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Background: Cancer cachexia (CC) is highly prevalent and associated with significant morbidity and mortality, yet underrecognized. In 2011, an international cachexia consensus (ICC) proposed a definition, assessment framework, and stages for classification: cancer precachexia, cachexia, and refractory cachexia. The authors anticipated that a "more practical classification approach for clinical practice" would be required, which we interpreted as a bedside assessment based on clinical data. We investigated whether the ICC classification could be employed in routine dietetic practice without access to objective muscle mass measures., Methods: Data from 200 consecutive patients with solid tumors were collected as part of clinical practice by oncology dietitians in five tertiary referral hospitals. Dietitians used information gathered during their routine assessment and applied the ICC framework to assign a stage. When the dietitian was unable to assign a stage, the reason was noted., Results: Based on available data, classification was possible in 177 (88%); 23 (12%) could not be staged. The reasons cited were as follows: unknown C-reactive protein (n = 14), complex clinical situation (n = 5), unknown weight loss (n = 2), and acute illness (n = 2). Thirty (17%) of the 177 participants were judged to be noncachectic.  One hundred twelve (83%) met the criteria for 1 of the 3 ICC stages: 92 (52%) were cachectic; 35 (20%) precachectic, and 20 (11%) refractory., Conclusions: CC staging based on the ICC classification was feasible and practical in routine dietetic practice even without access to objective muscle mass measures. Once validated and operationalized, expert clinical assessment by a dietitian could be a cost-effective means to identify and stage CC, with more resource-intensive means used when there is clinical doubt., (© 2022 American Society for Parenteral and Enteral Nutrition.)

Purpose: To evaluate the MOVE exercise programme in supporting the recovery of young people affected by cancer., Methods: Participants in an 8-week exercise rehabilitation programme delivered online by cancer rehabilitation specialists completed self-reported questionnaires at baseline and after programme completion. Assessments included cancer-related fatigue (FACIT fatigue scale) and health-related quality of life (EORTC-QLC-30). Qualitative data were provided through written accounts of participant experiences and underwent content analysis., Results: Seventy-one participants commenced the exercise rehabilitation programme and 57 completed the programme and provided data for analysis (63% female; median age 22 years). Statistically significant improvements were observed in post-programme scores for all measured outcomes (cancer-related fatigue, quality of life, physical functioning, role functioning, emotional functioning). Content analysis of written experiences generated ten unique codes. The highest frequency codes were enjoyment (n = 34), motivation (n = 14) and fitness (n = 13)., Conclusions: These findings indicate feasibility of delivery, acceptability to patients and physical and psychological benefits of a personalised online exercise rehabilitation programme for young people living with and beyond cancer. Further research involving a control arm and long-term follow-up would be beneficial., Implications for Cancer Survivors: These results support the inclusion of a personalised exercise programme as part of cancer rehabilitation for young people living with and beyond cancer., (© 2023. The Author(s).)

Purpose: Dyspnea is frequently experienced in advanced cancer patients and is associated with poor prognosis and functional decline. This study used the Edmonton Symptom Assessment System (ESAS) to characterize the relationship between dyspnea and concurrent symptoms experienced by advanced cancer patients., Methods: A prospective database was collected and analyzed to extract patient demographics and ESAS scores. Logistic regression analysis and generalized estimating equations (GEE) identified correlations of other ESAS symptoms in three categories: severity of dyspnea (none, mild, moderate, severe), moderate/severe dyspnea (ESAS ≥ 4), and presence of dyspnea (ESAS ≥ 1), at patients' first visit and over time, respectively., Results: Multivariable analysis revealed drowsiness (p = 0.001), and anxiety (p = 0.01) and appetite loss (p = 0.02) were associated with increased severity of dyspnea at first visit. Over time, tiredness (p = 0.02), drowsiness (p = 0.04), nausea (p = 0.02), and anxiety (p = 0.0006) were more likely to experience increased dyspnea severity. Tiredness (p = 0.0003), depression (p = 0.03), and appetite loss (p = 0.003) were significant for moderate/severe dyspnea at first visit. Over multiple visits, tiredness (p < 0.0001), anxiety (p = 0.0008), and appetite loss (p = 0.0008) had higher probabilities of moderate/severe dyspnea. For the presence of dyspnea at the first visit, anxiety (p = 0.03) and drowsiness (p = 0.002) were significantly correlated with an increased frequency of dyspnea. Over time, anxiety (p < 0.0001) and drowsiness (p < 0.0001) remained significant with the addition of nausea (p = 0.0007)., Conclusions: The highly interactive relationship between dyspnea and other common cancer symptoms necessitates the development of comprehensive symptom assessments and utilization of multimodal management approaches that consider concurrent symptoms for improved identification and treatment of dyspnea.

