisplatin-5fu (hazard ratio: 0.34; p = 0.0016) and carboplatin-5fu (hazard ratio: 0.55; p = 0.20) than with carboplatin-paclitaxel.

CONCLUSIONS

In a dcrt regimen, a better os is associated with cisplatin-5fu than with carboplatin-paclitaxel. Clinical trials to determine optimal chemotherapy regimens are warranted for patients who are not suitable for surgery.

Evaluation of the utility of the ISTH-BAT in haemophilia carriers: a multinational study

INTRODUCTION

There has been increasing recognition in recent years that female carriers of haemophilia manifest abnormal bleeding; however, data on the use of bleeding assessment tools in this population are lacking.

AIM

Our objective was to validate the ISTH-BAT in haemophilia carriers to describe bleeding symptoms and allow for comparisons with factor levels and other patient groups.

METHODS

This was a prospective, observational, cross-sectional study performed by members of Global Emerging HEmostasis Panel (GEHEP). Unselected consecutive haemophilia carriers were recruited and a CRF and the ISTH-BAT were completed by study personnel.

RESULTS

A total of 168 haemophilia carriers were enrolled: 155 haemophilia A and 13 haemophilia B. The mean age was 40 years (range: 20-82). Carriers had higher mean bleeding scores (BS) compared with age-matched controls (n = 46; 5.7 vs. 1.43; P < 0.0001) and Type 3 VWD OC (n = 32; 3.0; P = 0.009), but lower BS compared with women with Type 1 VWD (n = 83; 8.7; P < 0.0001). Fifteen carriers reported haemarthrosis, and of those six had normal FVIII/FIX levels. There was a significant but weak negative correlation between BS and factor level (Spearman's r²  = -0.36, P < 0.001).

CONCLUSION

Our results show that haemophilia carriers experience abnormal bleeding, including haemarthrosis. Overall, BS in women with Type 1 VWD > haemophilia carriers > Type 3 VWD OC > controls. Understanding the performance of the ISTH-BAT in this population is a critical step in future research aimed at investigating the underlying pathophysiology of abnormal bleeding, with the ultimate goal of optimizing treatment.

A retrospective analysis of the role of proton pump inhibitors in colorectal cancer disease survival

BACKGROUND

Proton pump inhibitors (ppis) are a commonly used medication. A limited number of studies have identified a weak-to-moderate association between ppi use and colorectal cancer (crc) risk, but none to date have identified an effect of ppi use on crc survival. We therefore postulated that an association between ppi use and crc survival might potentially exist.

METHODS

We performed a retrospective chart review of 1304 crc patients diagnosed from January 2005 to December 2011 and treated at the Cancer Centre of Southeastern Ontario. Kaplan-Meier analysis and Cox proportional hazards regression models were used to evaluate overall survival (os).

RESULTS

We identified 117 patients (9.0%) who were taking ppis at the time of oncology consult. Those taking a ppi were also more often taking asa or statins (or both) and had a statistically significantly increased rate of cardiac disease. No identifiable difference in tumour characteristics was evident in the two groups, including tumour location, differentiation, lymph node status, and stage. Univariate analysis identified a statistically nonsignificant difference in survival, with those taking a ppi experiencing lesser 1-year (82.1% vs. 86.7%, p = 0.161), 2-year (70.1% vs. 76.8%, p = 0.111), and 5-year os (55.2% vs. 62.9%, p = 0.165). When controlling for patient demographics and tumour characteristics, multivariate Cox regression analysis identified a statistically significant effect of ppi in our patient population (hazard ratio: 1.343; 95% confidence interval: 1.011 to 1.785; p = 0.042).

CONCLUSIONS

Our results suggest a potential adverse effect of ppi use on os in crc patients. These results need further evaluation in prospective analyses.

The Paced Auditory Serial Addition Test: to what extent is it performed as instructed, and is it associated with disease course?

One commonly used outcome measure in multiple sclerosis (MS) clinical trials is the Multiple Sclerosis Functional Composite, which includes the Paced Auditory Serial Addition Test (PASAT) as a measure of cognitive function. Concerns have been raised about the standard PASAT scoring method, whereby the number of correct responses is summed. This method does not take into account whether the test is performed as intended, which may affect interpretation of the results. Accordingly, another scoring method has been proposed, which examines the number of times a correct response is immediately preceded by another correct response (termed a dyad). We compared the two scoring methods for the PASAT, and found that the mean percentage of correct responses not accounted for by dyads ranged from 27.5% to 49.5%, indicating that much of the time the test is not performed as instructed. We also examined disease course and the PASAT score, as studies have produced conflicting results as to whether disease course is associated with cognitive impairment. Although disease course was significantly associated with the PASAT score, it accounted for little of the variation in scores, even when adjusting for other predictors. Finally, as 14.2% of participants refused to do the PASATor failed to complete it, we also examined whether the Perceived Deficits Questionnaire (PDQ), a self-reported measure of cognitive function, is a potential proxy measure for the PASAT. The correlation between the two tools was low (-0.14), suggesting that the PDQ is not a useful substitute for the PASAT.

