Patient perceptions of a comprehensive cancer navigation service

OBJECTIVE

Our aim was to determine the extent to which comprehensive navigation augments the provincial health system for meeting the needs of newly-diagnosed cancer patients (clients). We also assessed reactions of attending physicians to comprehensive navigation.

METHODS

Clients who completed navigation as an employee benefit or through membership in an insurance organization were polled to determine whether they needed help beyond that provided by the provincial health system and the extent to which that help was provided by navigation. Exit interviews were analyzed for perceptions of the clients about reactions by their attending physicians to navigation.

RESULTS

Of eligible clients, 72% responded. They reported needing help beyond that which the provincial system could provide in 64%-98% of specified areas. Navigation provided help in more than 90% of those cases. Almost all respondents (98%) appreciated having a designated oncology nurse navigator. Family doctors were perceived to be positive or neutral about navigation in 100% of exit interviews. Oncologists were positive or neutral in 92% (p < 0.001 for difference from family doctors).

CONCLUSIONS

In many areas, cancer patients need additional help beyond that which the provincial health system can provide. Comprehensive cancer navigation provides that help to a considerable extent. Clients perceived the reactions of attending physicians to comprehensive navigation to be generally supportive or neutral.

Breast cancer mortality reduction in the western world: therapeutic versus diagnostic interventions. Implications for cancer care organization processes

Abstract #6083

INTRODUCTION. Recent epidemiology data show a substantial Breast Cancer (BrCa) mortality reduction in the western countries over the last decade. The literature indicates that both Adjuvant systemic treatments (Adj. SystTh) and Screening mammography (ScrM) contribute, but their interaction is not clear.&#x2028; Our study examines if contribution of Adj. SystTh separate from ScrM could be more clearly identified; and also, - as a second objective, - if organization of cancer care could be correlated with BrCa mortality outcomes.&#x2028; METHODOLOGY:&#x2028; The mortality trends were compared among three Provinces of Canada with different Levels of Provincial Diagnostic and Therapy Guidelines (PDTG):&#x2028; LEVEL I: most uniform coordination of PDTG: British Columbia (Brit.Col.), with a single Provincial budget; earliest implementation of Provincial Community Oncology Program (since the mid-1970's); and a uniform start of Adj. SystTh (late 1970's); and of ScrM (late -1980's).&#x2028; LEVEL II: medium (Ontario).&#x2028; LEVEL III: least uniform (Atlantic Provinces)*.&#x2028; BrCa annual age-standardized mortality rates per 100,000/population were obtained from Statistics Canada for the years 1950-2004, and expressed relative to the year 1950 (the baseline).&#x2028; RESUTLS: The 1950 BrCa mortality rates were: 30.9 for Canada; 31.4 for BC; 30.7 Ontario; 26.1 for Atlantic Provinces*.&#x2028; &#x2028; CONCLUSIONS:&#x2028; While both Adj. SystTh and ScrM contribute towards recent BrCa mortality reduction, the British Columbia data indicate that the impact of Adj. SystTh antedates that of ScrM, at least by a decade.&#x2028; Our data support a correlation of BrCa mortality trends with the organization of cancer care: Effective implementation of PDTG (- i.e. incorporating early curative interventions into guidelines), will have a strong impact on mortality trends, particularly if executed&#x2028; a. ongoingly,&#x2028; b. uniformly, and&#x2028; c. across the whole population.&#x2028; Our data therefore indicate that early implementation of curative systemic therapy - or of any curative intervention - is essential, as their delay may prevent materialization of survival gains.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6083.

