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Malnutrition, muscle loss, and cachexia are prevalent in cancer and remain key challenges in oncology today. These conditions are frequently underrecognized and undertreated and have devastating consequences for patients. Early nutrition screening/assessment and intervention are associated with improved patient outcomes. As a multifaceted disease, cancer requires multimodal care that integrates supportive interventions, specifically nutrition and exercise, to improve nutrient intake, muscle mass, physical functioning, quality of life, and treatment outcomes. An integrated team of healthcare providers that incorporates societies’ recommendations into clinical practice can help achieve the best possible outcomes. A multidisciplinary panel of experts in oncology, nutrition, exercise, and medicine participated in a 2-day virtual roundtable in October 2020 to discuss gaps and opportunities in oncology nutrition, alone and in combination with exercise, relative to current evidence and international societies’ recommendations. The panel recommended five principles to optimize clinical oncology practice: (1) position oncology nutrition at the center of multidisciplinary care; (2) partner with colleagues and administrators to integrate a nutrition care process into the multidisciplinary cancer care approach; (3) screen all patients for malnutrition risk at diagnosis and regularly throughout treatment; (4) combine exercise and nutrition interventions before (e.g., prehabilitation), during, and after treatment as oncology standard of care to optimize nutrition status and muscle mass; and (5) incorporate a patient-centered approach into multidisciplinary care.

The chapter focuses on the assessment and management of the multidimensional components, while discussing the role of exercise and its impact on the physical, emotional, and psychosocial state of patients with cancer-related fatigue (CRF). It also reviews the mechanism and pathophysiology of CRF and describes the various assessment tools used in clinical practice to measure fatigue. It describes the role of counselling, education and psychosocial and other integrative interventions like mindfulness-based stress reduction (MBSR) in the management of CRF. It reviews the treatment modalities that include selecting the appropriate pharmacological psycho-stimulants and nutraceutical interventions, based on the evidence behind their use. The chapter also reviews the types of physical exercise and safety profile, lists exercise prescription, and provides the results of meta-analyses, while enlisting the future directions for a better understanding of CRF.

The lack of timely symptom reporting remains a barrier to effective symptom management and comfort for patients with cancer-related palliative care needs. Poor symptom management at home can lead to unwanted outcomes, such as emergency department visits and death in hospital. We developed and evaluated RELIEF, a remote symptom self-reporting app for community patients with palliative care needs. A pilot feasibility study was conducted at a large, community hospital in Ontario, Canada. Patients self-reported their symptoms each morning using validated clinical symptom measures and RELIEF would alert for worsening or severe symptoms. RELIEF alerts were monitored by palliative care nurses who would then contact patients to determine if appropriate clinical intervention could be initiated to avoid unnecessary emergency department visits. A total of 20 patients were recruited to use RELIEF for two months. Patients completed 80% of daily self-report assessments, 133 alerts were trigged, half of which required clinical intervention. No patient visited the emergency department for symptom management during the study. Clinical staff estimated five emergency department visits were avoided because of RELIEF—saving an estimated cost of over CAD 60,000. RELIEF is a feasible and acceptable method for the remote monitoring of patients with palliative care needs through regular symptom self-reporting.

Initial investigation of the impact of a Cancer Survivorship Clinic following its introduction in February 2017. A systematic chart review of 176 patients enrolled in the Cancer Survivorship Clinic (CSC) who completed a minimum of one follow-up visit after the initial baseline visit. This was assessed using three screening tools: distress thermometer (DT), Canadian Problem Checklist (CPC), and Edmonton Symptom Assessment Scale (ESAS). Descriptive statistics and t tests were utilized to assess the impact of the CSC. Distress thermometer: Statistically significant decline in scores from the baseline visit to the follow-up visit among the study population (p

International audience; Background: Cancer-associated weight loss (WL) associates with increased mortality. International consensus suggests that WL is driven by a variable combination of reduced food intake and/or altered metabolism, the latter often represented by the inflammatory biomarker C-reactive protein (CRP). We aggregated data from Canadian and European research studies to evaluate the associations of reduced food intake and CRP with cancer-associated WL (primary endpoint) and overall survival (OS, secondary endpoint).Methods: The data set included a total of 12,253 patients at risk for cancer-associated WL. Patient-reported WL history (% in 6 months) and food intake (normal, moderately, or severely reduced) were measured in all patients; CRP (mg/L) and OS were measured in N = 4960 and N = 9952 patients, respectively. All measures were from a baseline assessment. Clinical variables potentially associated with WL and overall survival (OS) including age, sex, cancer diagnosis, disease stage, and performance status were evaluated using multinomial logistic regression MLR and Cox proportional hazards models, respectively.Results: Patients had a mean weight change of -7.3% (±7.1), which was categorized as: ±2.4% (stable weight; 30.4%), 2.5-5.9% (19.7%), 6.0-10.0% (23.2%), 11.0-14.9% (12.0%), ≥15.0% (14.6%). Normal food intake, moderately, and severely reduced food intake occurred in 37.9%, 42.8%, and 19.4%, respectively. In MLR, severe WL (≥15%) (vs. stable weight) was more likely (P < 0.0001) if food intake was moderately [OR 6.28, 95% confidence interval (CI 5.28-7.47)] or severely reduced [OR 18.98 (95% CI 15.30-23.56)]. In subset analysis, adjusted for food intake, CRP was independently associated (P < 0.0001) with ≥15% WL [CRP 10-100 mg/L: OR 2.00, (95% CI 1.58-2.53)] and [CRP > 100 mg/L: OR 2.30 (95% CI 1.62-3.26)]. Diagnosis, stage, and performance status, but not age or sex, were significantly associated with WL. Median OS was 9.9 months (95% CI 9.5-10.3), with median follow-up of 39.7 months (95% CI 38.8-40.6). Moderately and severely reduced food intake and CRP independently predicted OS (P < 0.0001).Conclusions: Modelling WL as the dependent variable is an approach that can help to identify clinical features and biomarkers associated with WL. Here, we identify criterion values for food intake impairment and CRP that may improve the diagnosis and classification of cancer-associated cachexia.

