Long term trends at a comprehensive cancer center during the COVID-19 pandemic

BACKGROUND

As the ongoing public health crisis from Coronavirus Disease 2019 (COVID-19) pandemic puts strains on current models of cancer care, many health care centers had to adapt to minimize the risk of exposure and infection. The effects of the COVID-19 pandemic in a comprehensive cancer center were determined.

AIMS

To measure the impact of the COVID-19 pandemic on care delivery at a comprehensive cancer center.

METHODS

The number of on-site and telehealth visits (TH) were obtained from scheduling software. Multiple factors including total visits, telehealth visits, screenings for cancer diagnosis, and cancer treatments were tracked from 2 years before the pandemic onset through 2022. The length of stay (LOS) and Case Mix Index (CMI) were calculated using hospital database.

RESULTS

In the third quarter of FY 2020, telehealth visits (TH) represented a fifth of total patient encounters. Cancer treatments, such as chemotherapy, radiation therapy, and surgery, decreased during the pandemic with number of surgeries being most affected (23% decrease in 2020 compared to the previous fiscal year). The average length of stay (LOS) was also longer with less discharges per given time during the pandemic. The increased LOS was related to increased severity of patient illnesses since CMI was higher. Screening mammograms decreased to a nadir of 58% in 2021 as compared to those screened in pre-pandemic fiscal years.

CONCLUSION

The COVID-19 pandemic impacted many aspects of care, such as treatment and screenings. Many of these factors had to be postponed due to the fear of acquiring COVID-19 and access to care. The findings presented implicate that the delays and changes in cancer care during the pandemic resulted in less screening and treatment of more advanced disease.

Co-enrolment of Participants into Multiple Cancer Trials: Benefits and Challenges

Opportunities to enter patients into more than one clinical trial are not routinely considered in cancer research and experiences with co-enrolment are rarely reported. Potential benefits of allowing appropriate co-enrolment have been identified in other settings but there is a lack of evidence base or guidance to inform these decisions in oncology. Here, we discuss the benefits and challenges associated with co-enrolment based on experiences in the Add-Aspirin trial - a large, multicentre trial recruiting across a number of tumour types, where opportunities to co-enrol patients have been proactively explored and managed. The potential benefits of co-enrolment include: improving recruitment feasibility; increased opportunities for patients to participate in trials; and collection of robust data on combinations of interventions, which will ensure the ongoing relevance of individual trials and provide more cohesive evidence to guide the management of future patients. There are a number of perceived barriers to co-enrolment in terms of scientific, safety and ethical issues, which warrant consideration on a trial-by-trial basis. In many cases, any potential effect on the results of the trials will be negligible - limited by a number of factors, including the overlap in trial cohorts. Participant representatives stress the importance of autonomy to decide about trial enrolment, providing a compelling argument for offering co-enrolment where there are multiple trials that are relevant to a patient and no concerns regarding safety or the integrity of the trials. A number of measures are proposed for managing and monitoring co-enrolment. Ensuring acceptability to (potential) participants is paramount. Opportunities to enter patients into more than one cancer trial should be considered more routinely. Where planned and managed appropriately, co-enrolment can offer a number of benefits in terms of both scientific value and efficiency of study conduct, and will increase the opportunities for patients to participate in, and benefit from, clinical research.

Randomised clinical trial: addition of alginate-antacid (Gaviscon Double Action) to proton pump inhibitor therapy in patients with breakthrough symptoms

BACKGROUND

Symptomatic breakthrough in proton pump inhibitor (PPI)-treated gastro-oesophageal reflux disease (GERD) patients is a common problem with a range of underlying causes. The nonsystemic, raft-forming action of alginates may help resolve symptoms.

AIM

To assess alginate-antacid (Gaviscon Double Action, RB, Slough, UK) as add-on therapy to once-daily PPI for suppression of breakthrough reflux symptoms.

METHODS

In two randomised, double-blind studies (exploratory, n=52; confirmatory, n=262), patients taking standard-dose PPI who had breakthrough symptoms, assessed by Heartburn Reflux Dyspepsia Questionnaire (HRDQ), were randomised to add-on Gaviscon or placebo (20 mL after meals and bedtime). The exploratory study endpoint was change in HRDQ score during treatment vs run-in. The confirmatory study endpoint was "response" defined as ≥3 days reduction in the number of "bad" days (HRDQ [heartburn/regurgitation] >0.70) during treatment vs run-in.

