Diagnostic assessment program for prostate cancer: Lessons learned after 2 years and degree of compliance to Canadian guidelines

BACKGROUND

In 2018, our Institute launched the Diagnostic Assessment Program (DAP) for prostate cancer. It enabled quick access to a urologist for patients presented to family physician with elevated PSA and allowed fast multidisciplinary patient care. We aim to document our data over 2 years in comparison to data before implementation of DAP and its impact on the degree of adherence to Canadian guidelines.

METHODS

From April 2016 to April 2020, 880 patients who were evaluated for prostate cancer at Thunder Bay Regional Health Sciences Centre (TBRHSC) were included in this study. Patients' characteristics, clinical data, waiting times and line of treatment before and after implementation of DAP were calculated and statistically analysed.

RESULTS

The median waiting time to urology consultation was significantly reduced from 68 (IQR 27-168) days to 34 (23-44) days (p < 0.001). The time from patient's referral to prostate biopsy decreased substantially from 34 (20-66) days to 18(11- 25) days after DAP (p < 0.001). After DAP, the percentage of Gleason 6 detected prostate cancers were significantly increased (19.7% to 30%) (p = 0.02). After DAP, rate for intermediate-risk patients elected for external beam radiotherapy (from 53.5% to 57.9%, p = 0.53) and radical prostatectomy (from 34.5% to 39.4%, p = 0.47) increased. More compliance to Canadian guidelines was observed in intermediate risk patients (88% vs 97.3%, p =.008).

CONCLUSIONS

Implementation of DAP has led to a notable reduction of waiting time to urology consult and prostate biopsy. There is significant increase in Gleason 6 detected prostate cancer. Increased compliance to Canadian guidelines was detected in intermediate risk patients.

Craniospinal irradiation in the treatment of chemotherapy refractory leptomeningeal metastasis from breast cancer: A case report

Background

Leptomeningeal carcinomatosis is a relatively uncommon complication of solid tumors that is associated with significant morbidity and mortality. Prognosis is typically weeks to months and the neurologic complications of this disease can significantly affect quality of life. The role of craniospinal irradiation is unclear as evidence exploring this treatment option is limited. Despite lack of evidence, its use has decreased due to its associated acute toxicities and newer intrathecal alternatives.

Case

Here we report the case of a 50‐year‐old patient who received craniospinal irradiation for chemotherapy‐refractory leptomeningeal disease, with survival well beyond the median and good quality of life for the majority of that time.

Conclusion

This patient's remarkable survival and performance after treatment suggests that craniospinal irradiation could be considered more frequently in the treatment of leptomeningeal metastases. To our knowledge, this is the first case with significant survival following craniospinal irradiation for chemotherapy refractory disease presented. Further study on the use of craniospinal irradiation to treat leptomeningeal metastasis is recommended.

Surgery after chemoradiotherapy in patients with stage III (N2 or N3, excluding T4) non-small-cell lung cancer: a systematic review

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.

Initial management of small-cell lung cancer (limited- and extensive-stage) and the role of thoracic radiotherapy and first-line chemotherapy: a systematic review

Background

Patients with limited-stage (ls) or extensive-stage (es) small-cell lung cancer (sclc) are commonly given platinum-based chemotherapy as first-line treatment. Standard chemotherapy for patients with ls sclc includes a platinum agent such as cisplatin combined with the non-platinum agent etoposide. The objective of the present systematic review was to investigate the efficacy of adding radiotherapy to chemotherapy in patients with es sclc and to determine the appropriate timing, dose, and schedule of chemotherapy or radiation for patients with sclc.

Methods

The medline and embase databases were searched for randomized controlled trials (rcts) comparing treatment with radiotherapy plus chemotherapy against treatment with chemotherapy alone in patients with es sclc. Identified rcts were also included if they compared various timings, doses, and schedules of treatment for patients with es sclc or ls sclc.

Results

Sixty-four rcts were included. In patients with ls sclc, overall survival was greatest with platinum-etoposide compared with other chemotherapy regimens. In patients with es sclc, overall survival was greatest with chemotherapy containing platinum-irinotecan than with chemotherapy containing platinum-etoposide (hazard ratio: 0.84; 95% confidence interval: 0.74 to 0.95; p = 0.006). The addition of radiation to chemotherapy for patients with es sclc showed mixed results. There was no conclusive evidence that the timing, dose, or schedule of thoracic radiation affected treatment outcomes in sclc.

