Publications by authors named "Selina Chow"

27 Publications

  • Page 1 of 1

Patient-Reported Pain in Patients with Breast Cancer Who Receive Radiotherapy.

Pain Manag Nurs 2021 Jan 20. Epub 2021 Jan 20.

Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Patients who receive radiation treatment (RT) for breast cancer often report pain, which contributes negatively to quality of life (QoL).

Aims: To identify demographic, treatment, and disease characteristics associated with pain and changes in pain before and after RT using the Edmonton Symptom Assessment Scale (ESAS).

Design: Retrospective study.

Settings: Odette Cancer Centre.

Participants: Patients diagnosed with nonmetastatic breast cancer from January 2011-June 2017 with at least one ESAS completed pre-RT and one completed post-RT.

Methods: Data on systemic treatment, radiation, patient demographics, and disease stage were extracted. To identify factors associated with pain before and after RT and changes in pain, univariate and multivariate general linear regression analysis were conducted. p < .05 was considered statistically significant.

Results: This study included 1,222 female patients with a mean age of 59 years. ESAS was completed an average of 28 days before RT (baseline) and 142 days after RT, respectively. In multivariable analysis, higher baseline pain scores were associated with having recently completed adjuvant chemotherapy (p = .002) and eventual receipt of locoregional (p = .026) or chest wall (p = .003) radiation. Adjuvant chemotherapy (p = .002) and chest wall radiation (p = .03), were associated with a significant reduction in pain score after radiotherapy, while locoregional RT was associated with a higher pain score after RT (p < .001).

Conclusions: Patients with locoregional RT had higher baseline pain that remained elevated after RT completion and should be screened for pain and provided with pain management and support when necessary.
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http://dx.doi.org/10.1016/j.pmn.2020.12.007DOI Listing
January 2021

Recommendations and outcomes from a geriatric assessment guided multidisciplinary clinic prior to autologous stem cell transplant in older patients.

J Geriatr Oncol 2020 Nov 5. Epub 2020 Nov 5.

City of Hope, Duarte, CA, United States of America.

Background: Autologous hematopoietic stem cell transplant (autoHCT) is a mainstay of treatment for multiple myeloma and non-Hodgkin lymphoma but is underutilized in older adults. We investigated the association of vulnerabilities identified by a geriatric assessment (GA)-guided multidisciplinary clinic (MDC) on the receipt of autoHCT and evaluated its ability to predict outcomes in older autoHCT candidates.

Methods: Patients 50+ years received GA-informed optimization recommendations: 'decline' if unlikely to realize benefits of autoHCT, 'defer' if optimization necessary before autoHCT, and 'proceed' if autoHCT could proceed without delay. We compared characteristics and outcomes of autoHCT recipients (n = 62) to non-autoHCT patients (n = 29) and evaluated GA deficits on outcomes.

Results: 91 patients were evaluated; the MDC recommendation was 'decline' for 5 (6%), 'defer' for 25 (27%), and 'proceed' for 61 (67%). AutoHCT recipients had fewer GA-rated impairments relative to non-autoHCT patients, as did patients with a 'proceed' recommendation relative to 'defer'. Among autoHCT recipients, 1-year and 3-year non-relapse morality (NRM) was 0% and 5%, and there was no difference in length of hospitalization, readmission rate, or mortality after transplant by MDC recommendation. Frail grip strength and poor performance status were associated with inferior post-autoHCT progression-free survival and overall survival.

Conclusions: Patients pursuing autoHCT after MDC-directed optimization achieved excellent outcomes, including patients deferred but ultimately receiving autoHCT. GA-identified functional deficits, especially frail grip strength, may improve risk stratification in older autoHCT candidates. Employing a GA earlier in the disease trajectory to inform early referral to an MDC may increase autoHCT safety and utilization in older patients.
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http://dx.doi.org/10.1016/j.jgo.2020.10.019DOI Listing
November 2020

Results from a multidisciplinary clinic guided by geriatric assessment before stem cell transplantation in older adults.

Blood Adv 2019 11;3(22):3488-3498

Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA.

Limitations found on geriatric assessment (GA) track with worse outcomes after hematopoietic cell transplantation (HCT). We report on a multidisciplinary team clinic (MDC), consisting of a cancer-specific GA and a multidisciplinary team of providers, to assess candidacy and create an individualized optimization plan for allogeneic HCT candidates aged ≥60 years and autologous HCT and adoptive T-cell therapy candidates aged ≥70 years. Among the 247 patients evaluated in the MDC, allogeneic HCT candidates comprised the majority (60%), followed by autologous HCT (37%) with occasional older cellular therapy candidates (3%). Almost all patients meeting program-required minimum ages for MDC optimization at our institution were assessed (98%). Relative to historical control subjects undergoing GA alone, allogeneic HCT patients aged ≥60 years who underwent MDC appraisal had similar frequencies of high-risk disease, reduced intensity regimens, and high comorbidity but fewer GA-graded functional impairments. The MDC cohort experienced fewer inpatient deaths, shorter length of stay, and fewer discharges to nursing facilities compared with control subjects. Improvements in early mortality were observed over time; 1-year overall survival improved from 43% in the pre-MDC era to 70% in the recent MDC era, and 1-year nonrelapse mortality decreased from 43% to 18%. The 31 autologous HCT recipients aged ≥70 years optimized by the MDC achieved 0% nonrelapse mortality and 97% overall survival at 1 year. A GA-guided MDC for older HCT candidates is feasible and seems to reduce transplant-associated morbidity and mortality. An MDC should encourage broader and safer utilization of transplantation in older patients.
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http://dx.doi.org/10.1182/bloodadvances.2019000790DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880895PMC
November 2019

Psychological morbidity in women diagnosed with ductal carcinoma in situ compared with women with early breast cancer receiving radiotherapy.

