Accelerated Education Program in Radiation Medicine: International Learner Perceptions of Experiences, Outcomes, and Impact

PURPOSE

The Accelerated Education Program (AEP) at the Princess Margaret Cancer Centre (PM) has been offering continuing medical education courses since 2006. The purpose of this study was to assess learner experiences, perspectives, and outcomes using Kirkpatrick's Four Level Training Evaluation Model (ie, reaction, learning, behavior, results) to ascertain whether it was meeting stated goals.

METHODS AND MATERIALS

Past course participants (2010-2018) were invited to participate in a semistructured interview. Interviews were transcribed verbatim; thematic analysis was conducted by a 4-person research team.

RESULTS

Seventeen participants including 2 medical physicists, 6 radiation oncologists, and 9 radiation therapists from 6 countries on 4 continents participated in the study. Interviews lasted an average of 25 minutes. Consistently positive outcomes were reported at each level of Kirkpatrick's model. At the reaction level, participants liked the small, interactive case-based design, exposure to renowned faculty and practices from PM and other major centers, and the interprofessional practice (IPP) approach. Suggestions for improvements include enhancing practical content. At the learning level, participants reported gaining new knowledge or skills and new awareness or attitudes. Behavior changes described included sharing learnings with colleagues, implementing changes in practice or techniques, departmental structure, and IPP. Participants described the effects on clinical practice (results) in quality of care, access to care, and academic contribution. Identified barriers to change related to the restricted internal capacity for change and the need for wider staff training.

CONCLUSIONS

AEP courses were found to have a positive effect on local practices ranging from confirmation of current practice through to increased access to and quality of advanced radiotherapeutic techniques and care. Our findings confirm that AEP is achieving its goal of "putting innovation to work" and suggest curricular improvements that can enhance these effects.

POS0076 S100A8/A9 AND S100A12 AS POTENTIAL PREDICTIVE BIOMARKERS OF ABATACEPT RESPONSE IN POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS

Background:

The calcium-binding proteins S100A8/A9 (calprotectin) and S100A12 (extracellular newly identified receptor for advanced glycation end-products binding protein [EN-RAGE]) are involved in multiple signalling pathways to mediate inflammation, can be secreted by activated monocytes/macrophages and exhibit cytokine-like extracellular functions. Circulating levels of these proteins have been associated with disease and clinical responses in systemic juvenile idiopathic arthritis (sJIA), including treatment response.1 Studies suggest that serum S100A8/A9 and S100A12, which are released at inflammation sites, are more specific biomarkers of local inflammation (e.g. in the synovium) than systemic biomarkers such as CRP and ESR.2,3

Objectives:

To investigate if baseline S100A8/A9 and S100A12 predict clinical response to abatacept treatment in polyarticular JIA (pJIA), and to assess whether changes from baseline in S100A8/A9 or S100A12 can be better prognostic markers for response to abatacept treatment than CRP in pJIA.

Methods:

Data are from a phase III trial of SC abatacept for the treatment of pJIA (NCT01844518).4 This 24-month, single-arm, open-label, international, multicentre, two-part study included male and female patients with pJIA aged 2–17 years. This analysis examined the correlation between biomarkers (S100A8/A9, S100A12 and high-sensitivity CRP [hsCRP]) and disease activity (measured using Juvenile Arthritis Disease Activity Score [JADAS]) at baseline, baseline biomarker values as predictors of future treatment response (ACR and JADAS endpoints), and the correlation between change from baseline in biomarker values and treatment response at Day 113.

Results:

Of 219 total patients, 158 (72%) had S100A8/A9 values and 155 (71%) had S100A12 values at baseline. Median S100A8/A9 and S100A12 values were 3295 ng/mL (normal range, 716–3004 ng/mL) and 176 ng/mL (normal range, 32–385 ng/mL), respectively. S100A8/A9, S100A12 and hsCRP (median 0.20 mg/dL; normal ≤0.6 mg/dL) had a low-to-moderate but significant association with disease activity at baseline; coefficients for associations between JADAS71-CRP low disease activity (LDA) and the biomarkers S100A8/A9, S100A12 and hsCRP were 0.23 (p=0.0038), 0.16 (p=0.0448) and 0.26 (p=0.0001), respectively. Baseline S100A8/A9 level above the median was associated with lower odds of ACR100 at Day 113 (p=0.0052). Figure 1 shows the associations of baseline biomarker values with Day 113 ACR and JADAS scores in the overall population. Baseline S100A8/A9 or S100A12 did not significantly influence ACR50 or ACR70 responses at Day 113, but high baseline values were associated with reduced odds of ACR90 (p=0.01), ACR100 (p=0.005), ACR-inactive disease (ID) (p=0.0001), and JADAS71-CRP (LDA) (p=0.02). By Day 477, elevated baseline S100A12 was still significantly associated with lower odds of ACR100 overall (0.467; p=0.0248) but baseline S100A8/A9 was not; at Day 645, neither was significantly associated with ACR100 response. At Day 113, changes from baseline in S100A8/A9 and S100A12 were correlated with ACR100 (coefficients of 0.22 [p=0.0082] and 0.26 [p=0.0015], respectively) and with ACR-ID (0.22 [p=0.0067] and 0.26 [p=0.0014], respectively); change in hsCRP was not significantly correlated with disease response.

