A catalyst for transforming health systems and person-centred care: Canadian national position statement on patient-reported outcomes

Background

Patient-reported outcomes (pros) are essential to capture the patient's perspective and to influence care. Although pros and pro measures are known to have many important benefits, they are not consistently being used and there is there no Canadian pros oversight. The Position Statement presented here is the first step toward supporting the implementation of pros in the Canadian health care setting.

Methods

The Canadian pros National Steering Committee drafted position statements, which were submitted for stakeholder feedback before, during, and after the first National Canadian Patient Reported Outcomes (canpros) scientific conference, 14-15 November 2019 in Calgary, Alberta. In addition to the stakeholder feedback cycle, a patient advocate group submitted a section to capture the patient voice.

Results

The canpros Position Statement is an outcome of the 2019 canpros scientific conference, with an oncology focus. The Position Statement is categorized into 6 sections covering 4 theme areas: Patient and Families, Health Policy, Clinical Implementation, and Research. The patient voice perfectly mirrors the recommendations that the experts reached by consensus and provides an overriding impetus for the use of pros in health care.

Conclusions

Although our vision of pros transforming the health care system to be more patient-centred is still aspirational, the Position Statement presented here takes a first step toward providing recommendations in key areas to align Canadian efforts. The Position Statement is directed toward a health policy audience; future iterations will target other audiences, including researchers, clinicians, and patients. Our intent is that future versions will broaden the focus to include chronic diseases beyond cancer.

Employment outcomes for recent Canadian radiation oncology graduates

Introduction

Radiation oncology (ro) is one of several specialties identified by the Royal College of Physicians and Surgeons of Canada with employment difficulties for graduating trainees. The purpose of the present study was to determine the employment status and location of recent Canadian ro trainees within 2 years after graduation, to monitor workforce recruitment trends over time, and to capture the opinions of program directors about employment difficulty for graduates and resident morale. Visa trainee graduates were excluded.

Methods

Results of the survey administered to ro program directors in 2016 and again in 2018, both with 100% response rates, are presented here.

Results

In both surveys, approximately 57% of ro graduates had attained staff or locum employment in Canada or abroad within 2 years from graduation (p = 0.92). However, graduates with Canadian staff employment increased by 46% to 32 in 2018 from 22 in 2016, while the proportion of graduates with staff positions abroad decreased to 6% from 27% (p = 0.04). Most trainees without staff positions were employed as fellows. The proportion of program directors reporting employment difficulties for graduates in the Canadian labour market declined to 38% from 85% (p = 0.04), and the morale of residents in training programs remained high.

Conclusions

Employment challenges for newly certified Canadian-trained radiation oncologists continue. However, compared with the situation 2 years ago, trends in the Canadian ro job market suggest a modest improvement, with more staff employment in Canada and lower emigration rates for jobs abroad.

OV21/PETROC: a randomized Gynecologic Cancer Intergroup phase II study of intraperitoneal versus intravenous chemotherapy following neoadjuvant chemotherapy and optimal debulking surgery in epithelial ovarian cancer

Background

The purpose of this multistage, adaptively, designed randomized phase II study was to evaluate the role of intraperitoneal (i.p.) chemotherapy following neoadjuvant chemotherapy (NACT) and optimal debulking surgery in women with epithelial ovarian cancer (EOC).

Patients and methods

We carried out a multicenter, two-stage, phase II trial. Eligible patients with stage IIB-IVA EOC treated with platinum-based intravenous (i.v.) NACT followed by optimal (<1 cm) debulking surgery were randomized to one of the three treatment arms: (i) i.v. carboplatin/paclitaxel, (ii) i.p. cisplatin plus i.v./i.p. paclitaxel, or (iii) i.p. carboplatin plus i.v./i.p. paclitaxel. The primary end point was 9-month progressive disease rate (PD9). Secondary end points included progression-free survival (PFS), overall survival (OS), toxicity, and quality of life (QOL).