A retrospective study on the role of diabetes and metformin in colorectal cancer disease survival

BACKGROUND

Recent studies have suggested an effect of metformin on mortality for patients with both diabetes and colorectal cancer (crc). However, the literature is contradictory, with both positive and negative effects being identified. We set out to determine the effect of metformin with respect to prognosis in crc patients.

METHODS

After a retrospective chart review of crc patients treated at the Cancer Centre of Southeastern Ontario, Kaplan-Meier analyses and Cox proportional hazards regression models were used to compare overall survival (os) in patients with and without diabetes.

RESULTS

We identified 1304 crc patients treated at the centre. No significant differences between the diabetic and nondiabetic groups were observed with respect to tumour pathology, extent of metastatic disease, time or toxicity of chemotherapy, and the os rate (1-year os: 85.6% vs. 86.4%, p = 0.695; 2-year os: 73.6% vs. 77.0%, p = 0.265). In subgroup analysis, diabetic patients taking metformin survived significantly longer than their counterparts taking other diabetes treatments (os for the metformin group: 91% at 1 year; 80.5% at 2 years; os for the group taking other treatments, including diet control: 80.6% at 1 year, 67.4% at 2 years). Multivariate analysis suggests that patients with diabetes taking treatments other than metformin experience worse survival (p = 0.025).

CONCLUSIONS

Our results suggest that crc patients with diabetes, excluding those taking metformin, might have a worse crc prognosis. Taking metformin appears to have a positive association with prognosis. The protective nature of metformin needs further evaluation in prospective analyses.

Generation and optimization of the self-administered bleeding assessment tool and its validation as a screening test for von Willebrand disease

INTRODUCTION/AIM

Our aim was to generate, optimize and validate a self-administered bleeding assessment tool (self-BAT) for von Willebrand disease (VWD).

METHODS

In Phase 1, medical terminology in the expert-administered International Society on Thrombosis and Haemostasis (ISTH)-BAT was converted into a Grade 4 reading level to produce the first version of the Self-BAT which was then optimized to ensure agreement with the ISTH-BAT. In Phase 2, the normal range of bleeding scores (BSs) was determined and test-retest reliability analysed. In Phase 3, the optimized Self-BAT was tested as a screening tool for first time referrals to the Haematology clinic.

RESULTS

Bleeding score from the final optimized version of the Self-BAT showed an excellent intra-class correlation coefficient (ICC) of 0.87 with ISTH-BAT BS in Phase 1. In Phase 2, the normal range of BSs for the optimized Self-BAT was determined to be 0 to +5 for females and 0 to +3 for males and excellent test-retest reliability was shown (ICC = 0.95). In Phase 3, we showed that a positive Self-BAT BS (≥6 for females, ≥4 for males) has a sensitivity of 78%, specificity of 23%, positive predictive value (PPV) of 0.15 and negative predictive value (NPV) of 0.86 for VWD; these figures improved when just the females were analysed; sensitivity of 100%, specificity of 21%, PPV = 0.17 and NPV = 1.0.

CONCLUSION

We show an optimized Self-BAT can generate comparable BS to the expert-administered ISTH-BAT and is a reliable, effective screening tool to incorporate into the assessment of individuals, particularly women, referred for a possible bleeding disorder.

Abstract P6-06-56: Emergency room visits and hospital admission rates after curative chemotherapy for breast cancer. A retrospective single center experience

Purpose:Patients undergoing curative (adjuvant or neoadjuvant) chemotherapy (CT) for breast cancer in the Southeast Ontario Local Heath Integration Network (LHIN) have higher rates of emergency room (ER) visits and hospital admissions (HA) compared to other LHINs in Ontario, Canada. This study is to determine factors associated with ER visits and HA after curative chemotherapy for breast cancer in a tertiary Ontario hospital.

Methods:A retrospective study was conducted of all patients who completed at least one cycle of curative CT for breast cancer at the Cancer Centre for Southeastern Ontario (CCSEO) in 2011 and 2012. We recorded all ER visits and/or HA within 30 days of any cycle of CT. Data collected included demographics, co-morbidities, type and date of surgery, pathologic tumour characteristics (stage, grade and receptor status), type of CT (adjuvant or neoadjuvant) and number of cycles, use and type of granulocyte-colony stimulating factors (G-CSF). We recorded dates and reasons for ER visits, referring patterns to the ER, date of admission and length of stay. Chi-square and t-tests were calculated to determine factors associated with ER visits and HA.