Conclusion:

S100A8/A9 and S100A12 may serve as prognostic biomarkers to predict response to abatacept treatment at Day 113. Changes from baseline S100A8/A9 and S100A12 levels were more highly correlated with efficacy outcomes including ACR100 and ACR-ID at Day 113 compared with hsCRP.

References:

[1]Aljaberi N, et al. Pediatr Rheumatol Online J 2020;18:7.

[2]Hammer H, et al. Arthritis Res Ther 2011;13:R178.

[3]Nordal HH, et al. BMC Musculoskelet Disord 2014;15:335.

[4]Brunner H, et al. Arthritis Rheumatol 2018;70:1144–1154.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Rob Coover, MPH, at Caudex and was funded by Bristol Myers Squibb.

Disclosure of Interests:

Nicolino Ruperto Speakers bureau: NR has received honoraria for consultancies or speaker bureaus (< 10.000 USD each) from the following pharmaceutical companies in the past 3 years: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Eli Lilly, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Consultant of: NR has received honoraria for consultancies or speaker bureaus (< 10.000 USD each) from the following pharmaceutical companies in the past 3 years: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Eli Lilly, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Grant/research support from: The IRCCS Istituto Giannina Gaslini (IGG), where NR works as full-time public employee has received contributions (>10.000 USD each) from the following industries in the last 3 years: Bristol Myers Squibb, Eli Lilly, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi. This funding has been reinvested for the research activities of the hospital in a fully independent manner, without any commitment with third parties., Grant Schulert Speakers bureau: Novartis, Consultant of: SOBI, Alyssa Sproles: None declared, Sherry Thornton: None declared, Gabriel Vega Cornejo Speakers bureau: AbbVie, Grant/research support from: Bristol Myers Squibb, Eli Lilly, Janssen, Parexel, Sanofi, Jordi Anton Speakers bureau: AbbVie, Gebro, GlaxoSmithKline, Novartis, Pfizer, Roche, Sobi, Consultant of: AbbVie, Gebro, GlaxoSmithKline, Novartis, Pfizer, Roche, Sobi, Grant/research support from: AbbVie, Amgen, Gebro, GlaxoSmithKline, Lilly, Novartis, Novimmune, Pfizer, Roche, Sanofi, Sobi, Ruben Cuttica Speakers bureau: AbbVie, Bristol Myers Squibb, GlaxoSmithKline, Lilly, Novartis, Pfizer, Roche, UCB, Paid instructor for: AbbVie, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, GlaxoSmithKline, Lilly, Novartis, Pfizer, Roche, UCB, Michael Henrickson: None declared, Ivan Foeldvari Consultant of: Bristol Myers Squibb, Gilead, Hexal, MEDAC, Novartis, Pfizer, Sanofi, Daniel Kingsbury Consultant of: Pfizer, Margarita Askelson Consultant of: Currently working for Syneos Health providing services to Bristol Myers Squibb, Jinqi Liu Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sumanta Mukherjee Shareholder of: Bristol Myers Squibb, GlaxoSmithKline, Employee of: Bristol Myers Squibb, GlaxoSmithKline, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Daniel J Lovell Speakers bureau: Genentech, Wyeth Pharm, Consultant of: Abbott, Amgen, AstraZeneca, Boehringer Ingelheim, Celgene, GlaxoSmithKline, Hoffman-La Roche, Novartis, Pfizer, Regeneron, Takeda, UBC, Wyeth Pharma, Xoma, Alberto Martini Speakers bureau: AbbVie, Novartis, Consultant of: AbbVie, Eli Lilly, EMD Serono, Idorsia, Janssen, Novartis, Pfizer, Alexei Grom Consultant of: AB2Bio, Novartis, Sobi (NovImmune), Grant/research support from: AB2Bio, Novartis, Sobi (NovImmune), Hermine Brunner Speakers bureau: GlaxoSmithKline, Novartis, Pfizer, Roche, Paid instructor for: Novartis, Pfizer (funds go to CCHMC/employer), Consultant of: Boehringer Ingelheim, Bristol Myers Squibb, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Roche, UCB (funds go to CCHMC/employer), Grant/research support from: Bristol Myers Squibb, Pfizer (funds go to CCHMC/employer).

