TECLA-an innovative technical approach for prostate cancer registries

Objective: To present a code-driven, electronic database for patients TrEated with robotic-assisted radiCaL prostAtectomy (TECLA), developed at Innlandet Hospital (IH), Trust, Norway, for research, local quality control and to deliver data to the National Cancer Registry of Norway (CRN). Clinical data are directly extracted from the structured documentation in the electronic medical record (EMR).Materials and methods: The urological department at IH treats about 200 patients with robotic-assisted radical prostatectomy (RARP) annually. All consenting patients registered with the procedure code for RARP are included in TECLA. Clinical data are obtained automatically from the EMR, by structured forms. Patient-reported outcome and experience measures (PROMs and PREMs) are filled in by the patients on an iPad or a smartphone.Results: The basic construct of TECLA is presented. From August 2017 to June 2018, 200 men were treated with RARP, of which 182 (91%) provided consent for inclusion in the register. Of these, 97% completed the PROM survey before treatment and 91% at 3 months follow-up. PREMs were completed by 78%. All clinical variables for the hospital stay and for the 6-week follow-up were more than 95% complete.Conclusion: This entirely electronic surgical quality register is easy to use, both for patients and clinicians, and has a high capture rate. The data collection is linked to the clinicians' workflow, without double data entry, so entering data does not add any extra work. The register design can be used by other hospitals for various surgical procedures.

Muscle mass and association to quality of life in non-small cell lung cancer patients

BACKGROUND

Cancer wasting is characterized by muscle loss and may contribute to fatigue and poor quality of life (QoL). Our aim was to investigate associations between skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD) and selected QoL outcomes in advanced non-small cell lung cancer (NSCLC) at diagnosis.

METHODS

Baseline data from patients with stage IIIB/IV NSCLC and performance status 0-2 enrolled in three randomized trials of first-line chemotherapy (n = 1305) were analysed. Associations between SMI (cm² /m² ) and SMD (Hounsfield units) based on computed tomography-images at the third lumbar level and self-reported physical function (PF), role function (RF), global QoL, fatigue, and dyspnoea were investigated by linear regression using flexible non-linear modelling.

RESULTS

Complete data were available for 734 patients, mean age 65 years. Mean SMI was 47.7 cm² /m² in men (n = 420) and 39.6 cm² /m² in women (n = 314). Low SMI values were non-linearly associated with low PF and RF (men P = 0.016/0.020, women P = 0.004/0.012) and with low global QoL (P = 0.001) in men. Low SMI was significantly associated with high fatigue (P = 0.002) and more pain (P = 0.015), in both genders, but not with dyspnoea. All regression analyses showed poorer physical outcomes below an SMI breakpoint of about 42-45 cm² /m² for men and 37-40 cm² /m² for women. In both genders, poor PF and more dyspnoea were significantly associated with low SMD.

CONCLUSIONS

Low muscle mass in NSCLC negatively affects the patients' PF, RF, and global QoL, possibly more so in men than in women. However, muscle mass must be below a threshold value before this effect can be detected.

Skeletal muscle radiodensity is prognostic for survival in patients with advanced non-small cell lung cancer

BACKGROUND & AIMS

Recent research indicates that severe muscular depletion (sarcopenia) is frequent in cancer patients and linked to cachexia and poor survival. Our aim was to investigate if measures of skeletal muscle hold prognostic information in advanced non-small cell lung cancer (NSCLC).

METHODS

We included NSCLC patients with disease stage IIIB/IV, performance status 0-2, enrolled in three randomised trials of first-line chemotherapy (n = 1305). Computed tomography (CT) images obtained before start of treatment were used for body composition analyses at the level of the third lumbar vertebra (L3). Skeletal muscle mass was assessed by measures of the cross sectional muscle area, from which the skeletal muscle index (SMI) was obtained. Skeletal muscle radiodensity (SMD) was measured as the mean Hounsfield unit (HU) of the measured muscle area. A high level of mean HU indicates a high SMD.