Support Care Cancer 2020 May 26;28(5):2247-2254. Epub 2019 Aug 26.

Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.

Purpose: Despite having an excellent prognosis, patients with ductal carcinoma in situ (DCIS) report significant anxiety and depression following diagnosis. This study evaluated psychological morbidity using the Edmonton Symptom Assessment Scale (ESAS) in patients with DCIS compared with women with early-stage invasive breast cancer (EIBC) receiving radiotherapy (RT).

Methods: We identified patients diagnosed with DCIS or EIBC (stage I or II breast cancer) from 2011 to 2017 who had at least one ESAS completed pre- and post-RT. Data on systemic treatment, radiation, patient demographics, and disease stage were extracted from existing databases. Psychological morbidity was evaluated through measurement of depression, anxiety, and overall wellbeing within the ESAS. The Wilcoxon rank-sum test or chi-square test was performed for continuous or categorical variables.

Results: This study included 137 women with DCIS and 963 women with EIBC. ESAS was completed on average 28 days before RT (baseline) and 142 days after RT. Baseline ESAS scores showed significantly higher rates of depression among women with EIBC compared with those with DCIS (p = 0.006). Patients with EIBC also reported higher levels of anxiety and lower overall wellbeing than patients with DCIS, but this difference was not statistically significant. Post-RT ESAS scores showed significantly higher anxiety in patients with EIBC compared with DCIS (p = 0.049). Post-RT measures of anxiety and overall wellbeing were higher in patients with EIBC but differences were not statistically significant.

Conclusion: Women with DCIS experience relatively less psychological morbidity than women with EIBC, pre- and post-RT.
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http://dx.doi.org/10.1007/s00520-019-05034-2DOI Listing
May 2020

Symptom clusters in patients with breast cancer receiving radiation therapy.

Eur J Oncol Nurs 2019 Oct 10;42:14-20. Epub 2019 Jul 10.

Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Purpose: Symptoms experienced by breast cancer patients often cluster together in groups known as "symptom clusters". The aim was to determine the symptom clusters in women with non-metastatic breast cancer treated by radiation therapy (RT).

Methods: Edmonton Symptom Assessment Scale (ESAS) scores were taken from breast cancer patients receiving RT before, at completion of RT, and after RT. Exploratory factor analysis (EFA), principal component analysis (PCA), and hierarchical cluster analysis (HCA) were used to identify symptom clusters among the nine ESAS items at all three time points.

Results: This study included 1224 patients. The PCA and EFA identified the same two symptom clusters before the start of RT: 1) pain, tiredness, nausea, drowsiness, appetite, and dyspnea; 2) depression, anxiety, and wellbeing. The HCA further split the symptoms into three clusters. Wellbeing, depression, and anxiety consistently clustered together. Among the ESAS scores collected at the end of and after RT, each statistical method identified different symptom clusters. For the symptom clusters experienced at the end of RT, the following symptoms were always in the same cluster: wellbeing, depression, and anxiety; nausea and appetite; drowsiness and dyspnea. Following RT, depression and anxiety consistently clustered together, with nausea and appetite in a second cluster.

Conclusion: Among the symptom clusters derived before, at the end of RT, and after RT, the following symptoms consistently presented together: depression and anxiety, nausea and appetite, pain and tiredness, and drowsiness, dyspnea, and tiredness. Understanding symptom clusters in this population can improve management of symptoms.
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http://dx.doi.org/10.1016/j.ejon.2019.07.004DOI Listing
October 2019

Seasonal fluctuations in psychological distress amongst women diagnosed with early breast cancer receiving radiotherapy.

Psychooncology 2019 10 26;28(10):2091-2097. Epub 2019 Aug 26.

Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.

Objective: Seasonal effects on patients diagnosed with depression/anxiety-related psychological disorders have varying impacts on symptom severity. Seasonal changes in psychological distress may be due to decreased daylight exposure during the fall/winter seasons. Patients receiving radiation therapy (RT) for early-stage invasive breast cancer (EIBC) are at high risk for developing depressive symptoms. Of interest is whether seasonal factors influence the psychological symptoms of patients being treated for EIBC.

Methods: Patients treated with RT for EIBC between January 2011 and June 2017 were identified. Patients who completed at least one Edmonton Symptom Assessment Scale (ESAS-r) pre-RT and post-RT were included in our analysis. Patients receiving RT during the autumn and winter (November-March) were compared with patients receiving RT during the spring and summer (April-August). Psychological distress was evaluated based on patient-reported depression, anxiety, and overall wellbeing on the ESAS-r. Data on systemic treatment and radiation were extracted from existing databases.

Results: Eight-four patients treated with RT in spring/summer and 102 patients treated with RT in autumn/winter were included. Patients receiving RT during spring/summer had better wellness score prior to RT, compared with those receiving RT during winter/autumn (P = .03). However, patients receiving RT in the spring/summer had worse symptom trajectories across three domains of depression, anxiety, and wellbeing (P = .03, P = .008, and P < .0001, respectively).