RESULTS

In the exploratory study, significantly greater reductions in HRDQ scores (heartburn/regurgitation) were observed in the Gaviscon vs placebo (least squares mean difference [95% CI] -2.10 [-3.71 to -0.48]; P=.012). Post hoc "responder" analysis of the exploratory study also revealed significantly more Gaviscon patients (75%) achieved ≥3 days reduction in "bad" days vs placebo patients (36%), P=.005. In the confirmatory study, symptomatic improvement was observed with add-on Gaviscon (51%) but there was no significant difference in response vs placebo (48%) (OR (95% CI) 1.15 (0.69-1.91), P=.5939).

CONCLUSIONS

Adding Gaviscon to PPI reduced breakthrough GERD symptoms but a nearly equal response was observed for placebo. Response to intervention may vary according to whether symptoms are functional in origin.

Metformin as an adjuvant treatment for cancer: a systematic review and meta-analysis

BACKGROUND

Metformin use has been associated with a reduced risk of developing cancer and an improvement in overall cancer survival rates in meta-analyses, but, to date, evidence to support the use of metformin as an adjuvant therapy in individual cancer types has not been presented.

PATIENTS AND METHODS

We systematically searched research databases, conference abstracts and trial registries for any studies reporting cancer outcomes for individual tumour types in metformin users compared with non-users, and extracted data on patients with early-stage cancer. Studies were assessed for design and quality, and a meta-analysis was conducted to quantify the adjuvant effect of metformin on recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS), to inform future trial design.

RESULTS

Of 7670 articles screened, 27 eligible studies were identified comprising 24 178 participants, all enrolled in observational studies. In those with early-stage colorectal cancer, metformin use was associated with a significant benefit in all outcomes [RFS hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.47-0.85; OS HR 0.69, CI 0.58-0.83; CSS HR 0.58, CI 0.39-0.86]. For men with early-stage prostate cancer, metformin was associated with significant, or borderline significant, benefits in all outcomes (RFS HR 0.83, CI 0.69-1.00; OS HR 0.82, CI 0.73-0.93; CSS HR 0.58, CI 0.37-0.93); however, there was significant heterogeneity between studies. The data suggest that prostate cancer patients treated with radical radiotherapy may benefit more from metformin (RFS HR 0.45, CI 0.29-0.70). In breast and urothelial cancer, no significant benefits were identified. Sufficient data were not available to conduct analyses on the impact of metformin dose and duration.

CONCLUSIONS

Our findings suggest that metformin could be a useful adjuvant agent, with the greatest benefits seen in colorectal and prostate cancer, particularly in those receiving radical radiotherapy, and randomised, controlled trials which investigate dose and duration, alongside efficacy, are advocated.

Anticholinergic burden in schizophrenia and ability to benefit from psychosocial treatment programmes: a 3-year prospective cohort study

BACKGROUND

Many medications administered to patients with schizophrenia possess anticholinergic properties. When aggregated, pharmacological treatments may result in a considerable anticholinergic burden. The extent to which anticholinergic burden has a deleterious effect on cognition and impairs ability to participate in and benefit from psychosocial treatments is unknown.

METHOD

Seventy patients were followed for approximately 3 years. The MATRICS consensus cognitive battery (MCCB) was administered at baseline. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. Ability to benefit from psychosocial programmes was measured using the DUNDRUM-3 Programme Completion Scale (D-3) at baseline and follow-up. Psychiatric symptoms were measured using the PANSS. Total antipsychotic dose was measured using chlorpromazine equivalents. Functioning was measured using the Social and Occupational Functioning Assessment Scale (SOFAS).

RESULTS

Mediation analysis found that the influence of anticholinergic burden on ability to participate and benefit from psychosocial programmes was completely mediated by the MCCB. For every 1-unit increase on the ACB scale, change scores for DUNDRUM-3 decreased by -0.27 points. This relationship appears specific to anticholinergic burden and not total antipsychotic dose. Moreover, mediation appears to be specific to cognition and not psychopathology. Baseline functioning also acted as mediator but only when MCCB was not controlled for.