Predictors of survival after metastasectomy of oligometastatic recurrence following gastroesophageal cancer treatment

e16060

Background: Recurrent gastroesophageal (GE) carcinomas carry a poor prognosis and are usually treated with palliative chemotherapy (CTX). However, recent studies suggest that certain patients with oligometastatic recurrence can have long term survival after metastasectomy. Appropriate patient selection for metastasectomy remains a challenge, as few predictors of overall survival (OS) after metastasectomy have been identified. Our primary aim was to identify predictors of OS following metastasectomy in GE cancers. Methods: We conducted a retrospective study of GE cancer patients treated from 2007 to 2015 using the Princess Margaret Hospital Cancer Registry. We included patients who underwent curative-intent surgery or definitive chemoradiation (CRT) for localized GE cancer who then had single organ recurrence treated with metastasectomy. The probability of OS from date of recurrence was estimated with the Kaplan Meier method. Predictors of OS after metastasectomy for isolated recurrence were determined using Cox proportional hazards analysis. Covariates included time to recurrence (interval from curative-intent surgery or completion of definitive CRT), site of recurrence (lung/non-lung), sex, age and race (Asian/Non-Asian). Within the multivariable model, predictors with a p-value less than 0.05 were deemed significant. Results: Of 44 patients, median age was 58 years (28-78), and 59% were male. Primary sites were: esophagus 25%, GE junction 41% and gastric 34%. Treatment of the primary was: surgery alone 13%, surgery and (neo)adjuvant CTX 76%, and CRT 11%. Recurrent sites were brain 22%, ovary 20%, lung 18%, bone 7%, adrenals 7%, liver 7%, distant lymph node 6%, and other 13%. The median follow up time was 38.9 months. The 1, 3 and 5-year (yr) OS following metastasectomy were 79% (95% CI 68-92%), 40% (27-58%) and 28% (16-49%). Univariable analysis revealed that time to recurrence greater than 1 yr (HR=0.45 95% CI 0.21-0.93, p=0.032) and lung site recurrence (HR=0.16 95% CI 0.04-0.67, p=0.012) were associated with longer OS. On multivariable analysis, only lung site recurrence was significant (HR=0.12 95% CI 0.03-0.54, p=0.0056). The 1, 3 and 5-yr OS for patients after resection of isolated lung recurrence were 100% (95% CI 100-100%), 86% (63-100%) and 69% (40-100%). Conclusions: In our study, patients with isolated pulmonary recurrences demonstrated prolonged overall survival following metastasectomy. These patients could be considered for resection following recurrence of GE cancer. [Table: see text]

A Risk Score Model for Locoregional Recurrence Following Upfront Surgery for Pancreatic Adenocarcinoma: Implications for Adjuvant Therapy

AIMS

The aims of the study were to identify predictors of locoregional failure (LRF) following surgery for pancreatic adenocarcinoma, develop a prediction risk score model of LRF and evaluate the impact of postoperative radiation therapy (PORT) on LRF.

MATERIALS AND METHODS

A retrospective review was conducted on patients with stages I-III pancreatic adenocarcinoma who underwent surgery at our institution (2005-2016). Univariable and then multivariable analyses were used to evaluate clinicopathological factors associated with LRF for patients who did not receive PORT. The risk score of LRF was calculated based on the sum of coefficients of the predictors of LRF. The model was applied to the entire cohort to evaluate the impact of PORT on the high- and low-risk groups for LRF.

RESULTS

In total, 467 patients were identified (median follow-up 22 months). Among patients who did not receive PORT (n = 440), predictors of LRF were pN+, involved or close ≤1 mm margin(s), moderately and poorly differentiated tumour grade and lymphovascular invasion. After adding patients who received PORT, the 2-year LRF in the high-risk group was 57% for patients who did not receive PORT (n = 242) and 32% among patients who received PORT (n = 22), with an absolute benefit to LRF of 25% (95% confidence interval 5-52%, P = 0.07). The 2-year overall survival for the high-versus the low-risk group was 36% versus 67% (P < 0.001).

CONCLUSION

This risk group classification could be used to identify pancreatic adenocarcinoma patients with higher risk of LRF who may benefit from PORT. However, validation and prospective evaluation are warranted.

