Publications by authors named "Shabbir M H Alibhai"

216 Publications

Evaluation of Sarcopenia in Older Patients Undergoing Head and Neck Cancer Surgery.

Laryngoscope 2021 Aug 12. Epub 2021 Aug 12.

Department of Otolaryngology Head and Neck Surgery/Surgical Oncology, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada.

Objectives/hypothesis: Sarcopenia is a hallmark of aging and its identification may help predict adverse postoperative events in patients undergoing head and neck surgery. The study objective was to assess the relationship between sarcopenia and postoperative complications and length of stay in patients undergoing major head and neck cancer surgery.

Study Design: Prospective cohort study.

Methods: A prospective cohort study was performed of patients 50 years and older undergoing major head and neck surgery. Sarcopenia was defined as low muscle mass (determined by neck muscle cross-sectional imaging) with either low muscle strength (grip strength) or low muscle performance (timed walk test). Logistic regression was applied on binary outcomes, and linear regression was used for log-transformed length of hospital stay (LOS). Univariate and multivariate analyses were performed.

Results: Of the 251 patients enrolled, pre-sarcopenia was present in 34.9% (n = 87) and sarcopenia in 15.6% (n = 39) of patients. Patients with sarcopenia were more likely to be older (P = .001), female (P = .001), have a lower body mass index (P = .001), and lower preoperative hemoglobin (P < .001). On univariate analysis, the presence and severity of sarcopenia was associated with the development of medical complications (P = .029), higher grade of complications (P = .032), LOS (P = .015), and overall survival (P = .001). On multivariate analysis, sarcopenia was associated with a longer LOS (β = 0.32 [95% CI: 0.19-0.45], P < .001) and worse overall survival (HR = 2.21 [95% CI: 1.01-4.23], P = .017).

Conclusions: Sarcopenia may aid in the prediction of prolonged hospital stay and death in patients who are candidates for major head and neck surgery.

Level Of Evidence: 3 Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29782DOI Listing
August 2021

Association of Chemotherapy, Enzalutamide, Abiraterone, and Radium 223 With Cognitive Function in Older Men With Metastatic Castration-Resistant Prostate Cancer.

JAMA Netw Open 2021 Jul 1;4(7):e2114694. Epub 2021 Jul 1.

Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Importance: Older adults are at greater risk of cognitive decline with various oncologic therapies. Some commonly used therapies for advanced prostate cancer, such as enzalutamide, have been linked to cognitive impairment, but published data are scarce, come from single-group studies, or focus on self-reported cognition.

Objective: To longitudinally examine the association between cognitive function and docetaxel (chemotherapy), abiraterone, enzalutamide, and radium Ra 223 dichloride (radium 223) in older men with metastatic castration-resistant prostate cancer.

Design, Setting, And Participants: A multicenter, prospective, observational cohort study was conducted across 4 academic cancer centers in Ontario, Canada. A consecutive sample of 155 men age 65 years or older with metastatic castration-resistant prostate cancer starting any treatment with docetaxel, abiraterone acetate, enzalutamide, or radium Ra 223 dichloride (radium 223) were enrolled between July 1, 2015, and December 31, 2019.

Exposures: First-line chemotherapy (docetaxel), abiraterone, enzalutamide, or radium 223.

Main Outcomes And Measures: Cognitive function was measured at baseline and end of treatment using the Montreal Cognitive Assessment, the Trail Making Test part A, and the Trail Making Test part B to assess global cognition, attention, and executive function, respectively. Absolute changes in scores over time were analyzed using univariate and multivariable linear regression, and the percentages of individuals with a decline of 1.5 SDs in each domain were calculated.

Results: A total of 155 men starting treatment with docetaxel (n = 51) (mean [SD] age, 73.5 [6.2] years; 34 [66.7%] with some postsecondary education), abiraterone (n = 29) (mean [SD] age, 76.2 [7.2] years; 18 [62.1%] with some postsecondary education), enzalutamide (n = 54) (mean [SD] age, 75.7 [7.4] years; 33 [61.1%] with some postsecondary education), and radium 223 (n = 21) (mean [SD] age, 76.4 [7.2] years; 17 [81.0%] with some postsecondary education) were included. Most patients had stable cognition or slight improvements during treatment. A cognitive decline of 1.5 SDs or more was observed in 0% to 6.5% of patients on each measure of cognitive function (eg, 3 of 46 patients [6.5%; 95% CI, 2.2%-17.5%] in the group receiving chemotherapy [docetaxel] had a decline of 1.5 SDs for Trails A and Trails B). Although patients taking enzalutamide had numerically larger declines than those taking abiraterone, differences were small and clinically unimportant.