Results

Between 2009 and 2015, 275 patients were randomized; i.p. cisplatin containing arm did not progress beyond the first stage of the study after failing to meet the pre-set superiority rule. The final analysis compared i.v. carboplatin/paclitaxel (n = 101) with i.p. carboplatin, i.v./i.p. paclitaxel (n = 102). The intention to treat PD9 was lower in the i.p. carboplatin arm compared with the i.v. carboplatin arm: 24.5% (95% CI 16.2% to 32.9%) versus 38.6% (95% CI 29.1% to 48.1%) P = 0.065. The study was underpowered to detect differences in PFS: HR PFS 0.82 (95% CI 0.57-1.17); P = 0.27 and OS HR 0.80 (95% CI 0.47-1.35) P = 0.40. The i.p. carboplatin-based regimen was well tolerated with no reduction in QOL or increase in toxicity compared with i.v. administration alone.

Conclusion

In women with stage IIIC or IVA EOC treated with NACT and optimal debulking surgery, i.p. carboplatin-based chemotherapy is well tolerated and associated with an improved PD9 compared with i.v. carboplatin-based chemotherapy.

Clinical trial number

clinicaltrials.gov, NCT01622543.

OV21/PETROC: a randomized Gynecologic Cancer Intergroup phase II study of intraperitoneal versus intravenous chemotherapy following neoadjuvant chemotherapy and optimal debulking surgery in epithelial ovarian cancer

Background

The purpose of this multistage, adaptively, designed randomized phase II study was to evaluate the role of intraperitoneal (i.p.) chemotherapy following neoadjuvant chemotherapy (NACT) and optimal debulking surgery in women with epithelial ovarian cancer (EOC).

Patients and methods

We carried out a multicenter, two-stage, phase II trial. Eligible patients with stage IIB-IVA EOC treated with platinum-based intravenous (i.v.) NACT followed by optimal (<1 cm) debulking surgery were randomized to one of the three treatment arms: (i) i.v. carboplatin/paclitaxel, (ii) i.p. cisplatin plus i.v./i.p. paclitaxel, or (iii) i.p. carboplatin plus i.v./i.p. paclitaxel. The primary end point was 9-month progressive disease rate (PD9). Secondary end points included progression-free survival (PFS), overall survival (OS), toxicity, and quality of life (QOL).

Results

Between 2009 and 2015, 275 patients were randomized; i.p. cisplatin containing arm did not progress beyond the first stage of the study after failing to meet the pre-set superiority rule. The final analysis compared i.v. carboplatin/paclitaxel (n = 101) with i.p. carboplatin, i.v./i.p. paclitaxel (n = 102). The intention to treat PD9 was lower in the i.p. carboplatin arm compared with the i.v. carboplatin arm: 24.5% (95% CI 16.2% to 32.9%) versus 38.6% (95% CI 29.1% to 48.1%) P = 0.065. The study was underpowered to detect differences in PFS: HR PFS 0.82 (95% CI 0.57-1.17); P = 0.27 and OS HR 0.80 (95% CI 0.47-1.35) P = 0.40. The i.p. carboplatin-based regimen was well tolerated with no reduction in QOL or increase in toxicity compared with i.v. administration alone.

Conclusion

In women with stage IIIC or IVA EOC treated with NACT and optimal debulking surgery, i.p. carboplatin-based chemotherapy is well tolerated and associated with an improved PD9 compared with i.v. carboplatin-based chemotherapy.

Clinical trial number

clinicaltrials.gov, NCT01622543.

Use of low-value radiotherapy practices in Canada: an analysis of provincial cancer registry data

BACKGROUND

As part of Choosing Wisely Canada (a national campaign to encourage patient-provider conversations about unnecessary medical tests, treatments, and procedures), a list of ten oncology practices that could be low-value in some instances was developed. Of those practices, two were specific to radiation therapy (rt): conventional fractionation as part of breast-conserving therapy (bct) for women with early-stage breast cancer, and multifraction radiation for palliation of uncomplicated painful bone metastases. Here, we report baseline findings for the current utilization rates of those two rt practices in Canada.