Impact of COVID-19 on social media as perceived by the oncology community: results from a survey in collaboration with the European Society for Medical Oncology (ESMO) and the OncoAlert Network

BACKGROUND

The COVID-19 pandemic has impacted all aspects of modern-day oncology, including how stakeholders communicate through social media. We surveyed oncology stakeholders in order to assess their attitudes pertaining to social media and how it has been affected during the pandemic.

MATERIALS AND METHODS

A 40-item survey was distributed to stakeholders from 8 July to 22 July 2020 and was promoted through the European Society for Medical Oncology (ESMO) and the OncoAlert Network.

RESULTS

One thousand and seventy-six physicians and stakeholders took part in the survey. In total, 57.3% of respondents were medical oncologists, 50.6% aged <40 years, 50.8% of female gender and mostly practicing in Europe (51.5%). More than 90% of respondents considered social media a useful tool for distributing scientific information and for education. Most used social media to stay up to date on cancer care in general (62.5%) and cancer care during COVID-19 (61%) given the constant flow of information. Respondents also used social media to interact with other oncologists (78.8%) and with patients (34.4%). Overall, 61.1% of respondents were satisfied with the role that social media was playing during the COVID-19 pandemic. On the other hand, 41.1% of respondents reported trouble in discriminating between credible and less credible information and 30% stated social networks were a source of stress. For this reason, one-third of respondents reduced its use during the COVID-19 pandemic. Regarding meeting attendance, a total of 59.1% of responding physicians preferred in-person meetings to virtual ones, and 51.8% agreed that virtual meetings and social distancing could hamper effective collaboration.

CONCLUSION

Social media has a useful role in supporting cancer care and professional engagement in oncology. Although one-third of respondents reported reduced use of social media due to stress during the COVID-19 pandemic, the majority found social media useful to keep up to date and were satisfied with the role social media was playing during the pandemic.

Rapid assessment on the utilization of maternal and child health services during COVID-19 in Rwanda

SETTING

All public health facilities in Rwanda, East Africa.

OBJECTIVE

To assess the change in the utilization of maternal and child health (MCH) services during the COVID-19 outbreak.

DESIGN

This was a cross-sectional quantitative study.

RESULTS

During the COVID-19 outbreak in Rwanda, the utilization of 15 MCH services in all four categories-antenatal care (ANC), deliveries, postnatal care (PNC) and vaccinations-significantly declined. The Northern and Western Provinces were affected the most, with significant decrease in respectively nine and 12 services. The Eastern Province showed no statistically significant utilization changes. Kigali was the only province with significant increase in the fourth PNC visits for babies and mothers, while the Southern Province showed significant increase in utilization of measles + rubella (MR) 1 vaccination.

CONCLUSION

Access and utilization of basic MCH services were considerably affected during the COVID-19 outbreak in Rwanda. This study highlighted the need for pre-emptive measures to avoid disruptions in MCH service delivery and routine health services during outbreaks. In order for the reductions in MCH service utilization to be reversed, targeted resources and active promotion of ANC, institutional deliveries and vaccinations need to be prioritized. Further studies on long-term impact and geographical variations are needed.

Factors associated with pain at the end-of-life among older adults in Mexico

OBJECTIVES

The goal of care at the end-of-life has changed in recent years to encompass not only the relief of suffering but also improve the quality of death. Palliative care offers a coordinated and multidisciplinary approach to improving the quality of life and quality of care of individuals and their families facing illness at the end-of-life. This manuscript examines the end-of-life of older adults in Mexico and the factors associated with pain in this period of their life.

STUDY DESIGN

We used data from the Mexican Health and Aging Study (MHAS), a longitudinal panel study of adults 50 years and older in Mexico that is nationally representative of urban and rural areas and includes a next-of-kin questionnaire that captures the conditions during the last year of life of those who died. We used all four waves of data to construct a group of deceased individuals between 2001 and 2015, including information in the wave immediately before death and a complete next-of-kin questionnaire. We studied factors associated with pain at the end-of-life in this group.

METHODS

The dependent variable was pain reported over time among deceased individuals. We constructed pain categories based on whether the pain was reported in one or two waves (occasional and persistent), and the pain intensity reported (mild, moderate, or severe). We included independent variables previously reported to be related to pain, including sociodemographic, functional, and health characteristics. We used descriptive statistics and a multinomial regression model to examine the factors associated with pain in this group.