Conclusions

In patients with ls sclc, cisplatin-etoposide plus radiotherapy should remain the standard therapy. In patients with es sclc, the evidence is insufficient to recommend the addition of radiotherapy to chemotherapy as standard practice to improve overall survival. However, on a case-by-case basis, radiotherapy might be added to reduce local recurrence. The most commonly used chemotherapy is platinum-etoposide; however, platinum-irinotecan can be considered.

Guideline for the Initial Management of Small Cell Lung Cancer (Limited and Extensive Stage) and the Role of Thoracic Radiotherapy and First-line Chemotherapy

AIMS

We investigated the efficacy of adding radiotherapy to chemotherapy in patients with extensive stage small cell lung cancer (ES-SCLC) and the appropriate timing, dose and schedule of treatment for patients with ES-SCLC or limited stage SCLC (LS-SCLC).

MATERIALS AND 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 randomised controlled trials.

KEY RECOMMENDATIONS

In patients with LS-SCLC (stage I, II and III), the addition of thoracic radiotherapy to standard chemotherapy is recommended. However, there is no clear evidence to inform definitive recommendations for optimal timing, sequential versus concurrent therapies and optimal dose or regimen. In patients with LS-SCLC, etoposide-cisplatin is the preferred regimen for adults who are being treated with combined modality therapy with curative intent. In patients with ES-SCLC (stage IV), there is insufficient evidence to recommend the addition of thoracic radiotherapy to standard chemotherapy as a standard practice for survival benefit; however, it could be considered on a case-by-case basis to reduce local recurrence. In patients with ES-SCLC, a platinum agent plus etoposide is the preferred regimen for adult patients who are being treated with combined modality therapy. Cisplatin and irinotecan represents an alternative treatment option to this, but is associated with increased rates of adverse events such as diarrhoea.

A meta-analysis of trials of etoposide plus platinum agent versus irinotecan/topotecan plus platinum agent in first-line therapy of extensive stage small cell lung cancer (ES SCLC)

e20019

Background: Etoposide plus a platinum agent (EP) represents the standard treatment of ES SCLC. A trial conducted in Japan demonstrated improved overall survival (OS) for irinotecan and cisplatin (IP), but subsequent trials could not consistently replicate these findings. Genotypic differences may explain these findings. These trials have not undergone systematic analysis. Methods: We conducted a systematic review and metaanalysis of randomized trials (RCT) comparing etoposide plus a platinum agent (EP) with irinotecan (IP) or topotecan (TP) plus a platinum agent. A literature search was undertaken of Cochrane Database, MEDLINE and Embase from 1996 to June 2016 to identify RCTs addressing this question. Data were extracted by one author and checked independently, then synthesized using RevMan software using a random effects model. Outcomes of interest were OS, quality of life (QoL) and toxicity. Results: Three RCTs compared TP and EP. There was no difference in OS (HR 0.97, 95%CI 0.87 – 1.07). Eight RCTs compared IP and EP, although only 7 had data that could be combined. IP significantly improved OS compared with EP (HR 0.84, 95%CI 0.74 – 0.95). The estimated improvement in 12 month OS is 6.4%. There was evidence of statistical heterogeneity. After removal of the trial by Noda et al, there was still a significant improvement in OS (HR 0.88, 95%CI 0.79 – 0.98). IP was associated with less grade 3/4 neutropenia, febrile neutropenia, anemia, thrombocytopenia, but more diarrhea. QoL was assessed in 2 trials and no differences observed. Conclusions: IP results in modest improvements in OS in comparison with EP. IP is associated with less hematological toxicity but more diarrhea and should be considered an acceptable alternative to EP in the first-line treatment of ES SCLC. [Table: see text]

Quality of life and swallowing with standard chemoradiotherapy versus accelerated radiotherapy and panitumumab in locoregionally advanced carcinoma of the head and neck: A phase III randomised trial from the Canadian Cancer Trials Group (HN.6)

AIM

To compare quality of life (QOL) between standard (SFX) chemoradiotherapy (arm A) and altered fractionation radiotherapy (AFX) with panitumumab (PMab; arm B).