Introduction: The Rapid Response Radiotherapy Program (RRRP) is an outpatient radiotherapy clinic for palliative cancer patients where consultation, planning, and radiation treatment can take place in 1 day, allowing for rapid access to care. The objective of this study was to compare the patient population and overall survival of patients seen in the RRRP from 2014 to 2017 to that of patients seen in 1999., Method: Patient characteristics including sex, primary cancer site, sites of metastases, and Karnofsky Performance Status (KPS) were recorded at each clinic visit. Date of death (DOD) was retrieved from the Patient Care System (PCS) and Excelicare. To show overall survival from the first clinic visit, a Kaplan-Meier overall survival curve was generated in all patients from 2014 to 2017., Results: Five hundred ninety-six patients were included in the final analysis. Most patients were male (n = 347) with a primary cancer site of the lung (n = 165) and metastases to the bone (n = 475). Actuarial median overall survival was 15.3 months. In 1999, 395 patients were analyzed, in which a primary of the lung (n = 143) and metastases to the bone (n = 277) were the most prevalent. An additional 72 patients in this population had brain metastases. The actuarial median survival of the 1999 population was 4.5 months., Conclusion: The changing patient population in the RRRP has resulted in visible changes in survival. This may reflect differences in the proportion of patients with specific primaries and sites of metastases, as well as improvements in the availability of palliative radiation over the last two decades.

Background: Clinician predicted survival (CPS) plays a crucial role in palliative care, informing physicians of appropriate treatment best suited to the patient. The primary objective of this study was to assess the accuracy of CPS of cancer patients referred for palliative radiotherapy. Secondary objectives included an analysis of factors predictive of accurate CPS, comparisons of the accuracy of survival predictions over subsequent clinic visits, and comparisons to the previous study in the Rapid Response Radiotherapy Program (RRRP) in 2005., Methods: CPS was provided by one of four radiation oncologists from August 2014 to March 2017. Karnofsky Performance Status (KPS), primary cancer site, and sites of metastases were recorded. Date of death was retrieved from the Patient Care System (PCS) and Excelicare. Mean difference between actual survival (AS) and CPS was used to determine the accuracy of survival predictions., Results: One-hundred seventy-two patients were included in the final analysis. Survival was largely overestimated (n=135, 78.5%), with CPS being overestimated by 19.0 weeks on average. KPS (P=0.2), primary cancer site (P=0.08), and various sites of metastases were not significantly related to CPS accuracy. Gender was significantly related to CPS accuracy after multivariable analysis (P=0.04), but was no longer significant after excluding prostate and breast cancer patients in multivariable analysis (P=0.2). The mean difference between AS and CPS did not significantly change over subsequent visits (P=0.5) and CPS accuracy decreased significantly compared to the previous RRRP study (P=0.04)., Conclusions: The survival estimates provided by radiation oncologists are inaccurately overestimated. Further research should aim to increase the accuracy of CPS in order to improve patient outcomes.

Purpose: Radiotherapy-induced nausea and vomiting is a common side effect of radiotherapy. It is well-established that nausea and vomiting have a negative impact on quality of life, but the relative influence of each of symptom is infrequently reported. This study aimed to compare the effects of nausea and vomiting on quality of life in cancer patients receiving palliative radiotherapy., Methods: The Functional Living Index-Emesis (FLIE) is a quality of life questionnaire developed in the chemotherapy-induced nausea and vomiting setting. The FLIE consists of 18 questions, half of which address nausea and half of which address vomiting. Three prospective studies on the efficacy of various anti-emetic medications conducted at our center used the FLIE to assess radiotherapy-induced nausea and vomiting at various time points during and after palliative radiotherapy. FLIE data from these three studies were combined for the present analysis. Univariate and multivariate analyses were conducted to assess the relationships between nausea and vomiting, time of FLIE completion, and patient-reported quality of life., Results: Nausea and vomiting scores both decreased patients' quality of life. Multivariate modeling showed that both symptoms significantly influenced patients' ability to enjoy meals. Nausea was also associated with increased hardship for the patient, while vomiting imposed more difficulty on the patients' loved ones., Conclusions: Nausea and vomiting both significantly influence quality of life. Nausea seems to impact the patient more directly, whereas vomiting affects those closest to the patient.

Background: Approved almost 15 years ago for use in the chemotherapy setting, palonosetron, a 2nd generation 5-hydroxtryptamine 3 receptor antagonist (5-HT3 RA), has demonstrated efficacy in preventing chemotherapy-induced nausea and vomiting. However, its utility in the prophylaxis and treatment of radiation-induced nausea and vomiting (RINV) has yet to be evaluated. In this pilot study, we investigated the rates of control in RINV in patients with pre-existing emesis., Methods: Patients with pre-existing emesis undergoing palliative radiotherapy to sites with emetic risk were prescribed palonosetron 0.5 mg before the start of radiation treatment, and every other day until completion of treatment. Patients were followed up in acute (day 1 of treatment to day 1 after treatment) and delayed phases (days 2-10 after treatment). Prophylaxis and rescue (PR) was defined as a decrease in anti-emetic use, or episodes of nausea and/or vomiting from baseline. Complete prophylaxis (CP) was defined as no increase in anti-emetic use, or episodes of nausea and/or vomiting. Secondary endpoints included control of nausea and quality of life (QOL), as assessed with the Functional Living Index-Emesis and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 15 Palliative., Results: Fourteen patients were enrolled. Rates of control were higher in the acute phase (n=14) for nausea (PR =42.9%, CP =42.9%) and vomiting (PR =21.4%, CP =71.4%) compared to the delayed phase (n=13) for nausea (PR =42.9%, CP =7.7%) and vomiting (PR =15.4%, CP =53.8%)., Conclusions: Palonosetron appears to be safe and patients with pre-existing emesis receiving palliative radiotherapy. More studies are needed to investigate its efficacy in this patient population.

