The OncoSim Cancer Simulation Platform: A Tool to Project the Population Effects of Cancer Control Interventions in Canada

Background: Cancer control interventions exert their effects over multiple decades. To evaluate diverse and competing opportunities to reduce future cancer burden it is desirable to understand long-term effects prior to any new program implementation or significant change. Internationally, modeling is becoming an accepted source of planning information for decision-makers. Aim: We will describe the construction and use of the OncoSim microsimulation model, which was developed to evaluate cancer control strategies in Canada. Methods: OncoSim is a suite of models (cancers of the lung, colorectum, cervix and breast, plus a composite 32-cancer model) used to address key policy questions and support decision-making. It is led by the Canadian Partnership Against Cancer with model development by Statistics Canada. OncoSim incorporates risk factors, cancer natural history, screening, treatment, survival and end-of-life care. Wherever possible it is informed by Canadian data sources. Models are calibrated to reproduce a range of cancer-specific statistics, e.g., current and historical Canadian cancer-specific incidence and mortality, smoking patterns, and results of screening. The site-specific models have undergone further validation by replicating reported short-term effects of cancer prevention and screening interventions. Users may customize interventions through modifying input parameters. Outputs include incidence, mortality, costs, cost-effectiveness, and resource utilization. Users from the public sector have access at no cost to OncoSim and receive extensive support from a multidisciplinary technical team. The model is continually updated to incorporate emerging knowledge. Results: OncoSim has been used to support cancer control decision-making at the national and provincial/territorial levels. Applications include: national guidelines recommendations for colorectal and lung cancer screening; comparison of cytology vs. HPV based cervical cancer screening; and integration of smoking cessation into low-dose CT lung cancer screening. Conclusion: Validated simulation models such as OncoSim can be a versatile and efficient tool for cancer control planners to evaluate and prioritize cancer control strategies.

3D-printed components for quantum devices

Recent advances in the preparation, control and measurement of atomic gases have led to new insights into the quantum world and unprecedented metrological sensitivities, e.g. in measuring gravitational forces and magnetic fields. The full potential of applying such capabilities to areas as diverse as biomedical imaging, non-invasive underground mapping, and GPS-free navigation can only be realised with the scalable production of efficient, robust and portable devices. We introduce additive manufacturing as a production technique of quantum device components with unrivalled design freedom and rapid prototyping. This provides a step change in efficiency, compactness and facilitates systems integration. As a demonstrator we present an ultrahigh vacuum compatible ultracold atom source dissipating less than ten milliwatts of electrical power during field generation to produce large samples of cold rubidium gases. This disruptive technology opens the door to drastically improved integrated structures, which will further reduce size and assembly complexity in scalable series manufacture of bespoke portable quantum devices.

Comparison of muscle/lean mass measurement methods: correlation with functional and biochemical testing

DXA-measured lean mass is often used to assess muscle mass but has limitations. Thus, we compared DXA lean mass with two novel methods-bioelectric impedance spectroscopy and creatine (methyl-d3) dilution. The examined methodologies did not measure lean mass similarly and the correlation with muscle biomarkers/function varied.

INTRODUCTION

Muscle function tests predict adverse health outcomes better than lean mass measurement. This may reflect limitations of current mass measurement methods. Newer approaches, e.g., bioelectric impedance spectroscopy (BIS) and creatine (methyl-d3) dilution (D3-C), may more accurately assess muscle mass. We hypothesized that BIS and D3-C measured muscle mass would better correlate with function and bone/muscle biomarkers than DXA measured lean mass.

METHODS

Evaluations of muscle/lean mass, function, and serum biomarkers were obtained in older community-dwelling adults. Mass was assessed by DXA, BIS, and orally administered D3-C. Grip strength, timed up and go, and jump power were examined. Potential muscle/bone serum biomarkers were measured. Mass measurements were compared with functional and serum data using regression analyses; differences between techniques were determined by paired t tests.

RESULTS

Mean (SD) age of the 112 (89F/23M) participants was 80.6 (6.0) years. The lean/muscle mass assessments were correlated (.57-.88) but differed (p < 0.0001) from one another with DXA total body less head being highest at 37.8 (7.3) kg, D3-C muscle mass at 21.1 (4.6) kg, and BIS total body intracellular water at 17.4 (3.5) kg. All mass assessment methods correlated with grip strength and jump power (R = 0.35-0.63, p < 0.0002), but not with gait speed or repeat chair rise. Lean mass measures were unrelated to the serum biomarkers measured.