Conclusions: Seasonality influenced the symptoms reported by patients with EIBC receiving RT. Future studies are needed to understand when during treatment patients are at highest risk for psychological distress and how seasonality may influence high-risk periods.
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http://dx.doi.org/10.1002/pon.5199DOI Listing
October 2019

Patient-reported fatigue in breast cancer patients receiving radiation therapy.

Breast 2019 Oct 19;47:10-15. Epub 2019 Jun 19.

Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Purpose: Fatigue or tiredness is one of the most commonly reported symptoms in breast cancer patients treated with radiation therapy (RT). This study aimed to identify characteristics associated with fatigue in breast cancer patients receiving adjuvant RT.

Methods: Patients with non-metastatic breast cancer receiving RT at the Odette Cancer Centre from 2011 to 2017 were included in our study if they completed at least one ESAS pre- and post-RT. Information regarding patient, disease and treatment characteristics was retrieved from chart review. To identify variables associated with fatigue scores pre-RT, post-RT and changes in fatigue scores, a univariate and multivariate general linear regression analysis was conducted; p < 0.05 was considered statistically significant.

Results: Our study included 1223 female patients (mean age 59 years old) who completed ESAS on average 28 days before, and 142 days after RT. In multivariate analysis, higher baseline fatigue scores were found in women with higher disease stages (p = 0.001), and those who receive locoregional radiation (p < 0.001). No variables were significantly associated with post-RT fatigue scores. While adjuvant chemotherapy and locoregional RT were associated with higher baseline scores in univariate analysis, in multivariate analysis, they were associated with significant reduction in fatigue post-RT (p = 0.01, p = 0.007 respectively).

Conclusions: Fatigue is associated with higher disease stage and receipt of locoregional radiation. While the relationship between anxiety or depressive symptoms and fatigue is well-established, a major gap exists in our understanding of its etiology and treatment; further investigation to address this can better improve patient quality of life.
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http://dx.doi.org/10.1016/j.breast.2019.06.004DOI Listing
October 2019

Symptoms Predictive of Overall Quality of Life Using the Edmonton Symptom Assessment Scale in Breast Cancer Patients Receiving Radiotherapy.

Clin Breast Cancer 2019 12 18;19(6):405-410. Epub 2019 May 18.

Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Breast cancer patients often experience multiple symptoms that negatively affect quality of life (QOL). Patient-reported scores on symptom screening tools are used by health care professionals to manage QOL. We aimed to examine which symptoms from the Edmonton Symptom Assessment Scale (ESAS) were most predictive of overall well-being (QOL) in breast cancer patients over the course of radiotherapy (RT).

Patients And Methods: ESAS results completed before, at the end of, and after RT were obtained from all nonmetastatic breast cancer patients. Univariate and multivariable (backward stepwise selection) linear regression analyses were applied to select the most significant ESAS symptoms or treatment variables related to overall QOL at all 3 time points.

Results: A total of 1224 patients were included in the study. Before RT, multivariable analysis identified 5 symptoms that were significantly associated with overall QOL: pain, tiredness, anxiety, depression, and loss of appetite. At the end of RT, pain, tiredness, and anxiety were the most significant predictors of QOL. After RT, 6 symptoms were found to have the strongest correlation with QOL: pain, tiredness, anxiety, depression, loss of appetite, and drowsiness. At each time point, patients with higher scores for the identified significant symptoms were likely to have a worse overall QOL.

Conclusion: Of the ESAS symptoms identified as significant predictors of QOL, pain, tiredness, and anxiety correlated with overall well-being at all time points. Special attention should be paid to manage symptoms that are most predictive of overall QOL in order to ensure optimal symptom management in breast cancer patients receiving RT.
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http://dx.doi.org/10.1016/j.clbc.2019.05.007DOI Listing
December 2019

Allogeneic hematopoietic cell transplantation compared to chemotherapy consolidation in older acute myeloid leukemia (AML) patients 60-75 years in first complete remission (CR1): an alliance (A151509), SWOG, ECOG-ACRIN, and CIBMTR study.

Leukemia 2019 11 9;33(11):2599-2609. Epub 2019 May 9.

Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA.

The preferred post-remission therapy for older patients with acute myeloid leukemia (AML) in first complete remission (CR1) remains uncertain. In this retrospective, multicenter study, we compared the outcomes for older AML patients (age 60-77 years) receiving allogeneic hematopoietic cell transplantation (alloHCT) (n = 431) with those treated on prospective National Clinical Trials Network induction and nontransplantation chemotherapy (CT) consolidation trials (n = 211). AlloHCT patients were younger (median age: 64.2 versus 67.9 years, p < 0.001), but more frequently had high-risk AML (high WBC, secondary AML, and unfavorable cytogenetics). Overall survival (OS) was worse in alloHCT during the first 9 months after CR1 (HR = 1.52, p = 0.02), but was significantly better thereafter (HR = 0.53, p < 0.0001) relative to CT. Treatment-related mortality (TRM) following HCT was worse in the first 9 months (HR = 2.8, 95% CI: 1.5-5.2, p = 0.0009), while post-HCT relapse was significantly less frequent beyond 9 months (HR = 0.42, 95% CI: 0.29-0.61, p < 0.0001). Despite higher early TRM, alloHCT recipients had superior long-term OS [29% (24-34%) versus CT 13.8% (9-21%) at 5 years]. Although this is a retrospective analysis with potential biases, it indicates that alloHCT led to heightened early risks from TRM, yet reduced relapse and superior long-term survival relative to CT in older AML patients in CR1.
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http://dx.doi.org/10.1038/s41375-019-0477-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842042PMC
November 2019

Challenges of conducting research in long-term care facilities: a systematic review.