Background: Palonosetron is an effective antiemetic in chemotherapy-induced nausea and vomiting (CINV), but has yet to be studied in the radiation setting. The purpose of the present study was to investigate the efficacy and safety of palonosetron in the prophylaxis of radiation-induced nausea and vomiting (RINV)., Methods: Patients without existing nausea and vomiting undergoing palliative radiotherapy to sites with emetic risk were prescribed palonosetron 0.5 mg orally before the start of radiation treatment, and every other day until completion of treatment. Patients were followed up in acute (day 1 of treatment to day 1 after treatment) and delayed phases (days 2-10 after treatment). The primary endpoint was control of vomiting. Complete control was defined as no use of rescue medication and no episodes of nausea or vomiting. Secondary endpoints included control of nausea and quality of life (QOL). QOL was assessed with the Functional Living Index-Emesis and the European Organisation for Research and Treatment of Cancer QOL Questionnaire-Core 15 Palliative (C15-PAL)., Results: In all evaluable patients (n=75), complete control of vomiting was 93.3% in the acute phase and 93.2% in the delayed phase. Complete control of nausea was 74.7% in the acute phase and 74.0% in the delayed phase., Conclusions: Results suggest improved control in RINV compared to historical reports with first generation serotonin receptor antagonists (RA). A randomized study will be needed to confirm this finding.

Purpose: Dyspnea is a debilitating symptom commonly experienced by advanced cancer patients that can lead to negative effects on function and quality of life (QOL). The present study aims to determine the relationship between dyspnea and other Edmonton Symptom Assessment System (ESAS) symptoms in palliative cancer patients referred to a radiotherapy clinic., Methods: The presence and severity of dyspnea was measured using the ESAS. All patients that visited a palliative radiotherapy clinic between 1999 to 2002 and 2006 to 2009 and completed the ESAS were included. ESAS scores and other demographic and clinical information were extracted from a prospectively collected database. Statistical tests including chi-squared tests, Spearman correlations, and multivariate analysis were conducted to explore the relationship between dyspnea, other ESAS items, and other demographic factors. Kaplan-Meier overall survival curves were generated based on dyspnea severity., Results: One thousand three hundred forty-four patients were included in the dyspnea analysis; reported moderate or severe dyspnea. Dyspnea severity was significantly associated with eight other ESAS interference severities (p < 0.001). Upon multivariate analysis, greater severity of dyspnea was significantly related to higher ESAS scores for tiredness, nausea, depression, anxious, drowsiness, and poor appetite (p < 0.05). The actuarial median survival time was 6.57 months (95% CI 5.91-7.29 months). There were highly significant differences in overall survival between those with none, mild, and moderate dyspnea (p < 0.0001)., Conclusion: Cancer patients often experience dyspnea along with a multitude of other symptoms. Moderate and severe dyspnea should be assessed and optimally managed to reduce functional and QOL debilitations. As presence of increased dyspnea severity is associated with worse overall survival, interventions should occur at the end of life to reduce symptom burden in palliative patients.

Circadian rhythm-dependent cell cycle progression produces daily variations in radiosensitivity. This literature review aims to summarise the data on whether radiotherapy outcomes differ depending on administration time. A literature search was conducted on Ovid Medline, Embase, Cochrane Central Register of Controlled Trials and PubMed using key words such as 'radiotherapy', 'circadian rhythm', 'treatment outcome' and 'survival'. Articles evaluating the correlation between radiotherapy time and outcomes in cancer patients were included and relevant information was extracted. Nine studies met the inclusion criteria. Four investigated lung cancer patients undergoing stereotactic radiosurgery for brain metastases, with one study observing improved local control and survival in patients treated in the morning. Another two studies with breast and cervical cancer patients observed that the prevalence of toxicities was higher in afternoon and morning cohorts, respectively. Two studies in head and neck cancer patients found trends indicating morning patients experienced less oral mucositis. Increased toxicities and biochemical failure rates were associated with evening treatment in prostate cancer patients. As inconsistencies in the literature exist regarding the time dependency of radiotherapy outcomes, further investigation is warranted., (Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: Quality of life (QOL) is important for advanced cancer patients. Brief questionnaires are advantageous to reduce patient burden. In large clinical trials, statistically significant small changes can be achieved; however, whether such change is clinically relevant is unknown. The purpose of this study was to determine the minimal important differences (MID) of the European Organisation for Research and Treatment of Cancer quality of life core 15 palliative questionnaire (EORTC QLQ-C15-PAL)., Methods: Patients undergoing palliative radiotherapy completed the EORTC QLQ-C15-PAL at baseline and 1 month later. Anchor and distribution-based assessments were employed to determine the MID associated with this instrument. The anchor of overall QOL was used to determine meaningful change., Results: In all, 276 patients were included in MID calculation. Mean age was 65 years and primary lung, breast or prostate cancers were most common. Statistically significant MID for improvement was seen in emotional functioning and pain (20.9 and 15.6, respectively). MID for deterioration required a 20.4, 24.5, 17.1 and 23.0 change in physical functioning, fatigue, pain and appetite loss, respectively, to constitute meaningful change. Distribution-based estimates of MID were closest to the standard error of measurement. MID for brain and bone metastases patients yielded MID larger than previously determined in the incorporation of all patients., Conclusion: Meaningful change in the EORTC QLQ-C15-PAL is important for clinicians to determine the impact of treatment on the QOL of patients and can aid in determining the sample size required for clinical trials. Future studies should investigate MID in subgroups using symptom-specific modules., (© 2013 Wiley Publishing Asia Pty Ltd.)