RESULTS

The use of conventional fractionation as part of bct varied substantially from province to province. Of women 50 years of age and older, between 8.8% (Alberta) and 36.5% (Saskatchewan) received radiation in 25 fractions (excluding boost irradiation) as part of bct. The use of hypofractionated rt (that is, 16 fractions excluding boost irradiation)-a preferred approach for many patients-was more common in all 6 reporting provinces, ranging from 43.2% in Saskatchewan to 94.7% in Prince Edward Island. The use of multifraction rt for palliation of bone metastases also varied from province to province, ranging from 40.3% in British Columbia to 69.0% in Saskatchewan. The most common number of fractions delivered to bone metastases was 1, at 50.2%; the second most common numbers were 2-5 fractions, at 41.7%.

CONCLUSIONS

Understanding variation in the use of potentially low-value rt practices can help to inform future strategies to promote higher-value care, which balances high-quality care with the efficient use of limited system resources. Further work is needed to understand the factors contributing to the interprovincial variation observed and to develop benchmarks for the appropriate rate of use of these rt practices.

Health-related quality of life in recurrent platinum-sensitive ovarian cancer--results from the CALYPSO trial

BACKGROUND

In the CALYPSO trial, carboplatin-pegylated liposomal doxorubicin (CD) demonstrated superior therapeutic index versus carboplatin-paclitaxel (CP) in patients with recurrent ovarian cancer. This paper reports the health-related quality of life (HRQoL) findings.

MATERIALS AND METHODS

HRQoL was measured with the EORTC QoL-QC30 questionnaire and OV28 ovarian cancer module. Mean change scores from baseline in HRQoL subscales (five functional scales and global health status) in each arm and the proportion of patients improved or worsened were calculated every 3 months until 12 months.

RESULTS

Compliance was 90% at baseline and 76%, 64%, 57% at 3, 6, and 9 months, respectively. Baseline HRQoL showed already impaired global scores (mean 62/100) and considerable symptom burden (90% of patients reporting nonzero scores). Global QoL and abdominal symptom scores improved over time in both arms; at 6 months, 36% of patients met criteria for improved symptoms. Treatment with CD resulted in less peripheral neuropathy (9.8 versus 24.2), fewer other chemotherapy side-effects (9.5 versus 16.2), and less impact on body image (3.8 versus 10.4) versus CP (all P<0.02) at 6 months.

CONCLUSIONS

These patient-reported outcomes confirm the overall lower toxicity of CD versus CP. The improved disease-related outcomes achieved with CD were not at the expense of QoL.

Defining the optimal treatment strategy for localized prostate cancer patients: a survey of ongoing studies at the National Cancer Institute of Canada Clinical Trials Group

The designation "clinically localized prostate cancer" comprises a group of biologically heterogeneous tumours with different growth rates and risks of relapse. Because prostate cancer is primarily a disease of older men, treatment selection must take into account the prognosis of the tumour, patient age, comorbidities, side effects of treatment, and patient preferences. Clinical trials must identify the various prognostic groups and test the appropriate treatment strategies within these subgroups.

Quality of life (QOL) impact of adjuvant chemotherapy for early stage non-small cell lung cancer (NSCLC): Final analysis of JBR.10 randomized trial

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Background: Adjuvant chemotherapy for early stage NSCLC is now standard of care, but its impact on QOL is not known. We report the final QOL analysis of JBR.10, a North American intergroup randomized trial of adjuvant cisplatin/vinorelbine compared to observation in patients (pts) with completely resected stage IB/II NSCLC (n=482). Methods: QOL, a secondary endpoint of JBR.10, was assessed using the EORTC QLQ-C30 and a trial-specific checklist at baseline, weeks 5 and 9 for those on chemotherapy, and at 3, 6, 9, 12, 18, 24, 30 and 36 months of follow up. A 10-point change in QOL scores from baseline was considered clinically significant. Results: QOL assessment was not mandatory for all pts; 186/242 (76.9%) pts randomized to chemotherapy completed the baseline QOL assessment, compared to 173/240 (72.1%) pts on the observation arm. The overall survival of pts contributing QOL data, and the effect of adjuvant chemotherapy, was not different from the entire study population. Baseline QOL in the two study arms was comparable, with low global QOL scores and a significant symptom burden, especially pain and fatigue, following thoracotomy. A significantly greater proportion of chemotherapy pts experienced worsening symptoms including fatigue (p=0.02), appetite, hair loss, nausea and vomiting. At 6 months, a higher proportion of pts on the observation arm reported improved QOL in the global (p = 0.002), physical (p=0.02) and functional domains, compared to pts on the chemotherapy arm. However, by the 9 month time-point, global QOL of patients on chemotherapy was comparable to QOL of patients on observation, as were the five functional domains. Numbness (change scores: 22 vs 6, p<0.01) and pins & needles in fingers/toes (change scores: 21 vs 5, p<0.01) were the only symptoms that persisted, up to 24 months. Conclusion: Patients on adjuvant chemotherapy experience an initial slower recovery of QOL after thoracotomy, but following completion of treatment reach levels comparable to patients treated with surgery alone, in most aspects of QOL.