BMC Geriatr 2018 10 12;18(1):242. Epub 2018 Oct 12.

Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.

Background: The aim of this review is to describe the challenges and barriers to conducting research in long-term care facilities.

Methods: A literature search was conducted in Ovid MEDLINE, Embase, Cochrane Central, PsycINFO and CINAHL. Keywords used included "long term care", "nursing home", "research", "trial", "challenge" and "barrier", etc. Resulting references were screened in order to identify relevant studies that reported on challenges derived from first-hand experience of empirical research studies. Challenges were summarized and synthesized.

Results: Of 1723 references, 39 articles were selected for inclusion. To facilitate understanding we proposed a classification framework of 8 main themes to categorize the research challenges presented in the 39 studies, relating to the characteristics of facility/owner/administrator, resident, staff caregiver, family caregiver, investigator, ethical or legal concerns, methodology, and budgetary considerations.

Conclusions: Conducting research in long-term care facilities is full of challenges which can be categorized into 8 main themes. Investigators should be aware of all these challenges and specifically address them when planning their studies. Stakeholders should be involved from an early stage and flexibility should be built into both the methodology and research budget.
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http://dx.doi.org/10.1186/s12877-018-0934-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186062PMC
October 2018

National Dementia Strategies: What Should Canada Learn?

Can Geriatr J 2018 Jun 30;21(2):173-209. Epub 2018 Jun 30.

Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.

Background: In order to provide appropriate care for the aging population, many countries are adopting a National Dementia Strategy (NDS). On June 22, 2017, Canada announced it will become the 30th country to launch a NDS. In light of this announcement and as Canada prepares to develop its own NDS, we conducted this review to examine and compare the NDSs of the other previous 29 countries with Canadian government's policies to date.

Methods: NDSs were compared according to their major priorities. The primary endpoints were the framework conditions and key actions outlined in the strategies. Secondary endpoints included the years active, involvement of stakeholders, funding, and implementation.

Results: We were able to review and compare 25 of the 29 published NDSs. While the NDSs of each country varied, several major priorities were common among the strategies-increasing awareness of dementia, reducing its stigma, identifying support services, improving the quality of care, as well as improving training and education and promoting research.

Conclusions: This review comprehensively lists and compares the NDSs of different countries. The results should be of great interest to policy-makers, health-care professionals and other key stakeholders involved in developing Canada's forthcoming NDS. We hope that policy-makers in Canada can review other NDSs, learn from their example, and develop an effective NDS for our country.
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http://dx.doi.org/10.5770/cgj.21.299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028171PMC
June 2018

A Rules-Based Algorithm to Prioritize Poor Prognosis Cancer Patients in Need of Advance Care Planning.

J Palliat Med 2018 06 13;21(6):846-849. Epub 2018 Mar 13.

1 Department of Medicine, University of Chicago , Chicago, Illinois.

Background: Accurate understanding of the prognosis of an advanced cancer patient can lead to decreased aggressive care at the end of life and earlier hospice enrollment.

Objective: Our goal was to determine the association between high-risk clinical events identified by a simple, rules-based algorithm and decreased overall survival, to target poor prognosis cancer patients who would urgently benefit from advanced care planning.

Design: A retrospective analysis was performed on outpatient oncology patients with an index visit from April 1, 2015, through June 30, 2015. We examined a three-month window for "high-risk events," defined as (1) change in chemotherapy, (2) emergency department (ED) visit, and (3) hospitalization. Patients were followed until January 31, 2017.

Setting/subjects: A total of 219 patients receiving palliative chemotherapy at the University of Chicago Medicine with a prognosis of ≤12 months were included.

Measurements: The main outcome was overall survival, and each "high-risk event" was treated as a time-varying covariate in a Cox proportional hazards regression model to calculate a hazard ratio (HR) of death.

Results: A change in chemotherapy regimen, ED visit, hospitalization, and at least one high-risk event occurred in 54% (118/219), 10% (22/219), 26% (57/219), and 67% (146/219) of patients, respectively. The adjusted HR of death for patients with a high-risk event was 1.72 (95% confidence interval [CI] 1.19-2.46, p = 0.003), with hospitalization reaching significance (HR 2.74, 95% CI 1.84-4.09, p < 0.001).

Conclusions: The rules-based algorithm identified those with the greatest risk of death among a poor prognosis patient group. Implementation of this algorithm in the electronic health record can identify patients with increased urgency to address goals of care.
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http://dx.doi.org/10.1089/jpm.2017.0408DOI Listing
June 2018

Gender differences in pain and patient reported outcomes: a secondary analysis of the NCIC CTG SC. 23 randomized trial.

Ann Palliat Med 2017 Dec 29;6(Suppl 2):S185-S194. Epub 2017 Aug 29.

Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada.