In 1996, the Toronto Sunnybrook Regional Cancer Centre developed the Rapid Response Radiotherapy Program (RRRP). The objective of this clinic is to consult, simulate, plan, and treat patients with palliative radiotherapy on the same day. In 2004, the RRRP initiated a program to provide clinical and research experience to undergraduate students interested in health sciences. The purpose of this study is to review the 10-year (2004-2013) experience of the RRRP and to examine whether the goals of the student program have been met. Students who worked in the RRRP from 2004 to 2013 were contacted to complete a short survey regarding their overall experience with the program and their current endeavors. Student accomplishments were collected from an internal database as well as PubMed. Descriptive statistics were used to analyze results. A total of 54 students from ten postsecondary institutions have worked in the RRRP; 29 were from the University of Waterloo undergraduate co-op program. In total, 214 articles with first authorship from students were published, 93 (43%) of which can be found on PubMed. Other accomplishments include 40 book chapters, 58 invited presentations, and 99 awards cumulatively. Qualitative data regarding student perspectives of their experience in the RRRP were also analyzed. Over the past 10 years, the RRRP has achieved its goal of providing quality medical and research experience to students interested in the health sciences. Using the responses of past and present students, we hope to continue to shape our program and provide unique opportunities to future students.

Aims: Quality of life (QOL) is important in patients with advanced cancer. The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 is a general QOL tool used in cancer patients. Often, with a large enough sample, statistical significance of changecan be reached, however the clinical significance is often unknown. This study aimed to determine the magnitude of change that is meaningful to advanced cancer patients in the EORTC QLQ-C30., Methods: Patients completed the EORTC QLQ-C30 at baseline and 1 month post-radiation to assess changes in their QOL. Minimal important differences (MID) were calculated through anchor and distribution-based methods for improvement and deterioration. The two anchors of overall health and overall QOL were used to determine meaningful change., Results: Statistically significant meaningful changes were seen in the use of both anchors. The overall health anchor produced a greater number of scales and symptoms that reached a statistically significant meaningful change. Meaningful change for improvement with these two anchors ranged from 9.1 units (cognitive functioning) to 23.5 units (pain), and for deterioration it ranged from 7.2 units (physical functioning) to 13.5 units (role functioning). Distribution-based estimates were closest to 0.5 SD., Conclusion: Knowledge of meaningful change on the EORTC QLQ-C30 allows physicians to assess patients' changes over time, along with evaluating the impact of treatment on a patient's QOL. This knowledge gives insight into whether the treatment is effective and, ultimately, whether it should be continued. Knowledge of MID may assist in the determination of sample size for future trials., (© 2013 Wiley Publishing Asia Pty Ltd.)

Context: Longitudinal symptom monitoring is important in the setting of patients with advanced cancer. Scores over time may naturally fluctuate, although a patient may feel the same., Objectives: The purpose of this study was to determine the minimal levels of change required to be clinically relevant (minimal clinically important difference [MCID]) using the Edmonton Symptom Assessment System (ESAS)., Methods: Between 1999 and 2009, patients completed the ESAS before palliative radiotherapy and at follow-up. MCIDs were calculated using both the anchor- and distribution-based methods for improvement and deterioration; 95% confidence intervals for the differences in mean change scores between adjacent categories also were calculated., Results: A total of 276 patients completed the ESAS at baseline and during at least one follow-up visit. At the four-week follow-up, decrease of 1.2 and 1.1 units in pain and depression scales, respectively, constituted clinically relevant improvement, whereas increase of at least 1.4, 1.8, 1.1, 1.1, and 1.4 units, respectively, in pain, tiredness, depression, anxiety, and appetite loss items were required for deterioration. At the subsequent follow-ups, these values were similar. Overall, the MCID for improvement tended to be smaller than that for deterioration. The distribution-based method estimates tended to be larger than the 0.3 SD estimates, but closer to the 0.5 SD estimates., Conclusion: MCIDs allow health care professionals to determine the success of treatment in improving the patient's quality of life. MCIDs may prompt health care professionals to intervene with new treatment. Future studies should confirm our findings with a variety of anchors., (Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Objective: Shortened quality-of-life (QOL) tools are advantageous in palliative care patients. Development of such tools begins with the identification of issues relevant to a population. The purpose of this study was to identify the most important items of the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) to create an abbreviated questionnaire for future palliative care trials., Methods: A convenience sample of patients and health care professionals (HCPs) assessed the relevance of each item of the FACIT-Pal and whether they would include the item in a final questionnaire. Patients and HCPs identified their top 10 most important issues and were asked whether items were inappropriate, upsetting, or irrelevant; a shortened questionnaire was generated from this input., Results: Sixty patients and 56 HCPs participated. The median score in the Karnofsky Performance Scale (KPS) of patients was 70, and the majority of HCPs were radiation oncologists. The 46-item questionnaire was shortened to 14 questions, retaining several items from the Functional Assessment of Cancer Therapy-General (FACT-G) as well as issues pertaining specifically to palliative care patients. Items within the emotional, physical, and functional well-being subscales were retained along with those for various symptoms including constipation, nausea, dyspnea, and sleep. No new content beyond what is covered by the FACIT-Pal was identified consistently by either HCPs or patients. Similarly, no item was consistently rated as being inappropriate, upsetting, or irrelevant in the 14-item questionnaire., Conclusion: The FACIT-Pal-14, a shortened 14-item questionnaire has been generated for the palliative care population. Future studies should complete psychometric validation of this instrument for the assessment of QOL in palliative care patients.