Background The COVID-19 pandemic has resulted in drastic changes in the global healthcare delivery landscape and has had practical repercussions for cancer survivors. This systematic rapid living review has been undertaken to synthesise the available knowledge regarding the impact of the COVID-19 pandemic in a timely manner. This initial rapid review will present the findings of literature published up to August 27, 2020. Design A systematic search of PubMed, Scopus and Google Scholar databases was conducted to identify all articles, available in English language, regarding the impact of the COVID-19 pandemic on cancer survivors published between December 2019 and August 27, 2020. The search strategy employed the following search strings: “covid-19 OR coronavirus OR sars-cov-2” with “cancer survivors OR cancer survivorship”. Results The database search yielded 1639 articles, of which 19 were included. Of the 19 selected articles, there were 12 expert opinion articles, two literature reviews, two prospective cohort studies, one retrospective cohort study, one descriptive study and one pooled meta-analysis that comment on the impact of the COVID-19 pandemic on the physical wellbeing (16 articles), psychosocial wellbeing (15 articles) and financial wellbeing of cancer survivors (3 articles). Conclusions Limited definitive evidence exists regarding the impact of the COVID-19 pandemic on cancer survivors. Currently available literature provides preliminary indications of wide-ranging impacts of the pandemic on cancer survivors with respect to the requirement to adapt to new means of healthcare delivery as well as their physical, psychosocial and economic wellbeing. The pandemic has left survivors dealing with the consequences of rigorous cancer treatment in the context of new challenges related to social isolation, financial hardship and uncertainty with respect to their ongoing care. Additional rigorously designed research initiatives are required to elucidate the impact of the pandemic on cancer survivors.

Background: The use of Point-Of-Care Ultrasound (POCUS) has increased rapidly across various medical disciplines due to technological advancements providing high quality POCUS units. POCUS can help clinicians at the bed side with information regarding patient management in real time. However, literature reveals scant evidence of POCUS use in Palliative Care. This study’s objective was to examine the use of POCUS in a specialist palliative care setting. Methods: A retrospective chart review was conducted from January 2018 to June 2019 to evaluate characteristics of patients for whom POCUS was utilized. These patients were identified through pre-existing logs and descriptive information was collected from the electronic health records. This included demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS and, if applicable, volume of fluid drained.Results: We identified 126 uses of POCUS in 89 unique patients. 62 patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from GI, Lung and Breast pathologies. 61 POCUS cases (48.4%) were in the outpatient setting. 81 POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance.Conclusion: We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient & caregiver satisfaction and health care utilization in palliative care patients receiving POCUS.

Background Patients often view “palliative care” (PC) as an approach that is synonymous with end-of-life and death, leading to shock and fear. Differing cultural and social norms and religious affiliations greatly determine perception of PC among diverse populations. Methods This prospective observational study aimed to explore perceptions of PC among South Asian community members at one Canadian site. Patients who identified themselves as being of South Asian origin were consented and enrolled at a PC Clinic at a community hospital in Brampton, Ontario serving a large South Asian population. Participants filled out an 18-question survey created for the study and responded to a semi-structured interview consisting of 8 questions that further probed their perceptions of PC. Survey responses and semi-structured interviews content were analyzed by four authors who reached consensus on key exploratory findings. Results Thirty-four participants of South Asian origin were recruited (61.8% males), and they were distributed by their age group as follows: [(30–49) - 18%; (50–64) – 21%; (65–79) - 41%; (≥ 80) – 21%]. Five main exploratory findings emerged: (i) differing attitudes towards talking about death; (ii) the key role of family in providing care; (iii) a significant lack of prior knowledge of PC; (iv) a common emphasis on the importance of alleviating suffering and pain to maintain comfort; and (v) that cultural values, faith, or spiritual belief do not pose a necessary challenge to acceptance of PC services. Conclusions Observations from this study provide a source of reference to understand the key findings and variability in perceptions of palliative care in South Asian communities. Culturally competent interventions based on trends observed in this study could assist Palliative Physicians in delivering personalized care to South Asian populations.

Multiple immunologic parameters have provided useful prognostic and assessment significance in various cancers, including head-and-neck squamous cell carcinoma (scc). We sought to identify whether pretreatment inflammatory markers could prognosticate recurrence in patients with advanced (stage iii or iv) head-and-neck scc who underwent therapy with curative intent in a tertiary care centre between January 2010 and December 2012. In a chart review, we recorded demographics, primary tumour characteristics, p16 status, pretreatment inflammatory markers, including body mass index (bmi), neutrophil-to-lymphocyte ratio (nlr), C-reactive protein (crp), and serum albumin, therapy received, and date of relapse, death, or last follow-up. The main outcome was relapse-free survival (rfs). Overall survival (os) was a secondary outcome. From among 235 charts reviewed, 118 cases were included: 86 oropharyngeal (50 p16-positive, 18 p16-negative, 17 p16 unavailable, 1 p16 indeterminate), and 32 non-oropharyngeal (7 p16-positive, 19 p16-negative, 6 p16 unavailable). Median follow-up was 2.45 years (25%&ndash, 75% interquartile range: 1.65&ndash, 3.3 years). In univariate analysis, p16 status, bmi, modified Glasgow prognostic score, and crp were significant for rfs, but in multivariate analysis, only p16 status, bmi, and crp remained significant. For os, only crp and nlr were significant in both the univariate and multivariate analyses. After adjustment for p16 status, nlr did not remain significant. After adjustment for p16 status, crp remained significant for both rfs and os. In patients with head-and-neck scc, a stronger prognostic value is associated with human papillomavirus status than with nlr and many other factors, including bmi and albumin. However, even though few of our patients had high crp, serum crp remained significant despite p16-positive status.