RESULTS

Pain was reported by 71.5% of older adults who died between 2001 and 2015. The prevalence of pain differed significantly by sociodemographic characteristics. Women had 1.69 higher odds of reporting severe pain than men. Compared to those with zero years of education, the odds of reporting severe pain were 0.72 for those with 1-6 years of education (P < 0.05) and 0.55 for those with more than 7 years (P < 0.001). Poor self-reported health, arthritis, taking more medications, depression, and functional limitations in the wave prior to death were associated with higher odds of persistent pain at the end-of-life (P < 0.05). Conversely, older age, more years of education, and diabetes were associated with lower odds of persistent pain (P < 0.001).

CONCLUSIONS

The prevalence of pain among older Mexican adults is high at the end-of-life. Sociodemographic factors, some chronic diseases, number of medications, psychosocial factors, and functional status impact the odds of reporting pain in this group at the end-of-life. Providing education to families on psychosocial interventions to improve the quality of care at the end-of-life is a pressing need in Mexico. These findings provide information to help policymakers and healthcare providers in Mexico improve the quality of care at the end-of-life.

Variability of essential and non-essential trace elements in the follicular fluid of women undergoing in vitro fertilization (IVF)

Both essential and non-essential elements have been associated with female reproductive function in epidemiologic investigations, including among IVF populations. To date, most investigators have used blood or urine to assess biomarkers of exposure, with few employing ovarian follicular fluid (FF). FF may offer a more direct "snapshot" of the oocyte microenvironment than blood or urine, however previous studies report follicle-to-follicle variability in FF constituents that may contribute to exposure misclassification. Our objectives were to investigate sources of trace element variability, to estimate FF biomarker reliability among women undergoing IVF (n = 34), and to determine the minimum number of follicles required to estimate subject-specific mean concentrations. We measured As, Hg, Cd, Pb, Cu, Mn, Se, and Zn in FF samples using inductively coupled plasma tandem mass spectrometry. Inter-subject (between-women) variability contributed most of the variability in FF element concentrations, with ovarian, follicular, and analytical as smaller sources of variability. The proportion of variability attributable to sources between-follicles differed by age, body mass index (BMI), race, and cigarette smoking for Cu, Se, and Zn, by BMI and cigarette smoking for As, by primary infertility diagnosis for Hg, Cu, Se, and Zn, and by ovarian stimulation protocol for Mn and Se. Four to five individual follicles were sufficient to estimate subject-specific mean Cu, Se, and Zn concentrations, while >14 were necessary for As, Hg, Cd, Pb, and Mn. Overall, our results suggest that FF is a suitable source of biomarkers of As and Hg exposure in ovarian follicles. Although limited in size, our study offers the most comprehensive exploration of biological variation in FF trace elements to date and may provide guidance for future studies of ovarian trace element exposures.

Continuing Professional Development Needs Amongst University of Toronto's Department of Radiation Oncology Faculty

Continuing professional development (CPD) and lifelong learning are core tenets of most healthcare disciplines. Where undergraduate coursework lays the foundation for entry into practice, CPD courses and offerings are designed to aid clinicians in maintaining these competencies. CPD offerings need to be frequently revised and updated to ensure their continued utility. The purpose of this qualitative study was to better understand the CPD needs of members of the University of Toronto's Department of Radiation Oncology (UTDRO) and determine how these needs could be generalized to other CPD programs. Given that UTDRO consists of members of various health disciplines (radiation therapist, medical physicists, radiation oncologists, etc.), eleven semi-structured interviews were conducted with various health professionals from UTDRO. Inductive thematic analysis using qualitative data processing with NVivo® was undertaken. The data was coded, sorted into categories, and subsequently reviewed for emergent themes. Participants noted that a general lack of awareness and lack of access made participation in CPD programs difficult. Members also noted that topics were often impractical, irrelevant, or not inclusive of different professions. Some participants did not feel motivated to engage in CPD offerings due to a general lack of time and lack of incentive. To address the deficiencies of CPD programs, a formal needs assessment that engages stakeholders from different centers and health professions is required. Needs assessments of CPD programs should include analyzing elements related to access, how to utilize technology-enhanced learning (TEL), determine barriers to participation, and understand how to better engage members.

