Unveiling Disparities: Exploring Differential Attainment in Postgraduate Training Within Clinical Oncology

AIMS

Differential attainment (DA) in post graduate medical training is a recognised challenge and refers to unexplained variation across groups when split by several protected characteristics. The Royal College of Radiology is committed to fostering diversity, inclusivity, and equality with the goal of narrowing existing gaps and improving training outcomes.

MATERIALS AND METHODS

This was a mixed methods study aiming to understand the causes of DA with view to helping the RCR develop strategies to address this. A cross-sectional survey was completed by 140 clinical oncology trainees in September 2022. Trainees and trainers (17 and 6 respectively) from across England, Scotland, Wales and Northern Ireland, took part in focus group and interviews from August to December 2022. Quantitative and qualitative data merged and interpreted.

RESULT

Results showed international medical graduates and trainees from ethnic minority backgrounds were more likely to encounter challenges. The qualitative findings were used to identify three themes through which these problems could be framed. The trainee as a "space invader," the hidden curriculum of clinical oncology training and the process of navigating and tacking the training journey.

CONCLUSION

Differential attainment is the product of a complex interplay between the trainee, trainer, and the training environment. Therefore, interventions must be tailored to different people and contexts. At a national level, the RCR can adopt general policies to promote this such as mentorship programmes, protected time for supervision and cultural competency training. Efficacy of proposed interventions for trial and their impact on DA should be evaluated to drive evidence-based changes.

Bifunctional octadentate pseudopeptides as Zirconium-89 chelators for immuno-PET applications

BACKGROUND

Positron emission tomography (PET) is a highly sensitive method that provides fine resolution images, useful in the field of clinical diagnostics. In this context, Zirconium-89 (89Zr)-based imaging agents have represented a great challenge in molecular imaging with immuno-PET, which employs antibodies (mAbs) as biological vectors. Indeed, immuno-PET requires radionuclides that can be attached to the mAb to provide stable in vivo conjugates, and for this purpose, the radioactive element should have a decay half-life compatible with the time needed for the biodistribution of the immunoglobulin. In this regard, 89Zr is an ideal radioisotope for immuno-PET because its half-life perfectly matches the in vivo pharmacokinetics of mAbs.

RESULTS

The main objective of this work was the design and synthesis of a series of bifunctional octadentate pseudopeptides able to generate stable 89Zr complexes. To achieve this, here we investigated hydroxamate, N-methylhydroxamate and catecholate chelating moieties in complexing radioactive zirconium. N-methylhydroxamate proved to be the most effective 89Zr-chelating group. Furthermore, the increased flexibility and hydrophilicity obtained by using polyoxyethylene groups spacing the hydroxamate units led to chelators capable of rapidly forming (15 min) stable and water-soluble complexes with 89Zr under mild reaction conditions (aqueous environment, room temperature, and physiological pH) that are mandatory for complexation reactions involving biomolecules. Additionally, we report challenge experiments with the competitor ligand EDTA and metal ions such as Fe3+, Zn2+ and Cu2+. In all examined conditions, the chelators demonstrated stability against transmetallation. Finally, a maleimide moiety was introduced to apply one of the most promising ligands in bioconjugation reactions through Thiol-Michael chemistry.

CONCLUSION

Combining solid phase and solution synthesis techniques, we identified novel 89Zr-chelating molecules with a peptide scaffold. The adopted chemical design allowed modulation of molecular flexibility, hydrophilicity, as well as the decoration with different zirconium chelating groups. Best results in terms of 89Zr-chelating properties were achieved with the N-methyl hydroxamate moiety. The Zirconium complexes obtained with the most effective compounds were water-soluble, stable to transmetallation, and resistant to peptidases for at least 6 days. Further studies are needed to assess the potential of this novel class of molecules as Zirconium-chelating agents for in vivo applications.

Impact of COVID-19 pandemic among patients with lung and head and neck cancer assisted in a public cancer center in Brazil

BACKGROUND

There is no updated national data regarding the real impact of the COVID-19 pandemic on delaying diagnosis and treatment among patients with lung, and head, and neck cancers in Brazil. This study aimed to analyze the COVID-19 pandemic impact on cancer diagnosis and clinical outcomes among lung, head, and neck cancer patients assisted in a tertiary cancer center in Southeastern Brazil, as well as to analyze these patients' pretreatment clinical features.

METHODS

Retrospective cohort of patients with lung or head and neck cancer assisted in a tertiary cancer center in southeastern Brazil between January/2019 and December/2021. To assess statistical differences among groups [i.e., cohort 2019 versus (vs.) 2020 and 2019 vs. 2021] chi-square test was used with a 5% significance level and 90% power for sample size calculation. Differences among baseline clinical features and sociodemographic characteristics were evaluated either by T-test for two samples or Fisher's or Pearson's chi-square test (for quantitative or qualitative variables). All utilized tests had a 5% significance level.

RESULTS

Six hundred fifty-two patients were included, 332 with lung and 320 with head and neck cancer; it was observed a significant decrease in oncologic treatment recommendations and increase in palliative care recommendation for patients with lung cancer, despite similar stages at diagnosis. During the COVID-19 pandemic, more pain symptoms were reported at the first Oncology assessment for patients with head and neck cancer (p < 0.05). Compared to 2019, head and neck cancer patients diagnosed in 2021 presented a worse initial performance status (p = 0.008). There was a statistically significant increase in survival for patients diagnosed with head and neck cancer in 2021 when compared to 2019 (p = 0.003).

CONCLUSIONS

This research highlights low survival rates for patients with lung and head and neck cancer in Brazil, even before the pandemic started, as consequence of advanced diseases at diagnosis at the public health system and clinical degrading features. Additionally, there was an increase incidence in both lung cancer and head and neck cancer despite no differences in clinical stage. This reflects how fragile is the public healthcare system even before facing an acute public health crisis such as the COVID-19 pandemic. Yet, the total impact on public health may follow for many years.

Botulinum toxin: a new differential diagnosis for a lytic bone lesion

BACKGROUND

Botulinum toxin, produced by the Gram-positive anaerobe Clostridium botulinum, is composed of seven antigenic subtypes (A, B, C, D, E, F, and G). Currently, only Botulinum toxin type A, commonly referred to as "Botox," is approved for clinical use, given its relatively safe clinical profile. Botulinum toxin type A has a wide range of therapeutic indications, including treatment for dystonia, migraine headache, neurogenic bladder, and large muscle spastic disorders. However, the toxin is most widely known for its cosmetic effects in treating wrinkles and facial lines.

CASE PRESENTATION

This article describes a 62-year-old Caucasian female who presented for investigation and workup of an isolated lytic lesion of her frontal bone a few weeks after administration of botulinum toxin injection into the corresponding site in the frontalis muscle. This presented as a large, palpable, painless forehead lump causing significant psychological distress. After no neoplastic cause for the lesion was found and histopathology was performed, our researchers concluded that the most likely explanation was that the bony lytic lesion resulted from inadvertent injection of the "Botox" neurotoxin through the intended target muscle and into the cortex of the underlying bone.

CONCLUSIONS

Our search of the literature failed to identify any previous cases of this occurring. However, as the popularity of this cosmetic procedure only increases, we believe that this represents an important possible differential for isolated lytic lesion after administration of "Botox" injection.

Analysis of pharmaceutical interventions in chemotherapy prescriptions of adult and pediatric patients at an oncology reference institute

Chemotherapy, one of the primary cancer treatments, has a high risk of causing significant harm in cases of its misuse. Pharmaceutical intervention is one of the strategies used to prevent medication errors from reaching the patient by identifying drug-related problems or other discrepancies related to patient data or medical progress. The primary objective of this study was to analyze the profile of the pharmaceutical intervention made in chemotherapy prescriptions for adult and pediatric patients in order to measure its impact on patient safety. A retrospective cross-sectional and observational study was conducted at a reference center for cancer treatment in Rio de Janeiro, Brazil. Pharmaceutical interventions performed in chemotherapy prescriptions from January to October 2022 were quantified, classified, and analyzed by their type, most common medicine, and acceptability. From the patients treated in the period, 220 (14.8%) adults and 64 (23.4%) children and teenagers received at least one pharmaceutical intervention. The most common types for adults were dose adjustments: overdose (22.5%) and underdose (22.5%). However, in pediatry, incompleteness of supporting drug protocol (22.1%) was the most registered. The most common medicines involved in pharmaceutical intervention were carboplatin (for adults) and electrolytes/hydration (for pediatric patients). Pharmaceutical intervention acceptability by prescriptors was very similar, reaching 80.4% for adults and 77.9% for pediatrics. The pharmaceutical intervention profile was quite distinct by virtue of the singularities of each population. The pharmacists' role was shown to be paramount in intercepting medication errors in the prescription of chemotherapy protocols, contributing to patient safety.

DPYD genotyping and 5-fluoropyrimidine toxicity: An overview of systematic reviews protocol

INTRODUCTION

The increased risk of severe and life-threatening toxicity in patients with dihydropyridine dehydrogenase deficiency, under treatment with fluoropyrimidines, has been widely studied. An up-to-date overview of systematic reviews summarizing existing literature can add value by highlighting most relevant information and supports decision-making regarding treatment in dihydropyridine dehydrogenase deficient patients. The main objective of this overview is to identify published systematic reviews on the association between germline variations in the DPYD gene and fluoropyrimidine toxicity.

METHODS AND ANALYSIS

This protocol was developed following the Preferred Reported Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) checklist, and the overview of systematic reviews will be reported in accordance with the PRISMA statement. PubMed, Embase, Scopus and the Cochrane Library will be searched from inception to 2023. Systematic reviews irrespective of study designs that analyze the association between germline variations in the DPYD and fluoropyrimidine toxicity will be considered. Methodological quality will be assessed using AMSTAR2 checklist (Measurement Tool to Assess Systematic Reviews 2). Two independent investigators will perform the study selection, quality assessment and data collection. Discrepancies will be solved by a third investigator.