Results:149 patients received curative CT at the CCSEO in 2011 and 2012. Mean age was 58 (range 31-88). 97.3% of patients were female. Comorbidities included hypertension (28.4%), diabetes (10.1%), dyslipidemia (10.1%), coronary artery disease (4.7%) and COPD (2%). Stage distribution was: 4.3% stage 1, 48.6% stage 2 and 36.4% stage 3. 60.8% of patients had grade 3 tumors. 69.8% were ER positive and 61.1% were PR positive. 26.2% were Her2 positive. 62.4% had breast conserving surgery and 56.4% had sentinel lymph node biopsy. Most patients received adjuvant CT (85.2%). The most common CT regimen was FEC-D (89.9%), followed by TC (5.4%) and CMF (4%). 88.6% of patients received G-CSF (either Neupogen or Neulasta) at some point during CT. 53% (n = 79) of patients were seen in the ER at least once within 30 days of CT while 13.4% (n = 20) were admitted to hospital. 36.7% (n = 29) had multiple ER visits. There were a total of 133 ER visits. The most common causes of ER visits were fever without neutropenia (23.3%), pain (13.5%) and febrile neutropenia (9%). Most ER visits occurred on weekdays (74%). We analyzed the following factors associated with ER visits and HA rates: age, gender, comorbidities, TNM staging, grade, receptor status, type of surgery and CT (adjuvant versus neoadjuvant). The only statistically significant factor associated with a higher likelihood of ER visits was stage IIIC breast cancer (p = 0.045). Statistically significant factors associated with HA were tumor size with T2 more likely to be admitted (p = 0.019), adjuvant CT (p = 0.045) and number of CT cycles (p = 0.017).

Conclusions:Over half of all patients receiving curative CT for breast cancer at the CCSEO in 2011 and 2012 visited the ER at least once and more than 1/3 required multiple visits. The only factor associated with ER visits included stage of disease. Factors associated with HA were tumour size, adjuvant CT and number of CT cycles. While most patients received G-CSF at some point during their CT, febrile neutropenia was still the third most common reason for ER visits.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-56.

The role of psycho-education in improving outcome at a general hospital psychiatry clinic in Uganda

OBJECTIVE

While psychoeducation has been shown to positively affect outcomes in psychiatric disorders, its utility has been little studied in developing countries. The current study sought to examine the role of psychoeducation at a general psychiatric outpatient clinic in Kampala, Uganda in improving clinic attendance, treatment adherence, and clinical outcomes.

METHOD

A prospective case-control study using a quasi-experimental design was conducted in 117 patients suffering various psychiatric disorders. Participants were recruited for two months and then followed for a further three months after recruitment ended. Participants in the intervention group received formalized psychoeducation sessions at each clinic visit in addition to the usual psychiatric evaluation and care. Participants in the control group received the usual clinical care. Measured outcomes were knowledge of mental illness, compliance with medications and follow-up, and Clinical Global Impression (CGI).

RESULTS

The groups did not differ with respect to sociodemographic characteristics or attendance at scheduled follow-up visits. Both groups significantly improved on the CGI, but with no significant difference between the groups. However, the intervention group was more likely to adhere to medication, and their knowledge of mental illness was significantly higher at follow-up.

CONCLUSION

These data suggest that psychoeducation is a beneficial mental health intervention in a developing country that may increase compliance with medication and result in greater knowledge of mental illness. However, other factors such as distance from a centralized clinic or cost of treatment may impact outcomes, including attendance at scheduled follow-up visits.

Real-world impact of granulocyte-colony stimulating factor on febrile neutropenia

BACKGROUND

Primary prophylaxis with granulocyte colony-stimulating factors (pp-g-csf) is recommended in patients undergoing chemotherapy carrying a febrile neutropenia (fn) risk of 20% or more. In the present study, we examined clinical practice patterns and the impact of pp-g-csf on fn incidence in women with early-stage breast cancer (ebc) treated with modern adjuvant chemotherapy (act).

METHODS

This single-centre retrospective cohort study of women with ebc, who were identified from the pharmacy database and who received at least 1 cycle of modern act from January 2009 to December 2011, was conducted at the Cancer Centre of Southeastern Ontario. Data on patient demographics, pathology, stage distribution, chemotherapy, pp-g-csf use, dose reductions, chemotherapy delays, treatment discontinuation, relative dose intensity, and fn events were collected. Chi-square tests, t-tests, univariate and multivariate logistic regression analyses, and nonparametric Mann-Whitney U-tests were used for data analysis.

RESULTS

Of the 239 women eligible for analysis, 145 (61%) received pp-g-csf, and 50 (21%) developed at least 1 episode of fn. Use of pp-g-csf was associated with a significantly lower rate of fn (14% vs. 31%, p = 0.002) and trends to fewer dose delays (17% vs. 27%, p = 0.060) and dose reductions (19% vs. 25%, p = 0.28). Among women receiving pp-g-csf, higher fn rates were associated with an age of 65 years or older, taxane-based chemotherapy, and prophylaxis with filgrastim.