Gastric and gastroesophageal adenocarcinoma survival outcomes relative to completion of perioperative fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT): A single-center retrospective analysis

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Background: Perioperative FLOT is standard-of-care for locally advanced resectable gastric and gastroesophageal (GEJ) adenocarcinoma. Completion of perioperative chemotherapy (8 cycles) is potentially jeopardised by significant toxicity and intolerance. Only 46% of patients completed all cycles in the initial phase 2/3 trial (FLOT-AIO). We sought to determine the rate of treatment completion in a real-world population and any subsequent impact on survival of incomplete treatment. Methods: A retrospective analysis of gastric and GEJ adenocarcinoma patients treated with perioperative FLOT at Princess Margaret Cancer Centre, Toronto between September 2017 and July 2020 was performed. The rate of perioperative FLOT administration, disease-free survival (DFS) and overall survival (OS) was analysed, with outcomes compared between patients that completed perioperative FLOT and those that didn’t. Results: 32 patients were identified as receiving neoadjuvant FLOT. Mean age was 61.5y, 26 (81%) were male and 29 (91%) were non-Asian. All patients were ECOG 0-1. The median number of neoadjuvant cycles was 4. 29 (91%) had surgery (2 = disease progression; 1 = declined surgery). 10 (34%) patients had minimal/nil response upon resection (College of American Pathologists Tumour Regression Grading (TRG) Score 3), 5 of whom received adjuvant FLOT whilst 5 did not (p0.28). 10 (34%) patients did not receive adjuvant FLOT, 18 (62%) did and 1 received 8 cycles of neoadjuvant chemotherapy. Nil demographic differences were observed between ‘yes’ and ‘no’ adjuvant FLOT groups. The reasons for not having adjuvant chemotherapy were: metastatic disease diagnosed post-operatively (n = 2), TRG Score 3 (n = 4), patient declined further chemotherapy (n = 1), reduced performance status and/or toxicity (n = 2), and the patient requiring treatment for a second malignancy (n = 2). 10 (34%) patients completed perioperative chemotherapy. Median DFS was 12.5m (95% CI 7.9-12.5) for ‘no’ FLOT’ and was not-reached for ‘yes’ FLOT (p = 0.29). 18m DFS was 50% (95% CI 27-93) v 81% (95% CI 64-100) respectively. The median OS for ‘no’ adjuvant FLOT was 16.7m (95% CI 11.5-16.7) with 5 deaths. Zero deaths due to malignancy had occurred at 23.3m in those who received adjuvant FLOT (p0.00164). 1 death in the ‘yes’ group occurred due to interstitial lung disease. Conclusions: In our small population size 34% of patients completed perioperative FLOT. Whilst nil statistically significant difference was observed in mDFS, an improved mOS was observed in those that received adjuvant FLOT suggesting an importance in receiving the maximum number of cycles of chemotherapy. Given the challenges of administering adjuvant FLOT future trials into the feasibility and efficacy of 8 cycles of neoadjuvant FLOT should be considered.

Prognostic significance of nutritional markers in metastatic gastric and esophageal adenocarcinoma

Background

Malnutrition and sarcopenia are poor prognostic factors in many cancers. Studies in gastric and esophageal (GE) cancer have focused on curative intent patients. This study aims to evaluate the prognostic utility of malnutrition and sarcopenia in de novo metastatic GE adenocarcinoma.

Methods

Patients with de novo metastatic GE adenocarcinoma seen at the Princess Margaret Cancer Centre from 2010 to 2016 with an available pre‐treatment abdominal computed tomography (CT) were included. Malnutrition was defined as nutritional risk index (NRI) <97.5. Skeletal muscle index (SMI) was measured at the L3 level (sarcopenia defined as SMI <34.4 cm²/m² in women and <45.4 cm²/m² in men). Patients receiving chemotherapy had NRI and SMI recalculated at the time of first restaging CT.

Results

Of 175 consecutive patients, 33% were malnourished and 39% were sarcopenic at baseline. Patients with pretreatment malnourishment had significantly shorter overall survival (OS; 5.8 vs. 10.9 months, p = 0.000475). Patients who became malnourished during chemotherapy had worse OS compared to those who maintained their nutrition (12.2 vs. 17.5 months p = 0.0484). On univariable analysis, ECOG (p < 0.001), number of metastatic sites (p = 0.029) and NRI (p < 0.001) were significant prognostic factors while BMI (p = 0.57) and sarcopenia (p = 0.19) were not. On multivariable analysis, ECOG (p < 0.001), baseline NRI (p = 0.025), and change in NRI during treatment (p < 0.001) were significant poor prognostic factors for OS.

Conclusions

In de novo metastatic GE adenocarcinoma patients, ECOG, pretreatment NRI and change in NRI were significant prognostic factors for OS while sarcopenia was not. Use of NRI at baseline and during treatment can provide useful prognostic information.