DPYD genotyping and 5-fluoropyrimidine toxicity: An overview of systematic reviews protocol

INTRODUCTION

The increased risk of severe and life-threatening toxicity in patients with dihydropyridine dehydrogenase (DPD) deficiency, under treatment with fluoropyrimidines, has been widely studied. An up-to-date overview of systematic reviews summarizing existing literature can add value by highlighting most relevant information and supports decision-making regarding treatment in DPD deficient patients. The main objective of this overview of systematic reviews is to identify published systematic reviews on the association between germline variations in the DPYD gene and fluoropyrimidine toxicity.

METHODS AND ANALYSIS

This protocol was developed following the Preferred Reported Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) checklist, and the overview of systematic reviews will be reported in accordance with the PRISMA statement. PubMed, Embase, Scopus, and the Cochrane Library will be searched from inception to 2023. Systematic reviews irrespective of study designs that analyze the association between germline variations in the DPYD and fluoropyrimidine toxicity will be considered. Methodological quality will be assessed using AMSTAR2 checklist (Measurement Tool to Assess Systematic Reviews 2). Two independent investigators will perform the study selection, quality assessment, and data collection. Discrepancies will be solved by a third investigator.

REGISTRATION DETAILS

Registration number in PROSPERO: CRD42023401226.

Impact of telenurse-led intervention in clinical trials on health literacy, empowerment, and health outcomes in patients with solid tumours: a pilot quasi-experimental study

BACKGROUND

During the COVID-19 pandemic, decentralised clinical trials incorporated self-monitoring, self-reporting, and telenursing tools to address health literacy and health empowerment of patients enrolled in clinical trials. We aimed to determine the impact of an educational intervention using telenursing consultations on health literacy, health empowerment, and health-related quality of life in cancer patients enrolled in clinical trials by measuring the level of satisfaction with the care received and assessing the views of healthcare professionals concerning the advanced practice nurse (APN) role in oncology clinical trials.

METHODS

In this pilot analytical, descriptive, longitudinal, quasi-experimental, and pre-post test study, an educational intervention was conducted by 5 visits with an APN using synchronous teleconsultation in patients starting cancer treatment for the first time in a clinical trial (n = 60), and health professionals working with the APN (n = 31). A descriptive analysis of the samples and questionnaires were utilised along with statistical comparisons.

RESULTS

After the intervention, patients' health literacy (31.7%), health empowerment (18.3%), and health-related quality of life (33.3%) increased (p < 0.05), with a decrease and trend towards resolution of care needs (p < 0.05). Satisfaction with the quality and care received in terms of perceived convenience, transition, and continuity of care showed positive results in 64.9 ± 20.7, 77.6 ± 19.5, and 72.1 ± 20.4 of respondents, respectively. On the overall assessment of the APN role, healthcare professionals expressed a high level of agreement with the statements related to their work performance.

CONCLUSIONS

The data indicates that a clinical trial APN-led telenursing educational intervention results in an overall increase in health literacy, an improvement in health empowerment and health-related quality of life, and a decrease in care needs of oncology clinical trials patients. Patients stated that they received a high quality of care and health professionals indicated high levels of acceptance with APNs. Based on these results, we suggest that the APN role should gain more recognition in the Spanish healthcare system and their professional competencies should be aligned with those of other countries.

Can AI-based body composition assessment outperform body surface area in predicting dose-limiting toxicities for colonic cancer patients on chemotherapy?

PURPOSE

Gold standard chemotherapy dosage is based on body surface area (BSA); however many patients experience dose-limiting toxicities (DLT). We aimed to evaluate the effectiveness of BSA, two-dimensional (2D) and three-dimensional (3D) body composition (BC) measurements derived from Lumbar 3 vertebra (L3) computed tomography (CT) slices, in predicting DLT in colon cancer patients.

METHODS

203 patients (60.87 ± 12.42 years; 97 males, 47.8%) receiving adjuvant chemotherapy (Oxaliplatin and/or 5-Fluorouracil) were retrospectively evaluated. An artificial intelligence segmentation model was used to extract 2D and 3D body composition measurements from each patients' single mid-L3 CT slice as well as multiple-L3 CT scans to produce a 3D BC report. DLT was defined as any incidence of dose reduction or discontinuation due to chemotherapy toxicities. A receiver operating characteristic (ROC) analysis was performed on BSA and individual body composition measurements to demonstrate their predictive performance.

RESULTS

A total of 120 (59.1%) patients experienced DLT. Age and BSA did not vary significantly between DLT and non-DLT group. Females were significantly more likely to experience DLT (p = 4.9 × 10-3). In all patients, the predictive effectiveness of 2D body composition measurements (females: AUC = 0.50-0.54; males: AUC = 0.50-0.61) was equivalent to that of BSA (females: AUC = 0.49; males: AUC = 0.58). The L3 3D skeletal muscle volume was the most predictive indicator of DLT (AUC of 0.66 in females and 0.64 in males).

CONCLUSION

Compared to BSA and 2D body composition measurements, 3D L3 body composition measurements had greater potential to predict DLT in CRC patients receiving chemotherapy and this was sex dependent.

The impact of national holidays on postoperative radiotherapy of squamous cell carcinoma of the head and neck

Background

Delays in starting postoperative radiotherapy (PORT) have been established as negative predictors for clinical outcomes in head and neck squamous cell carcinomas (HNSCC). Our study aimed to examine the effect of delays during PORT, and the impact of national holidays in Canada, a publicly funded system, on oncologic outcomes such as Overall Survival (OS) and Local Recurrence (LR).

Methods

The provincial cancer registry was queried to obtain demographic, pathologic, and outcomes data from cancer patients treated for all squamous cell carcinomas of the head and neck region treated between January 1, 2007 and November 30, 2019. All extracted information was cross-referenced and supplemented by chart review of patient electronic medical records. Extracted data were analyzed for OS and LR, in the context of Canadian national holidays causing delays during PORT.

Results

1433 patients treated for HNSCCs were identified, of whom 338 were treated curatively with surgery followed by PORT. 68.6% of patients experienced at least one day of interruption during treatments due to holidays. LR was 15.4% and OS was 59.6% at 5 years. Treatment interruptions by holidays were predictive of local recurrence (HR, 2.38; 95% CI 1.17-4.83; p = 0.017). Patients that developed early recurrence prior to PORT had very poor oncologic outcomes.

Conclusion

Our findings were consistent with previously published studies in limiting the interval between surgery and PORT. We identified the novel finding of paired holidays as a significant predictor in determining LR, suggesting the importance of modifying RT delivery schedules and timing.

Capicua (CIC) mutations in gliomas in association with MAPK activation for exposing a potential therapeutic target

Gliomas are the most prevalent neurological cancer in the USA and care modalities are not able to effectively combat these aggressive malignancies. Identifying new, more effective treatments require a deep understanding of the complex genetic variations and relevant pathway associations behind these cancers. Drawing connections between gene mutations with a responsive genetic target can help drive therapy selections to enhance patient survival. We have performed extensive molecular profiling of the Capicua gene (CIC), a tumor and transcriptional suppressor gene, and its mutation prevalence in reference to MAPK activation within clinical glioma tissue. CIC mutations occur far more frequently in oligodendroglioma (52.1%) than in low-grade astrocytoma or glioblastoma. CIC-associated mutations were observed across all glioma subtypes, and MAPK-associated mutations were most prevalent in CIC wild-type tissue regardless of the glioma subtype. MAPK activation, however, was enhanced in CIC-mutated oligodendroglioma. The totality of our observations reported supports the use of CIC as a relevant genetic marker for MAPK activation. Identification of CIC mutations, or lack thereof, can assist in selecting, implementing, and developing MEK/MAPK-inhibitory trials to improve patient outcomes potentially.

Artificial intelligence-assisted selection and efficacy prediction of antineoplastic strategies for precision cancer therapy

The rapid development of artificial intelligence (AI) technologies in the context of the vast amount of collectable data obtained from high-throughput sequencing has led to an unprecedented understanding of cancer and accelerated the advent of a new era of clinical oncology with a tone of precision treatment and personalized medicine. However, the gains achieved by a variety of AI models in clinical oncology practice are far from what one would expect, and in particular, there are still many uncertainties in the selection of clinical treatment options that pose significant challenges to the application of AI in clinical oncology. In this review, we summarize emerging approaches, relevant datasets and open-source software of AI and show how to integrate them to address problems from clinical oncology and cancer research. We focus on the principles and procedures for identifying different antitumor strategies with the assistance of AI, including targeted cancer therapy, conventional cancer therapy, and cancer immunotherapy. In addition, we also highlight the current challenges and directions of AI in clinical oncology translation. Overall, we hope this article will provide researchers and clinicians with a deeper understanding of the role and implications of AI in precision cancer therapy, and help AI move more quickly into accepted cancer guidelines.

Direct inference of Patlak parametric images in whole-body PET/CT imaging using convolutional neural networks

Purpose

This study proposed and investigated the feasibility of estimating Patlak-derived influx rate constant (K_i) from standardized uptake value (SUV) and/or dynamic PET image series.