Background: Advanced cancer patients often experience multiple concurrent symptoms, which can have prognostic effects on patients' quality of life. Including patients who did not experience all of the symptoms measured by an assessment tool may interfere with accurate symptom cluster identification. Varying statistical methods may also contribute to inconsistencies of cluster results., Aims: To compare symptom clusters in a subgroup of patients reporting exclusively non-zero ESAS scores with those in the total patient sample. To examine whether using different statistical methods results in varied symptom clusters., Design: Principal Component Analysis (PCA), Hierarchical Cluster Analysis (HCA) and Exploratory Factor Analysis (EFA) were performed on the 'non-zero' subgroup and the total patient sample to identify symptom clusters at baseline and weeks 1, 2, 4, 8 and 12 following palliative radiotherapy., Setting/participants: A previous single-centre study used Principal Component Analysis to explore symptom clusters in 1296 advanced cancer patients. The present study analyzed this previously reported data set., Results: Notably different symptom clusters were extracted between the two patient groups regardless of the statistical method at baseline, with the exception of a cluster composed of drowsiness, fatigue and dyspnea using Principal Component Analysis and Hierarchical Cluster Analysis. At follow-ups, different statistical methods yielded significantly varied symptom clusters. Only anxiety, depression and well-being consistently occurred in the same cluster across methods and over time., Conclusions: The composition of symptom clusters varied depending on if patients with non-zero scores were excluded at baseline and on the statistical method employed. Identifying valid clusters may prove useful for bettering symptom diagnosis and management for cancer patients.

Context: The clinical relevance of symptom cluster research remains questionable if inconsistencies, partially attributable to the varying statistical analyses used, exist., Objectives: To investigate whether symptom clusters identified were consistent using three different statistical methods and to observe the temporal pattern of clusters. A secondary objective was to compare symptom clustering in responders and nonresponders to radiotherapy over time., Methods: Reanalysis of an existing data set compiled from 1296 patients with advanced cancer was performed using hierarchical cluster analysis (HCA) and exploratory factor analysis (EFA) to extract symptom clusters at baseline, 1-, 2-, 4-, 8-, and 12-week follow-up time points. Findings were compared with results obtained using principal component analysis (PCA) in our previously published study. The original sample was further divided into two subgroups: responders and nonresponders. The symptom clusters present in each subgroup were examined using PCA, HCA, and EFA at the same time points as mentioned above., Results: The symptom cluster findings of HCA and PCA correlated more frequently with each other than either did with the results of EFA. Complete consensus in all three statistical methods was never reached at any assessment time point in the present study. Increasingly diverging patterns of symptom cluster development over time were observed in the responder vs. nonresponder subgroups. Symptom pairs comprising anxiety and depression or fatigue and drowsiness consistently presented in the same cluster despite the shifting of other symptoms in the cluster over time., Conclusion: The presence and composition of symptom clusters identified varied depending on which statistical analysis method was used. A key step in achieving consistency in symptom cluster research involves the utilization of a common analytical method., (Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Introduction: Advanced cancer patients present with a variety of physical and psychological symptoms. Fatigue is one such symptom which reduces overall quality of life and is difficult to manage. The purpose of this study was to report the presence, severity, and correlating factors of fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic., Materials/methods: Patients referred to the Rapid Response Radiotherapy Program between January 1999 and October 2009 completed the Edmonton Symptom Assessment System (ESAS) prior to consultation. Demographic information including age, Karnofsky Performance Status (KPS), gender, and primary cancer sites were collected. Ordinal logistic regression analysis was conducted to determine relationships between demographic information, other ESAS items, and levels of fatigue. Multivariate ordinal logistic regression analysis was used to determine the most significant predictors of fatigue. A p value of <0.05 was considered statistically significant., Results: A total of 1,397 patients completed the ESAS prior to consultation. Median age was 68 years (range, 21-95), median KPS was 60 (range, 10-100), and slightly more males completed the ESAS (53.0%). Common primary cancers were of the lung (35.8%), breast (20.7%), and prostate (17.7%). Only 179 (12.8%) patients reported no fatigue; the majority of patients reported moderate (31.8%) or severe (34.4%) fatigue. A low KPS (p < 0.0001), being female (p = 0.0056), or being referred for bone metastases (p = 0.0185) significantly correlated with higher levels of fatigue. Patients with a genitourinary primary cancer (p = 0.0078) and/or referred for malignant spinal cord compression (p = 0.0004) reported less fatigue. All other ESAS items were significantly related to fatigue. The most significant predictors of fatigue were pain (p < 0.0001, odds ratio (OR) = 1.07), nausea (p = 0.0010, OR = 1.10), depression (p < 0.0001, OR = 1.10), drowsiness (p < 0.0001, OR = 1.33), dyspnea (p = 0.0003, OR = 1.08), and overall well-being (p < 0.0001, OR = 1.19)., Conclusion: Moderate fatigue was reported in over 66% of our advanced cancer patients prior to radiotherapy. Since radiotherapy inherently causes fatigue, proactive and multidisciplinary management is required for these patients. Similar rates of fatigue severity, in lengthier, fatigue-specific tools, suggest that the ESAS may be a good tool for screening the advanced cancer population.