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A phase III randomized trial of BAY 12-9566 (tanomastat) as maintenance therapy in patients with advanced ovarian cancer responsive to primary surgery and paclitaxel/platinum containing chemotherapy: a National Cancer Institute of Canada Clinical Trials Group Study

OBJECTIVE

BAY 12-9566 (tanomastat) is a biphenyl matrix metalloprotease inhibitor (MMPI) with antiangiogenic and antimetastatic properties in vivo. The objective of the study was to determine whether the addition of BAY 12-9566 after optimal response to chemotherapy could improve time to progression (TTP).

PATIENTS AND METHODS

Patients enrolled in the study had received 6-9 cycles of platinum/paclitaxel containing chemotherapy for stage III or IV ovarian carcinoma, with a response of no evidence of disease, or complete or partial response with residual disease < 2 cm. Patients were then randomized to BAY 12-9566 800 mg p.o. b.i.d. or placebo. The primary endpoint was progression-free survival (PFS); secondary endpoints were quality of life, toxicity, changes in CA 125 levels, response, and overall survival (OS). The total planned sample size was 730.

RESULTS

The study was closed after 243 patients had been randomized because of Bayer's decision to close all ongoing trials due to negative results from other phase III trials in pancreatic and small cell lung cancer. The final analysis was performed in August 2000 after the requisite number of events for the first planned interim analysis had occurred; 54% of patients had progressed and 18% had died.

PATIENT CHARACTERISTICS

performance status was ECOG 0/1/2 in 65/33/2%; median age 57 years; 79% of patients were FIGO stage III; 41% were optimally debulked; 76% had serous histology, and 67% had > or = grade 3 histology. Toxicity was generally grade 1 or 2 in severity, with the most common (BAY 12-9566 vs. placebo) being nausea (26% vs. 13%), fatigue (24% vs. 12%), diarrhea (14% vs. 10%), rash (12% vs. 7%), grade 3/4 thrombocytopenia (3% vs. 1%), and grade 3/4 anemia (5% vs. 1%). Median time to progression (TTP) was 10.4 months (8.5-11.5) for BAY 12-9566 and 9.2 months (7.2-13.9) for placebo (P = 0.67). Median overall survival (OS) was 13.9 months (12.9-infinity) for BAY 12-9566 and 11.9 months (10.5-16.5) for placebo (P = 0.53).

CONCLUSION

We conclude that BAY 12-9566 was generally well tolerated and at the time of the final analysis, there was no evidence of an impact of BAY 12-9566 on PFS or OS.

Communicating quality of life information to cancer patients: a study of six presentation formats

PURPOSE

To determine which formats for presenting health-related quality of life (HRQL) data are interpreted most accurately and are most preferred by cancer patients. Patients often want a great deal of information about cancer treatments, including information relevant to HRQL. Clinical trials provide methodologically sound HRQL data that may be useful to patients.

PATIENTS AND METHODS

In a multicenter study, 198 patients with previously treated cancer participated in a structured interview. Participants judged HRQL information presented in one textual and five graphical formats. Outcome measures included the accuracy of patients' interpretations and ease-of-use and helpfulness ratings for each format.