Methods

Whole-body ¹⁸F-FDG dynamic PET images of 19 subjects consisting of 13 frames or passes were employed for training a residual deep learning model with SUV and/or dynamic series as input and K_i-Patlak (slope) images as output. The training and evaluation were performed using a nine-fold cross-validation scheme. Owing to the availability of SUV images acquired 60 min post-injection (20 min total acquisition time), the data sets used for the training of the models were split into two groups: “With SUV” and “Without SUV.” For “With SUV” group, the model was first trained using only SUV images and then the passes (starting from pass 13, the last pass, to pass 9) were added to the training of the model (one pass each time). For this group, 6 models were developed with input data consisting of SUV, SUV plus pass 13, SUV plus passes 13 and 12, SUV plus passes 13 to 11, SUV plus passes 13 to 10, and SUV plus passes 13 to 9. For the “Without SUV” group, the same trend was followed, but without using the SUV images (5 models were developed with input data of passes 13 to 9). For model performance evaluation, the mean absolute error (MAE), mean error (ME), mean relative absolute error (MRAE%), relative error (RE%), mean squared error (MSE), root mean squared error (RMSE), peak signal-to-noise ratio (PSNR), and structural similarity index (SSIM) were calculated between the predicted K_i-Patlak images by the two groups and the reference K_i-Patlak images generated through Patlak analysis using the whole acquired data sets. For specific evaluation of the method, regions of interest (ROIs) were drawn on representative organs, including the lung, liver, brain, and heart and around the identified malignant lesions.

Results

The MRAE%, RE%, PSNR, and SSIM indices across all patients were estimated as 7.45 ± 0.94%, 4.54 ± 2.93%, 46.89 ± 2.93, and 1.00 ± 6.7 × 10⁻⁷, respectively, for models predicted using SUV plus passes 13 to 9 as input. The predicted parameters using passes 13 to 11 as input exhibited almost similar results compared to the predicted models using SUV plus passes 13 to 9 as input. Yet, the bias was continuously reduced by adding passes until pass 11, after which the magnitude of error reduction was negligible. Hence, the predicted model with SUV plus passes 13 to 9 had the lowest quantification bias. Lesions invisible in one or both of SUV and K_i-Patlak images appeared similarly through visual inspection in the predicted images with tolerable bias.

Conclusion

This study concluded the feasibility of direct deep learning-based approach to estimate K_i-Patlak parametric maps without requiring the input function and with a fewer number of passes. This would lead to shorter acquisition times for WB dynamic imaging with acceptable bias and comparable lesion detectability performance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-022-05867-w.

Incidence and risk factors of adverse events in pediatric hemato-oncological patients: A cohort study

BACKGROUND

Pediatric hemato-oncological (HO) patients are highly susceptible to the occurrence of adverse events (AE), nevertheless few research has been done in this field. Our aim was to describe the incidence, type, severity and preventability of AE in these patients, including bone marrow transplant (BMT) patients, and to identify patient's risk factors for having an AE.

METHODS

Retrospective cohort study. Children under 18yo hospitalized at the HO or BMT ward in 2016 were eligible for the study. Type of AE, severity and preventability were described as absolute and relative frequencies. Cumulative incidence of patients with at least one AE (CI_AE) and the rate of occurrence of all AE were calculated. Risk factors (sex, recovery probability, comorbidities and being a BMT patient) were analyzed using logistic regression.

RESULTS

114 patients were included, 58% were male, average age was 8.7yo and 25 were BMT patients. 44 had at least one AE, with CI_AE of 38.6% (95%CI 29.7-47.5). Overall rate of occurrence of AE was 2.5 cases per 100 patients-day (95%CI 2.15-2.98). For BMT and non-BMT patients they were 2.8 (95%CI 2.2-3.6) and 2.5 (95%CI 1.98-3.1) respectively. Healthcare related infection was the most frequent AE. Most AE were moderate and with high preventability. Being a BMT patient was the only independent factor associated with the occurrence of at least one AE (OR=11.5, p<0.001).

CONCLUSIONS

Our findings suggest that AE tend to be moderate and preventable in HO pediatric patients. BMT patients seem to be at greater risk of having an AE. Strategies focused on patient safety need to account for their specific characteristics.

The emerging roles of NGS in clinical oncology and personalized medicine

Next-generation sequencing (NGS) has been increasingly popular in genomics studies over the last decade, as new sequencing technology has been created and improved. Recently, NGS started to be used in clinical oncology to improve cancer therapy through diverse modalities ranging from finding novel and rare cancer mutations, discovering cancer mutation carriers to reaching specific therapeutic approaches known as personalized medicine (PM). PM has the potential to minimize medical expenses by shifting the current traditional medical approach of treating cancer and other diseases to an individualized preventive and predictive approach. Currently, NGS can speed up in the early diagnosis of diseases and discover pharmacogenetic markers that help in personalizing therapies. Despite the tremendous growth in our understanding of genetics, NGS holds the added advantage of providing more comprehensive picture of cancer landscape and uncovering cancer development pathways. In this review, we provided a complete overview of potential NGS applications in scientific and clinical oncology, with a particular emphasis on pharmacogenomics in the direction of precision medicine treatment options.

Random survival forest model identifies novel biomarkers of event-free survival in high-risk pediatric acute lymphoblastic leukemia

High-risk pediatric B-ALL patients experience 5-year negative event rates up to 25%. Although some biomarkers of relapse are utilized in the clinic, their ability to predict outcomes in high-risk patients is limited. Here, we propose a random survival forest (RSF) machine learning model utilizing interpretable genomic inputs to predict relapse/death in high-risk pediatric B-ALL patients. We utilized whole exome sequencing profiles from 156 patients in the TARGET-ALL study (with samples collected at presentation) further stratified into training and test cohorts (109 and 47 patients, respectively). To avoid overfitting and facilitate the interpretation of machine learning results, input genomic variables were engineered using a stepwise approach involving univariable Cox models to select variables directly associated with outcomes, genomic coordinate-based analysis to select mutational hotspots, and correlation analysis to eliminate feature co-linearity. Model training identified 7 genomic regions most predictive of relapse/death-free survival. The test cohort error rate was 12.47%, and a polygenic score based on the sum of the top 7 variables effectively stratified patients into two groups, with significant differences in time to relapse/death (log-rank P = 0.001, hazard ratio = 5.41). Our model outperformed other EFS modeling approaches including an RSF using gold-standard prognostic variables (error rate = 24.35%). Validation in 174 standard-risk patients and 3 patients who failed to respond to induction therapy confirmed that our RSF model and polygenic score were specific to high-risk disease. We propose that our feature selection/engineering approach can increase the clinical interpretability of RSF, and our polygenic score could be utilized for enhance clinical decision-making in high-risk B-ALL.

Somatic mutations in oral squamous cell carcinomas in 98 Japanese patients and their clinical implications

INTRODUCTION

The somatic mutational profile of oral squamous cell carcinoma (OSCC) among Japanese patients has been less investigated, partly because of the rarity of the tumor. Moreover, previous studies have either used formalin-fixed paraffin-embedded samples or lacked paired normal tissues. We aimed to determine somatic mutations in the exomes of 76 genes, including 50 driver genes of solid cancers and NOTCH-related genes, some of which are previously reported as frequently mutated in head and neck squamous cell carcinoma or OSCC.

MATERIALS AND METHODS

We used fresh-frozen tumor/normal-paired samples from 98 treatment-naïve Japanese patients with OSCC and analyzed their correlations with clinicopathological characteristics and survival.

RESULTS

We identified 136 exonic mutations, including 78 non-synonymous mutations, 13 synonymous mutations, 22 nonsense mutations, 2 non-frameshift deletions, 11 frameshift deletion, and 5 each of splice-site and frameshift insertions. The most frequently mutated genes were TP53 (36.7%), FAT1 (9.2%), NOTCH1 (8.2%), CDKN2A (7.1%), ZFHX4 (5.1%), CASP8 (4.1%), EP300 (4.1%), and KMT2D (4.1%). We followed up 90 of the 98 patients for 3 years. Among them, TP53 mutation was associated with significantly shorter 3-year disease-free survival. Most of the identified TP53 mutations occurred in the DNA-binding domain and were functionally deleterious.

DISCUSSION

Our findings and the mutation spectra can contribute to the development of a therapeutic strategy for Japanese patients with OSCC.

The predictive value of tumor infiltrating leukocytes in Hepatocellular Carcinoma: A systematic review and meta-analysis

BACKGROUND

For Hepatocellular carcinoma (HCC) surgery either through resection or transplantation often provides the only chance for cure. Since hepatocarcinogenesis and postsurgical prognosis is not only dependent on cirrhosis but also on immune activation and exhaustion, many studies have investigated tumor infiltrating leukocyte (TIL) subsets. This systematic review and meta-analysis aims at describing the cell groups and their predictive power regarding overall (OS), disease free (DFS) and recurrence free survival (RFS).

MATERIAL AND METHODS

A systematic search of the PubMed database was conducted (PROSPERO 172324). Data on CD3⁺, CD8⁺, Treg, B cells, macrophages, neutrophil and NK-cells were collected from Pubmed and related references up to December 2018. Overall (OS), disease-free (DFS) and recurrence free survival (RFS) in dependence of high vs. low infiltration rates were compared using a random effects meta-analysis.

RESULTS

Altogether data from 3541 patients enrolled in 20 publications were included. Except for Tregs and Neutrophils, heterogeneity analysis was found to be moderate to high across the studies. High CD3⁺, CD8⁺, NK-cell infiltration predicted better survival (OS, DFS and RFS; p < 0.05). Higher Treg and Neutrophil infiltration predicted lower OS and DFS. For Macrophages and B cells no difference in survival could be found.

DISCUSSION

As with other solid tumors immune infiltration has a great influence on survival after resection. However, a considerable publication bias cannot be ruled out in mostly retrospective analyses. Nevertheless, in light of novel immune modulatory treatments this opens a new avenue towards effective and well-tolerated adjuvant treatment.

Potentially inappropriate medication (PIM) use and severe drug interactions (SDIs) in older adults with cancer

BACKGROUND

Older adults with cancer frequently have other co-morbidities requiring prescription pharmacotherapy. The objectives of this study were to identify the prevalence of potentially inappropriate medications (PIMs), severe drug interactions (SDIs) and associated risk factors in these patients.

MATERIALS AND METHODS

This twelve-month prospective observation study was conducted at an Irish Hospital. PIMs were identified in older adults (≥65 years) using STOPP and OncPal criteria; potential SDIs using Stockley's interaction checker.