CONCLUSIONS

These three methodologies do not similarly measure muscle/lean mass and should not be viewed as being equivalent. Functional tests assessing maximal muscle strength/power (grip strength and jump power) correlated with all mass measures whereas gait speed was not. None of the selected serum measures correlated with mass. Efforts to optimize muscle mass assessment and identify their relationships with health outcomes are needed.

Lessons learned implementing a province-wide smoking cessation initiative in Ontario’s cancer centres

Purpose A large body of evidence clearly shows that cancer patients experience significant health benefits with smoking cessation. Cancer Care Ontario, the provincial agency responsible for the quality of cancer services in Ontario, has undertaken a province-wide smoking cessation initiative. The strategies used, the results achieved, and the lessons learned are the subject of the present article.Methods Evidence related to the health benefits of smoking cessation in cancer patients was reviewed. A steering committee developed a vision statement for the initiative, created a framework for implementation, and made recommendations for the key elements of the initiative and for smoking cessation best practices.Results New ambulatory cancer patients are being screened for their smoking status in each of Ontario’s 14 regional cancer centres. Current or recent smokers are advised of the benefits of cessation and are directed to smoking cessation resources as appropriate. Performance metrics are captured and used to drive improvement through quarterly performance reviews and provincial rankings of the regional cancer centres.Conclusions Regional smoking cessation champions, commitment from Cancer Care Ontario senior leadership, a provincial secretariat, and guidance from smoking cessation experts have been important enablers of early success. Data capture has been difficult because of the variety of information systems in use and non-standardized administrative and clinical processes. Numerous challenges remain, including increasing physician engagement; obtaining funding for key program elements, including in-house resources to support smoking cessation; and overcoming financial barriers to access nicotine replacement therapy. Future efforts will focus on standardizing processes to the extent possible, while tailoring the approaches to the populations served and the resources available within the individual regional cancer programs.

Implementing low-dose computed tomography screening for lung cancer in Canada: implications of alternative at-risk populations, screening frequency, and duration

BACKGROUND

Low-dose computed tomography (ldct) screening has been shown to reduce mortality from lung cancer; however, the optimal screening duration and "at risk" population are not known.

METHODS

The Cancer Risk Management Model developed by Statistics Canada for the Canadian Partnership Against Cancer includes a lung screening module based on data from the U.S. National Lung Screening Trial (nlst). The base-case scenario reproduces nlst outcomes with high fidelity. The impact in Canada of annual screening on the number of incident cases and life-years gained, with a wider range of age and smoking history eligibility criteria and varied participation rates, was modelled to show the magnitude of clinical benefit nationally and by province. Life-years gained, costs (discounted and undiscounted), and resource requirements were also estimated.

RESULTS

In 2014, 1.4 million Canadians were eligible for screening according to nlst criteria. Over 10 years, screening would detect 12,500 more lung cancers than the expected 268,300 and would gain 9200 life-years. The computed tomography imaging requirement of 24,000-30,000 at program initiation would rise to between 87,000 and 113,000 by the 5th year of an annual nlst-like screening program. Costs would increase from approximately $75 million to $128 million at 10 years, and the cumulative cost nationally over 10 years would approach $1 billion, partially offset by a reduction in the costs of managing advanced lung cancer.

CONCLUSIONS

Modelling various ways in which ldct might be implemented provides decision-makers with estimates of the effect on clinical benefit and on resource needs that clinical trial results are unable to provide.

Designing pharmaceutical trials for sarcopenia in frail older adults: EU/US Task Force recommendations

An international task force of academic and industry leaders in sarcopenia research met on December 5, 2012 in Orlando, Florida to develop guidelines for designing and executing randomized clinical trials of sarcopenia treatments. The Task Force reviewed results from previous trials in related disease areas to extract lessons relevant to future sarcopenia trials, including practical issues regarding the design and conduct of trials in elderly populations, the definition of appropriate target populations, and the selection of screening tools, outcome measures, and biomarkers. They discussed regulatory issues, the challenges posed by trials of different types of interventions, and the need for standardization and harmonization. The Task Force concluded with recommendations for advancing the field toward better clinical trials.