RESULTS

Correct interpretations ranged from 85% to 98% across formats (F = 10.3, P < .0001) with line graphs of mean HRQL scores over time being interpreted correctly most often. Older patients and less-educated patients were less likely to interpret graphs accurately (F = 7.3, P = .008; and F = 10.6, P = .001, respectively), but all groups were most accurate on simple line graphs. Multivariate analysis revealed that format type, participant age and education were independent predictors of accuracy rates. Patients' ratings also varied across formats both for ease of understanding scores (F = 12.1, P < .0001) and for helpfulness scores (F = 13.2, P < .0001), with line graphs being rated highest on both outcomes.

CONCLUSION

Patients generally prefer a simple linear representation of group mean HRQL scores, and can accurately interpret data presented in this format more than 98% of the time irrespective of their age group and educational level. The findings have important implications for the communication of clinical trial HRQL results.

Randomized phase II study of two doses of gefitinib in hormone-refractory prostate cancer: a trial of the National Cancer Institute of Canada-Clinical Trials Group

PURPOSE

Overexpression of the epidermal growth factor receptor has been demonstrated in advanced prostate cancer and is associated with a poor outcome. A multi-institutional, randomized, phase II study was undertaken by the National Cancer Institute of Canada-Clinical Trials Group to evaluate the efficacy and toxicity of two doses of oral gefitinib in patients with minimally symptomatic, hormone-refractory prostate cancer (HRPC).

PATIENTS AND METHODS

Between July and November 2001, 40 patients with HRPC and increasing prostate-specific antigen (PSA) or progression in measurable disease who had not received prior chemotherapy were randomly assigned to 250 mg (n = 19) or 500 mg (n = 21) oral gefitinib daily continuously. The primary end points were PSA response rate and objective measurable response. Functional Assessment of Cancer Therapy Prostate Cancer Subscale (FACT-P) quality-of-life questionnaires were completed at baseline and during treatment.

RESULTS

None of the patients demonstrated a PSA or objective measurable response. Five (14.3%) of 35 assessable patients had stable PSA (one patient at 250 mg and four patients at 500 mg), and five patients (14.3%) had a best response of stable disease (duration, 2.5 to 16.8 months). No significant effect on the rate of increase in PSA was seen. The most common drug-related nonhematologic toxicities observed were grade 1 to 2 diarrhea (250 mg, 65%; 500 mg, 56%), fatigue (250 mg, 29%; 500 mg, 33%), and grade 1 to 2 skin rash (250 mg, 24%; 500 mg, 39%). FACT-P scores decreased during treatment, indicating worsening of symptoms compared with baseline.

CONCLUSION

Gefitinib did not result in any responses in PSA or objective measurable disease at either dose level. Gefitinib has minimal single-agent activity in HRPC.

Cancer patients' preferences for communicating clinical trial quality of life information: a qualitative study

Health-related quality of life (HRQL) is a prevalent outcome measure in clinical trials, but it is not known how best to communicate HRQL results to new patients with cancer. The purpose was to explore cancer patients' attitudes toward, and preferences for, 10 visual and written formats for communicating HRQL information. Using standardized qualitative methods, six focus groups were held (two groups in each of three cancer centres) with patients who had completed treatment for cancer at least 6 months earlier. Groups were stratified according to patients' education. To ensure consistency across centres, group moderators used the same detailed guide, training video, and props. Three investigators independently coded the resulting transcripts. Participants also rated each of the 10 presentation formats as to their perceived usefulness. Fourteen men and 19 women with a variety of cancer diagnoses participated; 13 (39%) participated in the three lower-education groups and 20 (61%) in the three higher-education groups. We found that simple formats (simple graphs or written text) were generally preferred to more complex graphical information, regardless of educational level. The same format was rated favourably by the highest proportion of participants in both the high (85%) and low (85%) education level groups. Individual patients, however, varied as to which visual format they most preferred. Patients did not wish to receive HRQL information out of context or without explanation. We conclude that cancer patients desire HRQL information, but vary in their preferences for its communication. Simple formats are generally preferred.

Phase III trial comparing radical radiotherapy with and without cisplatin chemotherapy in patients with advanced squamous cell cancer of the cervix

PURPOSE

To test the hypothesis that cisplatin (CDDP) administered concurrently with standard radiotherapy (RT) would improve pelvic control and survival in patients with advanced squamous cell cancer of the cervix.