RESULTS

We enrolled 186 patients; mean age 72.5(SD5.7) years, 46.2% female, mean co-morbidities 7.5(SD3.4), median medications 7(IQR4-9). Polypharmacy (≥6 medications) and major polypharmacy (≥11 medications) were identified in 60.8% and 17.7% respectively. STOPP PIMs were observed in 73.1%; median 2(IQR1-3). The most common PIM identified was any drug prescribed beyond the recommended duration (46.5%). For each additional prescription, the odds of receiving a STOPP PIM increased by 79.2% (OR 1.792, 95% CI 1.459-2.02). Potential SDIs were identified in 50.5% participants. The most common were beta-blocker/alpha-blocker (6.5%), selective-serotonin re-uptake inhibitor (SSRI)/proton pump inhibitor (PPI) (5.9%) and SSRI/Aspirin (4.8%). For each additional prescription, the odds of an SDI increased by 50.8% (OR 1.508, 95% CI 1.288-1.764). Seventy-seven (41.4%) participants died within six months of enrolment. OncPal PIMs were observed in 81.8% of this cohort, median 2(IQR1-3). The most common OncPal PIM was statin therapy (38%). For each additional prescription, the odds of receiving an OncPal PIM increased by 38.2%, (OR 1.382, 95% CI 1.080-1.767).

CONCLUSIONS

PIMs and SDIs are common in this population. Comprehensive specialist evaluation of medications by a geriatrician may identify PIMs thereby reducing related adverse outcomes such as SDIs.

Lower Extremity Reconstruction After Soft Tissue Sarcoma Resection

Surgical resection with wide margins and perioperative radiation therapy is the standard treatment of extremity soft tissue sarcomas. This combination often results in complex wounds and functional compromise. Reconstructive surgery is integral to limb salvage after sarcoma resection. Advances in adjuvant therapy and reconstructive surgical techniques have made functional limb salvage, instead of amputation, possible for most patients. This article reviews key concepts in the multidisciplinary care of patients with extremity soft tissue sarcomas and details reconstructive surgical techniques, including locoregional and free tissue transfer, free functional muscle transfer, and vascularized bone transfer, to optimize functional limb restoration after sarcoma resection.

Cancer gene expression profiles associated with clinical outcomes to chemotherapy treatments

Background

Machine learning (ML) methods still have limited applicability in personalized oncology due to low numbers of available clinically annotated molecular profiles. This doesn’t allow sufficient training of ML classifiers that could be used for improving molecular diagnostics.

Methods

We reviewed published datasets of high throughput gene expression profiles corresponding to cancer patients with known responses on chemotherapy treatments. We browsed Gene Expression Omnibus (GEO), The Cancer Genome Atlas (TCGA) and Tumor Alterations Relevant for GEnomics-driven Therapy (TARGET) repositories.

Results

We identified data collections suitable to build ML models for predicting responses on certain chemotherapeutic schemes. We identified 26 datasets, ranging from 41 till 508 cases per dataset. All the datasets identified were checked for ML applicability and robustness with leave-one-out cross validation. Twenty-three datasets were found suitable for using ML that had balanced numbers of treatment responder and non-responder cases.

Conclusions

We collected a database of gene expression profiles associated with clinical responses on chemotherapy for 2786 individual cancer cases. Among them seven datasets included RNA sequencing data (for 645 cases) and the others – microarray expression profiles. The cases represented breast cancer, lung cancer, low-grade glioma, endothelial carcinoma, multiple myeloma, adult leukemia, pediatric leukemia and kidney tumors. Chemotherapeutics included taxanes, bortezomib, vincristine, trastuzumab, letrozole, tipifarnib, temozolomide, busulfan and cyclophosphamide.

Vitamin C as an Anticancer Agent: Regulation of Signaling Pathways

Treatment options for effective treatment of cancer with minimum off-target effects and maximum clinical outcomes have remained overarching goals in the clinical oncology. Vitamin C has remained in the shadows of controversy since the past few decades; burgeoning evidence has started to shed light on wide-ranging anticancer effects exerted by Vitamin C to induce apoptosis in drug-resistant cancer cells, inhibit uncontrolled proliferation of the cancer cells and metastatic spread. Landmark achievements in molecular oncology have ushered in a new era, and researchers have focused on the identification of oncogenic pathways regulated by Vitamin C in different cancers. However, there are visible knowledge gaps in our understanding related to the ability of Vitamin C to modulate a myriad of transduction cascades. There are scattered pieces of scientific evidence about promising potential of Vitamin C to regulate JAK-STAT, TGF/SMAD, TRAIL and microRNAs in different cancers. However, published data is insufficient and needs to be investigated comprehensively to enable basic and clinical researchers to reap full benefits and promote result-oriented transition of Vitamin C into various phases of clinical trials. In this review, we will emphasize on available evidence related to the regulation of oncogenic cell signaling pathways by Vitamin C in different cancers. We will also highlight the conceptual gaps, which need detailed and cutting-edge research.

A systematic scoping review of multidisciplinary cancer team and decision-making in the management of men with advanced prostate cancer

PURPOSE

The early diagnosis of prostate cancer and subsequent access to the treatment options helps to achieve optimal cancer outcomes. As the treatment options for patients with advanced prostate cancer continues to evolve, patients need to access a multidisciplinary team (MDT) meeting to receive best-practice care.

METHODS

In this paper a MEDLINE review was performed to assess clinical decision making in the context of MDT discussions for patients with advanced prostate cancer.

RESULTS

From 441 returned articles and abstracts, 50 articles were assessed for eligibility and 16 articles included for analysis. Sixteen articles were identified, 9 of the 16 articles used quantitative methodology including three retrospective analysis of clinical registry data, patient medical records and/or MDT meeting notes and three cross-sectional surveys. Other study designs included one observation study and one study using a combination of qualitative and quantitative methodologies and one mini-review. There were also four editorials included in the review and two consensus statements.

CONCLUSION

This paper highlights the important role the inter-disciplinary MDT has on shared decision making for men with advanced prostate cancer. The application of MDT care is a rapidly growing trend in uro-oncology and an efficient MDT service requires further research to assess its efficiency so that it may expand through all aspect of uro-oncology.

Design, data linkage, and implementation considerations in the first cooperative group led study assessing financial outcomes in cancer patients and their informal caregivers

BACKGROUND

Few studies have assessed the financial impact of cancer diagnosis on patients and caregivers in diverse clinical settings. S1417CD, led by the SWOG Cancer Research Network, is the first prospective longitudinal cohort study assessing financial outcomes conducted in the NCI Community Oncology Research Program (NCORP). We report our experience navigating design and implementation barriers.

METHODS

Patients age ≥ 18 within 120 days of metastatic colorectal cancer diagnosis were considered eligible and invited to identify a caregiver to participate in an optional substudy. Measures include 1) patient and caregiver surveys assessing financial status, caregiver burden, and quality of life and 2) patient credit reports obtained from the credit agency TransUnion through a linkage requiring social security numbers and secure data transfer processes. The primary endpoint is incidence of treatment-related financial hardship, defined as one or more of the following: debt accrual, selling or refinancing home, ≥20% income decline, or borrowing money. Accrual goal was n = 374 patients in 3 years.

RESULTS

S1417CD activated on Apr 1, 2016 and closed on Feb 1, 2019 after reaching its accrual goal sooner than anticipated. A total of 380 patients (median age 59.7 years) and 155 caregivers enrolled across 548 clinical sites. Credit data were not obtainable for 76 (20%) patients due to early death, lack of credit, or inability to match records.

CONCLUSIONS

Robust accrual to S1417CD demonstrates patients' and caregivers' willingness to improve understanding of financial toxicity despite perceived barriers such as embarrassment and fears that disclosing financial status could influence treatment recommendations.

Learning radiotherapy: the state of the art

BACKGROUND

The last two decades have seen revolutionary developments in both radiotherapy technology and postgraduate medical training. Trainees are expected to attain competencies using a mix of experiential learning, formal postgraduate teaching, self-directed learning and peer education. Radiation (Clinical) Oncology is a recognised 'craft specialty' where the apprenticeship model of training is applicable. This scoping review examines the evidence in relation to how medical trainees learn radiotherapy.

METHODS

A systematic search of MEDINE and EMBASE was undertaken to identify studies of trainee and/or trainer experience of radiotherapy learning published 1999-2018. Results pertaining to Medical Oncology, workforce trends, undergraduate radiotherapy exposure, academic training, global health, non-medical staff, health service infrastructure and recruitment to training programmes were not included.

RESULTS

A total of 146 publications were included in the synthesis. Five themes were apparent through careful iterative analysis representing broadly inter-related issues. Most articles studied radiotherapy training from the perspective of the trainee doctor. Most literature reports results of observational, local or national surveys with a tightly defined scope. Considerable variation exists within hospitals, within countries, over time and between different curricular areas.

CONCLUSIONS

Medical education has not kept pace with changes in the field of radiotherapy and large differences are demonstrated in experience between trainees in different hospitals, countries and training stages. Interpersonal relationships, departmental organisation, and national curricula impact on training quality. Qualitative and quantitative research examining modern radiotherapy learning has been uncommon and uncoordinated, until recently. To date no single study has been designed to comprehensively assess a department's training scheme.

Impact of spectral body imaging in patients suspected for occult cancer: a prospective study of 503 patients

Objectives

To investigate the diagnostic impact and performance of spectral dual-layer detector CT in the detection and characterization of cancer compared to conventional CE-CT.