Background: Gender differences may contribute to variations in disease presentations and health outcomes. To explore the gender difference in pain and patient reported outcomes in cancer patients with bone metastases undergoing palliative radiotherapy on the National Cancer Institute of Canada (NCIC) SC.23 randomized trial.

Methods: Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life (QOL) bone metastases module (QLQ-BM22) and EORTC QOL Core-15-Palliative (QLQ-C15-PAL) before treatment and at days 10 and 42 after a single 8 Gy radiation treatment. Patient demographics, performance status, analgesic consumption, BM22 and C15 were compared between males and females using the 2-sample t-test for continuous variables or the Chi-squared test for categorical variables. Multiple linear regression models were used to check the difference between gender groups adjusting for the baseline demographics and primary disease sites.

Results: There were 298 patients (170 male, 128 female) with median age of 69 years. The most common primary cancer sites were lung, prostate and breast. At baseline, there were no differences in BM22 and C15 scores, except a worse nausea and vomiting score (P=0.03) in females on the C15. In patients with moderate baseline worst pain scores (WPS), females reported worse scores in painful sites of BM22. At day 42, there was no significant difference in response to radiotherapy. Among the responders, females reported better improvement in emotional aspect.

Conclusions: In cancer patients with bone metastases undergoing palliative radiotherapy, the majority of symptom presentations, patient reported outcomes, and response to radiation was not significantly different between genders.

Trial Registration: NCT01248585.
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http://dx.doi.org/10.21037/apm.2017.08.12DOI Listing
December 2017

Patient Reported Outcomes After Radiation Therapy for Bone Metastases as a Function of Age: A Secondary Analysis of the NCIC CTG SC-Twenty-Three Randomized Trial.

Am J Hosp Palliat Care 2018 Apr 26;35(4):718-723. Epub 2017 Sep 26.

1 Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.

Purpose: To explore the age difference in response and patient-reported outcomes in patients with cancer having bone metastases undergoing palliative radiotherapy.

Methods: Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) Quality-of-Life (QOL) Bone Metastases module (QLQ-BM22), EORTC QOL Core-15-Palliative (QLQ-C15-PAL), and Dexamethasone Symptom Questionnaire (DSQ) before a single 8-Gy radiation treatment, on days 10 and 42 after treatment. Patient demographics, performance status, analgesic consumption, BM22, C15, and DSQ were compared with multivariant analysis between patients under 75 years and 75 years and older. Multiple linear regression models were used to assess the differences between age-groups, adjusting for baseline demographics and primary disease sites.

Results: There were 298 patients (170 male) with 209 (70%) less than 75 years of age. Most common primary cancer sites include lung, prostate, and breast. At baseline, younger patients had better performance status, consumed more analgesic, and reported worse scores in nausea, insomnia, and functional interference, while older patients more commonly had prostate cancer. There were no significant differences in the incidence of radiation-induced pain flare; response to radiation; changes from baseline for BM22, C15-PAL; and DSQ, nor overall survival at day 42 between the 2 groups. Responders to radiation in the elderly group reported better improvement in physical and emotional domains when compared with nonresponders.

Conclusions: In patients with cancer having bone metastases undergoing palliative radiotherapy, there was no significant difference in general with age in response to radiation and patient-reported outcomes. Palliative radiotherapy should be offered to elderly patients when needed.
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http://dx.doi.org/10.1177/1049909117733435DOI Listing
April 2018

Attendance of older patients with bone metastases at a multidisciplinary bone metastases clinic: an 8-year experience.

Ann Palliat Med 2017 Aug 11;6(Suppl 1):S47-S51. Epub 2017 Jul 11.

Bone Metastases Clinic, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.

Background: Bone metastases clinic (BMC) is a multidisciplinary clinic where patients with bony metastases are assessed in conjunction by orthopedic surgery, radiation oncology, interventional radiology, and palliative medicine teams. The objective of the study was to determine the number of older adult (OA) referrals made to BMC and to examine their case dispositions.

Methods: Patients who were referred to the BMC from 2007 to 2015 were included in the study. Demographic information including gender, age, Karnofsky Performance Status (KPS), primary cancer site and reason for referral, as well as case dispositions were recorded for each patient. The proportion of OA attendance was calculated for each year from the total number of patient visits. OA attendance was defined as individuals ≥65 years of age who attended the BMC, and non-OA patients were those <65 years of age. Descriptive statistics were employed.

Results: A total of 551 patients were included with a median age of 64 years. The median KPS was 70 for OA and 80 for non-OA patients. OA attendance ranged per year from 42.5% to 58.7%. 14.1% of non-OA and 10.9% of OA patients were offered surgery. 62 patients in both cohorts (22.6% of OA and 22.4% of non-OA patients) were offered palliative radiation.

Conclusions: From 2007 to 2015, OA patients comprised a significant proportion of referrals to the BMC. Younger patients were offered surgery slightly more often when compared to OA patients. Age did not appear to be a precluding factor for BMC referral or a deterrent in treatments offered.
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http://dx.doi.org/10.21037/apm.2017.06.06DOI Listing
August 2017

Use of multimedia in patient and caregiver education for cancer pain management: a literature review.

Ann Palliat Med 2017 Jan 30;6(1):66-72. Epub 2016 Nov 30.

Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.