PATIENTS AND METHODS

A total of 259 patients with International Federation of Gynecology and Obstetrics stage IB to IVA squamous cell cervical cancer with central disease greater-than-or-equal 5 cm or histologically confirmed pelvic lymph node involvement were randomized to receive RT (external-beam RT plus brachytherapy) plus weekly CDDP chemotherapy (40 mg/m(2)) (arm 1) or the same RT without chemotherapy (arm 2).

RESULTS

A total of 253 patients were available for analysis. Median follow-up was 82 months. No significant difference was found in progression-free survival (P =.33). No significant difference in 3- and 5-year survival rates was found (69% v 66% and 62% v 58%, respectively; P =.42). The hazard ratio for survival (arm 2 to arm 1) was 1.10 (95% confidence interval, 0.75 to 1.62).

CONCLUSION

This study did not show a benefit to either pelvic control or survival by adding concurrent weekly CDDP chemotherapy in a dose of 40 mg/m(2) to radical RT as given in this trial. Careful attention to RT details is important for achieving optimum outcome for patients with this disease.

Controversies in prostate cancer radiotherapy: consensus development

The GU Radiation Oncologists of Canada (GUROC) had a consensus meeting in November 2000 to discuss and develop consensus on four controversial areas: risk assessment of localized prostate cancer, conformal radiotherapy, role of brachytherapy in prostate cancer and combined hormonal therapy and radiotherapy for prostate cancer. The meeting was a success and resulted in consensus being achieved on a number of areas. The group agreed on three risk groupings: low risk, intermediate risk and high risk localized prostate cancer based on clinical stage, Gleason score and PSA level. The participants agreed that based on available toxicity data from randomized controlled trials, conformal treatment techniques should be offered to patients receiving prostatic radiotherapy. Consensus was reached on the role of dose escalation in each of the three risk groups and is summarized in the article. At present there is insufficient evidence from randomized clinical trials to recommend the use of brachytherapy over current other standard therapy (radical prostatectomy or external beam radiotherapy). Non randomized published studies show promising short and intermediate term results. Where ever possible patients should be approached about participation in ongoing RCT's evaluating brachytherapy versus current other standard therapy. Outside a clinical trial the participants felt permanent seed implants should be considered an acceptable treatment option for appropriate patients with low risk prostate cancer. Based on randomized controlled trials the group agreed that patients with high risk disease should be treated with prolonged (up to 2-3 years) adjuvant hormonal therapy. Part of this hormonal treatment may be given in a neoadjuvant fashion. The group agreed that adjuvant hormones should not be routinely used in low and intermediate risk patients. Neoadjuvant hormones have been demonstrated to improve outcome in patients with bulky tumors. The role of neoadjuvant hormones in other patients with intermediate and low risk prostate cancer is unclear and will be clarified with the publication of recently completed studies. The consensus meeting strongly endorsed continued accrual to current studies investigating clinically relevant questions.

A shorter fractionation schedule for postlumpectomy breast cancer patients

PURPOSE

The purpose of this retrospective review was to determine the effectiveness of 40 Gy in 16 daily fractions in preventing local recurrence in postlumpectomy invasive breast cancer patients whose margins of resection were clear of tumor by at least 2 mm.

METHODS

Between September 1989 and December 1993, 294 breasts were treated with this regimen. The entire breast was treated, using a tangential parallel pair, with wedges as necessary, to a dose of 40 Gy in 16 daily fractions. No additional boost was given. The median duration of follow-up of surviving patients is 5.5 years. Recently, the patients' assessment of the cosmetic outcome of their treatment was obtained, using a mailed questionnaire.

RESULTS

The 5-year actuarial breast-relapse rate was 3.5%, with an overall 5-year survival and disease-specific survival of 87.8% and 92.1%, respectively. In response to the cosmesis questionnaire, 77% of patients stated they were either extremely or very satisfied with the overall appearance of the breast, 19.5% moderately satisfied, and 3.5% either slightly or not at all satisfied. The corresponding responses for overall level of comfort of the breast were 79%, 16.5%, and 4.5% respectively.