Methods

In a national workup program for occult cancer, 503 patients (286 females and 217 males) were prospectively enrolled for a contrast-enhanced spectral CT scan. The readings were performed with and without spectral data available. A minimum of 3 months between interpretations was implemented to minimize recall bias. The sequence of reads for the individual patient was randomized. Readers were blinded for patient identifiers and clinical outcome. Two radiologists with 9 and 33 years of experience performed the readings in consensus. If disagreement, a third radiologist with 11 years of experience determined the outcome of the reading

Results

Significantly more cancer findings were identified on the spectral reading. In 73 cases of proven cancer, we found a sensitivity of 89% vs 77% and a specificity of 77% vs 83% on spectral CT compared to conventional CT. A slight increase in reading time in spectral images of 82 s was found (382 vs 300, p < 0.001). For all cystic lesions, the perceived diagnostic certainty increased from 30% being completely certain to 96% most pronounced in the kidney, liver, thyroid, and ovaries. And adding the spectral information to the reading gave a decrease in follow-up examination for diagnostic certainty (0.25 vs 0.81 per reading, p < 0.001).

Conclusion

The use of contrast-enhanced spectral CT increases the confidence of the radiologists in correct characterization of various lesions and minimizes the need for supplementary examinations.

Key Points

• Spectral CT is associated with a higher sensitivity, but a slightly lower specificity compared to conventional CT.

• Spectral CT increases the confidence of the radiologists.

• The need for supplementary examinations is decreased, with only a slight increase in reading times.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06878-7) contains supplementary material, which is available to authorized users.

Radiomics: A primer for the radiation oncologist

PURPOSE

Radiomics are a set of methods used to leverage medical imaging and extract quantitative features that can characterize a patient's phenotype. All modalities can be used with several different software packages. Specific informatics methods can then be used to create meaningful predictive models. In this review, we will explain the major steps of a radiomics analysis pipeline and then present the studies published in the context of radiation therapy.

METHODS

A literature review was performed on Medline using the search engine PubMed. The search strategy included the search terms "radiotherapy", "radiation oncology" and "radiomics". The search was conducted in July 2019 and reference lists of selected articles were hand searched for relevance to this review.

RESULTS

A typical radiomics workflow always includes five steps: imaging and segmenting, data curation and preparation, feature extraction, exploration and selection and finally modeling. In radiation oncology, radiomics studies have been published to explore different clinical outcome in lung (n=5), head and neck (n=5), esophageal (n=3), rectal (n=3), pancreatic (n=2) cancer and brain metastases (n=2). The quality of these retrospective studies is heterogeneous and their results have not been translated to the clinic.

CONCLUSION

Radiomics has a great potential to predict clinical outcome and better personalize treatment. But the field is still young and constantly evolving. Improvement in bias reduction techniques and multicenter studies will hopefully allow more robust and generalizable models.

Positron-emission tomography-guided radiation therapy: Ongoing projects and future hopes

Radiation therapy has undergone significant advances these last decades, particularly thanks to technical improvements, computer science and a better ability to define the target volumes via morphological and functional imaging breakthroughs. Imaging contributes to all three stages of patient care in radiation oncology: before, during and after treatment. Before the treatment, the choice of optimal imaging type and, if necessary, the adequate functional tracer will allow a better definition of the volume target. During radiation therapy, image-guidance aims at locating the tumour target and tailoring the volume target to anatomical and tumoral variations. Imaging systems are now integrated with conventional accelerators, and newer accelerators have techniques allowing tumour tracking during the irradiation. More recently, MRI-guided systems have been developed, and are already active in a few French centres. Finally, after radiotherapy, imaging plays a major role in most patients' monitoring, and must take into account post-radiation tissue modification specificities. In this review, we will focus on the ongoing projects of nuclear imaging in oncology, and how they can help the radiation oncologist to better treat patients. To this end, a literature review including the terms "Radiotherapy", "Radiation Oncology" and "PET-CT" was performed in August 2019 on Medline and ClinicalTrials.gov. We chose to review successively these novelties organ-by-organ, focusing on the most promising advances. As a conclusion, the help of modern functional imaging thanks to a better definition and new specific radiopharmaceuticals tracers could allow even more precise treatments and enhanced surveillance. Finally, it could provide determinant information to artificial intelligence algorithms in "-omics" models.

Thresholds for clinical importance were established to improve interpretation of the EORTC QLQ-C30 in clinical practice and research

OBJECTIVE

The objective of this study was to establish thresholds for clinical importance (TCIs) for the five functioning and nine symptom scales of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30).

STUDY DESIGN AND SETTING

In this diagnostic study, cancer patients with mixed diagnoses and treatments completed the EORTC QLQ-C30 and anchored the questions in each domain in terms of their clinical importance. The anchor questions, concerned limitations in daily life, need for help/care, and the worries of the patient and his/her partner/family. These questions allowed categorizing patients into whether they exhibited a clinically important symptom/functional impairment for each scale and performing a receiver operating characteristic curve analysis to establish TCIs.

RESULTS

Data from 498 patients from six European countries (mean age 60.4 years, 55.2% women) were analyzed. For the TCIs generated using the patient questionnaire data, the EORTC QLQ-C30 scales showed sensitivity values between 0.71 and 0.97 and specificity values between 0.62 and 0.92 (area under the curve above 0.80 for all scales).

CONCLUSION

This EORTC Quality of Life Group study provides TCIs for the functioning and symptom scales of the EORTC QLQ-C30. These TCIs can increase the interpretability of the questionnaire results and foster its use in daily clinical practice and in clinical research.

RNA sequencing for research and diagnostics in clinical oncology

Molecular diagnostics is becoming one of the major drivers of personalized oncology. With hundreds of different approved anticancer drugs and regimens of their administration, selecting the proper treatment for a patient is at least nontrivial task. This is especially sound for the cases of recurrent and metastatic cancers where the standard lines of therapy failed. Recent trials demonstrated that mutation assays have a strong limitation in personalized selection of therapeutics, consequently, most of the drugs cannot be ranked and only a small percentage of patients can benefit from the screening. Other approaches are, therefore, needed to address a problem of finding proper targeted therapies. The analysis of RNA expression (transcriptomic) profiles presents a reasonable solution because transcriptomics stands a few steps closer to tumor phenotype than the genome analysis. Several recent studies pioneered using transcriptomics for practical oncology and showed truly encouraging clinical results. The possibility of directly measuring of expression levels of molecular drugs' targets and profiling activation of the relevant molecular pathways enables personalized prioritizing for all types of molecular-targeted therapies. RNA sequencing is the most robust tool for the high throughput quantitative transcriptomics. Its use, potentials, and limitations for the clinical oncology will be reviewed here along with the technical aspects such as optimal types of biosamples, RNA sequencing profile normalization, quality controls and several levels of data analysis.

Pseudo- or real progression? An ovarian cancer patient under nivolumab: A case report

BACKGROUND

Checkpoint-Inhibition has revolutionized the treatment for several entities such as melanoma and renal cell carcinoma. The first encouraging experience in ovarian cancer was reported for nivolumab, a fully humanized anti-programmed death-1 antibody. Pseudoprogression is a new phenomenon associated with these novel immuno-oncologic agents. It can be explained by infiltrating leucocytes and edema that result in a temporary increase in tumor size and delayed subsequent shrinkage due to tumor cell destruction.

CASE SUMMARY

We report on a 47-year old patient with platinum-resistant ovarian cancer that was treated off-label with nivolumab 3mg/kg iv d1q14d. She first experienced classic pseudoprogression with inguinal lymph node swelling after cycle two and subsequent shrinkage. After 6 cycles she presented with rectal bleeding and progressive disease was diagnosed due to new tumor infiltration into the rectum.

CONCLUSION

Clinicians should be aware of pseudoprogression, its underlying mechanisms and strategies to discriminate pseudo- from real progression in ovarian cancer.

Calling Variants in the Clinic: Informed Variant Calling Decisions Based on Biological, Clinical, and Laboratory Variables

Deep sequencing genomic analysis is becoming increasingly common in clinical research and practice, enabling accurate identification of diagnostic, prognostic, and predictive determinants. Variant calling, distinguishing between true mutations and experimental errors, is a central task of genomic analysis and often requires sophisticated statistical, computational, and/or heuristic techniques. Although variant callers seek to overcome noise inherent in biological experiments, variant calling can be significantly affected by outside factors including those used to prepare, store, and analyze samples. The goal of this review is to discuss known experimental features, such as sample preparation, library preparation, and sequencing, alongside diverse biological and clinical variables, and evaluate their effect on variant caller selection and optimization.

Adverse Drug Reactions in an Oncological Population: Prevalence, Predictability, and Preventability

BACKGROUND

Our goal was to determine (a) the prevalence of multimorbidity and polypharmacy in patients with cancer and (b) the prevalence, predictability, and preventability of adverse drug reactions (ADRs) causing/contributing to hospitalization.

MATERIALS AND METHODS

We conducted a 12-month prospective observational study of patients aged ≥16 years admitted to an oncology center. Older adults were aged ≥70 years.

RESULTS

We enrolled 350 patients: 52.3% (n = 183) female, mean age 63.6 years (SD 12.1), 36.6% (n = 121) aged ≥70 years. Multimorbidity (≥2 conditions) was identified in 96.9%; 68% had ≥5 conditions. The median number of medications was 6 (interquartile range [IQR] 4-8); 47% were prescribed ≥6 medications and 11.4% ≥11 medications. Older adults had higher numbers of comorbid conditions (7 [IQR 5-10] vs. 5 [IQR 3-7]) and were prescribed more medications (median 7 [IQR 4-9] vs. 4 [IQR 2-7]). ADRs caused/contributed to hospitalization in 21.5% (n = 75): 35.8% (n = 72) of emergency admissions and 4.7% (n = 3) of elective admissions. The most common ADRs were neutropenia with infection (25.3%), dyspepsia/nausea/vomiting (20%), and constipation (20%). Causative medications included systemic anticancer therapies (SACTs; 53.3%), opioids (17.3%), corticosteroids (6.7%), and nonsteroidal anti-inflammatory drugs (5.3%). ADR prevalence was similar in older and younger adults secondary to SACTs (8.3% vs. 13.1%), non-cancer medications (10.7% vs. 8.3%), and both (0% vs. 1.3%). ADRs were predictable in 89.3% (n = 67), definitely avoidable in 29.3% (n = 22), and possibly avoidable in 33.3% (n = 25). No association was identified between ADRs and age, gender, daily medication number, length of stay, or death. No ADR predictor variables were identified by logistic regression.