CONCLUSIONS

Clinical practice patterns at our institution showed that more than 50% of ebc patients treated with modern act received pp-g-csf, which led to fewer fn episodes and increased delivery of planned act. The observed high fn risk despite pp-g-csf was linked to older age, taxane-based chemotherapy, and filgrastim.

Pain and health-related quality of life in people with chronic leg ulcers

INTRODUCTION

Venous leg ulceration is associated with pain and poor health-related quality of life (HRQL). The purpose of this study was to identify demographic and clinical characteristics associated with pain and decreased HRQL in patients with active venous ulcers.

METHODS

Baseline data were combined from two trials that took place between 2001 and 2007 (n = 564). Pain was measured using the Numeric Pain Scale (NPS), and HRQL was measured using the Medical Outcomes Survey 12-item Short Form (SF-12), which generates a Physical (PCS) and Mental Component Summary (MCS). Analyses included logistic and linear regression (for pain and HRQL, respectively).

RESULTS

Mean age was 66.5 years; 47% were male. Median NPS score was 2.2 (out of 10) and mean PCS and MCS scores were 38.0 and 50.5, respectively (scores are standardized to a mean of 50 representing average HRQL). Younger age, living with others, and arthritis were associated with pain. Poorer PCS was associated with being female, venous/mixed ulcer etiology, larger ulcers, longer ulcer duration, cardiovascular disease, arthritis and higher pain intensity. Poorer MCS was associated with younger age, longer ulcer duration, comorbidity and higher pain intensity.

CONCLUSION

Research is needed to test strategies to reduce pain and possibly improve HRQL in high risk groups.

Pain and health-related quality of life in people with chronic leg ulcers

Introduction

Venous leg ulceration is associated with pain and poor health-related quality of life (HRQL). The purpose of this study was to identify demographic and clinical characteristics associated with pain and decreased HRQL in patients with active venous ulcers.

Methods

Baseline data were combined from two trials that took place between 2001 and 2007 (n = 564). Pain was measured using the Numeric Pain Scale (NPS), and HRQL was measured using the Medical Outcomes Survey 12-item Short Form (SF-12), which generates a Physical (PCS) and Mental Component Summary (MCS). Analyses included logistic and linear regression (for pain and HRQL, respectively).

Results

Mean age was 66.5 years; 47% were male. Median NPS score was 2.2 (out of 10) and mean PCS and MCS scores were 38.0 and 50.5, respectively (scores are standardized to a mean of 50 representing average HRQL). Younger age, living with others, and arthritis were associated with pain. Poorer PCS was associated with being female, venous/mixed ulcer etiology, larger ulcers, longer ulcer duration, cardiovascular disease, arthritis and higher pain intensity. Poorer MCS was associated with younger age, longer ulcer duration, comorbidity and higher pain intensity.

Conclusion

Research is needed to test strategies to reduce pain and possibly improve HRQL in high risk groups.

Real-world experience with adjuvant fec-d chemotherapy in four Ontario regional cancer centres

BACKGROUND

The efficacy of adjuvant chemotherapy with fec-d (5-fluorouracil-epirubicin-cyclophosphamide followed by docetaxel) is superior to that with fec-100 alone in women with early-stage breast cancer. As the use of fec-d increased in clinical practice, health care providers anecdotally noted higher-than-expected toxicity rates and frequent early treatment discontinuations because of toxicity. In the present study, we compared the rates of serious adverse events in patients who received adjuvant fec-d chemotherapy in routine clinical practice with the rates reported in the pacs-01 trial.

METHODS

We retrospectively reviewed all patients prescribed adjuvant fec-d for early-stage breast cancer at 4 regional cancer centres in Ontario. Information was collected from electronic and paper charts by a physician investigator from each centre. Data were analyzed using chi-square tests, independent samples t-tests, one-way analysis of variance, and univariate regression.

RESULTS

The 671 electronic and paper patient records reviewed showed a median patient age of 52.2 years, 229 patients (34.1%) with N0 disease, 508 patients (75.7%) with estrogen or progesterone receptor-positive disease (or both), and 113 patients (26%) with her2/neu-overexpressing breast cancer. Febrile neutropenia occurred in 152 patients (22.7%), most frequently at cycle 4, coincident with the initiation of docetaxel [78/152 (51.3%)]. Primary prophylaxis with hematopoietic growth factor support was used in 235 patients (35%), and the rate of febrile neutropenia was significantly lower in those who received prophylaxis than in those who did not [15/235 (6.4%) vs. 137/436 (31.4%); p < 0.001; risk ratio: 0.20].