CONCLUSION

This regimen is very effective at preventing recurrent breast cancer in this group of patients, and it provides a high level of patient satisfaction with cosmetic outcome. Its short duration offers the added advantage of a more efficient use of resources and greater patient convenience.

Do doctors know when their patients don't? A survey of doctor-patient communication in lung cancer

OBJECTIVES

a) To determine how much patients with recently diagnosed lung cancer know about their illness and its treatment, and b) to find out if doctors know what their patients know and what they don't.

PATIENTS AND METHODS

One hundred patients with recently diagnosed lung cancer, who were undergoing radiotherapy or chemotherapy, were interviewed to determine their view of their diagnosis, the extent of the cancer, the intent of treatment, and the risks and benefits of treatment. Their attending physicians' view were elicited contemporaneously, using a self-administered questionnaire. The principle outcome measure of the study was the level of agreement between the views of the patients and the doctors about the disease, the treatment, and the prognosis. Concordance between doctors' and patients' views was expressed in terms of percentage agreement, and Kappa (kappa).

RESULTS

Ninety-nine percent of the patients knew that they had lung cancer. Sixty-four percent (64%) agreed with their doctor about the extent of the disease (kappa = 0.48). Most of those who disagreed underestimated the extent of their cancer. Seventy-two percent (72%) agreed with their doctor about the intent of treatment (kappa = 0.49). Thirty-six percent (36%) agreed with their doctors about their probability of cure, (kappa = 0.17): most of those who disagreed systematically overestimated it. Sixty-eight patients were receiving palliative treatment. Of these, 56% agreed with their doctor about the probability of symptomatic benefit (kappa = 0.42), but only 14% agreed with their doctor about the probability that the treatment would prolong life (kappa = 0.06). Doctors frequently failed to recognize their patients' misconceptions about the intent of treatment and the prognosis.

CONCLUSION

Many patients did not understand their situation well enough to make a truly autonomous treatment decision, and their doctors often failed to recognize this.

Phase II study to evaluate the toxicity and efficacy of concurrent cisplatin and radiation therapy in the treatment of patients with locally advanced squamous cell carcinoma of the cervix

Sixty patients presenting with poor prognosis squamous cell cancer of the cervix have been studied in a phase II clinical trial. Patients were treated with radiotherapy and concurrent cisplatin chemotherapy every 10 days. Treatment was well tolerated with all patients completing radiotherapy as prescribed. There was one case of grade 4 acute bowel toxicity. Significant late morbidity was acceptable for this group of patients being restricted to two cases (3.3%) of grade 4 toxicity to the bowel. Pelvic control rates of 78% have been observed. There have been no pelvic recurrences after 26 months, although recurrences beyond the pelvis have occurred up to 4 years later. Actuarial 4-year survival is encouraging at 60%.

Waiting for radiotherapy in Ontario

PURPOSE

Waiting lists for radiotherapy are a fact of life at many Canadian cancer centers. The purpose of this study was to provide a detailed description of the magnitude of the problem in Ontario.

METHODS AND MATERIALS

The interval between diagnosis and initiation of radiation treatment was calculated for all patients receiving primary radiotherapy for carcinoma of the larynx, cervix, lung, and prostate at seven Ontario cancer centers between 1982 and 1991. The interval between surgery and initiation of postoperative radiotherapy for breast cancer was also calculated over the same period. The intervals between diagnosis and referral (t1), between referral and consultation (t2), and between consultation and initiation of radiotherapy (t3), were analyzed separately to determine where delay occurred.

RESULTS

Median waiting times between diagnosis and initiation of radical treatment for carcinoma of the larynx, carcinoma of the cervix, nonsmall cell lung cancer, and carcinoma of the prostate were 30.3 days, 27.2 days, 27.3 days, and 93.3 days, respectively. The exceptional interval between diagnosis and treatment of prostate cancer was due to much longer delays between diagnosis and referral. The median waiting time between diagnosis and initiation of postoperative radiotherapy for breast cancer was 61.4 days and the median time between the completion of surgery and initiation of postoperative radiotherapy was 57.8 days. There were significant intercenter variations in median waiting times, but in every situation the median waiting time in Ontario as a whole increased steadily between 1982 and 1991. Median waiting times from diagnosis to the start of curative treatment for laryngeal cancer, cervical cancer, nonsmall cell lung cancer, and prostate cancer increased by 178.7%, 105.6%, 158.3%, and 62.9%, respectively. Waiting time from completion of surgery to initiation of postoperative radiotherapy for breast cancer increased by 102.7%. Most of the increase in treatment delay was found in the interval between consultation and initiation of radiotherapy.