CONCLUSION

More than 21% of admissions to an oncology service are ADR-related. ADRs are caused by both SACTs and non-cancer-specific medications. The majority are predictable; ≥60% may be preventable. Patients with cancer have high levels of multimorbidity and polypharmacy, which require vigilance for related adverse outcomes.

IMPLICATIONS FOR PRACTICE

A diagnosis of cancer often occurs in patients with multimorbidity and polypharmacy. Cancer can cause an altered physiological environment, placing patients at risk of drug-drug interactions, drug-disease interactions, and adverse drug reactions (ADRs). This study identified that ADRs caused or contributed to one in five hospital admissions of patients with cancer. ADRs were caused by systemic anticancer therapies (SACTs) in 53.3% of cases and non-cancer medications in 45.4% of cases, and a combination of both in 1.3%. ADRs occurred in similar frequencies in older and younger patients secondary to SACTs (8.3% vs. 13.1%, p = .295), non-SACTs (10.7% vs. 8.3%, p = .107), and a combination of both (0% vs. 1.3%, p = .240). The majority of ADRs were predictable (89.3%) and potentially preventable (62.6%). These findings support the need for increased awareness of medication-related adversity in patients with cancer and interventions to minimize their occurrence, thus supporting the American Society of Clinical Oncology guidelines that recommend adults ≥65 years of age receiving chemotherapy have geriatric assessment to identify medical and medication issues.

Validation of the Danish version of the musculoskeletal tumour society score questionnaire

BACKGROUND

The musculoskeletal tumour society score (MSTS) is a well-known questionnaire for measuring functional outcome in patients with neoplasms in the extremities. Standardized guidelines for cross-cultural translation and validation ensure the equivalence of content between the original and translated versions. The translation and validation provide the possibility to compare different sarcoma populations on an international level. This study is based on the hypothesis that the Danish MSTS questionnaire is a valid tool for measuring the end result after surgery for neoplasms in the extremities.

AIM

To validate the Danish version of the upper and lower extremity version of the MSTS.

METHODS

The translation of the MSTS was conducted in accordance with international guidelines. Patients operated for sarcomas and aggressive benign tumors were invited to participate in the study. The psychometric properties of the Danish version of the MSTS were tested in terms of validity and reliability and for the risk of floor or ceiling effect. Spearman’s rank coefficient was used to test the validity by comparing with the Toronto Extremity Salvage Score (TESS). The Intraclass Correlation Coefficient (ICC) was used to evaluate inter-rater reliability. Cronbach’s alpha was used to test for internal consistency. Spearman’s rank coefficient was used to compare the MSTS lower extremity version with the objective test, Timed Up and Go (TUG).

RESULTS

The upper extremity version demonstrated an ICC of 0.95 in the inter-rater reliability test. The lower extremity version had an ICC of 0.88 in the inter-rater reliability test, respectively. Both MSTS versions showed a ceiling effect. The validity of the MSTS was measured by Spearman’s rank correlation coefficient by comparing the MSTS with the TESS and found it to be of 0.80 (P < 0.01) and 0.83 (P < 0.01) for the upper extremity and lower extremity version, respectively. A Spearman’s rank correlation coefficient of - 0.26 (P < 0.01) was found between the TUG and the MSTS questionnaire. A Spearman’s rank correlation coefficient of - 0.38 (P < 0.01) was found between the TUG and the lower extremity version of the TESS questionnaire.

CONCLUSION

The Danish version of the MSTS questionnaires were found to have good reliability and validity, however a substantial ceiling effect was identified.

Correction for Partial Volume Effect Is a Must, Not a Luxury, to Fully Exploit the Potential of Quantitative PET Imaging in Clinical Oncology

The partial volume effect (PVE) is considered as one of the major degrading factors impacting image quality and hampering the accuracy of quantitative PET imaging in clinical oncology. This effect is the consequence of the limited spatial resolution of whole-body PET scanners, which results in blurring of the generated images by the scanner's response function. A number of strategies have been devised to deal with partial volume effect. However, the lack of consensus on the clinical relevance of partial volume correction and the most appropriate technique to be used in the context of clinical oncology limited their application in clinical setting. This issue is debated in this commentary.

Characterization of Comorbidities Limiting the Recruitment of Patients in Early Phase Clinical Trials

BACKGROUND

Early phase clinical trials evaluate the safety and efficacy of new treatments. The exclusion/inclusion criteria in these trials are usually rigorous and may exclude many patients seen in clinical practice. Our objective was to study the comorbidities limiting the participation of patients with breast, colorectal, or lung cancer in clinical trials.

MATERIALS AND METHODS

We queried ClinicalTrials.gov on December 31, 2016. We reviewed the eligibility criteria of 1,103 trials. Logistic regression analyses were completed, and exclusion was studied as a binary variable.

RESULTS

Out of 1,103 trials, 70 trials (6%) excluded patients >75 years of age, and 45% made no reference to age. Eighty-six percent of trials placed restrictions on patients with history of prior malignancies. Regarding central nervous system (CNS) metastasis, 416 trials (38%) excluded all patients with CNS metastasis, and 373 (34%) only allowed asymptomatic CNS metastasis. Regarding chronic viral infections, 347 trials (31%) excluded all patients with human immunodeficiency virus, and 228 trials (21%) excluded all patients with hepatitis B or C infection. On univariate analysis, chemotherapy trials were more likely to exclude patients with CNS metastasis and history of other malignancies than targeted therapy trials. Multivariate analysis demonstrated that industry-sponsored trials had higher odds of excluding patients with compromised liver function.

CONCLUSION

Many clinical trials excluded large segments of the population of patients with cancer. Frequent exclusion criteria included patients with CNS metastasis, history of prior malignancies, and chronic viral infections. The criteria for participation in some clinical trials may be overly restrictive and limit enrollment.

IMPLICATIONS FOR PRACTICE

The results of this study revealed that most early phase clinic trials contain strict exclusion criteria, potentially excluding the patients who may be more likely to represent the population treated in clinical settings, leaving patients susceptible to unintended harm from inappropriate generalization of trial results. Careful liberalization of the inclusion/exclusion criteria in clinical trials will allow investigators to understand the benefits and drawbacks of the experimental drug for a broader population, and possibly improve recruitment of patients with cancer into clinical trials.

A survey of perceptions, attitudes, knowledge and practices of medical oncologists about cancer pain management in Spain

PURPOSE

To monitor oncologists' perspective on cancer pain management.

METHODS

An anonymized survey was conducted in two waves. First, over a convenience sample of oncologists known to be particularly concerned with the management of pain. Second, using a random sample of oncologists.

RESULTS

In total, 73 and 82 oncologists participated in the first and second wave, respectively. Many oncologists reported to have good knowledge of analgesic drugs (95.9%), the mechanism of action of opioids (79.5%), and good skills to manage opioid-related bowel dysfunction (76.7%). Appropriate adjustment of background medication to manage breakthrough pain was reported by 95.5% of oncologists. Additionally, 87.7% (68.3% in the second wave, p = 0.035) of oncologists reported suitable opioid titration practices, and 90.4% reported to use co-adjuvant medications for neuropathic pain confidently. On the other hand, just 9.6% of oncologists participated in multidisciplinary pain management teams, and merely 30.3 and 27.1% reported to routinely collaborate with the Pain Clinics or involve other staff, respectively. Only 26.4% of the oncologists of the second wave gave priority to pain pathophysiology to decide therapies, and up to 75.6% reported difficulties in treating neuropathic pain. Significantly less oncologists of the second wave (82.9 vs. 94.5%, p = 0.001) used opioid rotation routinely.

CONCLUSIONS

Unlike in previous surveys, medical oncologists reported in general good knowledge and few perceived limitations and barriers for pain management. However, multi-disciplinary management and collaboration with other specialists are still uncommon. Oncologists' commitment to optimize pain management seems important to improve and maintain good practices.

ENABLE (Exportable Notation and Bookmark List Engine): an Interface to Manage Tumor Measurement Data from PACS to Cancer Databases

Oncologists evaluate therapeutic response in cancer trials based on tumor quantification following selected "target" lesions over time. At our cancer center, a majority of oncologists use Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 quantifying tumor progression based on lesion measurements on imaging. Currently, our oncologists handwrite tumor measurements, followed by multiple manual data transfers; however, our Picture Archiving Communication System (PACS) (Carestream Health, Rochester, NY) has the ability to export tumor measurements, making it possible to manage tumor metadata digitally. We developed an interface, "Exportable Notation and Bookmark List Engine" (ENABLE), which produces prepopulated RECIST v1.1 worksheets and compiles cohort data and data models from PACS measurement data, thus eliminating handwriting and manual data transcription. We compared RECIST v1.1 data from eight patients (16 computed tomography exams) enrolled in an IRB-approved therapeutic trial with ENABLE outputs: 10 data fields with a total of 194 data points. All data in ENABLE's output matched with the existing data. Seven staff were taught how to use the interface with a 5-min explanatory instructional video. All were able to use ENABLE successfully without additional guidance. We additionally assessed 42 metastatic genitourinary cancer patients with available RECIST data within PACS to produce a best response waterfall plot. ENABLE manages tumor measurements and associated metadata exported from PACS, producing forms and data models compatible with cancer databases, obviating handwriting and the manual re-entry of data. Automation should reduce transcription errors and improve efficiency and the auditing process.

Resources Required for Semi-Automatic Volumetric Measurements in Metastatic Chordoma: Is Potentially Improved Tumor Burden Assessment Worth the Time Burden?