CONCLUSIONS

In routine clinical practice, treatment with fec-d is associated with a higher-than-expected rate of febrile neutropenia, in light of which, primary prophylaxis with growth factor should be considered, per international guidelines. Adoption based on clinical trial reports of new therapies into mainstream practice must be done carefully and with scrutiny.

A prospective evaluation of the prevalence of symptomatic von Willebrand disease (VWD) in a pediatric primary care population

The prevalence of von Willebrand disease (VWD) is reported as approximately 1%; however, these estimates were not based on individuals with significant symptoms. Four thousand five hundred ninety-two unselected parents/children were asked: "Does your child have a problem with bleeding/bruising?"; 223 (5%) answered yes, 41 of whom were administered the validated Pediatric Bleeding Questionnaire and had VWF testing. Five were diagnosed with VWD (three type 1, one type 2A, one type 2B). The prevalence of bleeding/bruising in a general pediatric population is 5%; the prevalence of symptomatic VWD at the level of pediatric primary care is at least 1 in 1,000.

The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian Multicentre Osteoporosis Study

Using prospective data from the Canadian Multicentre Osteoporosis Study (CaMos), we compared health utilities index (HUI) scores after 5 years of follow-up among participants (50 years and older) with and without incident clinical fractures. Incident fractures had a negative impact on HUI scores over time.

INTRODUCTION

This study examined change in health-related quality of life (HRQL) in those with and without incident clinical fractures as measured by the HUI.

METHODS

The study cohort was 4,820 women and 1,783 men (50 years and older) from the CaMos. The HUI was administered at baseline and year 5. Participants were sub-divided into incident fracture groups (hip, rib, spine, forearm, pelvis, other) and were compared with those without these fractures. The effects of both time and fracture type on HUI scores were examined in multivariable regression analyses.

RESULTS

Men and women with hip fractures, compared to those without, had lower HUI measures that ranged from -0.05 to -0.25. Both women and men with spine fractures had significant deficits on the pain attributes (-0.07 to -0.12). In women, self-care (-0.06), mobility and ambulation (-0.05) were also negatively impacted. Women with rib fractures had deficits similar to women with spine fractures, and these effects persisted over time. In men, rib fractures did not significantly affect HUI scores. Pelvic and forearm fractures did not substantially influence HUI scores.

CONCLUSION

The HUI was a sensitive measure of HRQL change over time. These results will inform economic analyses evaluating osteoporosis therapies.

Associations between chronic disease, age and physical and mental health status

This paper examines the associations between chronic disease, age, and physical and mental health-related quality of life (HRQOL), using data collected in 10 studies representing five chronic conditions. HRQOL was measured using the SF-36 or the shorter subset, SF-12. Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were graphed by condition in age increments of 10 years, and compared to age- and sex-adjusted normative data. Linear regression models for the PCS and MCS were controlled for available confounders. The sample size of 2418 participants included 129 with renal failure, 366 with osteoarthritis (OA), 487 with heart failure, 1160 with chronic wound (leg ulcer) and 276 with multiple sclerosis (MS). For the PCS, there were large differences between the normative data and the mean scores of those with chronic diseases, but small differences for the MCS. Female gender and comorbid conditions were associated with poorer HRQOL; increased age was associated with poorer PCS and better MCS. This study provided additional evidence that, while physical function could be severely and negatively affected by both chronic disease and advanced age, mental health remained relatively high and stable.

Generation and validation of the Condensed MCMDM-1VWD Bleeding Questionnaire for von Willebrand disease

BACKGROUND

Given the challenges involved in obtaining accurate bleeding histories, attempts at standardization have occurred and the value of quantifying hemorrhagic symptoms has been recognized.

PATIENTS/METHODS

An extensive validated bleeding questionnaire (MCMDM-1VWD) was condensed by eliminating all details that did not directly affect the bleeding score (BS) and the correlation between the two versions was tested. Additionally, the diagnostic utility of the condensed version was prospectively tested.

RESULTS

Data on 259 individuals who were administered the questionnaire are presented here; 217 being prospectively investigated for von Willebrand disease (VWD) (group 1) and 42 previously known to have type 1, 2 or 3 VWD (group 2). Of the 217 prospectively investigated, 35 had positive BS (> or =4) and 182 had negative scores. Seven individuals (all with positive BS) had laboratory results consistent with type 1 VWD. This results in a sensitivity of 100% and a specificity of 87%. The positive predictive value is 0.20 and the negative predictive value is 1. The correlation between the full MCMDM-1VWD and condensed versions is excellent (Spearman's 0.97, P < 0.001, linear regression r(2) = 96.4). Inter-observer reliability for the condensed version is reasonable (Spearman's 0.72, P < 0.001 and intra-class correlation coefficient 0.805, P < 0.001). There was a significant difference in BS between subtypes of VWD, with type 3 >> type 2 >> type 1 VWD (anova P < 0.001). There is a strong inverse relationship between VWF:Ag level and BS (Spearman's -0.411, P < 0.001).