Recent guidelines concerning exercise for people with cancer provide evidence-based direction for exercise assessment and prescription for clinicians and their patients. Although the guidelines promote exercise integration into clinical care for people with cancer, they do not support strategies for bridging the guidelines with related resources or programs. Exercise program accessibility remains a challenge in implementing the guidelines, but that challenge might be mitigated with conceptual frameworks (&ldquo, pathways&rdquo, ) that connect patients with exercise-related resources. In the present paper, we describe a pathway model and related resources that were developed by an expert panel of practitioners and researchers in the field of exercise and rehabilitation in oncology and that support the transition from health care practitioner to exercise programs or services for people with cancer. The model acknowledges the nuanced distinctions between research and exercise programming, as well as physical activity promotion, that, depending on the available programming in the local community or region, might influence practitioner use. Furthermore, the pathway identifies and provides examples of processes for referral, screening, medical clearance, and programming for people after a cancer diagnosis. The pathway supports the implementation of exercise guidelines and should serve as a model of enhanced care delivery to increase the health and well-being of people with cancer.

Patients are living extended life with advanced cancer making it chronic rather than imminently terminal. Literature on the experience of living with advanced cancer is emerging, indicating ongoing polysymptomatic burden, lack of information, burnout (patients and caregivers), and emotional concerns, all of which contribute to emotional distress. The interdisciplinary Ottawa Palliative Rehabilitation Program (PRP) offers a scarce clinical resource for this population. The current research aimed to explore changes in self-reported distress for patients who completed the PRP, from baseline to program completion. A secondary analysis of self-report and clinical measures was performed for 180 patients who completed the PRP. Measures included the Distress Thermometer and the Problem checklists. Descriptive statistics described the sample, paired-sample t tests examined changes in Distress Thermometer scores from baseline to PRP completion, and McNemar’s tests revealed whether the most commonly endorsed checklist items changed by PRP completion. Participants (n = 180) had advanced heterogeneous cancers (mean age = 62.18, 49.4% male). From baseline to completion, significant reported changes included decreases in endorsement of clinical distress (from 55.6 to 38.9%; p

Patients with advanced cancer have increased life expectancy but suffer from ongoing burden. Depressive symptomatology is their most common mental health concern. The Ottawa Palliative Rehabilitation Program (PRP) offers rehabilitation for this population. It offers 8 weeks of individualized interdisciplinary rehabilitation, post cancer treatment. Interventions include medical (physician and nurse), physiotherapy, occupational therapy, dietary, and social work using a general self-efficacy framework. Pilot data suggest benefits in a range of domains, including ratings of feeling "depressed." We examined whether reduced symptomatology was maintained 3 months after PRP completion.Participants with advanced heterogeneous cancers who completed the PRP were mailed the Hospital Anxiety and Depression Scale (among others) 3-month post-PRP (n = 44). Demographic and medical information were obtained from patient files.There was a significant linear trend (mean T1: 6.79 ± 2.29; T2: 5.23 ± 3.06; T3: 4.59 ± 3.34; p = 0.007) with statistically and clinically significant decreases in reported depressive symptomatology between T1 and T2 (p = 0.042) and T1 and T3 (p = 0.007). There was a significant decreases in number of cases reporting symptomatology scores in the clinical range from T1 to T3 (p = 0.038).Patients who undergo a palliative rehabilitation program may experience relief of mild depressive symptomatology, maintainable 3-month post-PRP. The sample was exhibiting mild symptomatology and these results may not be generalizable to those with higher scores; a lack of specialized psychosocial clinician may have affected the acquired sample. Experimental designs are needed to more thoroughly compare these findings to independent rehabilitation interventions.

PURPOSE/OBJECTIVES To examine oncology nurses' attitudes toward and reported use of the Edmonton Symptom Assessment System (ESAS) and to determine whether the length of work experience and presence of oncology certification are associated with their attitudes and reported usage. . DESIGN Exploratory, mixed-methods study employing a questionnaire approach. . SETTING 14 regional cancer centers (RCCs) in Ontario, Canada. . SAMPLE Oncology nurses who took part in a larger province-wide study that surveyed 960 interdisciplinary providers in oncology care settings at all of Ontario's 14 RCCs. . METHODS Oncology nurses' attitudes and use of ESAS were measured using a 21-item investigator-developed questionnaire. Descriptive statistics and Kendall's tau-b or tau-c test were used for data analyses. Qualitative responses were analyzed using content analysis. . MAIN RESEARCH VARIABLES Attitudes toward and self-reported use of standardized symptom screening and ESAS. . FINDINGS More than half of the participants agreed that ESAS improves symptom screening, most said they would encourage their patients to complete ESAS, and most felt that managing symptoms is within their scope of practice and clinical responsibilities. Qualitative comments provided additional information elucidating the quantitative responses. Statistical analyses revealed that oncology nurses who have 10 years or less of work experience were more likely to agree that the use of standardized, valid instruments to screen for and assess symptoms should be considered best practice, ESAS improves symptom screening, and ESAS enables them to better manage patients' symptoms. No statistically significant difference was found between oncology-certified RNs and noncertified RNs on attitudes or reported use of ESAS. . CONCLUSIONS Implementing a population-based symptom screening approach is a major undertaking. The current study found that oncology nurses recognize the value of standardized screening, as demonstrated by their attitudes toward ESAS. . IMPLICATIONS FOR NURSING Oncology nurses are integral to providing high-quality person-centered care. Using standardized approaches that enable patients to self-report symptoms and understanding barriers and enablers to optimal use of patient-reported outcome tools can improve the quality of patient care.