Dosage parameters in chemotherapy of breast cancer

The concept of dose intensity provides a starting point for studying dose-response relationships. The summation dose intensity method (SDI) is an improvement over previous methods of calculating dose intensity because it accounts for differences in drug activity and allows the dose intensity of combinations containing the different drugs to be compared on one scale. It may also ultimately prove useful in defining the contribution of cumulative dose and dose size. Results from initial randomized trials testing dose intensification in breast cancer suggested but did not confirm its importance because dose size and cumulative dose were usually increased concurrently. Results from several recent trials in which dose intensity was increased while cumulative dose was held constant suggest that dose intensity may not be pre-eminent, but that both dosage parameters affect outcome. In addition, there may be a threshold dose intensity that must be exceeded before treatment causes tumor regression. From both retrospective analyses and prospective trials of adjuvant chemotherapy, it is clear that the subsets of patients who benefit most from dosage increases are those with poor prognostic factors. Larger dose sizes contribute more toxicity but, within the conventional range, probably contribute little independent therapeutic benefit. In contrast, reduced size doses of non-antimetabolites given at very short intervals may reduce acute toxicity, maintain dose intensity above threshold, and allow delivery of larger cumulative amounts of chemotherapy. This dose dense strategy may produce results superior to the use of fewer but larger doses.

The relationship between high-dose treatment and combination chemotherapy: the concept of summation dose intensity

The most important variables for the clinical use of antitumor agents (AAs) are dose and combination chemotherapy. The objectives of this study were to analyze the relationship between these two variables and to propose a unified conceptual framework for the construct and interpretation of clinical trials. Definitions and variables with respect to dose include potency, therapeutic index, standard dose, efficacy, relative efficacy, dose-limiting toxicity (DLT), dose rate, dose density, dose intensity, and fractional dose intensity. Our overarching concept, that is, summation dose intensity (SDI), was calculated in several ways, depending upon the nature of the data, and included the relative efficacy method, the unit regimen method, and the high dose method. The SDI concept was then applied to disease categories and strategies to determine its usefulness and effectiveness in integrating dose and combinations. The tumors and settings were: mustargen-vincristine-procarbazine-prednisone in Hodgkin's disease, combination chemotherapy for acute lymphocytic leukemia in children, metastatic breast cancer including dose and combinations, selected other solid tumors, alternating chemotherapy, and high dose studies in the leukemias and lymphomas. SDI was effective in integrating and quantifying dose and combination chemotherapy. For classical AAs, the implication of SDI for the construct and analysis of clinical trials was emphasized. In addition to new drug development, emphasis should be given to reducing or eliminating DLTs, such as those of the marrow, now and, in the future, those of the gastrointestinal tract toxicity and other DLTs. The above was derived from and applies to the classical AAs. Whether they will apply to, with appropriate adjustment, agents with significantly different dose-response curves, such as biotherapeutics and hormonal agents, remains to be determined.

A single scale for comparing dose-intensity of all chemotherapy regimens in breast cancer: summation dose-intensity

PURPOSE

To construct a single scale for comparing the dose-intensity of all chemotherapy regimens in breast cancer.

MATERIALS AND METHODS

First-line single-agent trials in metastatic disease were reviewed. The unit dose-intensity (UDI) that was required to produce a 30% complete response plus partial response (CR + PR) rate was determined for each drug. Randomized trials were then analyzed that prospectively tested dose-intensity. The dose-intensities of the drugs in each arm were expressed as fractions of their UDIs and added together. This yielded each arm's summation dose-intensity (SDI), which was then correlated with treatment outcomes.

RESULTS

In the single-agent trials, dose-response relationships were linear when the studies covered a range of dose-intensities. In the randomized trials that tested dose-intensity in metastatic disease, response rates and median survival correlated linearly with the SDIs of the treatment arms. An increment of one SDI unit increased CR + PR rate by approximately 30%, CR rate by 10%, and median survival by 3.75 months. Metastatic disease trials were negative if the difference between the arms was less than 0.54 SDI units. Adjuvant trials that tested a dose-intensity difference of less than 0.65 SDI units were also negative.