A pilot investigation of couple-level phthalates exposure and in vitro fertilization (IVF) outcomes

Phthalates are reproductive toxicants in experimental animal studies and exposure has been associated with infertility in human populations, although the results have been inconsistent. To help to address the data gap, we conducted a hypothesis-generating investigation of associations between urinary phthalate metabolites and reproductive outcomes among women (n = 56) and their male partners (n = 43) undergoing in vitro fertilization (IVF). Urine was collected from participants on the day of oocyte retrieval. Samples were analyzed for a series of phthalates, MEP, MBP, MPP, MHxP, MEHP, MEHHP, MECPP, MiNP, MiDP, MCHP, and MBzP, using liquid chromatography-tandem mass spectrometry. We employed Poisson regression with robust variance estimation to estimate associations between urinary phthalate levels and biochemical pregnancy and live birth, adjusted for partner's concentration and confounding factors. Doublings in women's MBP (relative risk (RR) = 0.32, 95 % CI: 0.13, 0.78), and men's MEHP (RR = 0.28, 95 % CI: 0.09, 0.83), were associated with a lower likelihood for pregnancy. Doublings in women's (RR = 0.08, 95 % CI: 0.01, 0.67) and men's (RR = 0.13, 95 % CI: 0.02, 0.92) MHxP were associated with a lower likelihood of live birth. Our results suggest that phthalate exposure may impact IVF outcomes, and underscore the importance of including male partners when investigating the impact of phthalate exposure on IVF. These results also suggest that clinical recommendations should include male partners for limiting phthalate exposure. Still, a larger and more comprehensive investigation is necessary to more definitively assess the risks.

Chemoradiotherapy Using Carboplatin plus Paclitaxel versus Cisplatin plus Fluorouracil for Esophageal or Gastroesophageal Junction Cancer

BACKGROUND

Trimodality therapy (TMT) with neoadjuvant chemoradiotherapy (nCRT) using concurrent carboplatin plus paclitaxel (CP) followed by surgery is the standard of care for locoregional esophageal or gastroesophageal junction (GEJ) cancers. Alternatively, nCRT with cisplatin plus fluorouracil (CF) can be used. Definitive chemoradiotherapy (dCRT) with CP or CF can be used if surgery is not planned. In the absence of comparative trials, we aimed to evaluate outcomes of CP and CF in the settings of TMT and dCRT.

METHODS

A single-site, retrospective cohort study was conducted at the Princess Margaret Cancer Centre to identify all patients who received CRT for locoregional esophageal or GEJ cancer. Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan-Meier method and multivariable Cox regression model. The inverse probability treatment weighting (IPTW) method was used for sensitivity analysis.

RESULTS

Between 2011 and 2015, 93 patients with esophageal (49%) and GEJ (51%) cancers underwent nCRT (n = 67; 72%) or dCRT (n = 26; 28%). Median age was 62.3 years and 74% were male. Median follow-up was 23.9 months. Comparing CP to CF in the setting of TMT, the OS and DFS rates were similar. In the setting of dCRT, CP was associated with significantly inferior 3-year OS (36 vs. 63%; p = 0.001; HR 3.1; 95% CI: 1.2-7.7) and DFS (0 vs. 41%; p = 0.004; HR 3.6; 95% CI: 1.4-8.9) on multivariable and IPTW sensitivity analyses.

CONCLUSIONS

TMT with CF and CP produced comparable outcomes. However, for dCRT, CF may be a superior regimen.

Regional Therapies for Colorectal Liver Metastases: Systematic Review and Clinical Practice Guideline

BACKGROUND

Resection is the foundation for cure for colorectal cancer (CRC) liver metastases; however, only 20% of patients are suitable for surgery. Those suitable would be considered for resection or local therapies before being considered for regional therapies. Noncurative treatment is usually systemic chemotherapy. For patients with liver-only or liver-predominant metastases that are unresectable, regional therapies [conventional transarterial chemoembolization (cTACE), drug-eluting bead transarterial chemoembolization (DEB-TACE), and transarterial radioembolization (TARE)] may be considered. We review the current evidence for regional therapies for CRC liver metastases.

PATIENTS AND METHODS

Literature searches (January 2000 to March 2019 or January 2010 to March 2019 depending on the specific systematic review question) were conducted, including Medline, Embase, Cochrane Library, and 2018 American Society of Clinical Oncology (ASCO) abstracts.

RESULTS

A total of 4100 articles were identified; 15 studies were included in the review. There were no comparative data regarding the resectable population. There was either insufficient evidence (cTACE or DEB-TACE) or evidence against (TARE) the addition of regional therapies to systemic therapy in the first line in the unresectable population. There was either no evidence (cTACE) or weak evidence (DEB-TACE or TARE) for the addition of regional therapies with or without systemic therapy in the second line or later in the unresectable population.