Aims: To assess patients' understanding of their illness and expectations of palliative radiotherapy for symptomatic metastases before and after consultation and to explore the relationship between response and demographics/Edmonton Symptom Assessment Scale (ESAS) scores., Materials and Methods: In total, 100 participants completed a survey before and after consultation from March to October 2009. Descriptive statistics and statistical analyses were conducted to compare responses and to determine any relationship between responses and demographics or ESAS variables., Results: Up to 25% believed their cancer was curable; there was no change in belief that radiotherapy would cure their cancer (17% before and 15% after) or prolong their life (40% before and 45% after). There were significant differences in radiotherapy expectation for symptom relief (P=0.0094) and for patients who did not know the role of radiotherapy (P=0.0025). Patient anxiety was reduced after consultation on questions about radiotherapy (P<0.001), concerns on effectiveness (P<0.0001) and side-effects of treatment (P<0.0001); 96, 24 and 46% said after consultation that they were satisfied with information from the team, better understood their diagnosis of cancer and the role of radiotherapy, respectively., Conclusion: A significant proportion of patients with advanced disease believe their cancer is curable, expect that radiotherapy will cure their cancer and prolong their life despite understanding the intent of radiotherapy is for symptom relief. After consultation, patients say they have a better understanding of their cancer and feel more confident about treatment. More work is needed to improve patients' understanding of their illness and expectations of the role of palliative radiotherapy., (Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Purpose: The primary objective of this study was to compare the symptom severity in two different patient populations assessed in an outpatient palliative radiotherapy clinic over two time periods spanning 10 years. The secondary objective was to assess any changes in the baseline demographics of these patients., Methods: Data were collected from 1999 to 2009. Upon initial presentation to the clinic, the Edmonton Symptom Assessment Scale (ESAS) was administered to patients to capture symptom severity. This validated assessment tool asks patients to score their level of pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, well-being, and dyspnea on an 11-point Likert scale. Differences between the two patient groups were assessed using chi-squared analysis and Wilcoxon rank-sum tests. A p value of <0.05 was considered significant., Results: A total of 1,439 patients completed the ESAS from 1999 to 2009. Patients were divided into two time periods 1999-2002 (n = 689) and 2006-2009 (n = 750). Pain, depression, nausea, fatigue, anxiety, drowsiness, and dyspnea were significantly better in 2006-2009 (p < 0.0001). Loss of appetite was not statistically different between the two time periods (p = 0.236). Significantly more patients with genitourinary cancers (p = 0.03) or a referral for a mass (p < 0.0001) were seen in 2006-2009. More patients with breast cancer (p = 0.04) and bone pain (p = 0.0002) were seen in 1999-2002. The median age was significantly higher (70 years vs. 68 years, p = 0.03) for patients seen in 2006-2009. No significant differences were seen in performance status or gender between the two groups., Conclusion: There have been statistically significant lower scores in the severity of the majority of symptoms as scored by the latter patient cohort; however, whether this difference in magnitude is clinically significant is debatable. The reason for referral and demographics in patients sent for palliative radiotherapy has changed over a 10-year period. This may be a reflection of the changes in systemic therapies and improvements in supportive care for patients with advanced cancer.