CONCLUSION

A single-agent dose-response database can be derived from historic literature that enables comparison of the dose-intensity of all combination regimens on one scale. The dose-intensity increase required to improve outcome can then be identified in earlier trials that tested that variable. SDI methodology should be tested prospectively in contemporary patients, and may be useful in guiding dosage increases beyond the conventional range.

Feasibility of a randomized trial of a high-vegetable diet to prevent breast cancer recurrence

Epidemiologic evidence supports the concept that diet influences risk for breast cancer and suggests that prognosis after the diagnosis of breast cancer may also be related to modifiable nutritional factors. The purpose of this study was to investigate the feasibility of a randomized trial of a high-vegetable, reduced-fat, and increased-fiber diet intervention to reduce risk for recurrence among breast cancer survivors. This major change in dietary pattern was promoted through intensive telephone counseling. Participants were 93 women who had been diagnosed with breast cancer (stages I, II, and IIIA) within the previous four years and who had completed their initial treatment. We assessed adherence to the study diet using repeated 24-hour dietary recalls at 6 and 12 months and measurement of circulating carotenoid concentrations. Six months after randomization, the intervention group had significantly increased their mean intake of vegetables (+4.6 servings/day), fruit (+0.7 servings/day), and fiber (+6.4 g/1,000 kcal) and significantly reduced their intake of dietary fat (-9.9% of energy) compared with the control group. Circulating concentrations of carotenoids also increased in the intervention group. These changes persisted at the 12-month visit. Results of this study demonstrate that telephone counseling can be a useful approach in diet intervention and that breast cancer survivors can adopt and maintain a high-vegetable, reduced-fat dietary pattern.

Importance of multiagent chemotherapy regimens in ovarian carcinoma: dose intensity analysis

BACKGROUND

In the previous meta-analysis of dose intensity (dosage) of chemotherapy in advanced ovarian cancer, we analyzed data on cyclophosphamide, altretamine (hexamethylmelamine), doxorubicin, and cisplatin. Only cisplatin showed statistically significant association of complete and partial clinical response with dose intensity.

PURPOSE

This analysis updates the previous results and further characterizes response to cisplatin alone or in multiagent regimens.

METHODS

We analyzed data from 18 regimens containing platinum (cisplatin or carboplatin) that were used in nine new randomized trials, in addition to data from the 60 groups of patients in our previous study in which responses were reported. Relative dose intensity was calculated as a fraction of the dosage of a drug in the standard regimen of cyclophosphamide, altretamine, doxorubicin, and platinum (CHAP). We performed single and multiple regression analyses to determine the relationship between disease outcome and relative dose intensity for cyclophosphamide, platinum, and doxorubicin alone or in combination.

RESULTS

The association between outcome and dose intensity for platinum alone or in multiagent regimens was statistically significant. This association was of borderline significance for cyclophosphamide alone but was not significant for this drug in multiagent regimens. There were insufficient data to test the relationship for doxorubicin as a single agent, but in multiagent regimens, the relationship was borderline (P = .05). Multiagent regimens containing platinum produced greater response rates than platinum alone for any fixed, planned relative dose intensity for platinum.

CONCLUSIONS

Our results support other published findings that use of cyclophosphamide and doxorubicin increases the efficacy of single-agent platinum. Relative dose intensity values for cyclophosphamide used alone were larger than those used in multiagent regimens, which might explain why the relationship between relative dose intensity and outcome for cyclophosphamide was not significant for use in multiagent regimens. Similarly, none of the multiagent regimens incorporated doxorubicin at a relative dose intensity for which the drug is found to be effective as a single agent.

IMPLICATIONS

Prospective clinical trials are required to test the effect of higher relative dose intensity for doxorubicin and cyclophosphamide added to platinum in advanced ovarian cancer. An important element in the design of prospective trials will be to test for the relative importance of dose intensity versus total dose. This testing is best achieved in a three-arm study design such as that reported in adjuvant treatment of stage II breast cancer conducted by the Cancer and Leukemia Group B.