CONCLUSIONS

Anticholinergic burden has a significant impact on patients' ability to participate in and benefit from psychosocial treatment programmes. Physicians need to be mindful of the cumulative effect that medications can have on patient cognition, functional capacity and ability to benefit from psychosocial treatments.

Do women who intermittently attend breast screening differ from those who attend every invitation and those who never attend?

Objectives

Analysis of screening uptake usually dichotomizes women into attenders and non-attenders, though many women respond positively to some but not all invitations. This paper studies these intermittent attenders.

Methods

A cohort of 8,571 women invited for consecutive breast screens in the Northern Ireland Breast Screening Programme were followed in a study linking screening and census records. Multivariate logistic analysis was used to analyze the characteristics of those who attended both times (consistent), once (intermittent or ‘one-time only’), or not at all (non-attenders).

Results

Overall, 15.5% of women attended once and 13.4% were non-attenders. Non-attenders were characteristically disadvantaged (as measured by social renting, car access, and employment status), less likely to be married, and more likely to be healthy. One-time attenders were younger, and suffering poor health, though there was no association with either social renting or employment status. Privately rented accommodation and city living was associated with both one-time attendance and non-attendance.

Conclusions

One-time attenders are an important and distinct subgroup of screening invitees in this analysis. Their distinct characteristics suggest that transitory factors, such as change in marital status, ill-health, or addressing difficulties through change of residence are important. These distinct characteristics suggest the need for different approaches to increase attendance, among both intermittent attenders and those not attending at all.

Breast cancer in older patients: national cancer registry data

BACKGROUND

The population in developed countries is ageing. Cancer is a disease of ageing, and this is likely to lead to an increase in the number of older patients diagnosed with cancer with significant implications for resource allocation and research priorities. Breast Cancer in older women presents a number of challenges.

AIMS

This paper describes the trends in number of new breast cancer registrations in older patients over the last 38 years.

MATERIALS AND METHODS

Data were extracted from the Office for National Statistics describing new registrations of breast cancer for patients aged 65 or over, from 1971 to 2009.

RESULTS

The number of diagnoses of breast cancer across all age groups increased from 17,694 in 1971 to 40,260 in 2009. The proportion of diagnoses of breast cancer made in women aged 65 and over increased from 42% in 1971 to 45% in 2009. The proportion of diagnoses of breast cancer made in women aged 70 and over increased from 30% in 1971 to 33% in 2009. The number of cases of breast cancer registered in patients aged 65 and over has increased from 7376 in 1971 to 17,934 in 2009.

DISCUSSION

The reasons for the large increases in the number of older women diagnosed with breast cancer, and older women represent an increasing proportion of those diagnosed are multi-factorial. These include the ageing of the population, obesity, alcohol consumption, use of hormone replacement therapy and reproductive factors, improved breast cancer awareness and the UK National Screening Programme. Clinician attitudes and behaviours and also cancer registries striving to increase their levels are other causes. The effective management of these women will present constraints to service delivery and should therefore influence research priorities.

CONCLUSION

This short communication reports on the increasing registration of breast cancer in the older age group which will present a number of challenges for the future.

Salvaging locoregional recurrence with radiotherapy after surgery in early cervical cancer

AIMS

To determine the outcome and morbidity after radiotherapy for locally recurrent cervical cancer.

MATERIALS AND METHODS

Women who presented with locally recurrent cervical cancer after surgery alone during 1985 and 1997 were identified from the hospital database. Data were collected and analysed to include the stage at first diagnosis, staging investigations before surgery, the surgical procedure, the indication for radiotherapy, the type of radiotherapy, morbidity and survival.

RESULTS

In total, 130 women had radical external beam radiotherapy and/or intracavitary brachytherapy for locoregional recurrence during the defined study period. The 5-year disease-specific survival for the study population was 40.2%. Women who were treated for vault recurrence had a significantly better 5-year disease-free survival compared with women who developed nodal recurrence alone (55.4% vs 12.5%). This group of women also had a significantly slower rate of disease progression after radiotherapy than women with nodal recurrence (48.7% vs 87.5%, P=0.0001).