Conclusions And Relevance: These findings suggest that most older men do not experience significant cognitive decline in attention, executive function, and global cognition while undergoing treatment for advanced prostate cancer regardless of the treatment used.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.14694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254132PMC
July 2021

Geriatric Assessment and Management in Cancer.

J Clin Oncol 2021 Jul 27;39(19):2058-2067. Epub 2021 May 27.

Department of Geriatric Medicine, Diakonessenhuis, Utrecht, the Netherlands.

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http://dx.doi.org/10.1200/JCO.21.00089DOI Listing
July 2021

The frequency and quality of delirium documentation in discharge summaries.

BMC Geriatr 2021 05 12;21(1):307. Epub 2021 May 12.

Division of General Internal Medicine and Geriatrics, Department of Medicine, University Health Network, Toronto, Ontario, Canada.

Background: The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services.

Methods: This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary.

Results: We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01).

Conclusions: The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term "delirium" more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.
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http://dx.doi.org/10.1186/s12877-021-02245-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117503PMC
May 2021

Examining the ability of the Cancer and Aging Research Group tool to predict toxicity in older men receiving chemotherapy or androgen-receptor-targeted therapy for metastatic castration-resistant prostate cancer.

Cancer 2021 Jul 2;127(14):2587-2594. Epub 2021 Apr 2.

Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Background: Because multiple treatments are available for metastatic castrate-resistant prostate cancer (mCRPC) and most patients are elderly, the prediction of toxicity risk is important. The Cancer and Aging Research Group (CARG) tool predicts chemotherapy toxicity in older adults with mixed solid tumors, but has not been validated in mCRPC. In this study, its ability to predict toxicity risk with docetaxel chemotherapy (CHEMO) was validated, and its utility was examined in predicting toxicity risk with abiraterone or enzalutamide (A/E) among older adults with mCRPC.

Methods: Men aged 65+ years were enrolled in a prospective observational study at 4 Canadian academic cancer centers. All clinically relevant grade 2 to 5 toxicities over the course of treatment were documented via structured interviews and chart review. Logistic regression was used to identify predictors of toxicity.

Results: Seventy-one men starting CHEMO (mean age, 73 years) and 104 men starting A/E (mean age, 76 years) were included. Clinically relevant grade 3+ toxicities occurred in 56% and 37% of CHEMO and A/E patients, respectively. The CARG tool was predictive of grade 3+ toxicities with CHEMO, which occurred in 36%, 67%, and 91% of low, moderate, and high-risk groups (P = .003). Similarly, grade 3+ toxicities occurred among A/E users in 23%, 48%, and 86% with low, moderate, and high CARG risk (P < .001). However, it was not predictive of grade 2 toxicities with either treatment.

Conclusions: There is external validation of the CARG tool in predicting grade 3+ toxicity in older men with mCRPC undergoing CHEMO and demonstrated utility during A/E therapy. This may aid with treatment decision-making.
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http://dx.doi.org/10.1002/cncr.33523DOI Listing
July 2021

Intensive versus less-intensive antileukemic therapy in older adults with acute myeloid leukemia: A systematic review.

PLoS One 2021 30;16(3):e0249087. Epub 2021 Mar 30.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.

To compare the effectiveness and safety of intensive antileukemic therapy to less-intensive therapy in older adults with acute myeloid leukemia (AML) and intermediate or adverse cytogenetics, we searched the literature in Medline, Embase, and CENTRAL to identify relevant studies through July 2020. We reported the pooled hazard ratios (HRs), risk ratios (RRs), mean difference (MD) and their 95% confidence intervals (CIs) using random-effects meta-analyses and the certainty of evidence using the GRADE approach. Two randomized trials enrolling 529 patients and 23 observational studies enrolling 7296 patients proved eligible. The most common intensive interventions included cytarabine-based intensive chemotherapy, combination of cytarabine and anthracycline, or daunorubicin/idarubicin, and cytarabine plus idarubicin. The most common less-intensive therapies included low-dose cytarabine alone, or combined with clofarabine, azacitidine, and hypomethylating agent-based chemotherapy. Low certainty evidence suggests that patients who receive intensive versus less-intensive therapy may experience longer survival (HR 0.87; 95% CI, 0.76-0.99), a higher probability of receiving allogeneic hematopoietic stem cell transplantation (RR 6.14; 95% CI, 4.03-9.35), fewer episodes of pneumonia (RR, 0.25; 95% CI, 0.06-0.98), but a greater number of severe, treatment-emergent adverse events (RR, 1.34; 95% CI, 1.03-1.75), and a longer duration of intensive care unit hospitalization (MD, 6.84 days longer; 95% CI, 3.44 days longer to 10.24 days longer, very low certainty evidence). Low certainty evidence due to confounding in observational studies suggest superior overall survival without substantial treatment-emergent adverse effect of intensive antileukemic therapy over less-intensive therapy in older adults with AML who are candidates for intensive antileukemic therapy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249087PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009379PMC
March 2021

A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations.

