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Background Our aim was to establish if presence of circulating tumor cells (CTCs) predicted worse outcome in patients with non-metastatic esophageal cancer undergoing tri-modality therapy. Methods We prospectively collected CTC data from patients with operable non-metastatic esophageal cancer from April 2009 to November 2016 enrolled in our QUINTETT esophageal cancer randomized trial (NCT00907543). Patients were randomized to receive either neoadjuvant cisplatin and 5-fluorouracil (5-FU) plus radiotherapy followed by surgical resection (Neoadjuvant) or adjuvant cisplatin, 5-FU, and epirubicin chemotherapy with concurrent extended volume radiotherapy following surgical resection (Adjuvant). CTCs were identified with the CellSearch® system before the initiation of any treatment (surgery or chemoradiotherapy) as well as at 6-, 12-, and 24-months post-treatment. The threshold for CTC positivity was one and the findings were correlated with patient prognosis. Results CTC data were available for 74 of 96 patients and identified in 27 patients (36.5%) at a median follow-up of 13.1months (interquartile range:6.8-24.1 months). Detection of CTCs at any follow-up visit was significantly predictive of worse disease-free survival (DFS;hazard ratio [HR]: 2.44; 95% confidence interval [CI]: 1.41-4.24; p =0.002), regional control (HR: 6.18; 95% CI: 1.18-32.35; p =0.031), distant control (HR: 2.93; 95% CI: 1.52-5.65; p =0.001) and overall survival (OS;HR: 2.02; 95% CI: 1.16-3.51; p =0.013). After adjusting for receiving neoadjuvant vs. adjuvant chemoradiotherapy, the presence of CTCs at any follow-up visit remained significantly predictive of worse OS ([HR]:2.02;95% [Cl]:1.16-3.51; p =0.013) and DFS (HR: 2.49;95% Cl: 1.43-4.33; p =0.001). Similarly, any observed increase in CTCs was significantly predictive of worse OS (HR: 3.14; 95% CI: 1.56-6.34; p =0.001) and DFS (HR: 3.34; 95% CI: 1.67-6.69; p <0.001). Conclusion The presence of CTCs in patients during follow-up after tri-modality therapy was associated with significantly poorer DFS and OS regardless of timing of chemoradiotherapy.

Background Direct observation is necessary for specific and actionable feedback, however clinicians often struggle to integrate observation into their practice. Remotely audio-monitoring trainees for periods of time may improve the quality of written feedback given to them and may be a minimally disruptive task for a consultant to perform in a busy clinic. Methods Volunteer faculty used a wireless audio receiver during the second half of students’ oncology rotations to listen to encounters during clinic in real time. They then gave written feedback as per usual practice, as did faculty who did not use the listening-in intervention. Feedback was de-identified and rated, using a rubric, as strong/medium/weak according to consensus of 2/3 rating investigators. Results Monitoring faculty indicated that audio monitoring made the feedback process easier and increased confidence in 95% of encounters. Most students (19/21 respondents) felt monitoring contributed positively to their learning and included more useful comments. 101 written evaluations were completed by 7 monitoring and 19 non-monitoring faculty. 22/23 (96%) of feedback after monitoring was rated as high quality, compared to 16/37 (43%) ( p  < 0.001) for monitoring faculty before using the equipment (and 20/78 (26%) without monitoring for all consultants ( p  < 0.001)). Qualitative analysis of student and faculty comments yielded prevalent themes of highly specific and actionable feedback given with greater frequency and more confidence on the part of the faculty if audio monitoring was used. Conclusions Using live audio monitoring improved the quality of written feedback given to trainees, as judged by the trainees themselves and also using an exploratory grading rubric. The method was well received by both faculty and trainees. Although there are limitations compared to in-the-room observation (body language), the benefits of easy integration into clinical practice and a more natural patient encounter without the observer physically present lead the authors to now use this method routinely while teaching oncology students.