RESULTS

Complete data were available for 734 patients, mean age 65 years. Both skeletal muscle index (SMI) and muscle radiodensity (SMD) varied largely. Mean SMI and SMD were 47.7 cm²/m² and 37.4 HU in men (n = 420), 39.6 cm²/m² and 37.0 HU in women (n = 314). Multivariable Cox regression analyses, adjusted for established prognostic factors, showed that SMD was independently prognostic for survival (Hazard ratio (HR) 0.98, 95% CI 0.97-0.99, p = 0.001), whereas SMI was not (HR 0.99, 95% CI 0.98-1.01, p = 0.329).

CONCLUSION

Low SMD is associated with poorer survival in advanced NSCLC. Further research is warranted to establish whether muscle measures should be integrated into routine practice to improve prognostic accuracy.

Low muscle mass is associated with chemotherapy-induced haematological toxicity in advanced non-small cell lung cancer

BACKGROUND

Recent research suggests a significant relationship between lean body mass (LBM) and toxicity from chemotherapeutic agents. We investigated if higher drug doses per kg LBM were associated with increased toxicity in stage IIIB/IV non-small cell lung cancer (NSCLC) patients receiving a first-line chemotherapy regimen dosed according to body surface area (BSA).

METHODS

Data from patients randomised to receive intravenous gemcitabine 1000 mg/m(2) plus orally vinorelbine 60 mg/m(2) days 1 and 8 in a phase III trial comparing two chemotherapy regimens were analysed. LBM was estimated from assessment of the cross-sectional muscle area at the third lumbar level (L3) on computed tomography images obtained before chemotherapy commenced. Common terminology criteria for adverse events (CTCAE) grade 3-4 haematological toxicity and dose reduction and/or stop of treatment after the first course of chemotherapy were defined as primary and secondary toxicity outcomes.

RESULTS

The study sample included 153 patients, mean age was 66 years, 55% were men, 87% had disease stage IV and 75% had performance status (PS) 0-1. Gemcitabine doses per kg LBM varied from 23.2 to 53.1 mg/kg LBM, and vinorelbine doses from 1.5 to 3.3 mg/kg LBM. Higher doses of gemcitabine per kg LBM were significantly associated with grade 3-4 haematological toxicity in bivariate (OR=1.12, 95% CI 1.03-1.23, p=0.008) and multivariate analyses (OR=1.15, 95% CI 1.01-1.29, p=0.018), as were also higher doses of vinorelbine per kg LBM. No significant association was found between drug doses per kg LBM and dose reduction and/or stop of treatment.

CONCLUSION

The study showed that dose estimates according to BSA lead to a substantial variation in drug dose per kg LBM, and higher doses per kg LBM are a significant predictor for chemotherapy-induced haematological toxicity. The results indicate that taking LBM into account may lead to a better dose individualisation of chemotherapy.

The impact of nutritional status, physical function, comorbidity and early versus late start in dialysis on quality of life in older dialysis patients

BACKGROUND

For the majority of the older patients in dialysis, the treatment will be lifelong. Thus, quality of life (QoL) is a crucial outcome. Our aim was to assess the QoL of older Norwegian dialysis patients and to investigate the impact of early (estimated glomerular filtration rate, eGFR ≥10 mL/min) versus late (eGFR <10 mL/min) start in dialysis, comorbidity, nutritional status and physical capacity.

METHODS

A self-report questionnaire including SF-36 (QoL) and the Subjective Global Assessment (SGA; nutritional status) was mailed to all patients (n = 320) ≥75 years registered in the Norwegian Renal Registry (NRR) as being in dialysis by September 2009. Reply was received from 233 patients (73%). Medical data including comorbidities and eGFR at dialysis start (obtained for 194 patients) were retrieved from the NRR. Functional capacity was determined from the SGA.

RESULTS

Compared to reports from younger dialysis patients, our patients scored poorer on all SF-36 subscales. Early start in dialysis was registered for 52 patients, 142 patients started late, 51.4% were well nourished (SGA A), 32.3% moderately malnourished (SGA B) and 16.4% were severely malnourished (SGA C). No significant association between any SF-36 scores and early versus late start, nutritional status or comorbidity was found. Better physical function was significantly associated with better scores on all SF-36 scales.