The Response Evaluation Criteria in Solid Tumors (RECIST) is the current standard for assessing therapy response in patients with malignant solid tumors; however, volumetric assessments are thought to be more representative of actual tumor size and hence superior in predicting patient outcomes. We segmented all primary and metastatic lesions in 21 chordoma patients for comparison to RECIST. Primary tumors were segmented on MR and validated by a neuroradiologist. Metastatic lesions were segmented on CT and validated by a general radiologist. We estimated times for a research assistant to segment all primary and metastatic chordoma lesions using semi-automated volumetric segmentation tools available within our PACS (v12.0, Carestream, Rochester, NY), as well as time required for radiologists to validate the segmentations. We also report success rates of semi-automatic segmentation in metastatic lesions on CT and time required to export data. Furthermore, we discuss the feasibility of volumetric segmentation workflow in research and clinical settings. The research assistant spent approximately 65 h segmenting 435 lesions in 21 patients. This resulted in 1349 total segmentations (average 2.89 min per lesion) and over 13,000 data points. Combined time for the neuroradiologist and general radiologist to validate segmentations was 45.7 min per patient. Exportation time for all patients totaled only 6 h, providing time-saving opportunities for data managers and oncologists. Perhaps cost-neutral resource reallocation can help acquire volumes paralleling our example workflow. Our results will provide researchers with benchmark resources required for volumetric assessments within PACS and help prepare institutions for future volumetric assessment criteria.

From a Patient Advocate's Perspective: Does Cancer Immunotherapy Represent a Paradigm Shift?

PURPOSE OF REVIEW

In 2016, the American Society of Clinical Oncology (ASCO) announced immunotherapy as the year's top cancer advance in its "Clinical Cancer Advances 2016: ASCO's Annual Report on Progress Against Cancer." Further, ASCO again named "Immunotherapy 2.0" as the 2017 advance of the year, emphasizing the recent, rapid pace of research into new agents that harness and enhance the innate abilities of the immune system to recognize and fight cancers-and stressing that such agents have extended the lives of many patients with late-stage cancers for which there have been few treatment options. This article discusses the history of cancer immunotherapy and the recent promising advances, yet also presents a note of caution on limitations of immunotherapies, their potential harms, and the critical need for oncologists to appropriately engage with and educate patients to effectively manage their expectations.

RECENT FINDINGS

Learning how to effectively harness the immune system to treat cancer represents an investigative journey of more than 100 years. However, after many failures and disappointments, this decade has seen several important successes. In 2011, the Food and Drug Administration (FDA) approved the first immunotherapy agent known as a "checkpoint inhibitor." Beginning in 2014, several additional checkpoint blockage drugs have been FDA-approved, and new indications and drug combinations have emerged. Further, on August 30, 2017, the FDA announced its first approval of a new form of immunotherapy known as CAR T cell therapy. Since the 2011 approval of the first checkpoint inhibitor, cancer immunotherapy research among the pharmaceutical industry and research institutions has exploded, with thousands of clinical trials currently taking place. The current "cancer immunotherapy revolution" is in the headlines daily and is also the primary topic of conversation among major cancer research conferences and symposia attendees. However, a once quiet voice has begun to emerge, where an increasing number of scientists, clinicians, and patient advocates are stressing the need for caution concerning the limitations and potential harms associated with cancer immunotherapy. Many oncologists, scientists, medical professional associations, and advocates agree that no recent cancer advance has been as successful, transformative, and potentially paradigm-shifting as immunotherapy. With this decade, we have seen the approval of several immunotherapy agents that have successfully treated a percentage of patients with notoriously resistant cancers, an increasing number of combination immunotherapy treatments, and new indications for approved agents. However, patients need to be aware that much of the popular media has breathlessly inflated positive outcomes of cancer immunotherapies, while neglecting to stress that just a small percentage of patients actually benefit from such treatments. Further, they often completely overlook the unique, potentially life-threatening harms that may be associated with these agents and fail to cover negative findings where immunotherapies have appeared to paradoxically accelerate cancer growth. Fortunately, the majority of journal articles presenting trial results and comprehensive review articles appropriately discuss the important limitations associated with immunotherapies, the unique spectrum of adverse effects, and the need for further research to improve our ability to identify those patients who are most likely to benefit from specific agents, sparing other patients from exposure to agents that will not be effective, yet may carry potentially life-threatening toxicities.

Breast cancer metastases to the thyroid gland - an uncommon sentinel for diffuse metastatic disease: a case report and review of the literature

Background

Metastases to the thyroid are rare. The most common primary cancer to metastasize to the thyroid is renal cell carcinoma, followed by malignancies of the gastrointestinal tract, lungs, and skin, with breast cancer metastases to the thyroid being rare. Overall, the outcomes in malignancies that have metastasized to the thyroid are poor. There are no prospective studies addressing the role of surgery in metastatic disease of the thyroid. Isolated thyroidectomy has been proposed as a local disease control option to palliate and prevent the potential morbidity of tumor extension related to the airway. Here, we present a case of a patient with breast cancer metastases to the thyroid gland and discuss the role of thyroidectomy in the context of the current literature.

Case presentation

A 62-year-old Afro-Caribbean woman was diagnosed as having bilateral breast carcinoma in 2004, for which she underwent bilateral mastectomy. The pathology revealed multifocal disease on the right, T2N0(0/20)M0 grade 1 and 2 invasive ductal carcinoma, and on the left side, T3N1(2/18)M0 grade 1 invasive ductal carcinoma. Surgery was followed by adjuvant chemotherapy and regional radiotherapy. The disease was under control on hormonal therapy until 2016, when she developed cervical lymphadenopathy. The fine-needle aspiration cytology of the thyroid was reported as papillary thyroid cancer; and the fine-needle biopsy of the left lateral nodal disease was more suggestive of breast malignancy. She underwent a total thyroidectomy and a clearance of the central compartment lymph nodes and a biopsy of the lateral nodal disease. The histopathological analysis was consistent with metastatic breast cancer in the thyroid and lymph nodes with no evidence of a primary thyroid malignancy.

Conclusions

A past history of a malignancy elsewhere should raise the index of suspicion of metastatic disease in patients presenting with thyroid lumps with or without cervical lymphadenopathy. Detection of metastases to the thyroid generally indicates poor prognosis, obviating the need of surgery in an already compromised patient. An empirical thyroidectomy should be considered in select patients for local disease control.

The Potential Role of Symptom Questionnaires in Palliative and Supportive Cancer Care Delivery

PURPOSE OF REVIEW

The American Society of Clinical Oncology (ASCO) palliative care recommendations have been updated into a full guideline. Symptom questionnaires-completed and reviewed with patients during care delivery-are poised to play a large role in this guideline because they provide a more comprehensive understanding of symptoms. This article provides an overview of the guideline and describes how symptom questionnaires can be used to satisfy the guideline.

RECENT FINDINGS

Standardized symptom questionnaires can be used for three purposes in care delivery: symptom management, referral to specialty palliative and supportive care, and to assess high-quality care. Challenges include necessary changes to clinic workflow to collect patient responses and respond to electronic alerts for worsening symptoms. Symptom questionnaires administered as part of routine care delivery are highly informative and worth the time to enhance symptom management in routine care, to increase referrals, and to standardize performance metrics.

Novel Immunologic Approaches to Melanoma Treatment

Approaches to treating melanoma have changed radically since the introduction of immunotherapy, and survival figures are now higher than possible with earlier therapies. The immunomodulators currently available mainly block CTLA-4 (cytotoxicT lymphocyte-associated molecule-4) and PD-1 (programed cell death protein 1) translocated to the cell surface, where they inhibit the antitumor immune response. Treatments blocking these molecules are being more widely used. Research now seeks new molecular targets, the best combinations of available drugs, and biomarkers that can identify ideal candidates for each one.

Accessibility, Availability, and Potential Benefits of Psycho-Oncology Services: The Perspective of Community-Based Physicians Providing Cancer Survivorship Care

BACKGROUND

As persons of trust, community-based physicians providing survivorship care (e.g., general practitioners [GPs]) often serve as the primary contacts for cancer survivors disclosing distress. From the perspective of physicians providing survivorship care for cancer patients, this study explores (a) the accessibility, availability, and potential benefits of psycho-oncology services; (b) whether physicians themselves provide psychosocial support; and (c) predictors for impeded referrals of survivors to services.

METHODS

In a cross-sectional survey, all GPs and community-based specialists in a defined region were interviewed. In addition to descriptive analyses, categorical data were investigated by applying chi-square tests. Predictors for impeded referrals were explored through logistic regression.

RESULTS

Of 683 responding physicians, the vast majority stated that survivors benefit from psycho-oncology services (96.8%), but the physicians also articulated that insufficient coverage of psycho-oncology services (90.9%) was often accompanied by impeded referrals (77.7%). A substantial proportion (14.9%) of physicians did not offer any psychosocial support. The odds of physicians in rural areas reporting impeded referrals were 1.91 times greater than the odds of physicians in large urban areas making a similar report (95% confidence interval [1.07, 3.40]).

CONCLUSION

Most community-based physicians providing survivorship care regard psycho-oncology services as highly beneficial. However, a large number of physicians report tremendous difficulty referring patients. Focusing on those physicians not providing any psychosocial support, health policy approaches should specifically (a) raise awareness of the role of physicians as persons of trust for survivors, (b) highlight the effectiveness of psycho-oncology services, and (c) encourage a proactive attitude toward the assessment of unmet needs and the initiation of comprehensive care.

IMPLICATIONS FOR PRACTICE

Community-based physicians providing survivorship care for cancer patients regard psycho-oncology services as a highly reasonable and beneficial addition to medical care. In light of insufficient local coverage with services, difficulties with seamless referrals constitute a major challenge for physicians. Apart from emphasizing the effectiveness of psycho-oncology services and proactive attitudes toward the assessment of unmet needs, future policies should focus on the integration of medical and psychosocial follow-up of cancer survivors, especially in rural areas.