I've just had my first patient receive medical assistance in dying (MAiD). He had lived with metastatic cancer for 11 years, but I had never really asked him how and why he kept going all these years. Nor do I feel now, despite having questioned him about his decision, that I truly understand why he chose MAiD. Many of my palliative care colleagues reassure me that good palliative care and alleviation of suffering can be (and some say, should be) a viable alternative to MAiD. But he had received good palliative care, as many of my patients do, cared for by our hospice or community team, and yet not all choose MAiD. Some do, and some don't. Finally, those in whom the adversity of cancer has served as a \"call to arms\" may not contemplate turning to MAiD. Instead, it may be a matter of personal pride and character as to how and how long they fight what is seen primarily as an opponent.

Goals Hope is an important factor to consider when caring for cancer patients as a key component of coping with adversity. The aim of our study was to address the following questions: Is there a difference in level of hope between those patients being curatively and those palliatively treated, and how does this change over time? What are patients’ most important hopes? Better understanding of patients’ hopes may promote more effective patient-centered care. Materials and methods Outpatients referred to medical oncology or pain and symptom clinics at the London Regional Cancer Program were surveyed before consultation. The Herth Hope Index (HHI) questionnaire was administered to assess level of hope, and the patients were asked to indicate their highest priority hopes. Qualitative thematic analysis was performed on the responses, and comparison was made between patients treated with curative vs those treated with palliative intent. This survey was repeated 4 months after initial assessment. Results Fifty patients were surveyed (29 curative-intent; 21 palliative). Highest priority initial hopes were categorized as follows: cure, other positive health outcomes, emotional well-being, life achievements/return to normalcy, interpersonal goals, other. There was no association noted between treatment intent and choice of highest-priority hope. Follow-up assessments after 4 months revealed no significant differences in the distribution pattern of hopes. There was a statistically significant increase in the HHI over time in curatively treated patients, but none in the combined analysis. Discussion and conclusion Our study indicates that patients receiving palliative therapy have a HHI score not significantly different from patients being treated for cure. The hope deemed most important is also similar between groups. Over time, overall hope was maintained or increased even in the presence of a trend towards fewer patients hoping for a cure. These results remind oncologists to explore the experience of hope with all patients to ensure that the subjective needs and goals of the patients are met by the proposed therapies.

Oncology residents routinely engage in ethically complex decision-making discussions with patients, while observing and interacting with their teaching consultant. If clinical competency in oncology decision-making guidance is to be taught deliberately and effectively, it is necessary to understand resident experiences in this context to develop appropriate educational and faculty development initiatives. Four junior and two senior postgraduate oncology residents participated in semi-structured interviews during October and November 2021 which explored their experiences of real-world decision-making scenarios. Van Manen’s phenomenology of practice was used in an interpretivist research paradigm. Transcripts were analysed to articulate essential experiential themes, and composite vocative narratives were created. Three essential themes were identified: (1) residents often endorsed different decision-making approaches than supervising consultants, (2) residents experienced inner conflict, and (3) residents struggled to find their own approach to decision-making. Residents experienced being torn between a perceived obligation to defer to consultant directives, and a desire for increasing ownership of decision-making while not feeling empowered to discuss their opinions with the consultants. Residents described their experiences around ethical position awareness during decision-making in a clinical teaching context as challenging, with experiences suggesting moral distress combined with inadequate psychological safety to address ethical conflicts and unresolved questions of decision ownership with supervisors. These results suggest the need for enhanced dialogue and more research to reduce resident distress during oncology decision-making. Future research should be aimed at discovering novel ways in which residents and consultants could interact in a unique clinical learning context including graduated autonomy, a hierarchical gradient, ethical positions, physician values, and sharing of responsibility.