CONCLUSIONS

Our results indicate that physical function is important to all QoL aspects. Increased focus on physical rehabilitation seems pertinent. Early start of dialysis treatment was not associated with better long term QoL scores.

Classification of pain in cancer patients--a systematic literature review

One of the aims of the European Palliative Care Research Collaborative (EPCRC) is to achieve consensus on a classification system for cancer pain. We performed a systematic literature review to identify existing classification systems and domains/items used to classify cancer patients with pain. In a systematic search in the databases Medline and Embase, covering 1986-2006, 692 hits were obtained. 92 papers were evaluated to address pain classification. Six standardised classification systems were identified; three of them systematically developed and partially validated. Both pain characteristics and patient characteristics relevant for cancer pain classification were included in the classification systems. All but one of the standardised systems aim at predicting treatment response or adequacy of treatment. Several domains and items used to describe cancer pain but not formally described as part of a classification system were also identified and systematized. The existing approaches to pain classification in cancer patients are different, mostly not thoroughly validated, and none is widely applied. An internationally accepted classification system for cancer pain could improve research and cancer pain management. This systematic review suggests a need for developing an international consensus on how to classify pain in cancer patients.

Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients

BACKGROUND

Patients with chronic non-malignant pain (CNMP) conditions are known to report reduced health-related quality of life (HRQoL). The objective of this exploratory study was to compare HRQoL between patients admitted to a multidisciplinary pain centre, palliative cancer (PC) patients and national norms.

METHODS

HRQoL data from 288 patients with CNMP admitted to the multidisciplinary pain centre at Trondheim University Hospital were compared with 434 patients with advanced cancer included in a trial of comprehensive palliative care in the hospital palliative medicine unit and national norms. HRQoL was assessed using the EORTC QLQ-C30. Age- and gender-adjusted norm data were calculated and compared between the two groups.

RESULTS

Scores from both groups deviated from adjusted norm data on all scales, with poorer functioning and more symptoms. Compared with PC patients, CNMP patients reported a larger deviation (worse scores) on global quality of life, cognitive functioning, pain, sleep disturbances and financial difficulties. Deviations from norm data were similar for physical, social and emotional functioning, diarrhoea, dyspnoea and fatigue. PC patients reported worse scores on role functioning, nausea/vomiting, loss of appetite and constipation.

CONCLUSION

CNMP patients admitted to multidisciplinary pain centres report significantly reduced HRQoL, in addition to severe pain. They consider their HRQoL to be as poor as HRQoL reported from dying cancer patients and substantially poorer than national norms. Factors other than the biological severity of the disease seem to be of major importance for self-reported HRQoL.

Randomised trial of in-hospital geriatric intervention: impact on function and morale

BACKGROUND

In two previous publications, we have shown that treatment of acutely sick, frail elderly patients in a Geriatric Evaluation and Management Unit (GEMU) compared to treatment in the general Medical Wards (MW) reduced mortality and improved the chances of living at home in contrast to living in nursing homes or being dead.

OBJECTIVE

The aim of this presentation was to study the impact on function, symptoms of depression and general well-being of treatment in the GEMU as compared to treatment in MW.

METHODS

Acutely sick, frail patients aged >or=75 years, admitted as emergencies to the Department of Internal Medicine, were randomised either to treatment in the GEMU (n = 127) or the MW (n = 127). In the GEMU the treatment strategy emphasised comprehensive interdisciplinary assessment of all relevant disorders, prevention of complications and iatrogenic conditions, early mobilisation, rehabilitation and discharge planning. The control group received treatment as usual from the Department of Internal Medicine. After discharge neither group received specific follow-up. Activities of daily living (ADL), instrumental ADL, cognitive function, symptoms of depression and general well-being were assessed 3, 6 and 12 months after discharge from hospital.

RESULTS

There was no difference in function, depression or general well-being in the GEMU as compared to the MW group. If the dead were included in the analysis at the highest ADL dependency level, there was better function in the GEMU group at 3 months (p = 0.03).

CONCLUSION

Treatment in the GEMU had no measurable beneficial impact on function, morale or symptoms of depression. Taken the previously shown mortality reduction into consideration an additional effect on function was less likely and the overall treatment effect was considered to be positive.