Pain is one of the most prominent symptoms faced by cancer patients. It is known that patient and caregiver-targeted educational interventions addressing the proper use of pain management may provide significant clinical value. This review examines the literature surrounding the use of multimedia interventions for patient and caregiver education (PCE) on pain management compared to traditional educational interventions. A literature search was conducted in Ovid MEDLINE (1946-July Week 2, 2016), Ovid Embase (1947-2016 Week 29), and Ovid Cochrane Central Register of Controlled Trials (up to June 2016). Paired reviewers conducted title and abstract screening and full-text screening to identify experimental, quasi-experimental and cohort studies evaluating one or more multimedia-based PCE interventions focused on cancer pain and pain management and targeting patients and/or caregivers. Findings were extracted by paired reviewers and synthesized qualitatively. Of the 68 full-text papers assessed, 7 were deemed relevant, of which 5 were RCTs and 2 were observational studies. We found limited but convincing quantitative data to suggest that the use of multimedia use in pain management education for patients/caregivers has greater value-added benefit compared to standard education. While there is evidence suggesting a positive effect on pain-related outcomes with the use of multimedia-based patient and caregiver-targeted interventions, it is limited to a small number of lower-quality studies. More robust and large-scale studies are needed to supplement existing evidence and provide more insight regarding the usability and user-friendliness of these tools in practice.
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http://dx.doi.org/10.21037/apm.2016.11.06DOI Listing
January 2017

Pain assessment tools for older adults with dementia in long-term care facilities: a systematic review.

Neurodegener Dis Manag 2016 12 18;6(6):525-538. Epub 2016 Nov 18.

Sunnybrook Health Sciences Centre, University of Toronto, Room FG19, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.

Aim: The aim of this review is to document pain assessment tools used primarily for older adults in long-term care facilities and compare self-report and observer-rated tools.

Methods: A literature search was conducted in Ovid MEDLINE, Embase, Cochrane and PsycINFO. Keywords included 'dementia', 'pain management' and 'managing pain'.

Results: Of 1033 references, 23 articles were selected for inclusion. Six tools were self-rated and 18 tools were administered by an observer. 13 studies evaluated the reliability/validity of their scales; four studies compared different scales against each other.

Conclusion: Self-report should be the first-line approach when possible, with observational assessment used as a supplementary tool. Reliable observational tools have been shortened, and shown to maintain high reliability/validity, and positive psychometric properties.
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http://dx.doi.org/10.2217/nmt-2016-0033DOI Listing
December 2016

Shared Goal Setting in Team-Based Geriatric Oncology.

J Oncol Pract 2016 11 30;12(11):1115-1122. Epub 2016 Sep 30.

University of Rochester; SCOREboard, Rochester, NY; The University of Chicago, Chicago, IL; and Wayne State University School of Medicine, Detroit, MI.

We present the case of a 92-year-old man, MH, who was given a diagnosis of colorectal cancer. His primary care physician, surgeon, geriatric oncologist, and family members all played important roles in his care. MH's case is an example of a lack of explicit shared goal setting by the health care providers with the patient and family members and how that impeded care planning and health. This case demonstrates the importance of explicitly discussing and establishing shared goals in team-based cancer care delivery early on and throughout the care process, especially for older adults. Each individual member's goals should be understood as they fit within the overarching shared team goals. We emphasize that shared goal setting and alignment of individual goals is a dynamic process that must occur several times at critical decision points throughout a patient's care continuum. Providers and researchers can use this illustrative case to consider their own work and contemplate how shared goal setting can improve patient-centered care and health outcomes in various team-based care settings. Shared goal setting among team members has been demonstrated to improve outcomes in other contexts. However, we stress, that little investigation into the impact of shared goal setting on team-based cancer care delivery has been conducted. We list immediate research goals within team-based cancer care delivery that can provide a foundation for the understanding of the process and outcomes of shared goal setting.
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http://dx.doi.org/10.1200/JOP.2016.013623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5455415PMC
November 2016

No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations.

J Oncol Pract 2016 10;12(10):e901-e911

University of Chicago Medicine; and University of Chicago, Chicago, IL.

Purpose: Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs.

Methods: This was a retrospective case series of patients cared for in an academic medical center's ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient's electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations.

Results: Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05).

Conclusion: Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care.
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http://dx.doi.org/10.1200/JOP.2016.012823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063186PMC
October 2016

The incidence of neuropathic pain in bone metastases patients referred for palliative radiotherapy.

Radiother Oncol 2016 Mar 25;118(3):557-61. Epub 2016 Feb 25.

Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada. Electronic address:

Background And Purpose: To estimate the prevalence of neuropathic pain in patients with symptomatic bone metastases referred for palliative radiotherapy.

Material And Methods: A prospective study of patients with symptomatic bone metastases was conducted. Patients referred for palliative radiotherapy completed the Self-Reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire to assess for neuropathic pain. Patient demographics, medication use, and radiotherapy prescribed were collected. Statistical approaches to identify relationships between the presence of neuropathic and other patient factors were conducted.

Results: 62 patients completed the S-LANSS and 16 (25.8%) patients had a score suggesting neuropathic pain. Fifty-nine (95.2%) patients received radiotherapy with total of 81 sites treated, the most common sites were spine and pelvis. No statistically significant difference in fractionation was found between patients with and without neuropathic pain. Of the 16 patients with neuropathic pain, only 2 were receiving a neuropathic specific analgesic. No significant difference between demographic factors or radiation treatments between patients with and without neuropathic pain was found. There was no significant difference in worst pain score between these two groups.