METHODS

Patients with T any N + M0 or T3-4N0M0 squamous cell head-neck carcinoma were randomised to SFX (70 Gy/35/7 wks) plus cisplatin (100 mg/m² IV × 3) versus AFX (70 Gy/35/6 wks) plus PMab (9 mg/kg IV × 3). QOL was collected at baseline, end of radiation therapy (RT) and 2, 4, 6, 12, 24 and 36 months post-RT using the Functional Assessment of Cancer Therapy Head and Neck (FACT-H&N), MD Anderson Dysphagia Index (MDADI) and SWAL-QOL. We hypothesised a 6-point more favourable change in FACT-H&N score from baseline to 1 year in arm B over arm A.

RESULTS

Among 320 patients, median follow-up was 46 (range: 0.1-64.3) months, median age 56, 84% male, Eastern Cooperative Oncology Group PS 0 (71%), 1 (29%). Primary site was oropharynx in 81% (p16+ 68%, p16- 16%, missing 16%). Baseline scores did not differ by arm (A/B): FACT-H&N 116.5/115, MDADI Global 83/77, SWAL-QOL General 67/68. At 1 year, no difference was seen between arms in FACT-H&N change from baseline: A -1.70, B -4.81, p = 0.194. Subscale change scores by arm were (A/B): last week RT, FACT-Physical (-11.6, -10, p = 0.049), MDADI Physical (-40.4, -33.9, p = 0.045), and SWAL-QOL Eating Duration (-61.2, -51.2, p = 0.02), Eating Desire (-53.3, -43.9, p = 0.031) and Mental Health (-42, -32.6, p = 0.009); 4 months, HN subscale (-7.7, -10, p = 0.014). No clinically important differences by arm were seen post-treatment.

CONCLUSIONS

PMab with AFX did not durably improve QOL or swallowing as compared with SFX with cisplatin.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00820248.

The happy docs study: a Canadian Association of Internes and Residents well-being survey examining resident physician health and satisfaction within and outside of residency training in Canada

Background

Few Canadian studies have examined stress in residency and none have included a large sample of resident physicians. Previous studies have also not examined well-being resources nor found significant concerns with perceived stress levels in residency. The goal of "The Happy Docs Study" was to increase knowledge of current stressors affecting the health of residents and to gather information regarding the well-being resources available to them.

Findings

A questionnaire was distributed to all residents attending all medical schools in Canada outside of Quebec through the Canadian Association of Internes and Residents (CAIR) during the 2004–2005 academic years.

In total 1999 resident physicians responded to the survey (35%, N = 5784 residents). One third of residents reported their life as "quite a bit" to "extremely" stressful (33%, N = 656). Time pressure was the most significant factor associated with stress (49%, N = 978). Intimidation and harassment was experienced by more than half of all residents (52%, N = 1050) with training status (30%, N = 599) and gender (18%, N = 364) being the main perceived sources. Eighteen percent of residents (N = 356) reported their mental health as either "fair" or "poor". The top two resources that residents wished to have available were career counseling (39%, N = 777) and financial counseling (37%, N = 741).

Conclusion

Although many Canadian resident physicians have a positive outlook on their well-being, residents experience significant stressors during their training and a significant portion are at risk for emotional and mental health problems. This study can serve as a basis for future research, advocacy and resource application for overall improvements to well-being during residency.

Intracranial Hodgkin's lymphoma in an HIV positive patient

Intracranial Hodgkin's lymphoma (ICHL) in the HIV positive population is a rarely reported event with only three prior cases reported in the literature. In these prior reports, the outcome of the patients was uncertain or very poor. We report here the case of an HIV seropositive patient with an isolated intracranial recurrence of Hodgkin's Lymphoma (HL) who achieved long-term control of his cranial disease and continues to have a high performance status more than 3 years following treatment.

Spontaneous Facial Subcutaneous Emphysema

Patients with spontaneous pneumomediastinum present with various manifestations, but it is extremely rare for head and neck signs to be the sole presenting feature. In fact, our search of the literature found only 1 previously documented case of spontaneous facial subcutaneous emphysema of the head and neck. In this article, we report what to the best of our knowledge is the second such case—and the first in which pneumomediastinum manifested as an isolated cheek swelling.

Spontaneous facial subcutaneous emphysema

Patients with spontaneous pneumomediastinum present with various manifestations, but it is extremely rare for head and neck signs to be the sole presenting feature. In fact, our search of the literature found only 1 previously documented case of spontaneous facial subcutaneous emphysema of the head and neck. In this article, we report what to the best of our knowledge is the second such case-and the first in which pneumomediastinum manifested as an isolated cheek swelling.