CONCLUSIONS

The Condensed MCMDM-1VWD Bleeding Questionnaire is an efficient, effective tool in the evaluation of patients for VWD.

Decreased dose density of standard chemotherapy does not compromise survival for ovarian cancer patients

For women diagnosed with ovarian cancer, the standard practice of surgery followed by adjuvant platinum-taxane combination chemotherapy, with cycles administered every 3 weeks, is based on randomized control trials. However, a substantial number of patients require delays or reductions on this schedule. The Cancer Centre of Southeastern Ontario (CCSEO) has historically administered chemotherapy every 4 weeks. We analyzed survival outcomes of our cohort. All ovarian cancer patients treated with chemotherapy at the CCSEO from 1995 to end-2002 were included in this study. Overall survival and progression-free survival were calculated from initiation of chemotherapy using the Kaplan-Meier technique and log-rank tests. Cox regression analysis was used to adjust for age and disease stage. A total of 171 patients were treated with chemotherapy (cisplatin-paclitaxel or carboplatin-paclitaxel), of which 144 received chemotherapy every 4 weeks and 27 every 3 weeks. Median progression-free survival was 19.2 months for the group treated every 4 weeks vs 13.2 months for the 3-weekly group. Median overall survival was 36.5 months compared to 27.1 months, respectively. Trends favored treatment every 4 weeks. In early-stage disease, 5-year overall survival was 74% and 5-year progression-free survival was 68%. Administration of platinum-paclitaxel chemotherapy every 4 weeks did not reduce survival of ovarian cancer patients. Importantly, median survival is favorable compared to results from landmark trials where patients were treated every 3 weeks. These results suggest that decreasing the frequency of chemotherapy cycles does not decrease survival. Prospective trials would be required to compare quality of life and cost-effectiveness.

Prevalence of and factors associated with glucosamine use in Canada

OBJECTIVE

Glucosamine is commonly used for the treatment of osteoarthritis, and its use is increasing in the general population. The Canadian Multicentre Osteoporosis Study (CaMos) provided an opportunity to examine the prevalence of glucosamine use across age and gender groups, and to assess the factors associated with its use.

METHOD

CaMos is a random, population-based sample of 9423 Canadians. Baseline assessments took place in 1996-1997 and the 5-year follow-up assessments in 2001-2002. The primary outcome of this analysis was glucosamine use at year 5. Prevalence estimates were age- and sex-standardized to the Canadian population. A number of factors potentially associated with glucosamine use were identified from the literature. Multivariable logistic regression was used to identify variables associated with glucosamine use.

RESULTS

At 5 years, complete data were available for 7652 of the original 9423 participants (81.2%). For men, glucosamine use increased from 0.9% to 4.7% (weighted values), and for women, it increased from 1.3% to 8.2%. Glucosamine use was higher among older participants, those living in western Canada, and those with arthritis, back pain, higher calcium intake from supplements, physical activity and prior glucosamine use.

CONCLUSIONS

Glucosamine use increased substantially over 5 years, and its use is associated with a number of factors. Some may use glucosamine to manage pain and symptoms of arthritis and back pain, while others use it as a preventive measure to maintain health.

Health-related quality of life measurements in elderly Canadians with osteoporosis compared to other chronic medical conditions: a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos)

The objective of this research was to determine the relative decrement in health-related quality of life, as measured by the health utilities index mark 3 (HUI3), in osteoporosis compared to other chronic medical conditions. The impact of chronic medical conditions other than osteoporosis on HUI3 measurements had been previously established in the 1996/1997 Canadian National Population Health Survey (NPHS). The Canadian Multicentre Osteoporosis Study (CaMos) is a national population-based study in which regional participants were randomly recruited, regardless of presence of osteoporosis. We analyzed data from participants aged > or = 65 years who completed a baseline HUI3 questionnaire and provided information on their medical history (n=3,750). We determined the age- and gender-adjusted mean decrement in HUI3 for several chronic medical conditions, including osteoporosis. The mean changes in HUI3 adjusted for age and gender (with 95% confidence intervals) were as follows: arthritis -0.10 (-0.11, -0.09), chronic obstructive pulmonary disease (COPD) -0.07 (-0.09, -0.05), diabetes mellitus -0.05 (-0.08, -0.03), heart disease -0.06 (-0.08, -0.04), hypertension -0.02 (-0.03, -0.01), and osteoporosis -0.08 (-0.11, -0.06), respectively (model r2=0.17; P<0.0001). These findings were comparable to those observed in the NPHS, with the exception of osteoporosis, which had not been previously studied in this fashion. The decrement in HUI3 score seen in participants with osteoporosis was comparable to that observed in other chronic medical conditions, such as arthritis, COPD, diabetes mellitus or heart disease.