Anorexia–cachexia syndrome (ACS) is a complex condition in advanced cancer patients, defined by disproportionate loss of skeletal muscle mass, and a lack or loss of appetite. This condition greatly lowers the quality of life and limits the treatment options. ACS is commonly associated with gastrointestinal symptoms such as nausea and vomiting. Ginger has been successful in treating these symptoms but has not yet been tested on patients with advanced cancer. Electrogastrography is a technology that allows the direct recording of the gastric myoelectrical activity (GMA). The aim of this study is to (1) determine the effects of ginger on the GMA in these patients, (2) evaluate the subjective symptoms using 3 validated scales, and (3) correlate the level of inflammatory factors and ghrelin in this patient population. Patients with ACS and advanced cancer were recruited from the Palliative Rehabilitation outpatient program at Elisabeth Bruyere Hospital. Patients were instructed to take a daily capsule of 1650 mg of ginger for 14 days and outcome measures were recorded at pre- and post-intervention, which included a blood test for analysis of CRP, albumin and ghrelin levels, 3 self-administered surveys (DSSI, PG-SGA, ESAS), patient-reported symptoms, and an EGG diagnosis. Fifteen patients with a median age of 58 and varying cancer diagnoses were enrolled. EGG diagnosis showed that 9 of the 15 patients had a direct improvement in their GMA, and all patients showed improvement in reported symptoms, most notably nausea, dysmotility- and reflux-like symptoms. There was no correlation found for ginger administration and inflammatory factors. These findings suggest that ginger may improve GMA as measured by EGG and may have a notable effect on symptom improvement.

In recent years, there has been renewed scientific interest in, and associated media coverage of, psychedelics. [...]

e24086 Background: Chemotherapy induced nausea and vomiting (CINV) following carboplatin containing chemotherapy regimen remains a considerable problem for cancer patients (pts) despite standard antiemetic prophylaxis. This study was undertaken to prospectively evaluate the incidence of CINV in pts undergoing carboplatin-based chemotherapy receiving guidelines consistent CINV prophylaxis (GCCP). All sites did not prescribe NK1-RA as it is not included in all institutional guidelines. Methods: The study enrolled 207 pts undergoing carboplatin-based chemotherapy, the final analysis evaluated cycle 1 - 6 with a total of 183 evaluable pts from 6 countries. Pt diaries were used to collect data from day 1-10 beginning with cycle 1. Nausea was reported by the pts using a visual analog scale (VAS) with the end-point being no nausea. Vomiting episodes were recorded in the pts’ diaries. Demographic, occurrence and severity of emesis, numbers of emetic episodes and time to the onset of emesis, were summarized using descriptive statistics. Results: There were 129 females and 54 males. The overall incidence of acute and delayed nausea for was 17% and 25% respectively. The incidence of nausea of entire population was significantly higher than vomiting (58% vs. 14%; Chi2 22.271 p

Purpose Addition of rolapitant to standard antiemetic therapy improved protection against chemotherapy-induced nausea and vomiting (CINV) in phase 3 trials of patients receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Here, we assessed the impact of CINV on the daily lives of patients receiving HEC or MEC using the Functional Living Index-Emesis (FLIE). Methods In three double-blind phase 3 studies, patients receiving HEC or MEC were randomized 1:1 to receive oral rolapitant 180 mg or placebo prior to chemotherapy plus 5-hydroxytryptamine type 3 receptor antagonist and dexamethasone therapy. Patients completed the FLIE questionnaire on day 6 of cycle 1. Endpoints included FLIE total score, nausea and vomiting domain scores, and the proportion of patients with no impact on daily life (total score >108 [range 18–126]). We performed a prespecified analysis of the MEC/anthracycline-cyclophosphamide (AC) study and a post hoc analysis of two pooled cisplatin-based HEC studies. Results In the pooled HEC studies, rolapitant significantly improved the FLIE total score (114.5 vs 109.3, p

Chemotherapy-induced nausea and vomiting (CINV), both acute and delayed, has a dramatic effect on the well-being and quality of life of patients with cancer. Improved understanding of the mechanisms involved in CINV has led to the development of agents targeting the 5-HT3 receptor as well as the NK-1 receptor. Antiemetic prophylaxis given to patients receiving highly emetogenic chemotherapy combines agents blocking the 5-HT3 and NK-1 receptors along with corticosteroids given regularly and repeatedly. Rolapitant is a long-acting NK-1 receptor antagonist with proven efficacy in controlling CINV as part of the prophylaxis regimen. This review will detail the clinical efficacy and safety of rolapitant in the treatment of patients with cancer receiving highly or moderately emetogenic chemotherapy.

The development of evidence-based exercise guidelines for people with cancer represents a major achievement in research and provides direction to programming initiatives. The prevalence of sedentary cancer survivors and the risk posed by inactivity suggests a knowledge-to-action gap for which the evidence has not led to increased exercise levels in that population. To address that gap, researchers continue to explore opportunities to improve the understanding of exercise within the oncologic context&mdash, from tumour biology to behaviour-change theories&mdash, to drive improved access and participation in exercise and rehabilitative activity. In Canada, such efforts have largely been invested by individuals and small teams across the country rather than by unifying stakeholders to drive nationwide impact. Accordingly, a national group of leading researchers, clinicians, and other stakeholders convened a meeting to discuss and strategize initiatives on how to conduct innovative research into the effects of exercise and rehabilitation in cancer survivors, to increase access to exercise and rehabilitation services in cancer survivors, and to reduce sedentary behaviour in cancer survivors. The 2-day meeting, titled Ex/Cancer, was held April 2017 in Toronto, Ontario, and was attended by 83 stakeholders from across Canada, representing knowledge end-users (cancer survivors), clinicians (oncologists, nurses, counsellors), a provincial cancer care agency, community-based exercise and cancer organizations, and researchers. Attendees participated in networking events, roundtable discussions, and breakout sessions to identify, discuss, and develop clinical and research experiences and opportunities. In addition to knowledge exchange between attendees, the meeting set the foundation for the development of a collaborative network to support the development, dissemination, and support of clinical and research activity in exercise and rehabilitation for cancer survivors. With unanimous support from attendees, a major product of the Ex/Cancer meeting was the formation of the Canadian Oncology Rehabilitation and Exercise Network&mdash, coren.