Background: Few studies incorporate patient self-assessment scales in prognostic models of survival prediction. The Edmonton Symptom Assessment Scale (ESAS) is commonly used as a symptom screening tool in cancer patients., Objective: The goal of this study was to evaluate the prognostic value of the ESAS for survival prediction in the advanced cancer population., Materials and Methods: Patients completed the ESAS and demographic information prior to palliative radiotherapy consultation and at follow-up at the Odette Cancer Centre between 1999 and 2009. Generalized estimating equation (GEE) methodology was applied to analyze ESAS trends within the last months of life. One-way analysis of variance (ANOVA) with repeated measurements was used to characterize trends between time periods., Results: ESAS records (2377) from 808 patients (433 male and 375 female) were included in this cohort. Median age was 68 years (range 32-95) with median Karnofsky performance status (KPS) of 60 (range 10-100). Primary cancer sites were of the lung (36%), breast (20%), and prostate (19%). All nine ESAS symptoms significantly deteriorated in the last 4 weeks immediately before death when compared with those scores in the preceding months. At one week prior to death, the worst ESAS symptoms experienced by patients were fatigue, appetite, and well-being with mean scores of 7.4, 6.9, and 6.1, respectively., Conclusions: All ESAS scores significantly worsened in the last 4 weeks prior to death compared with those in the previous months. Sudden deterioration of the global ESAS symptoms may predict impending death. Future studies on a prognostic model should incorporate both ESAS symptom severity and trends.

In-field cancer recurrence after previous adjuvant or radical radiotherapy presents particularly challenging clinical issues to the oncologists. A Canadian pattern of practice survey showed a wide range of approaches in treatment intent, planning and dose fractionation. A workshop on re-irradiation was conducted at the 2009 Canadian Association of Radiation Oncology annual scientific meeting, under the guidance of the Symptom Control Committee, in an effort to promote a uniform approach among radiation oncologists in their approach to re-irradiation. The workshop has made various recommendations in an effort to bring consistency among radiation oncologists across Canada to their approach towards re-irradiation., (Copyright © 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Context: The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization's "analgesic ladder" approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain., Objectives: The aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI., Methods: All patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, "weak" opioids, and "strong" opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearson's r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors., Results: One thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P<0.0001). Higher Karnofsky Performance Status (P<0.0001) and breast primary cancer site (P<0.0001) were significantly associated with negative PMI after adjusting for year variable., Conclusion: Despite publication of numerous cancer pain management guidelines, undermedication appears to be a persistent problem for patients with painful bone metastases referred for radiotherapy., (Crown Copyright 2010. Published by Elsevier Inc. All rights reserved.)

Purpose: To update the clinical activity of the Rapid Response Radiotherapy Program (RRRP)., Materials and Methods: We conducted a retrospective review of our clinic database from January 2004 until July 2008. The number of patients referred to the RRRP, relevant demographic data, diagnosis and treatment dispositions were recorded. Time interval between referral to consultation and consultation to simulation were also calculated., Results: During the study period, 3,267 patients were seen in the RRRP. Forty-five percent (1,494) of the patients were new to the clinic. Of the 3,267 patients seen, 1,548 (47.4%) were female and 1,719 (52.6%) were male. The median age was 69.2 years (range, 22-101 years). The most common primary sites were lung (34.2%), breast (21.2%) and prostate (17.0%). The majority of patients were referred for palliative treatment of bone metastases (52.4%) or treatment for brain metastases (20.7%). Of the patients referred, 2,311 (70.5%) patients received palliative radiotherapy. The median duration from referral to consultation was 4 days. The majority (82.3%) of patients were simulated and treated within the first 7 days following consultation., Conclusion: The number of patients referred to the RRRP from January 2004-July 2008 remains comparable to our previous report (1996-2003). The overall median interval from referral to consultation for the analysed time period was 4 days. Therefore, we are continuing to meet our goal of providing rapid access to palliative radiation treatment for symptomatic cancer patients. Further information relating to progression and advancements within the clinic aimed at improving our patients' quality of life are explored.

This paper traces the history of the specialist meanings of 'cure' in paediatric oncology in the UK, how they have changed with increasing organization of the discipline, ever-rising survival rates for all childhood cancers, and with feedback from patients and families. It examines the differing ways in which those involved in researching, treating, and raising funds for work on childhood cancers have understood and used the language of cure, and speculates as to why talking about the 'cure' of survivors of childhood cancers is so problematic. The paper discusses the particular importance of holistic care in the development of paediatric oncology. Psychosocial support is delivered alongside surgery, radiotherapy and chemotherapy. The focus for support is the patient's whole family, building a tenet of palliative care into curative treatment. The concept of the 'truly cured child' is argued to have been crucial in the discipline's decision in the 1970s and 1980s to make the psychosocial needs of patients and their families central in the programme of curing children with cancer.

Fatigue is the most common symptom in patients with advanced cancer. It is a subjective sensation with physical, cognitive, and affective modes of expression. The etiology is often unclear, and multiple potential etiologic factors for fatigue may coexist. Assessing fatigue involves characterizing its severity, temporal features, exacerbating and relieving factors, associated distress, and impact on daily life. Potential factors contributing to fatigue are the cancer itself, cancer treatment, cancer or treatment complications, medications, and other physical and psychosocial conditions. Many fatigue assessment tools exist. Fatigue management involves specific (targeting potentially reversible causes of fatigue) and symptomatic (targeting symptoms because no obvious etiology or reversible cause for fatigue can be identified) intervention and treatment measures. Specific interventions include treating anemia or metabolic and endocrine abnormalities, as well as managing pain, insomnia, depression, and anxiety. Symptomatic treatment involves education, counseling, and pharmacologic, and nonpharmacologic measures. Pharmacologic agents that have been investigated for use in treating fatigue include corticosteroids, progestational agents, and psychostimulants. Agents that modulate cytokine activity are future treatment possibilities.