BackgroundPatients undergoing neoadjuvant chemoradiation for oesophageal cancer often experience dehydration from decreased fluid intake and increased losses. Despite frequent clinical visits during treatment, patients can still present with dehydration, suggesting the need for increased patient awareness and engagement around adverse event management at home. Evidence for benefits of self-monitoring may help motivate patients to engage proactively in their own care to improve their treatment experience.MethodsWe performed a randomised single-centre study of a urine colour self-monitoring card (UCC) during chemoradiation therapy for oesophageal cancer, compared with standard dietitian counselling. Primary outcome was self-efficacy as determined by the Self-Management Resource Centre Self-Efficacy for Managing Chronic Disease Scale (SMCD). Secondary outcomes included Burge thirst scores, Edmonton Symptom Assessment System scores (ESAS), patient-initiated hydrations, creatinine rise and satisfaction with the UCC.ResultsThirty-five patients were randomised. UCC use was not associated with improved SMCD or ESAS scores compared with standard counselling. The card was highly rated by patients as a welcome tool for self-monitoring.ConclusionsNo beneficial effect on self-efficacy or dehydration markers with UCC use was demonstrated. The study nonetheless drew attention to several factors potentially hindering its use for effective self-care: the unexpected severity of other symptoms consuming patients’ attention, reduced sensitivity of urine colour due to chemotherapy, absence of active inquiry by the healthcare team and the inconvenient location of the UCC in wallet/purse. Urine colour monitoring in patients with oesophageal cancer to improve the patient experience during treatment warrants further study but supported by active healthcare provider inquiry, more accessible format of the card, and possibly home vital checks to increase its sensitivity in the clinical context.

Background The use of neoadjuvant radiation therapy and chemotherapy in the treatment of locally advanced rectal adenocarcinoma has been shown to reduce disease recurrence when combined with surgery and adjuvant chemotherapy. We report a case of a patient who developed a debilitating bilateral myopathy of the hip flexors after successful treatment for rectal cancer. To the best of our knowledge, this is the first such complication from radiation therapy reported in a patient with colorectal cancer. The disproportionate severity of our patient’s myopathy relative to the dose of radiation used also makes this case unique among reports of neuromuscular complications from radiation therapy. Case presentation The patient is a 65-year-old male with node negative, high-grade adenocarcinoma of the rectum penetrating through the distal rectal wall. He underwent neoadjuvant concurrent pelvic radiation therapy and capecitabine-based chemotherapy, followed by abdominoperineal resection and post-operative FOLFOX chemotherapy. Five months post-completion of pelvic radiotherapy and 2 months after the completion of adjuvant chemotherapy, he presented with bilateral weakness of the iliopsoas muscles and severe pain radiating to the groin. The patient improved with 40 mg/d of prednisone, which was gradually tapered to 2 mg/d over 6 months, with substantial recovery of muscle strength and elimination of pain. Conclusions The timing, presentation and response of our patient’s symptoms to corticosteroids are most consistent with a radiation recall reaction. Radiation recall is a phenomenon whereby previously irradiated tissue becomes vulnerable to toxicity by subsequent systemic therapy and is rarely associated with myopathies. Radiation recall should be considered a potential complication of neoadjuvant radiation therapy for rectal cancer, and for ongoing research into the optimization of treatment for these patients. Severe myopathies caused by radiation recall may be fully reversible with corticosteroid treatment.