Social support has been shown to buffer some difficulties of living with advanced cancer. The Palliative Rehabilitation Program (prp) was an interdisciplinary outpatient program offering post-treatment palliative rehabilitation to patients with advanced cancer. Social support was directly integrated into the program. The aim of the present study was to examine the types and sources of social support that patients found most beneficial. Twelve patients participated in 30-minute semi-structured interviews. Thematic content analysis was used to explore the social support experiences of those patients in the prp. Patients were eligible to participate in the interview if they had completed the 8-week prp, spoke English, and did not have cognitive or auditory impairments affecting their ability to participate. The main sources of support reported by participants were team members and spouse, family, or close friends, peers attending the program, and spiritual beliefs. Social support varied based on sex and age, such that, compared with women, men reported relying less on social support, and the supportive needs of younger (&le, 50 years of age) and older participants differed. Team members were endorsed as frequently as family as social support. Emotional support was endorsed with the greatest frequency. The members of the interdisciplinary care team were also providers of emotional and informational support for patients, bolstering the support received from caregivers. Widowed or divorced women might rely on health care providers more readily than do married men, who chose their wives as support. Future rehabilitation programs might consider the importance of an interdisciplinary team, the formal integration of caregivers, and the incorporation of spirituality to meet the unique supportive needs of patients with advanced cancer.

Summary Background Highly emetogenic chemotherapy induces emesis in almost all patients in the absence of prophylaxis. Guidelines recommend use of a neurokinin-1 (NK-1) receptor antagonist in conjunction with a 5-HT 3 receptor antagonist and corticosteroid in patients receiving highly emetogenic chemotherapy. We aimed to assess rolapitant, an NK-1 receptor antagonist, for prevention of chemotherapy-induced nausea and vomiting in patients with cancer after administration of cisplatin-based highly emetogenic chemotherapy. Methods We conducted two global, randomised, double-blind, active-controlled, phase 3 trials (HEC-1 and HEC-2) at 155 cancer centres (76 in HEC-1 and 79 in HEC-2) in 26 countries (17 in HEC-1 and 14 in HEC-2). We enrolled patients with cancer aged 18 years or older, who had not previously been treated with cisplatin, with a Karnofsky performance score of 60 or higher, and a predicted life expectancy of 4 months or longer. We used an interactive web-based randomisation system to randomly assign patients to treatment. Patients were stratified by sex and randomly allocated to either oral rolapitant (180 mg dose; rolapitant group) or a placebo that was identical in appearance (active control group) about 1–2 h before administration of highly emetogenic chemotherapy. All patients received granisetron (10 μg/kg intravenously) and dexamethasone (20 mg orally) on day 1, and dexamethasone (8 mg orally) twice daily on days 2–4. Every cycle was a minimum of 14 days. In up to five subsequent cycles, patients were allowed to receive the same study drug they were assigned in cycle 1, unless removed at the clinician's discretion. Patients could also choose to leave the study at any point. Efficacy analysis was done in the modified intention-to-treat population (comprising all patients who received at least one dose of study drug at a cancer centre compliant with Good Clinical Practice [GCP]). The primary endpoint was the proportion of patients achieving a complete response (no emesis or use of rescue medication) in the delayed phase (>24–120 h after initiation of chemotherapy) in cycle 1. These studies are registered with ClinicalTrials.gov, numbers NCT01499849 and NCT01500213. Both studies have been completed. Findings Between Feb 21, 2012, and March 12, 2014, 532 patients in HEC-1 and 555 patients in HEC-2 were randomly assigned to treatment. 526 patients in HEC-1 (264 rolapitant and 262 active control) and 544 in HEC-2 (271 rolapitant and 273 active control) received at least one dose of study drug at a GCP-compliant site and were included in the modified intention-to-treat population. A significantly greater proportion of patients in the rolapitant group had complete responses in the delayed phase than did patients in the active control group (HEC-1: 192 [73%] vs 153 [58%]; odds ratio 1·9, 95% CI 1·3–2·7; p=0·0006; HEC-2: 190 [70%] vs 169 [62%]; 1·4, 1·0–2·1; p=0·0426; pooled studies: 382 [71%] vs 322 [60%]; 1·6, 1·3–2·1; p=0·0001). The incidence of adverse events was similar across treatment groups. The most commonly reported treatment-related treatment-emergent adverse events in the rolapitant versus active control groups were headache (three [ vs two [ vs four [ vs three [ vs three [ vs 14 [5%]; HEC-2: 16 [6%] vs 14 [5%]), anaemia (HEC-1: one [ vs one [ vs two [ vs two [ vs two [ Interpretation Rolapitant in combination with a 5-HT 3 receptor antagonist and dexamethasone is well-tolerated and shows superiority over active control for the prevention of chemotherapy-induced nausea and vomiting during the at-risk period (120 h) after administration of highly emetogenic cisplatin-based chemotherapy. Funding TESARO, Inc.