Dysautonomia among patients with fibromyalgia: a noninvasive assessment

OBJECTIVE

Fibromyalgia (FM) is a prevalent and poorly understood disorder associated with a significant amount of disability. Some clinical characteristics are common to both FM and vasovagal syncope (which is caused by dysautonomia). We assessed the response of patients with FM to a head up tilt table test (HUT). We also examined sympathovagal balance by assessing heart rate variability (HRV).

METHODS

We studied 17 women with FM and 14 female control subjects. After baseline functional assessments, they underwent a 3 stage HUT (with isoproterenol). HRV was assessed over a 24 h period and also before and during HUT. Quality of life was assessed using the Medical Outcomes Study SF-36 Short Form Health Survey.

RESULTS

HUT was positive in 64.7% of the patients with FM compared with 21.3% of controls (p = 0.016). FM patients had less HRV, as measured by either time domain or frequency domain analysis. The FM group had a different response to HUT than controls. Quality of life was significantly lower in patients with FM compared to controls (p < or = 0.001 in all domains).

CONCLUSION

Patients with FM have abnormal responses to 2 tests of autonomic nervous system function. Further research is needed to determine if dysautonomia plays a role in the pathogenesis of FM or is a result of FM.

Physical functioning and mental health in patients with chronic medical conditions

There is evidence to suggest that a decline in physical functioning with advancing age is independent of mental health, which appears to remain relatively stable. There is additional evidence to suggest that those with a chronic disease also experience a decline in physical function while the mental health remains relatively stable. Using a cross-sectional design, data from the US population norms for the Medical Outcomes Study SF-36 are examined and compared to SF-36 data collected for four patient groups. Patient groups include kidney dialysis patients, multiple sclerosis patients, kidney transplant patients and patients with severe osteoarthritis of the hip prior to total hip replacement. Overall scores and scores within 10-year age groupings are examined in order to compare the physical functioning and mental health scores of the general population with those of the four patient groups. Results support the hypothesis that physical functioning declines with advancing age and with the development of chronic disease, but mental health remains remarkably stable regardless of chronic disease and/or advancing age. This observation suggests a process of psychological adjustment or adaptation to the physical difficulties encountered with advanced age or disability, and implies that this adjustment process may in fact be quite strong.

Assessment of the effect of asthma education on outcomes

Community asthma care centers have been introduced to meet the increasing need for community-based assessment, management, and education of patients with asthma. The Asthma Education Centre at Oakville-Trafalgar Hospital, in Ontario, Canada, has implemented a comprehensive assessment, treatment, and education program with a collection of relevant patient data. The findings presented in this article suggest that these specific education and treatment programs are associated with not only significant reductions in the use of health services, but improvements in health outcomes as well.

Determinants of health-related quality of life following elective total hip replacement

This study examined the patient perspective of surgical success through the measurement of health-related quality of life (HRQOL), in order to identify the patient characteristics and process issues associated with postoperative changes in health status. Patients completed the RAND 36-item Health Survey 1.0 (SF-36) prior to surgery and at 6 months following surgery. Baseline patient demographic and clinical information were collected from the medical record and were used to develop models of change in HRQOL for 68 patients. While many patients improved, a number experienced no change or even a decline in HRQOL in the postoperative period. Factors associated with change in HRQOL are presented. The findings suggest that factors associated with change in health status can be systematically assessed, which may lead to the development of interventions aimed at those patient characteristics or process issues that impact on HRQOL.

Impact of portable APD on patient perception of health-related quality of life

We assessed the impact of the introduction of a portable automated peritoneal dialysis (APD) system (Homechoice, Baxter Healthcare) on health-related quality of life (HRQOL). We evaluated HRQOL in 26 patients using the RAND 36-item Health Survey 1.0, which measures physical functioning, role limitations (physical and emotional), social functioning, emotional well-being, pain, energy, and general health perceptions. Questionnaires were administered prior to changing to the new system and 3 months later. Kt/V and albumin levels were measured at both time points. Eight patients had been on continuous ambulatory peritoneal dialysis (CAPD), and 18 had been using other APD systems (PacXtra, Baxter and AMP80, Fresenius). Kt/V increased significantly (p = 0.026); albumin was unchanged (p = 0.09). There was an improvement in the pain score (p = 0.079), although this did not reach statistical significance in the overall sample. Subgroup analysis showed that most of the improvement was from the group that had used the AMP80. No other statistically significant differences were found overall in the domains of HRQOL. Questioning of a random sample of patients indicated that perceived advantages of the new system were ease of setup and portability within the home. Neither of these translated into improvement in role-functioning domains of HRQOL. The improvement in pain score may reflect the capacity of newer cyclers to switch from drain to fill after a set proportion of dialysate has drained, leaving the patient empty for less of the time. Portable APD systems did not bring about predicted improvements in HRQOL. The HRQOL instrument may be insensitive, but technologically convenient advances may have limited impact on HRQOL due to its multifactorial nature.