Frailty and sarcopenia: definitions and outcome parameters

An operational definition of musculoskeletal decline in older people is needed to allow development of interventions for prevention or treatment, as was developed for the treatment of osteoporosis. Frailty and sarcopenia are linked, but distinct, correlates of musculoskeletal aging that have many causes, including age-related changes in body composition, inflammation, and hormonal imbalance. With the emergence of a number of exciting candidate therapies to retard the loss of muscle mass with aging, the derivation of a consensual definition of sarcopenia and physical frailty becomes an urgent priority. Although several consensual definitions have been proposed, these require clinical validation. An operational definition, which might provide a threshold for treatment/trial inclusion, should incorporate a loss of muscle mass as well as evidence of a decrease in muscle strength and/or physical activity. Evidence is required for a link between improvements in the measures of muscle strength and/or physical activity and clinical outcomes to allow development of interventions to improve clinical outcomes in frail older patients.

PUFA supplements and type 2 diabetes in the elderly

The prevalence of type 2 diabetes is increasing continuously, especially in older people. Such a rapidly rising risk has been linked to physical inactivity and evolutionary changes in dietary patterns (mainly characterized by a greater intake in dietary fat). Increased physical activity in any age group is associated with a lower risk of developing type 2 diabetes. Epidemiological studies also reported a lower incidence of type 2 diabetes in individuals who consumed n-3 polyunsaturated fatty acids (PUFA), while intake of total, saturated and/or monounsaturated fat was associated with increased risk of type 2 diabetes in glucose-intolerant individuals. Furthermore, the beneficial effects of PUFA consumption on cardiovascular disease were mainly attributed to their effects on reducing triglyceride levels, increasing high density lipoprotein cholesterol, and improving endothelial function through anti-inflammatory mechanisms and reduced platelet aggregation. In addition to common diabetic complications such as dyslipidemia and cardiovascular disease, elderly people with type 2 diabetes are at greater risk of specific geriatric syndromes, such as cognitive decline and physical disability. The threats of physical disability, loss of independence and loss of cognitive performance which diminish quality of life may ultimately be the greatest concern for those with type 2 diabetes. In this review we will address: i) specific dietary fat intake patterns and the development of insulin resistance and type 2 diabetes, ii) the effects of PUFA supplementation on glucose metabolism, diabetic dyslipidemia and cardiovascular disease, iii) the potential advantages of PUFA supplementation on cognitive decline and physical disability in the elderly.

PET-CT compared to invasive mediastinal staging in non-small cell lung cancer (NSCLC)

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Background: In patients with NSCLC, preoperative staging tests including mediastinoscopy (M) are important in defining which patients are surgical candidates. 18FDG PET-CT is useful in identifying patients with mediastinal disease not evident by CT. Alternatively, M may not be required if PET-CT is negative. We have previously reported reduced rates of unnecessary thoracotomy (T) in the PET-CT arm of a trial which compared staging with PET-CT versus conventional imaging (bone scan and CT liver and adrenals) in patients with clinical stage I, II, or IIIA NSCLC being considered for surgery (J Clin Oncol 26 May 20 suppl: abstr 7502). Methods: In this analysis, we determined the accuracy of PET-CT in mediastinal staging compared to invasive surgical staging either by M alone or by M and T. Patients in the PET-CT arm had invasive mediastinal staging either by M or mediastinal nodal sampling at T. PET-CT was considered positive if N2 or N3 nodes exhibited increased 18FDG uptake. Results: M was performed in 81 of 143 patients in the PET-CT arm; the remainder had mediastinal nodal staging at T. Combining M with T, the sensitivity and specificity of PET-CT were 0.70 [95% CI: 0.48–0.85] and 0.94 [95%CI: 0.89–0.97], respectively. Of 21 patients with a positive PET-CT, 7 did not have tumor. The positive predictive value (PPV) and negative predictive value (NPV) were 0.67 [95% CI: 0.45–0.83] and 0.95 [95% CI: 0.90–0.98], respectively. The results for PET-CT versus M alone were: sensitivity, 1.0 [95% CI: 0.76–1.0]; specificity, 0.88 [95%CI: 0.79–0.94]; PPV, 0.60 [95%CI: 0.39–0.78]; NPV, 1.0 [95% CI: 0.94–1.0]. Based on PET-CT alone, 7 patients would have been denied T if PET-CT abnormalities had not been evaluated with invasive mediastinal staging. Conclusions: Mediastinal abnormalities on PET-CT should be confirmed by invasive mediastinal staging because of the risk of a false positive test. Patients should not be denied potentially curative therapy based on PET-CT alone. If PET-CT is negative in the mediastinum, the likelihood of occult metastatic disease in the mediastinum is very low and invasive staging may not be required depending on the clinical context.