Patients with advanced cancer, post-anticancer treatment, are living longer than 10-20 years ago. This emerging population of survivors has unique palliative and rehabilitation needs. A particular concern is depression, which can impair functioning, quality of life, and survival. The interdisciplinary Palliative Rehabilitation Program offers holistic palliative rehabilitation for this population using a self-efficacy framework. The current study examined the unique impact of three program factors that have been shown to improve depression: inflammation, exercise, and self-efficacy.Patients underwent a 2-month interdisciplinary intervention (up to six disciplines) and thorough pre-post assessments. Measures included serum C-reactive protein, 6-min walk test, General Self-efficacy Scale, and Hospital Anxiety and Depression Scale (depression subscale). Paired t tests analyzed pre-post changes in each variable, and a hierarchical linear regression analyzed the predictors' unique contributions of changes in depression in this quasi-experimental design.The sample included 80 patients (52.5% females), with stages 3/4 heterogeneous cancers. Results revealed that C-reactive protein (CRP) did not significantly change pre-post, from 7.39 (SD = 11.99) to 9.47 mg/L (SD = 16.41), p = 0.110, exercise significantly increased, from 372.55 (SD = 137.71) to 412.64 m (SD = 144.31), p 0.001, self-efficacy significantly increased from 27.86 (SD = 6.16) to 31.23 units (SD = 5.77), p 0.001, and depression scores significantly decreased, from 7.14 (SD = 3.91) to 5.95 units (SD = 3.51), p = 0.002. A hierarchical linear regression revealed that this model explained 15% of variance in changes in depression scores, p = 0.006. Change in self-efficacy accounted for 11% of change in depression scores (p 0.001). Change in CRP and exercise did not make a significant contribution.A self-efficacy framework may be a helpful ingredient in interdisciplinary intervention to decrease depressive symptomatology.

It is with much pride that I welcome Dr. Matthew Seftel to the editorial staff of Current Oncology. [...]

The evidence for early integration of palliative care into standard oncology care is growing.[...]

In patients with advanced cancer, AIDS and end-stage organ diseases, symptoms of cachexia syndrome include decrease in appetite, weight loss, decreased performance status, and an increase in the systemic inflammatory response. Inflammatory cytokines and other immune interactions affect the lean tissue mass and body fat. It is hopeful that modulation of these inflammatory interactions may contribute to the delay in the development and treatment of cachexia. This review summarizes the current state of the art.This article covers the role of inflammatory response in cachexia, measurement of inflammatory response, mechanism and measurement of cachexia, immunomodulation in cancer, drugs targeting inflammatory cytokines, effect of exercise in cachexia, and treatment of cancer cachexia using immunomodulatory agents.Understanding the immune response associated with cachexia may improve future pharmacological modification of the cytokines. In addition, the multifactorial contributions to the mechanisms of cachexia indicate that a multimodal approach may be necessary to treat cachexia and its associated symptoms.

Physicians embrace the concept of rehabilitation, but may think of it only as it relates to restoring function through exercise. We use a broader definition that applies to patients with advanced cancer. Cancer rehabilitation is a process that assists a person with a cancer diagnosis to obtain

The Canadian Lung Cancer Conference, held in Vancouver, 8–9 February 2018, was a successful, informative, and well-organized meeting. [...]

Background: Cancer can affect many dimensions of a patient’s life, and in turn, it should be targeted using a multimodal approach. We tested the extent to which an interdisciplinary nutrition–rehabilitation program can improve the well-being of patients with advanced cancer. Methods: Between January 10, 2007, and September 29, 2010, 188 patients with advanced cancer enrolled in the 10–12-week program. Body weight, physical function, symptom severity, fatigue dimensions, distress level, coping ability, and overall quality of life were assessed at the start and end of the program. Results: Of the enrolled patients, 70% completed the program. Patients experienced strong improvements in the physical and activity dimensions of fatigue (effect sizes: 0.8–1.1). They also experienced moderate reductions in the severity of weakness, depression, nervousness, shortness of breath, and distress (effect sizes: 0.5–0.7), and moderate improvements in Six Minute Walk Test distance, maximal gait speed, coping ability, and quality of life (effect sizes: 0.5–0.7) Furthermore, 77% of patients either maintained or increased their body weight. Conclusions: Interdisciplinary nutrition–rehabilitation can be advantageous for patients with advanced cancer and should be considered an integrated part of standard palliative care.

Malnutrition and psychological distress are often seen in patients with head-and-neck cancer, but little is known about the interrelationships between those two symptoms. The present study examined the relationship between malnutrition and psychological distress in patients with advanced head-and-neck cancer. Using the Patient-Generated Subjective Global Assessment, 99 patients with advanced-stage head-and-neck cancer were screened for nutrition status. The patients were also screened for psychosocial distress (using the Distress Thermometer) and for psychosocial issues (using the Problem Checklist). Any relationship between malnutrition and psychosocial distress was determined by regression and correlation analysis. We also used t-tests to compare distress levels for patients with and without specific nutrition-related symptoms. The study group included 80 men and 19 women [mean age: 58.4 &plusmn, 10.9 years (range: 23&ndash, 85 years)]. The correlation between poorer nutrition status and level of psychological distress was significant r = 0.37 (p < 0.001). Specifically, reduced food intake and symptoms were both positively associated with distress: r = 0.27 and r = 0.29 respectively, both significant at p < 0.01. After controlling for the effects of psychosocial problems and pain, nutrition status remained a significant predictor of distress, explaining 3.8% of the variance in the distress scores of the patients (p < 0.05). Malnutrition and symptoms were strongly related to distress in patients with advanced head-and-neck cancer. Our results suggest the need for further research into the complex relationship between nutrition status and distress and into the management of both nutrition and distress in cancer care.

Breast or chest-wall pain (bcp) is prevalent in 20%&ndash, 50% of breast cancer survivors, and it affects quality of life (qol). To determine the feasibility and potential efficacy of an exercise program to improve patient qol and bcp, such a program was offered to breast cancer patients suffering from bcp. The study enrolled 10 breast cancer patients with moderate-to-severe bcp at 3&ndash, 6 months after completion of all adjuvant treatments. These patients participated in a 12-week comprehensive health improvement program (chip). Intensity was adjusted to reach 65%&ndash, 85% of the patient&rsquo, s maximal heart rate. Before the chip and at 1 and 6 months after completion of the chip, qol and pain were measured using questionnaires [European Organisation for Research and Treatment of Cancer Quality of Life core and breast cancer modules (qlq-C30, -BR23) and the McGill Pain Questionnaire short form] completed by the patients. Results were compared with those from case-matched control subjects from another study at McGill University. After the chip, patients reported significant and clinically important improvements in qol and symptoms. At 1 and 6 months post-chip, patients in the study felt, on average, better in overall qol than did historical control subjects. Our study suggests that patients who experience chronic bcp may benefit from an exercise program. A randomized controlled trial is warranted.