Purpose: The purpose of this study was to assess the satisfaction and information needs of primary care physicians (PCPs) regarding communication with radiation oncologists (ROs), with respect to patients who receive palliative radiotherapy (RT). A selected objective was to evaluate the agreement between PCPs' expectations and the content of the RO letter sent after completion of RT. PCPs' knowledge of the role of palliative RT and their awareness of available patient support services were also determined., Methods: The PCPs of patients discharged from the Cross Cancer Institute after receiving palliative RT were surveyed using a mail-out questionnaire. Questions regarding communication, RT knowledge, and awareness of support services were asked. The corresponding RO letter was reviewed., Results: A total of 148 PCPs were identified and were mailed questionnaires, with 114 (77%) responding. Overall, 80% (87 of 109) of PCPs found the RO letter to be useful in patient management. However, there was poor (< 53%) agreement between PCPs' expectations and the actual content of the RO letter. Knowledge of the indications and effectiveness of palliative RT was limited, with PCPs obtaining a median score of 4 of a possible 8. Only 27% (31 of 114) of PCPs were aware of all five of the patient support services listed., Conclusion: Results show that although the majority of PCPs found the RO letter useful, they believed that the letter lacked important information while containing unnecessary details. Communication between PCPs and ROs needs improvement, especially considering that PCPs seem to have limited knowledge of palliative RT.

This study describes a survey of attitudes toward cancer held by faculty and house staff physicians in a major teaching hospital. The instrument was designed to measure the two groups' (a) responses to declaratory statements about cancer and cancer patient management, (b) anticipated reactions to situations involving cancer, and (c) perceptions of each other relative to cancer-oriented issues. Data obtained from this project indicated significant differences between the perceptions of faculty and house staff members as to their counterpart's approach to cancer. In addition, the study has specific implications for increased attention toward attitudes and interpersonal communication as factors for improved cancer education in medical schools.

Background Durvalumab monotherapy has demonstrated promising objective tumour response (OTR) and safety in advanced endometrial cancer with deficient MMR. We report here updated OTR, progression-free survival (PFS) and overall survival (OS) results based on central pathology MMR review from the PHAEDRA trial. Methods Participants (pts) had MMR-proficient (pMMR) or -deficient (dMMR) AEC progressing after 0-3 lines of chemotherapy and were treated with durvalumab 1500mg IV Q4W. The primary endpoint was OTR (complete response [CR] or partial response [PR] by iRECIST). Secondary endpoints included PFS, OS, OTR by RECIST 1.1, adverse events, quality of life, and tertiary translational objectives to determine associations between molecular biomarkers and OTR. Results 71 pts with AEC were recruited from Feb 2017 to Sep 2018: 36 dMMR and 35 pMMR based on central MMR review. Median follow-up for OS were 16 vs 21 months in dMMR vs pMMR pts. Median age: 67 (range 36-81); ECOG PS: 0-1 in 96%, and 2 in 4%. Pathology: endometrioid in 94% and 57%; serous in 0% and 31%; grade 3 (most recent histology): 41% and 85% (dMMR and pMMR respectively). Durvalumab was the 1st, 2nd and subsequent line of non-hormonal therapy in 58%, 39%, and 3% pts with dMMR and 9%, 63%, and 29% pts with pMMR. Among dMMR pts, the OTR rate was 47% (17/36, 95% CI 32-63%): 6 CR, 11 PR and 6 stable disease (SD). OTR rate was 57% as 1st line and 38% as 2nd line. Among pMMR pts, the OTR rate was 3% (1/35, 95% CI 1-15%): 1 PR and 10 SD. Median PFS was 5.5 vs 1.8 months in dMMR vs pMMR pts. 12-month OS was 71% vs 51% in dMMR vs pMMR, with median OS not reached for dMMR vs 11.5 months for pMMR participants. Conclusions Durvalumab monotherapy showed promising activity and safety in AEC with dMMR regardless of prior lines of chemotherapy, but there was limited evidence of activity in AEC with pMMR. Clinical trial identification ACTRN12617000106336. Legal entity responsible for the study University of Sydney. Funding AstraZeneca. Disclosure Y. Antill: Honoraria (self), Research grant / Funding (institution), Travel / Accommodation / Expenses: AstraZeneca; Travel / Accommodation / Expenses: Amgen. M.R. Stockler: Research grant / Funding (institution): As. D. Smith: Honoraria (self): Merck Sharp & Dohme; Shareholder / Stockholder / Stock options: SNP pathology. M.L. Friedlander: Honoraria (self), Advisory / Consultancy: AstraZeneca; Honoraria (self), Advisory / Consultancy: Lilly; Honoraria (self), Advisory / Consultancy: MSD; Honoraria (self), Advisory / Consultancy: Takeda. P.J. Beale: Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Roche. T. Meniawy: Research grant / Funding (self): AstraZeneca. [ABSTRACT FROM AUTHOR]