Recruitment for an efficacy study in chemoprevention--the Concerned Smoker Study

Efficacy studies are important for the development of long-term cancer prevention strategies. Recruitment aims for a highly motivated group of participants. The Concerned Smoker Study is aimed at smokers with at least a 15 pack-year history and bronchial atypia on sputum sampling Recruitment has been primarily through use of the media. During the first year of randomization 905 potential participants expressed interest. Of these, 80 were eventually randomized. With over 60 participants having completed the study only one has defaulted and compliance with the study protocol has been high. Participants became aware of the study through the following sources: daily newspaper 36.6%, weekly newspaper 16.2%, television 14.9%, radio 13.8%, community television 1.3%, other sources 13.3%. Over 90% of potential participants who initially express interest in such a chemoprevention project may not ultimately be suitable. The population chosen for such studies may not be very representative of the more general population; however, a high degree of compliance can be obtained which will provide valuable information on treatment efficacy.

The thrombogenic effect of anticancer drug therapy in women with stage II breast cancer

Thromboembolic disease has long been recognized as a complication of cancer. Recent reports have suggested that drugs used in the treatment of cancer, including chemotherapeutic agents and hormones, may contribute to this risk, but it has not been possible to separate the effect of these drugs from that of the cancer. We performed a randomized trial comparing 12 weeks of chemohormonal therapy (using cyclophosphamide, methotrexate, fluorouracil, vincristine, prednisone, doxorubicin, and tamoxifen) with 36 weeks of chemotherapy (using cyclophosphamide, methotrexate, fluorouracil, vincristine, and prednisone) in patients with Stage II breast cancer. Among 205 patients randomly assigned to treatment, there were 14 episodes of thrombosis (6.8 percent). These 14 episodes occurred during 979 patient-months of chemotherapy; by comparison, there were no events during 2413 patient-months without therapy. During the first 12 weeks of the study, five patients in the 12-week group and four patients in the 36-week group had thrombosis. During the subsequent 24 weeks, when only patients in the 36-week group were still receiving chemotherapy, there was no thrombosis in the 12-week group, but there were five additional events in the 36-week group (P = 0.03). These findings suggest that chemotherapy contributes to thrombosis in patients with breast cancer.

The application of dose intensity to problems in chemotherapy of ovarian and endometrial cancer

An attempt was made using dose intensity to resolve some of the conflicting issues regarding chemotherapy in ovarian cancer and endometrial cancer. Analyses were done to determine if dose intensity correlates with outcome of first-line and salvage chemotherapy of advanced ovarian cancer and chemotherapy of advanced endometrial cancer. The concept of dose intensity was used to analyze the relative contributions of individual drugs, such as cyclophosphamide, hexamethylmelamine, Adriamycin (Adria Laboratories, Columbus, OH) and cisplatin to outcome, and to suggest how such drugs should be used in combination.

Drug dosage intensity--a panel discussion

There is now widespread interest in the subject of drug dose intensity in cancer treatment. Recent retrospective analyses have shown a clear-cut benefit for those patients receiving either the intended drug dosage in a particular regimen or the highest dosage achievable through an escalation scheme. In this discussion, the participating physicians will review dose intensity in light of these retrospective studies, highlighting the particular tumor types in which benefits have been demonstrated. Other important issues will be discussed, such as scheduling of drug combinations and the importance of using toxicity as a biologic response monitor of drug efficacy. The panelists will also provide opinions as to the best design for a prospective clinical trial to test dose intensity.