Background Although perioperative chemotherapy for esophagogastric adenocarcinoma (ADC) improves survival, the overall poor prognosis suggests that further refinement of treatment is required. Docetaxel, cisplatin, and 5-fluorouracil (5-FU) (DCF) is effective for metastatic ADC of the upper gastrointestinal (GI) tract; we thus sought to investigate the efficacy of this regimen in patients with resectable disease. Patients and methods Patients with resectable ADC of the upper GI tract received DCF [docetaxel (Taxotere) 75 mg/m2 I.V. day 1, cisplatin 75 mg/m2 I.V. day 1, 5-FU 750 mg/m2 continuous infusion for 120 h, every 3 weeks] for three cycles before and after resection. Primary end point was complete resection; secondary end points were response, toxicity, surgical morbidity, and overall survival. Results Forty-three patients with ADC of the esophagus (11), gastroesophageal junction (25), or stomach (7) started treatment and 86% completed all preoperative cycles with grade 3–4 toxicity arising in 47%. Metabolic response to chemotherapy (reduction in maximal standard uptake value >35%) was achieved in 25/33 (76%) patients. Surgery was carried out in 41/43 and complete resection was achieved in all 41 patients with pathologic complete response in 4/41. Postoperative chemotherapy was started in 29 patients and completed in 24. Three-year overall survival was 60%. Conclusion Perioperative DCF is a tolerable and highly effective regimen for the treatment of esophagogastric ADC.

Background. Patients with head and neck cancer experience complex posttreatment challenges. In a preliminary uncontrolled study, we evaluated the extent to which they can benefit from an interdisciplinary rehabilitation program. Methods. Twenty-seven patients completed an 8-week nutrition- rehabilitation program. Six-minute walk distance (6MWD), body weight, symptom burden, distress, and quality of life were assessed at baseline and at the end of the program. Results. Patients improved their mean 6MWD by 59 m (effect size ¼ 0.8), and 78% of patients either maintained or increased their body weight. They also reported a clinically meaningful reduction in severity of insomnia, pain, weakness, anorexia, shortness of breath, depression and distress, and improvement in quality of life (effect sizes ¼ 0.6-0.9). However, they reported no change in symptom interference with function. Conclusion. An interdisciplinary rehabilitation program may be beneficial to patients with head and neck cancer after treatment, but its effects should be evaluated in a controlled trial. V C 2012 Wiley Periodicals, Inc. Head Neck 35: 343-349, 2013

Much has changed in the United States and worldwide since Richard Nixon signed the U.S. National Cancer Act of 1971. [...]

Our goal was to develop evidence-based recommendations for the organization and structure of cancer survivorship services, and best-care practices to optimize the health and well-being of post&ndash, primary treatment survivors. This review sought to determine the optimal organization and care delivery structure for cancer survivorship services, and the specific clinical practices and interventions that would improve or maximize the psychosocial health and overall well-being of adult cancer survivors. We conducted a systematic search of the Inventory of Cancer Guidelines at the Canadian Partnership Against Cancer, the U.S. National Guideline Clearinghouse, the Canadian Medical Association InfoBase, medline (ovid: 1999 through November 2009), embase (ovid: 1999 through November 2009), Psychinfo (ovid: 1999 through November 2009), the Cochrane Library (ovid, Issue 1, 2009), and cinahl (ebsco: 1999 through December 2009). Reference lists of related papers and recent review articles were scanned for additional citations. Articles were selected for inclusion as evidence in the systematic review if they reported on organizational system components for survivors of cancer, or on psychosocial or supportive care interventions HOWELL et al. designed for survivors of cancer. Articles were excluded from the systematic review if they focused only on pediatric cancer survivor populations or on populations that transitioned from pediatric cancer to adult services, if they addressed only pharmacologic interventions or diagnostic testing and follow-up of cancer survivors, if they were systematic reviews with inadequately described methods, if they were qualitative or descriptive studies, and if they were opinion papers, letters, or editorials. Evidence was selected and reviewed by three members of the Cancer Journey Survivorship Expert Panel (SM, TC, TKO). The resulting summary of the evidence was guided further and reviewed by the members of Cancer Journey Survivorship Expert Panel. Fourteen practice guidelines, eight systematic reviews, and sixty-thee randomized controlled trials form the evidence base for this guidance document. These publications demonstrate that survivors benefit from coordinated post-treatment care, including interventions to address specific psychosocial, supportive care, and rehabilitative concerns. Ongoing high-quality research is essential to optimize services for cancer survivors. Interventions that promote healthy lifestyle behaviours or that address psychosocial concerns and distress appear to improve physical functioning, psychosocial well-being, and quality of life for survivors.