Measurement of health-related quality of life in multiple sclerosis patients

BACKGROUND

Patient outcomes in multiple sclerosis (MS) have generally been measured by their neurological impairment using specific scales such as the Kurtzke Expanded Disability Status Scale (EDSS). However, this scale does not measure the multiple dimensions of health-related quality of life (HRQOL) such as functional status and general well-being, which are also important outcomes along with disease-specific measurements.

METHODS

HRQOL was measured in a group of 97 MS patients using the RAND 36-item Health Survey 1.0. The EDSS score was assigned by the clinic neurologist. Additional data were collected from the clinical record for each patient.

RESULTS

MS patients scored poorly in a number of HRQOL domains such as physical and role functioning and energy or vitality. Disability as quantified by the EDSS correlated only with the physical functioning domain. Regression models were developed to measure the relationship between patient characteristics (independent variables) and HRQOL domains (dependent variables).

DISCUSSION

A number of patient characteristics were associated with higher or lower scores on the HRQOL domains. Of particular interest is the finding that a family history of MS was associated with poorer physical and social functioning as well as more pain and less vitality. The occurrence of seizures had a negative impact on role functioning, social functioning and general health perceptions. HRQOL gives caregivers a broader measure of disease burden than the EDSS alone, and should be useful in planning and monitoring interventions.

Use of severity of illness to evaluate quality of care

This study compared a severity of illness system (APACHE II) and a 10% random sample of charts in terms of their ability to identify cases with quality problems. Using condition-specific data bases of 337 pneumonia, 363 acute myocardial infarction and 266 hip fracture charts, severity of illness information was used to separate cases into those with a high and a low likelihood of a poor outcome. Cases with low admission severity of illness combined with subsequent death were flagged as potential quality problems. Physician evaluation was used as the gold standard to measure flag performance. Flags were tested against a 10% random sample drawn from within the three condition-specific data bases. Analyses focused on a combination of sensitivity and positive predictive value. The low severity plus death flag performed much better than a 10% random sample approach, suggesting that outcomes monitoring flags based on severity of illness could play an important role in screening cases for potential quality problems.

Assessment of health status in peritoneal dialysis patients: a potential outcome measure

OBJECTIVES

To determine the feasibility and practicality of measuring general health status (GHS) in an outpatient peritoneal dialysis population. To determine whether GSH correlated intuitively with biochemical, socio-demographic and co-morbidity measurements.

DESIGN

The Medical Outcomes Study 20-item short form was administered on a voluntary basis in the outpatient setting. Demographic and current biochemical data were extracted from the medical record. The effects of the socio-demographic, biochemical and physiologic variables on the six subscales of GHS generated by the questionnaire were estimated using multivariate linear regression analysis resulting in the development of six separate models.

SETTING

Peritoneal dialysis program of a University Hospital.

PATIENTS

Sixty stable patients on home peritoneal dialysis completed the GHS questionnaire during regularly scheduled outpatient visits. Ages ranged from 13 to 81 years. The study group included 14 diabetics (23%).

RESULTS

Administering the questionnaire caused no logistical difficulties in the outpatient setting. Regression models for predicting GHS were both significant and intuitively correct. The presence of co-morbidities such as diabetes mellitus (p = 0.002; Social Subscale) and peripheral vascular disease (p = 0.016: General Health Subscale) had the most significant negative impact on GHS. An increased length of time on dialysis was associated with a higher GHS (p = 0.002; Physical Subscale).

CONCLUSION

General Health Status questionnaires can be readily administered to peritoneal dialysis patients in the outpatient setting. They have face validity as a measurement of wellness and functioning. The longitudinal use of such instruments in conjunction with clinical and laboratory findings may identify both medical and non-medical factors impacting on our peritoneal dialysis population.

Support services in Canadian schools for the hearing impaired: 10 years later

In January of 1977, a questionnaire regarding existing and desired professional support services was distributed to 20 schools for the hearing-impaired across Canada. Respondents were requested to provide information pertaining to the last few months of 1976. In December of 1986, a similar questionnaire was distributed to these schools, in order to update the information received 10 years earlier, and to compare current services to those desired 10 years ago. The survey also presented an opportunity to examine changes in focus, client population and number of schools for the hearing impaired in Canada. Despite the disparity between available and needed services in the schools, as well as the differences in support staff between them, it is clear that the schools are, for the most part, fairly well staffed by a good range of professionals. There is, however, a continued need for the review of current and future needs. The change from residential to day students, as well as the increase in the number of additionally handicapped students, requires changes in and re-assessment of support services. Continued research may assist in defining priorities in the area of support services as the needs of the schools change over time.