No significant financial relationships to disclose.

Integration between primary care providers and the cancer system: Gaps and opportunities

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Background: A number of reports suggest that family physicians (FPs) are poorly integrated with the cancer care system. The specific gaps in care integration are poorly understood. In this study we examine specific processes of care associated with integration between FPs and regional cancer programs. Methods: Cross sectional survey of all identified primary care providers within a representative health region in Ontario, Canada. The survey instrument was created specifically for this study with items generated from published literature and expert input and pilot tested in a representative sample. A modified dilman method was used. Results: 500 physicians responded (response rate 60%). Overall 90% of respondants reported confidence in the workup of a new cancer case for the major disease sites but only half (54%) knew the process of referring to the regional cancer program. Only 57% felt investigations necessary could be done in a timely manner and 44% indicated that coordination of care needs to be improved. Most indicated preferance for an active navigation structure for newly diagnosed patients. Despite over 80% of respondents indicating use of the internet only 10% reported accessing cancer program web portals for information on the regional cancer program (such as waiting times). The majority of respondants (75%) indicated ongoing involvement in care during the active treatment phase, mostly for non cancer related medical issues but 20% indicated that they were not properly infomed of patients’ health status by the oncology program and only 57% indicated that they felt their role was valued by the cancer program during this phase in the care trajectory. In the follow up phase, 35% were unclear of their role specific to monitoring and surveillance. 60% felt their current compensation model was inadequate to support care of cancer patients. This did not vary by compensation model reported. Factors associated with better integration included attendance at educational sessions and years in practice. Conclusions: Cancer systems need to be more responsive to the needs of FPs to better integrate them and support optimal quality of care for cancer patients. Policies to clarify and support roles and responsibilites are necessary to ensure that FPs are integrated team members.

No significant financial relationships to disclose.

Impact of positron emission tomography (PET) in stage III non-small cell lung cancer (NSCLC): A prospective randomized trial (PET START)

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Background: Patients with stage III NSCLC are potentially curable using combined modality therapy (CMT) with chemotherapy and radical radiation (RT). The use of PET-CT rather than conventional imaging (CI) may better identify patients for CMT by enhanced tumor staging and improved definition of RT treatment volumes. Methods: Patients with stage III NSCLC (based on histology/cytology, brain CT/MRI, CT thorax, CT/US abdomen, and bone scan) who were considered candidates for CMT were randomized to either PET-CT or CT for RT treatment planning. The primary outcome was the proportion of patients who did not receive CMT because their tumor was upstaged to Stage 4 or their intrathoracic tumor was too extensive for radical RT. Overall survival (OS) and alteration of RT treatment planning volume were secondary outcomes. Target sample size was 400 patients based on a hazard rate reduction of 30% in OS at 2 years in favor of PET-CT with 2-sided alpha = 0.05 and 80% power. We also postulated that 200 patients would be required to detect a 20% difference between arms for the primary endpoint. 5 centers in Ontario participated. Results: The trial commenced in August 2004. In November 2008 after a planned interim analysis for the primary outcome, the Data Safety Monitoring Board recommended stopping recruitment because of superior efficacy with PET-CT. 304 patients were randomized and 289 had analyzable data. 25 patients were unsuitable for CMT: 21 in the PET-CT arm (16 upstaged to Stage 4 and 5 unsuitable for radical RT) and 4 in the CT arm (unsuitable for radical RT). Thus, 21 of 140 (15%) patients in the PET-CT arm achieved the primary outcome compared with 4 of 149 (2.7%) in the CT arm, P= 0.0002. Conclusions: This is the first randomized trial in stage III NSCLC showing that PET-CT is superior to CT planning alone in selecting appropriate patients for CMT. Longer patient follow-up will determine potential impact on OS.

No significant financial relationships to disclose.