Background: Approximately 10% of new breast cancer patients will present with overt synchronous metastatic disease. Controversy exists about the optimal local management of these patients. While several series suggest that removal of primary tumour is associated with a survival benefit, the retrospective nature of these studies raises considerable methodological challenges. We decided to evaluate the experience at our centre around the impact of surgery in patients with synchronous metastasis. Method: Case records of all patients seen with primary breast cancer and concurrent distant metastases between 2005 to 2007 were reviewed. Demographic and treatment data was collected. The study endpoints compared both overall survival and symptomatic local progression rates between patients who had breast surgery and those who did not. RESULTS: 111 patients were identified. Median follow-up 40 months (0.6-71 months). Patients were divided into two groups: those patients who underwent breast surgery (n=48; 29/48 had surgery immediate prior to metastatic diagnosis) and those that did not have surgery(n = 63). The surgical group were less likely to present with T4 tumours (20% vs 36%), N3 nodal disease (8% vs 19%) and visceral metastasis (67% vs 73%)when compared with non-surgical group. Improved overall survival (49 months vs 33 months; p=0.01) and less symptomatic local progression rates ( 15% vs 43%, p < 0.001 ) were seen in the surgical group compared to the non-surgical group. CONCLUSIONS: The optimal local management of patients with metastatic breast cancer is unknown. Despite the surgery group demonstrating an improved overall survival and symptomatic local control, this group had less aggressive disease at presentation. These results confirm the need for prospective randomized studies. E2108, an ongoing Phase III Trial, was designed to assess the effect of breast surgery in metastatic patients responding to first line systemic therapy. If excision of the primary tumour is associated with a survival benefit, then the pre-selected subgroup of patients that have responded to initial systemic therapy is the desired population to put this hypothesis to test. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-15-05.

Cetuximab (Erbitux*) is the only new medical therapy for locally and regionally advanced SCCHN to be licensed in industrialized countries in the past 15 years and presents an alternative to cisplatin which is the current therapeutic standard. In the absence of a published head-to-head trial, we estimated the relative benefit of cetuximab and cisplatin using an indirect comparison methodology.We performed a systematic review of the Medline and Embase databases between 1998 and 2008 to find published trials of cisplatin plus radiotherapy vs. radiotherapy alone and synthesized the information with meta-analysis. Those results were combined with trial-based results of cetuximab plus radiotherapy vs. radiotherapy alone. Inclusion criteria stipulated that cisplatin be administered concurrently with radiation, the radiation protocol be comparable to the registration trial for cisplatin (once-daily, twice-daily, or concomitant boost) and cisplatin dosing be comparable to that in common use (i.e. day 1, 22 and 43 of treatment). Endpoints were locoregional control and overall survival. Two reviewers examined 269 abstracts which yielded four trials meeting the inclusion criteria.There was little evidence of superiority of either platinum-based radiotherapy or cetuximab-based radiotherapy. All estimated hazard ratios were near 1.0 (equivalence), all confidence intervals spanned the null value (1.0), and no consistent pattern was observed regarding the direction of the effect. The results remained robust in sensitivity analysis.This is the first quantitative analysis allowing formal comparison between cetuximab and radiotherapy versus cisplatin and radiotherapy. Based on state-of-the-art methodology for indirect comparisons, it was not possible to identify either treatment regimen as superior in prolonging either locoregional control or overall survival. Until the publication of more studies, and particularly a head-to-head comparison, the two treatments may be considered equally efficacious when given alongside radiotherapy. The choice of treatment may focus on the toxicity profile of the medications.

BACKGROUND A pilot study (NCT00316563) to determine if delta-9-tetrahydrocannabinol (THC) can improve taste and smell (chemosensory) perception as well as appetite, caloric intake, and quality of life (QOL) for cancer patients with chemosensory alterations. PATIENTS AND METHODS Adult advanced cancer patients, with poor appetite and chemosensory alterations, were recruited from two sites and randomized in a double-blinded manner to receive either THC (2.5 mg, Marinol(®); Solvay Pharma Inc., n = 24) or placebo oral capsules (n = 22) twice daily for 18 days. Twenty-one patients completed the trial. At baseline and posttreatment, patients completed a panel of patient-reported outcomes: Taste and Smell Survey, 3-day food record, appetite and macronutrient preference assessments, QOL questionnaire, and an interview. RESULTS THC and placebo groups were comparable at baseline. Compared with placebo, THC-treated patients reported improved (P = 0.026) and enhanced (P < 0.001) chemosensory perception and food 'tasted better' (P = 0.04). Premeal appetite (P = 0.05) and proportion of calories consumed as protein increased compared with placebo (P = 0.008). THC-treated patients reported increased quality of sleep (P = 0.025) and relaxation (P = 0.045). QOL scores and total caloric intake were improved in both THC and placebo groups. CONCLUSIONS THC may be useful in the palliation of chemosensory alterations and to improve food enjoyment for cancer patients.

Background and Objective OHR118 represents a new class of immunomodulatory and cytoprotective drugs in managing anorexia cachexia. Previously in patients with advanced HIV-AIDS, increases in appetite, strength, and alertness were noted. The objective was to determine the effect of OHR118 on appetite, early satiety, and nutritional intake in patients with advanced cancer. Secondary end points included changes in performance status, lean muscle mass, and quality of life (QOL). Methods Eligible patients received 4.0 mL of OHR118 in subcutaneous daily injections. Patients underwent bi-monthly evaluations during the 28-day initial treatment (phase A). Evaluations included Karnofsky performance status, Edmonton Symptoms Assessment Scale (ESAS), Patient-Generated Subjective Global Assessment (PG-SGA), Simmonds Functional Assessment (SFA), Dyspepsia Symptom Severity Index (DSSI), weight, lean body mass, skin fold thickness, and grip strength. Patients who benefited from phase A could elect to continue with therapy (phase B). Results Of 21 enrolled patients, 11 completed phase A. Eight patients chose to continue with OHR118 treatment (phase B). Weight stabilization or gain was observed in 7 of 11 patients. Total PG-SGA scores improved significantly (P ≤ .01). Appetite (P ≤ .01) and depression (P = .05) scores improved on ESAS. Frequent burping/belching (P = .02), feeling full (P = .04), and stomach distention (P = .03) improved on the DSSI. A deterioration in the timed sit to stand was noted (P = .01). OHR118 was well tolerated with no serious side effects reported. Conclusions OHR118 again mediated statistically significant improvements in anorexia, dyspepsia, strength, and depression in this trial, consonant with the previous AIDS trial results.