Conclusions: Pain with neuropathic features remains prevalent in a population of patients referred for palliative radiotherapy. More frequent prescription of pain medications targeting neuropathic pain may be warranted in this patient population.
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http://dx.doi.org/10.1016/j.radonc.2016.02.018DOI Listing
March 2016

Enteral and parenteral nutrition in cancer patients: a systematic review and meta-analysis.

Ann Palliat Med 2016 Jan;5(1):30-41

Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre,2075 Bayview Avenue, Toronto, Ontario M4N 3M5,Canada.

Background: In cancer patients, weight loss is an ominous sign suggesting disease progression and shortened survival time. As a result, providing nutrition support for cancer patients has been proposed as a logical approach for improving clinical outcomes. Nutrition support can be given to patients through enteral nutrition (EN) or parenteral nutrition (PN). The purpose of the review was to compare the outcomes of PN and EN in cancer patients.

Methods: A literature search was conducted in Ovid MEDLINE and OLDMEDLINE, Embase Classic and Embase, and Cochrane Central Register of Controlled Trials. Studies were included if over half of the patient population had cancer and reported on any of the following endpoints: the percentage of patients that experienced no infection, nutrition support complications, major complications or mortality. Risk ratios (RR) and 95% confidence intervals (CIs) using Review Manager Version 5.3 were calculated. Primary endpoints were stratified according to type of EN for subgroup analysis, grouping studies into either tube feeding (TF) or standard care (SC). Additionally, another subgroup analysis was conducted comparing studies with protein-energy malnutrition (PEM) patients and studies without PEM patients.

Results: The literature search yielded 674 articles of which 36 were included for the meta-analysis. There were no difference in the endpoints between the two study interventions except that PN resulted in more infection when compared with EN (RR =1.09, 95% CI: 1.01-1.18; P=0.03).

Conclusions: Other than increased incidence of infection, PN has not resulted in prolonging the survival, increasing nutrition support complications, or major complications when compared with EN in cancer patients.
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http://dx.doi.org/10.3978/j.issn.2224-5820.2016.01.01DOI Listing
January 2016

Socioeconomic Considerations and Shared-Care Models of Cancer Care for Older Adults.

Clin Geriatr Med 2016 Feb 9;32(1):35-44. Epub 2015 Oct 9.

Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA; Section of Hematology/Oncology, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.

Older adults with cancer require a geriatrics approach to treatment. Such an approach targets appropriate treatments based on physiologic, not chronologic, age. Patients older than 65 years of age constitute the largest group of patients with cancer, making them the most expensive group of patients with cancer, especially with the advent of expensive new treatments with minimal impact on overall survival. Geriatric assessment, combined with targeted inventions, can optimize the value propositions in caring for older patients with cancer. Over the past 20 years, geriatric oncology care models have emerged applying these care principles in clinical practice.
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http://dx.doi.org/10.1016/j.cger.2015.08.007DOI Listing
February 2016

The Use of Nipple Shields: A Review.

Front Public Health 2015 16;3:236. Epub 2015 Oct 16.

Toronto East General Hospital , Toronto, ON , Canada.

Introduction: A nipple shield is a breastfeeding aid with a nipple-shaped shield that is positioned over the nipple and areola prior to nursing. Nipple shields are usually recommended to mothers with flat nipples or in cases in which there is a failure of the baby to effectively latch onto the breast within the first 2 days postpartum. The use of nipple shields is a controversial topic in the field of lactation. Its use has been an issue in the clinical literature since some older studies discovered reduced breast milk transfer when using nipple shields, while more recent studies reported successful breastfeeding outcomes. The purpose of this review was to examine the evidence and outcomes associated with nipple shield use.

Methods: A literature search was conducted in Ovid MEDLINE, OLDMEDLINE, EMBASE Classic, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL. The primary endpoint was any breastfeeding outcome following nipple shield use. Secondary endpoints included the reasons for nipple shield use and the average/median length of use. For the analysis, we examined the effect of nipple shield use on physiological responses, premature infants, mothers' experiences, and health professionals' experiences.

Results: The literature search yielded 261 articles, 14 of which were included in this review. Of these 14 articles, three reported on physiological responses, two reported on premature infants, eight reported on mothers' experiences, and one reported on health professionals' experiences.

Conclusion: Through examining the use of nipple shields, further insight is provided on the advantages and disadvantages of this practice, thus allowing clinicians and researchers to address improvements on areas that will benefit mothers and infants the most.
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http://dx.doi.org/10.3389/fpubh.2015.00236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607874PMC
November 2015

A Selected Review of the Mortality Rates of Neonatal Intensive Care Units.

Front Public Health 2015 7;3:225. Epub 2015 Oct 7.

Toronto East General Hospital , Toronto, ON , Canada.

Introduction: Newborn babies in need of critical medical attention are normally admitted to the neonatal intensive care unit (NICU). These infants tend to be preterm, have low birth weight, and/or have serious medical conditions. Neonatal survival varies, but progress in perinatal and neonatal care has notably diminished mortality rates. In this selected review, we examine and compare the NICU mortality rates and etiologies of death in different countries.