CONCLUSION

Radical radiotherapy alone is able to salvage 55% of vaginal vault recurrences after surgery for cervical cancer with minimal late toxicity. Salvage rates in women with pelvic nodal recurrences are considerably lower. Chemoradiotherapy using intensity-modulated radiotherapy to deliver an escalated radiotherapy dose needs to be pursued to improve locoregional control.

Pattern of failure and long-term morbidity in patients undergoing postoperative radiotherapy for cervical cancer

The objective of this study was to assess treatment outcomes in a large case series of cervical cancer patients undergoing postoperative radiotherapy in a single center. Case notes of women referred to the Christie Hospital during 1985-1997 for postoperative adjuvant radiotherapy for cervical cancer were reviewed. Of 478 women eligible for analysis, 282 (58.9%) underwent radical hysterectomy and 196 (41.1%) had nonradical hysterectomy. The disease-specific 5-year survival for the study population is 70.1%, with a 5-year risk of developing any recurrence of 30.5% and a 5-year grade 3 morbidity rate of 3.9%. Survival was significantly higher, ie, 80.9% vs 62.7% (P = 0.0001) and recurrence was significantly lower, ie, 18.6% vs 38.8% (P < 0.00005) in the group of women who had adjuvant radiotherapy following a nonradical hysterectomy compared with radical surgery. Thirty percent of women having "radical" surgery had positive resection margins and required postoperative adjuvant pelvic radiotherapy. Women with node-positive disease, who received adjuvant radiotherapy, had a high rate of distant metastases. These women would receive chemoradiotherapy now as primary treatment because of the risk of developing distant metastases. If, despite staging investigations, surgery reveals node-positive disease, then these women should receive adjuvant chemoradiotherapy. Survival was better in women who had nonradical surgery due to smaller volume disease when cancers were unsuspected and hence will have been cured by surgery alone. Multidisciplinary team working, as recommended by national guidelines from 1999, should allow better patient selection for treatment.

An Internet-based cancer clinical trials matching resource

Background

Many patients are now accessing the Internet to obtain cancer clinical trials information. However, services offering clinical trials recruitment information have not been well defined.

Objectives

This study describes one of the first Web-based cancer clinical trials matching resources and the demographics of users who were successfully matched.

Methods

OncoLink is the Internet-based educational resource managed by the University of Pennsylvania Cancer Center (UPCC) and serves between 1 and 2 million pages per month to over 385000 unique IP addresses. OncoLink launched one of the first clinical trials matching resources on the Internet that allowed patients to enter demographic data through a secure connection and be matched to clinical trials. For patients with matches to potential trials, appointments were facilitated with the principal investigators.

Results

While we did not keep track of patients who could not be matched, 627 patients who submitted online applications between January 2002 and April 2003 were successfully matched for potential enrollment in clinical trials. The mean age of the patient population was 56 years (range 18–88 years). Males represented 60% of the patient population, and over 90% of users were Caucasian. Most of the applications were from patients with colorectal cancer (13%), lung cancer (14%), melanoma (10%), and non-Hodgkin's lymphoma (9%).

Conclusions

This report shows that a significant number of patients are willing to use the Internet for enrolling in clinical trials. Care must be taken to reach patients from a variety of socioeconomic and racial backgrounds. This Internet resource helps to facilitate a consultation with a cancer patient who is prescreened and motivated to enroll in clinical trials.

Recruitment of patients into an internet-based clinical trials database: the experience of OncoLink and the National Colorectal Cancer Research Alliance

PURPOSE

In March 2001, the National Colorectal Cancer Research Alliance (NCCRA) and OncoLink (http://www.oncolink.org) established a database to facilitate patient enrollment onto clinical trials. This study describes the population registering with the database and identifies discrepancies between individuals registering through the Internet and those registering through a telephone call center.

METHODS

Participants registered with the NCCRA/OncoLink database through the Internet or a telephone call center. All participants entering the database completed a questionnaire regarding basic demographics, colon cancer risk factors, and indicated how they became aware of the database. Comparisons were made between individuals registering through the Internet and those registering through the telephone call center.