CONCLUSION

Limited evidence supports the delivery of percutaneous regional therapies in patients with unresectable CRC liver metastases. There are strong data demonstrating positive effects of TARE within the liver, but they do not translate to a benefit in patient-important outcomes. DEB-TACE appears to offer a survival benefit in the second-line setting, although the evidence is limited by small sample size and larger trials are needed.

Association of technologically assisted integrated care with clinical outcomes in type 2 diabetes in Hong Kong using the prospective JADE Program: A retrospective cohort analysis

BACKGROUND

Diabetes outcomes are influenced by host factors, settings, and care processes. We examined the association of data-driven integrated care assisted by information and communications technology (ICT) with clinical outcomes in type 2 diabetes in public and private healthcare settings.

METHODS AND FINDINGS

The web-based Joint Asia Diabetes Evaluation (JADE) platform provides a protocol to guide data collection for issuing a personalized JADE report including risk categories (1-4, low-high), 5-year probabilities of cardiovascular-renal events, and trends and targets of 4 risk factors with tailored decision support. The JADE program is a prospective cohort study implemented in a naturalistic environment where patients underwent nurse-led structured evaluation (blood/urine/eye/feet) in public and private outpatient clinics and diabetes centers in Hong Kong. We retrospectively analyzed the data of 16,624 Han Chinese patients with type 2 diabetes who were enrolled in 2007-2015. In the public setting, the non-JADE group (n = 3,587) underwent structured evaluation for risk factors and complications only, while the JADE (n = 9,601) group received a JADE report with group empowerment by nurses. In a community-based, nurse-led, university-affiliated diabetes center (UDC), the JADE-Personalized (JADE-P) group (n = 3,436) received a JADE report, personalized empowerment, and annual telephone reminder for reevaluation and engagement. The primary composite outcome was time to the first occurrence of cardiovascular-renal diseases, all-site cancer, and/or death, based on hospitalization data censored on 30 June 2017. During 94,311 person-years of follow-up in 2007-2017, 7,779 primary events occurred. Compared with the JADE group (136.22 cases per 1,000 patient-years [95% CI 132.35-140.18]), the non-JADE group had higher (145.32 [95% CI 138.68-152.20]; P = 0.020) while the JADE-P group had lower event rates (70.94 [95% CI 67.12-74.91]; P < 0.001). The adjusted hazard ratios (aHRs) for the primary composite outcome were 1.22 (95% CI 1.15-1.30) and 0.70 (95% CI 0.66-0.75), respectively, independent of risk profiles, education levels, drug usage, self-care, and comorbidities at baseline. We reported consistent results in propensity-score-matched analyses and after accounting for loss to follow-up. Potential limitations include its nonrandomized design that precludes causal inference, residual confounding, and participation bias.

CONCLUSIONS

ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings.

Seafood consumption is associated with higher follicular fluid arsenic (As) and mercury (Hg) concentrations in women undergoing in vitro fertilization (IVF)

Human exposure to non-essential toxic metals such as cadmium (Cd), mercury (Hg), and lead (Pb), and metalloids such as arsenic (As) commonly occurs through diet. Toxic trace element exposures have been reported in association with fertility and fecundity in epidemiologic studies even at low to moderate levels. While most previous studies employed blood and urine biomarkers of exposure, few have assessed toxic trace elements in ovarian follicular fluid (FF), which surrounds the developing oocyte and hence may better reflect concentrations potentially affecting reproductive outcomes. Our objective was to identify dietary predictors of FF toxic trace elements in n = 56 women (mean age: 38.3 years) undergoing in vitro fertilization (IVF) at the University of California at San Francisco. We determined As, Hg, Cd, and Pb in 197 FF specimens, collected on the day of oocyte retrieval, using inductively coupled plasma tandem mass spectrometry. A comprehensive food frequency questionnaire was used to assess the weekly and annual dietary "patterns" of participants. Consumption of specific seafood items and turkey were correlated with individual FF toxic trace elements. We also found that each unit higher seafood consumption in the past week dominated by mollusks, shrimp, and bass was associated with 60% higher FF As (95% confidence interval (CI): 25%, 105%) and FF Hg (95%CI: 7%, 136%) concentrations. Higher annual seafood consumption dominated by urchin, crab, and trout was associated with 16% higher FF As (95%CI: -2%, 38%) and 31% higher FF Hg (95%CI: 7%, 60%) concentrations per unit intake. No associations were noted between diet and Cd and Pb levels in FF. Overall, our results suggest that higher seafood consumption contributes to elevated levels of As and Hg in FF. These findings are consistent with previous IVF studies that assessed toxic trace element exposures in blood and urine. To our knowledge, this is the first study to report that diet might be a source of As, Hg, Cd, and Pb in FF.