Methods: A literature search was conducted in Ovid MEDLINE, OLDMEDLINE, EMBASE Classic, and EMBASE. The primary endpoint was the mortality rates in NICUs. Secondary endpoints included the reasons for death and the correlation between infant age and mortality outcome. For the main analysis, we examined all infants admitted to NICUs. Subgroup analyses included extremely low birth weight infants (based on the authors' own definition), very low birth weight infants, very preterm infants, preterm infants, preterm infants with a birth weight of ≤1,500 g, and by developed and developing countries.

Results: The literature search yielded 1,865 articles, of which 20 were included. The total mortality rates greatly varied among countries. Infants in developed and developing countries had similar ages at death, ranging from 4 to 20 days and 1 to 28.9 days, respectively. The mortality rates ranged from 4 to 46% in developed countries and 0.2 to 64.4% in developing countries.

Conclusion: The mortality rates of NICUs vary between nations but remain high in both developing and developed countries.
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http://dx.doi.org/10.3389/fpubh.2015.00225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4595739PMC
October 2015

Effect of Renal Dysfunction on Toxicity in Three Decades of Cancer Therapy Evaluation Program-Sponsored Single-Agent Phase I Studies.

J Clin Oncol 2016 Jan 21;34(2):110-6. Epub 2015 Sep 21.

Jan H. Beumer, Fei Ding, Hussein Tawbi, Yan Lin, and Selina L. Chow, University of Pittsburgh Cancer Institute; Jan H. Beumer, University of Pittsburgh School of Pharmacy; Jan H. Beumer and Hussein Tawbi, University of Pittsburgh School of Medicine; Yan Lin, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Diana Viluh, Indrani Chatterjee, and Matthew Rinker, Theradex, Princeton, NJ; and S. Percy Ivy, Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD.

Purpose: Alterations in renal clearance of anticancer drugs can affect the occurrence of toxicities related to drug exposure. The National Cancer Institute and the US Food and Drug Administration (FDA) use different criteria to classify renal dysfunction. We examined those discrepancies and their potential association with the incidence of toxicities in patients enrolled onto Cancer Therapy Evaluation Program-sponsored single-agent phase I studies over three decades (1979 to 2010).

Methods: Data to estimate creatinine clearance according to the Cockcroft-Gault and Jelliffe formulas were available from 10,236 patients, and data to estimate creatinine clearance according to the six- and four-variable Modification of Diet in Renal Disease formulas were available from a subset (n = 4,084). Patients were classified according to National Cancer Institute and FDA criteria, and the rates of clinically relevant toxicities were evaluated within groups and compared among groups.

Results: Cockcroft-Gault estimated renal function improved over time, which may be attributed to an increase in weight of patients in the same time frame. Approximately 36% of patients enrolled onto phase I trials had mild renal dysfunction by FDA criteria. Relative to normal function, mild renal dysfunction was associated with a statistically significant but small increase in grade 3 or 4 nonhematologic toxicity and any relevant toxicities.

Conclusion: Patients with mild renal dysfunction by FDA criteria have routinely been enrolled onto phase I studies of antineoplastics without clinically meaningful increase in the risk of toxicity. In future oncology renal dysfunction trials based on the FDA classification, the FDA mild group may only need to be activated when the moderate and normal groups differ substantially in tolerability or pharmacokinetics.
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http://dx.doi.org/10.1200/JCO.2014.59.7302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980565PMC
January 2016

Technical considerations in the development of circulating peptides as pharmacodynamic biomarkers for angiogenesis inhibitors.

J Clin Pharmacol 2014 Jun 17;54(6):682-7. Epub 2014 Jan 17.

Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.

To determine the biological reproducibility and estimate relevant covariates for candidate circulating biomarkers of angiogenesis, we conducted 3 sub-studies with ≤15 subjects each. In study 1, 6 healthy subjects provided 13 blood samples across 14-24 days. In study 2, 15 advanced solid tumor patients provided single blood samples before, and approximately 8 and 40 days after sorafenib treatment. In study 3, 4 healthy subjects provided blood samples on 3 occasions over 14 days, processed simultaneously in 2 different laboratories at a single institution. Vascular endothelial growth factor (VEGFA), soluble VEGF receptor-2 (sVEGFR2), and angiopoietin-2 (Ang2) concentrations in plasma and serum were determined by standard immunoassays. Ang2 and sVEGFR2 demonstrated low variance within and high variance across individuals reflected by the high intraclass correlation coefficient (for Ang2: 0.86 for plasma, 0.89 for serum; for sVEGFR2: 0.91 for plasma, 0.87 for serum). Repeated measures linear modeling from 15 patients demonstrated increased Ang2 (P ≤ 0.05) and decreased sVEGFR2 (P ≤ 0.05) after exposure to sorafenib. VEGFA had high intraindividual variance, and study 3 demonstrated the laboratory to have significant effects on plasma measurements (P ≤ 0.05). The biological reproducibility of sVEGFR2 and Ang2 support further use of these markers in studies of vasculature-targeted therapeutics.
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http://dx.doi.org/10.1002/jcph.254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4276412PMC
June 2014

A liver transplant recipient with an infected explanted liver.

Clin Infect Dis 2005 Jan;40(2):279, 313-4

School of Medicine, University of Maryland, Baltimore 21201, USA.

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http://dx.doi.org/10.1086/426896DOI Listing
January 2005