Background We compared the health‐related quality of life (HRQOL) in patients undergoing trimodality therapy for resectable stage I‐III esophageal cancer. Methods A total of 96 patients were randomized to standard neoadjuvant cisplatin and 5‐fluorouracil chemotherapy plus radiotherapy (neoadjuvant) followed by surgical resection or adjuvant cisplatin, 5‐fluorouracil, and epirubicin chemotherapy with concurrent extended volume radiotherapy (adjuvant) following surgical resection. Results There was no significant difference in the functional assessment of cancer therapy‐esophageal (FACT‐E) total scores between arms at 1 year (p = 0.759) with 36% versus 41% (neoadjuvant vs. adjuvant), respectively, showing an increase of ≥15 points compared to pre‐treatment (p = 0.638). The HRQOL was significantly inferior at 2 months in the neoadjuvant arm for FACT‐E, European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ‐OG25), and EuroQol 5‐D‐3 L in the dysphagia, reflux, pain, taste, and coughing domains (p < 0.05). Half of patients were able to complete the prescribed neoadjuvant arm chemotherapy without modification compared to only 14% in the adjuvant arm (p < 0.001). Chemotherapy related adverse events of grade ≥2 occurred significantly more frequently in the neoadjuvant arm (100% vs. 69%, p < 0.001). Surgery related adverse events of grade ≥2 were similar in both arms (72% vs. 86%, p = 0.107). There were no 30‐day mortalities and 2% vs. 10% 90‐day mortalities (p = 0.204). There were no significant differences in either overall survival (OS) (5‐year: 35% vs. 32%, p = 0.409) or disease‐free survival (DFS) (5‐year: 31% vs. 30%, p = 0.710). Conclusion Trimodality therapy is challenging for patients with resectable esophageal cancer regardless of whether it is given before or after surgery. Newer and less toxic protocols are needed. This randomized trial assessed the health related quality of life in esophageal cancer patients undergoing neoadjuvant versus adjuvant trimodality therapy. Every patient experienced at least one adverse event. The quality of life was worse for patients undergoing neoadjuvant compared to adjuvant chemoradiation with no significant difference in either overall survival or disease‐free survival. More effective therapy is needed.

BACKGROUND: The issue of how to address patient pain in the outpatient setting remains challenging. At the London Regional Cancer Program (London, Ontario), patients complete the Edmonton Symptom Assessment System (ESAS) before most visits. OBJECTIVES:To perform a chart review assessing the frequency and, if applicable, the type of a clinical care plan that was developed if a patient indicated pain ≥7 on a 10‐point scale METHODS: The charts of 100 eligible sequential outpatient visits were reviewed and the initial pain management approaches were documented. RESULTS: Between December 2011 and May 2012, visits by 7265 unique patients included 100 eligible visits (pain ≥7 of 10). In 83 cases, active pain management plans, ranging from counselling to hospital admission, were proposed. Active pain management plans were more likely if the cause was believed to be cancer/treatment related: 63 of 65 (96.9%) versus 20 of 35 (57.1%, noncancer/unknown pain cause); P<0.001. There were no differences depending on cancer treatment intent or medical service. CONCLUSIONS: Active pain management plans were documented in 83% of visits. However, patients who reported severe pain that was assessed as benign or unknown in etiology received intervention less frequently, perhaps indicating that oncologists either consider themselves less responsible for noncancer pain, or believe that pain chronicity may lead to a higher ESAS pain score without indicating a need for acute intervention. Further study is needed to determine the subsequent effect of the care plans on patient‐reported ESAS pain scores at future clinic visits. Erratum to “Initial Pain Management Plans in Response to Severe Pain Indicators on Oncology Clinic Previsit Questionnaires” dx.doi.org/10.1155/2015/404187

Capecitabine monotherapy as palliation for advanced colorectal cancer (CRC) is generally well tolerated. Adding erlotinib, an EGFR-tyrosine kinase inhibitor, might improve efficacy versus capecitabine alone. 82 patients received capecitabine alone (Arm 1) or capecitabine with erlotinib (Arm 2). Median time-to-progression (TTP) in Arm 1 was 7.9 months versus 9.2 in Arm 2. In -wild type (WT) patients TTP was 8.4 and 11.7 months in Arms 1 and 2, respectively. In -mutated patients TTP was 7.4 and 1.9 months in Arms 1 and 2, respectively (p = 0.023). Arm 2 -WT patients, left-sided primaries, had an overall survival of 16.0 versus 12.1 months in right-sided primaries. Adding erlotinib to capecitabine increased TTP by 3.2 months in -WT patients. This study suggests that erlotinib harms patients with -mutated advanced CRC while it may provide benefit to those with -WT CRC. Further study of EGFR-tyrosine kinase inhibitors in patients with left-sided -WT CRC is warranted.