Analysis of dose intensity for adjuvant chemotherapy trials in stage II breast cancer

We have analyzed the relationship between dose intensity of cyclophosphamide, methotrexate, and fluorouracil (CMF)-containing adjuvant chemotherapy of stage II breast cancer and 3-year relapse-free survival. Studies using only one or two drugs of CMF or melphalan instead of cyclophosphamide were included in the analysis by using simple techniques developed for this purpose. There was a clear-cut relationship between relapse-free survival and dose intensity in trials containing all four prognostic groups: less than 50 years, one to three and more than three positive nodes; and greater than or equal to 50 years, one to three and more than three positive nodes (P less than 10(-5)). Relapse-free survival also correlated with dose intensity for each of the four prognostic groups analyzed separately (P less than .005). Dose intensity was an independently significant correlate of relapse-free survival in multivariate analysis (P less than 10(-5)). This is a retrospective study, and the hypothesis that dose intensity contributes to outcome independently of other variables should be tested prospectively. Methods of increasing dose intensity also require testing in randomized trials before they can be applied to routine clinical practice.

Prevention of infection and bleeding in leukemic patients receiving intensive remission maintenance therapy

Leukemic patients were treated with intensive chemotherapy to reduce the number of leukemic cells remaining after complete remission was induced. This therapy resulted in periods of severe granulocytopenia and thrombocytopenia. Considering 13 patients who did not receive antibacterial prophylaxis, documented infection was quite common including four episodes of bacteremia and three urinary tract infections. By contrast, patients who received co-trimoxazole as antibacterial prophylaxis experienced one half as many febrile episodes and no serious infections. Prophylactic co-trimoxazole is beneficial for patients with marrow remission in this study. Similar benefit in patients with leukemic marrows remains to be established. All patients received prophylactic platelet transfusion three times a week when their platelet counts were less than 20,000/microliter. There were no episodes of bleeding other than petechiae.

Remission induction in acute nonlymphocytic leukemia: comparison of a seven-day and ten-day infusion of cytosine arabinoside in combination with adriamycin

Forty-six previously untreated patients with acute nonlymphocytic leukemia were treated with a remission induction regimen consisting of three daily doses of Adriamycin (30 mg/m2/day) and a ten-day continuous infusion of cytosine arabinoside (ara C) (100 mg/m2/day). The overall remission rate was 72%, with 88% of the patients less than 50 and 62% of patients greater than 50 years old achieving complete remission status. Thirty-one of the 33 complete remissions occurred after a single course of chemotherapy. Retrospective comparison of this regimen with its predecessor (identical, except that a seven-day infusion of ara C was administered) demonstrated that the increase in duration of ara C administration resulted in greater antileukemic effectiveness without an increase in hematologic toxicity to the patient.

Intermittent cyclophosphamide treatment of autoimmune thombocytopenia

Cyclophosphamide was given intermittently rather than daily to 14 patients with autoimmune thrombocytopenic purpura. Eight patients responded and six did not. In those who responded the rise in platelet count was rapid, and in all patients the lack of toxicity was striking. Intermittent cyclophosphamide seems effective in some cases of autoimmune thrombocytopenia and is safe, at least in the short term. Controlled trials would be required to prove that intermittent is better than daily administration.

Cytosine arabinoside therapy for herpes simplex encephalitis--clinical experience with six patients

Two neonates and four adults with herpes simplex virus (HSV) encephalitis were treated with cytosine arabinoside (Ara-C). A low dose of 40 to 160 mg per m(2) per day was given for 4 to 6 days by continuous intravenous infusion and, except in two cases, by intrathecal administration. In one patient, idoxuridine (IUdR) at the dose of 1 g every 4 h was also administered after 4 days of Ara-C therapy. Both neonates and two of four adults survived. Their clinical improvement was closely related in time to the onset of therapy with Ara-C (cases 1, 2, 3) and with IUdR (case 4). In one adult who died on the 27th day of illness of a massive pulmonary embolus, postmortem examination of the brain did not disclose viral inclusions, and viral culture was negative. In the other patient who died, however, brain culture postmortem was still positive for HSV despite 4 days of Ara-C therapy. Ara-C, in addition to IUdR, may be effective in HSV encephalitis treatment, but double-blind, controlled studies appear to be necessary with these agents.