RESULTS

A total of 2,162 participants registered during the first 16 months of the database. Most patients registered through the Internet rather than the telephone call center (88% v 12%; P < .001). More females than males registered (73% v 27%; P < .001). The majority (89%) were white. Participants registering through the Internet were younger than those registering through the call center (mean, 48.8 v 55.0 years; P < .001). There was no difference between the two groups with regard to sex or ethnicity.

CONCLUSION

The Internet has the potential to increase the likelihood that interested individuals find appropriate clinical trials. Some of the discrepancies that are known to exist for access to the Internet were also seen for those registering with the database through the Internet. Despite these differences, the potential to increase clinical trial enrollment with this type of Internet-based database is high.

Dental students, social policy students and learning disability: do differing attitudes exist?

OBJECTIVES

To examine the attitudes of dental students and social policy students towards learning disabilities in order to identify whether attitudinal differences exist and to suggest recommendations in the dental undergraduate curriculum commensurate with Government legislation in the United Kingdom.

DESIGN

A cross-sectional survey of all undergraduate dental students at Queen's University, Belfast and all undergraduate social policy students at University of Ulster.

METHOD

A convenience sample of all undergraduate dental and social policy students was obtained. The students completed a questionnaire to assess attitude towards learning disability. The data were analysed using Cronbach's alpha, Student's t-test and analysis of variance (one-way fixed effect model). The level of statistical significance was set at 5%.

RESULTS

The response rate was 83% for dental students and 97% for social policy students. Dental students had significantly lower mean scores and hence less favourable attitudes to learning disability compared with social policy students. Female dental students had significantly higher mean scores and hence more favourable attitudes to learning disability compared with male students.

CONCLUSIONS

The findings show that dental undergraduates compared with social policy students had less favourable attitudes towards those with learning disability. Dental students should receive training in learning disability and undergraduate programmes should be conceptualised as a spiral curriculum. It is proposed that social policy theory should be introduced into undergraduate dental curricula, that early exposure to learning disability in a community setting should be incorporated into the first undergraduate years and in later undergraduate clinical years students should treat patients with learning disability in order to promote experiential learning and reflective practice.

Dental students, social policy students and learning disability: do differing attitudes exist?

OBJECTIVES

To examine the attitudes of dental students and social policy students towards learning disabilities in order to identify whether attitudinal differences exist and to suggest recommendations in the dental undergraduate curriculum commensurate with Government legislation in the United Kingdom.

DESIGN

A cross-sectional survey of all undergraduate dental students at Queen's University, Belfast and all undergraduate social policy students at University of Ulster.

METHOD

A convenience sample of all undergraduate dental and social policy students was obtained. The students completed a questionnaire to assess attitude towards learning disability. The data were analysed using Cronbach's alpha, Student's t-test and analysis of variance (one-way fixed effect model). The level of statistical significance was set at 5%.

RESULTS

The response rate was 83% for dental students and 97% for social policy students. Dental students had significantly lower mean scores and hence less favourable attitudes to learning disability compared with social policy students. Female dental students had significantly higher mean scores and hence more favourable attitudes to learning disability compared with male students.

CONCLUSIONS

The findings show that dental undergraduates compared with social policy students had less favourable attitudes towards those with learning disability. Dental students should receive training in learning disability and undergraduate programmes should be conceptualised as a spiral curriculum. It is proposed that social policy theory should be introduced into undergraduate dental curricula, that early exposure to learning disability in a community setting should be incorporated into the first undergraduate years and in later undergraduate clinical years students should treat patients with learning disability in order to promote experiential learning and reflective practice.

Painful blistered hands and feet

CAE is a self-limiting toxicity seen with several types of high-dose chemotherapy. Treatment of these patients requires pain management and supportive therapy, including wound care that promotes healing, comfort, mobility, and quality of life and prevents infection. Oncology nurses play an important role in monitoring patients for CAE and providing supportive care.