Improving Clinical Practice Using a Novel Engagement Approach: Measurement, Benchmarking and Feedback, A Longitudinal Study

BACKGROUND

Poor clinical outcomes are caused by multiple factors such as disease progression, patient behavior, and structural elements of care. One other important factor that affects outcome is the quality of care delivered by a provider at the bedside. Guidelines and pathways have been developed with the promise of advancing evidence-based practice. Yet, these alone have shown mixed results or fallen short in increasing adherence to quality of care. Thus, effective, novel tools are required for sustainable practice change and raising the quality of care.

METHODS

The study focused on benchmarking and measuring variation and improving care quality for common types of breast cancer at four sites across the United States, using a set of 12 Clinical Performance and Value(®) (CPV(®)) vignettes per site. The vignettes simulated online cases that replicate a typical visit by a patient as the tool to engage breast cancer providers and to identify and assess variation in adherence to evidence-based practice guidelines and pathways.

RESULTS

Following multiple rounds of CPV measurement, benchmarking and feedback, we found that scores had increased significantly between the baseline round and the final round (P < 0.001) overall and for all domains. By round 4 of the study, the overall score increased by 14% (P < 0.001), and the diagnosis with treatment plan domain had an increase of 12% (P < 0.001) versus baseline.

CONCLUSION

We found that serially engaging breast cancer providers with a validated clinical practice engagement and measurement tool, the CPVs, markedly increased quality scores and adherence to clinical guidelines in the simulated patients. CPVs were able to measure differences in clinical skill improvement and detect how fast improvements were made.

Promoting interprofessional collaboration in oncology through a teamwork skills simulation programme

Outcomes in clinical oncology can be improved when care is delivered by high-performance teams. The purpose of the initiative described in this article was to develop interprofessional team training opportunities using simulated cancer care scenarios to enhance collaborative practice skills within clinical oncology. Scenarios were developed based on internal needs assessment and review of patient safety data. Paired teams of haematology-oncology nurses and fellows completed the patient management scenarios, followed by debriefing and performance feedback. Research design consisted of an observational case study and questionnaire of participants in a cross-sectional analysis. Twenty-three learners participated in two separate sessions. All participants responded with scores of 4-5 on a 5-point Likert scale regarding the perceived value of the training programme and its effectiveness in developing skills in teamwork and communication. Simulation-based team training scenarios were successfully implemented into an interprofessional curriculum for haematology-oncology nurses and fellows. Participants valued the experience and indicated that they acquired new knowledge, skills, and attitudes to enhance interprofessional collaboration in cancer care. These types of training programmes have the potential to transform cancer care by creating high-performing teams resulting in improved patient outcomes, enhanced clinical effectiveness, and higher levels of satisfaction among patients, families, and healthcare providers.

Indeterminate Findings on Oncologic PET/CT: What Difference Does PET/MRI Make?

BACKGROUND

Positron emission tomography/computed tomography (PET/CT) with 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG) has become the standard of care for the initial staging and subsequent treatment response assessment of many different malignancies. Despite this success, PET/CT is often supplemented by MRI to improve assessment of local tumor invasion and to facilitate detection of lesions in organs with high background FDG uptake. Consequently, PET/MRI has the potential to expand the clinical value of PET examinations by increasing reader certainty and reducing the need for subsequent imaging. This study evaluates the ability of FDG-PET/MRI to clarify findings initially deemed indeterminate on clinical FDG-PET/CT studies.

METHODS

A total of 190 oncology patients underwent whole-body PET/CT, immediately followed by PET/MRI utilizing the same FDG administration. Each PET/CT was interpreted by our institution's nuclear medicine service as a standard-of-care clinical examination. Review of these PET/CT reports identified 31 patients (16 %) with indeterminate findings. Two readers evaluated all 31 PET/CT studies, followed by the corresponding PET/MRI studies. A consensus was reached for each case, and changes in interpretation directly resulting from PET/MRI review were recorded. Interpretations were then correlated with follow-up imaging, pathology results, and other diagnostic studies.

RESULTS

In 18 of 31 cases with indeterminate findings on PET/CT, PET/MRI resulted in a more definitive interpretation by facilitating the differentiation of infection/inflammation from malignancy (15/18), the accurate localization of FDG-avid lesions (2/18), and the characterization of incidental non-FDG-avid solid organ lesions (1/18). Explanations for improved reader certainty with PET/MRI included the superior soft tissue contrast of MRI and the ability to assess cellular density with diffusion-weighted imaging. The majority (12/18) of such cases had an appropriate standard of reference; in all 12 cases, the definitive PET/MRI interpretation proved correct. These 12 patients underwent six additional diagnostic studies to clarify the initial indeterminate PET/CT findings. In the remaining 13 of 31 cases with indeterminate findings on both PET/CT and PET/MRI, common reasons for uncertainty included the inability to distinguish reactive from malignant lymphadenopathy (4/13) and local recurrence from treatment effect (2/13).

CONCLUSIONS

Indeterminate PET/CT findings can result in equivocal reads and additional diagnostic studies. PET/MRI may reduce the rate of indeterminate findings by facilitating better tumor staging, FDG activity localization, and lesion characterization. In our study, PET/MRI resulted in more definitive imaging interpretations with high accuracy. PET/MRI also showed potential in reducing the number of additional diagnostic studies prompted by PET/CT findings. Our results suggest that whole-body PET/MRI provides certain diagnostic advantages over PET/CT, promotes more definitive imaging interpretations, and may improve the overall clinical utility of PET.

Conspicuity of FDG-Avid Osseous Lesions on PET/MRI Versus PET/CT: a Quantitative and Visual Analysis

BACKGROUND

Because standard MRI-based attenuation correction (AC) does not account for the attenuation of photons by cortical bone, PET/MRI may have reduced sensitivity for FDG-avid focal bone lesions (FFBLs). This study evaluates whether MRI-based AC compromises detection of FFBLs, by comparing their conspicuity both quantitatively and qualitatively on PET/MRI versus PET/CT.

METHODS

One hundred ninety general oncology patients underwent whole-body PET/CT followed by whole-body PET/MRI, utilizing the same FDG dose. Thirteen patients with a total of 50 FFBLs were identified. Using automated contouring software, a volumetric contour was generated for each FFBL. Adjacent regions of normal background bone (BB) were selected manually. For each contour, SUV-max and SUV-mean were determined. Lesion-to-background SUV ratios served as quantitative metrics of conspicuity. Additionally, two blinded readers evaluated the relative conspicuity of FFBLs on PET images derived from MRI-based AC versus CT-based AC. Visibility of an anatomic correlate for FFBLs on the corresponding CT and MR images was also assessed.

RESULTS

SUV-mean was lower on PET/MRI for both FFBLs (-6.5 %, p = 0.009) and BB (-20.5 %, p < 0.001). SUV-max was lower on PET/MRI for BB (-14.2 %, p = 0.002) but not for FFBLs (-6.2 %, p = 0.068). The ratio of FFBL SUV-mean to BB SUV-mean was higher for PET/MRI (+29.5 %, p < 0.001). Forty of 50 lesions (80 %) were visually deemed to be of equal or greater conspicuity on PET images derived from PET/MRI. Thirty-five of 50 FFBLs (70 %) had CT correlates, while 40/50 FFBLs (80 %) had a correlate on at least one MRI sequence. The mean interval from tracer administration to imaging was longer (p < 0.001) for PET/MRI (127 v. 62 min).

CONCLUSIONS

Both FFBLs and BB had lower mean SUVs on PET/MRI than PET/CT. This finding was likely in part due to differences in the handling of cortical bone by MRI-based AC versus CT-based AC. Despite this systematic bias, FFBLs had greater conspicuity on PET/MRI, both qualitatively and quantitatively. This difference was likely due to the longer tracer uptake times for PET/MRI, which allowed for more tracer accumulation by FFBLs and more tracer washout from BB. Our results suggest that whole-body PET/MRI and PET/CT provide comparable sensitivity for detection of FDG-avid focal bone lesions.

Psyche at the end of life: Psychiatric symptoms are prevalent in patients admitted to a palliative care unit

OBJECTIVE

Our aim was to evaluate the frequency and treatment of psychiatric symptoms in patients at palliative care units (PCUs).

METHOD

Patients admitted to one of five participating PCUs in Austria were included. The short version of the Patient Health Questionnaire (PHQ-D) was used to evaluate their mental health status. Pain intensity was rated on a numeric rating scale (NRS) from 0 to 10 by patients and physicians. Patients with a previously diagnosed psychiatric disorder were compared to those without or with newly diagnosed psychiatric symptoms, based on PHQ-D results. Pain and psychopharmacological medication were assessed. Opioid doses were converted into oral morphine equivalents (OMEs).

RESULTS

Some 68 patients were included. Previously undetected psychiatric symptoms were identified in 38% (26 of 68), preexisting psychiatric comorbidities were evident in 25% (17), and no psychiatric symptoms were observed in 37% (25). Patients with a preexisting psychiatric comorbidity received antidepressants and benzodiazepines significantly more often than patients without or with previously undetected psychiatric symptoms (p < 0.001). Patient and physician median NRS ratings of pain intensity correlated significantly (p = 0.001). Median NRS rating showed no significant difference between patients with preexisting, previously undetected, or without psychiatric symptoms. OMEs did not differ significantly between preexisting, without, or previously undetected psychiatric symptoms. Patients with undetected and preexisting psychiatric comorbidities had a greater impairment in their activities of daily living than patients without psychiatric symptoms (p = 0.003).

SIGNIFICANCE OF RESULTS

Undetected psychiatric comorbidities are common in patients receiving palliative care. Screening for psychiatric symptoms should be integrated into standard palliative care to optimize treatment and reduce the psychosocial burden of the disease.