CONCLUSIONS

The Committee on Standards of the Canadian Association of Radiation Oncologists recommends that the interval between referral and consultation should not exceed 2 weeks and that the interval between consultation and initiation of radiotherapy should also not exceed 2 weeks. The majority of patients treated in Ontario met both those standards in 1982, but by 1991 few patients received care within the prescribed intervals.

The effects of different steroids on costal and epiphyseal cartilage of fetal and adult rats

The effects of different doses of various steroids on growth, and on costal and epiphyseal chondrocytes, have been studied in prenatal, immature, and adult Long-Evans rats using histochemical techniques, and both light and electron microscopy. Both prenatal and postnatal treatments have been employed. The steroids used were cortisone (CA), betamethasome (BM), and, in the prenatal group only, dexamethasone (DM). Body weight is reduced in all treated rats (except the low dose of CA) by day 17 of gestation, with greater weight reductions occurring in rats receiving the higher dose level of each steroid. In rats treated prenatally or neonatally, and sacrificed postnatally on days 39-43 or days 116-127, body weights, and tibial and tail lengths, are less than in correspondingly aged controls, thus showing a persistence of the effects of treatment. Costal and epiphyseal cartilages in prenatal rats show cellular, synthetic, and ultrastructural alterations induced by treatment with glucocorticoids but the responses are not necessarily comparable. Except for the low dose of DM, the higher doses of each steroid are more effective in inhibiting, or altering, growth and cellular differentiation in the developing fetuses. Surprisingly, a low dose of DM has a more devastating effect on the cells and extracellular matrix of both costal and epiphyseal cartilage, than do higher dose-levels of the various steroids. Low doses of CA and BM are also effective in inhibiting or altering growth and cellular differentiation, but their effectiveness is largely limited to 17 days of gestation. The order of effect of the various doses of the different steroids on fetal cartilage, listed in decreasing order of severity, is as follows: 0.12 DM, 0.24 DM, 0.42 BM, 50 CA, with 25 CA and 0.18 BM being approximately equal and only slightly different from control cartilages. The effect of prenatal or neonatal glucocorticoid treatment on chondrocytes is minimal in the 30-43 days, or 116-127 day, postnatal groups. In immature and adult rats, cortisone affects the chondrocytes more deleteriously than does betamethasone, and a 5.0 mg dose of CA seems to affect chondrocytes, body weight, and tibial and tail lengths more than 0.2 or 7.5 mg doses.

Ultrastructural evidence of pulmonary capillary endothelial damage from paraquat

Because of lack of agreement concerning the toxicity of paraquat to the pulmonary microvasculature, we have undertaken an electron microscopic study of lungs of paraquat-treated rats. Rats were injected with paraquat or sterile water (controls) intraperitoneally; the animals were then killed at 24-h intervals for 10 days post-injection. In the control animals, lung ultrastructure remained normal throughout the study. In treated animals, the initial evidence of alveolar epithelial injury occurred 24 h post-paraquat. By 48 h, severe fragmentation and desquamation of membranous pneumocytes occurred, and both alveolar and interstitial edema were present. Epithelial damage was maximal 72-96 h post-paraquat. Pulmonary capillary endothelial abnormalities were less extensive than the alveolar epithelial lesions. Endothelial damage was first observed 48 h post-paraquat. In endothelial cells on the septal (thick) side of the capillaries, the number of pinocytotic vesicles was significantly increased (P less than 0.05) from 48 to 96 h post-paraquat. In endothelium adjacent to damaged epithelium, abnormalities included hydration, fragmentation, discontinuity, and widened intercellular junctions; these were maximal 72-96 h post-paraquat. Although other mechanisms are probably important, damaged pulmonary capillary endothelium seems to be a factor favoring paraquat-induced pulmonary edema.