Severity of osteopenia in estrogen-deficient women with anorexia nervosa and hypothalamic amenorrhea

Reduced bone density is observed in over half of women with anorexia nervosa (AN), in whom the risk of fracture is significantly increased even at a young age. It is unknown to what extent low bone density in AN differs from other conditions of premenopausal osteoporosis and is related to estrogen deficiency and/or other factors, such as nutritional status. We therefore investigated bone loss in nutritionally replete and nutritionally deplete amenorrheic women by comparing patients with AN (n = 30) to age-matched subjects with hypothalamic amenorrhea (HA; n = 19) in whom duration of amenorrhea, prior estrogen use, and age of menarche were comparable. Healthy, age-matched, eumenorrheic women were studied as a control group (NL; n = 30). Weight and nutritionally dependent factors including (body mass index, 20.7 +/- 0.3 vs. 16.7 +/- 0.3 kg/m2; P < 0.0001), insulin-like growth factor I (270 +/- 18 vs. 203 +/- 17 ng/mL; P < 0.01), percent body fat (26% vs. 19%; P < 0.0001), and lean body mass (38.7 +/- 1.1 vs. 34.3 +/- 0.8, P < 0.01) were significantly different between the HA and AN groups, respectively. The bone densities of the anterior-posterior (AP) spine, total hip, and total body measured by dual energy x-ray absortiometry were reduced in both amenorrheic groups compared to those in control subjects, but were significantly lower in women with AN than in those with HA. The t scores for AP spine and hip were -1.80 +/- 0.15 (AN), -0.80 +/- 0.22 (HA), and 0.28 +/- 0.19 SD (NL) for the AP spine and -1.62 +/- 0.17 (AN), -0.51 +/- 0.21 (HA), and 0.25 +/- 0.16 (NL) for the total hip, respectively (P < 0.01 for all comparisons). Among the amenorrheic subjects, duration of amenorrhea, age of menarche, and N-telopeptide were inversely correlated with bone density at all sites, whereas body mass index, insulin-like growth factor I, lean body mass, and fat intake were positively correlated with bone density at all sites measured. In multivariate regression analyses, bone density was most significantly related to lean body mass (P = 0.05 and P = 0.03 for the spine and hip, respectively), but not to the duration of amenorrhea or other indexes of estrogen status among patients with AN. In contrast, bone density of the lumbar spine was significantly related to weight and duration of amenorrhea among patients with HA. These data demonstrate that the severity of osteopenia in AN is greater than that in patients with HA and is critically dependent upon nutritional factors in addition to the degree or duration of estrogen deficiency itself. Lean body mass, independent of the duration or severity of estrogen deficiency, is an important predictor of bone loss among women with AN.

Resection of liver metastases from colorectal cancer: the real impact of the surgical margin

AIMS

The benefit of liver resection for metastatic colorectal cancer is now established. Nevertheless if the surgical margin on pre-operative imaging is considered to be less than 10 mm, this is considered an absolute contraindication to surgery by some, and a relative contraindication by others, so its real impact on prognosis is not clear.

METHODS

From 1984 to 1996, 269 patients underwent hepatectomy for liver metastases and were prospectively studied. The only two objectives of this surgery were to be curative (or achieve complete R0 resection), and to avoid mortality. Of the 269, 187 patients had surgical margins inferior to 10 mm. Sixty per cent had multiple liver metastases, and 37% had extrahepatic metastatic sites. Their clinical and pathological factors were specifically studied.

RESULTS

The crude 5-year survival of these 187 patients (including the 2% post-operative mortality) was 24.7%, and the disease-free survival was 18.8%. The surgical margin was 0 mm in 60 cases and was histologically invaded in 20 cases. The most important prognostic factor was whether the resection was considered palliative (R1-R2 resection according to UICC criteria) (P < 0.0001). When the cases with invaded margins were excluded, there was not prognostic difference between the 107 patients with a margin of 0-4 mm and the 143 patients with a margin greater than 4 mm. However, a surgical margin greater than 9 mm appears to be a second prognostic factor (P = 0.001), when these 187 patients are compared to others. The reasons behind this are that there is a close relationship between narrow margins and extensive disease (high number of metastases, bilateral localization and extended hepatectomy), and also an increased possibility of microscopic satellite lesions within 10 mm around the metastases.

CONCLUSION

The real prognostic impact of the surgical margin must not be overestimated. Hepatectomy for metastases can provide long-term survival in patients with supposed poor prognostic factors. Resection is justified so long as it is complete and with minimal risk. An experienced, specialized centre can be a prognostic determinant.