Front Oncol 2021 10;11:629207. Epub 2021 Mar 10.

Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

Background: Experimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies.

Methods: This is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a 'virtual program' using only telephone or internet-based communication for screening, assessments, or intervention was introduced.

Conclusion: This pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.
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http://dx.doi.org/10.3389/fonc.2021.629207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987917PMC
March 2021

Evaluation of the Braden scale in predicting surgical outcomes in older patients undergoing major head and neck surgery.

Laryngoscope Investig Otolaryngol 2021 Feb 9;6(1):103-108. Epub 2020 Dec 9.

Department of Otolaryngology Head and Neck Surgery/Surgical Oncology University Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada.

Background: Being able to predict negative postoperative outcomes is important for helping select patients for treatment as well for informed decision-making by patients. Frailty measures are often time and resource intensive to use as screening measures, whereas the Braden scale, a commonly used measure to assess patients at risk of developing pressure ulcers after surgery, may be a potential tool to predict postoperative complication rates and longer length of stay (LOS) in patients undergoing major head and neck cancer surgery.

Methods: A retrospective analysis of Braden scale scores was performed on a prospectively collected cohort of patients undergoing major head and neck surgery recruited between December 2011 and April 2014. The association of Braden scale score with the primary outcomes of complications and LOS was analyzed using logistic regression and linear regression models on univariate analysis (UVA), respectively. Multivariate analysis (MVA) was performed based on a backward stepwise selection algorithm.

Results: There were 232 patients with a mean (SD) Braden scale score of 14.9 (2.8) with a range from 9 to 23. The Braden scale (β = -.07 per point; 95% CI -0.09, -0.04,  < .001) was an independent predictor of increased LOS on UVA, but not on MVA when adjusted for other variables. For overall complications, as well as type of complication, the Braden scale score was not a significant predictor of complications on either UVA or MVA.

Conclusion: In the sample population, the Braden scale did not demonstrate an ability to predict negative outcomes in head and neck surgery patients.

Level Of Evidence: Level 2b individual cohort study.
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http://dx.doi.org/10.1002/lio2.491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883615PMC
February 2021

Multiphasic Prehabilitation Across the Cancer Continuum: A Narrative Review and Conceptual Framework.

Front Oncol 2020 11;10:598425. Epub 2021 Jan 11.

Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada.

The field of cancer survivorship has significantly advanced person-centered care throughout the cancer continuum. Within cancer survivorship, the last decade has seen remarkable growth in the investigation of prehabilitation comprising pre-treatment interventions to prevent or attenuate the burden of oncologic therapies. While the majority of evidence remains in the surgical setting, prehabilitation is being adapted to target modifiable risk factors that predict poor treatment outcomes in patients receiving other systemic and localized anti-tumor treatments. Here, we propose a multiphasic approach for prehabilitation across the cancer continuum, as a conceptual framework, to encompass the variability in cancer treatment experiences while adopting the most inclusive definition of the cancer survivor.
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http://dx.doi.org/10.3389/fonc.2020.598425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831271PMC
January 2021

Longitudinal Assessment of Frailty and Quality of Life in Patients Undergoing Head and Neck Surgery.

Laryngoscope 2021 07 11;131(7):E2232-E2242. Epub 2021 Jan 11.

Department of Otolaryngology - Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Objective: To understand changes in frailty and quality of life (QOL) in frail versus non-frail patients undergoing surgery for head and neck cancer (HNC).

Methods: Prospective cohort study of patients (median age 67 (50, 88)) with HNC undergoing surgery from December 2011 to April 2014. Fried's Frailty Index, Vulnerable Elders Survey (VES-13), and comprehensive QOL assessments (EORTC QLQ-C30 and HN35) were completed at baseline and 3, 6, and 12-month post-operative visits. Change in frailty and QOL over time was compared between frailty groups (non-frail (score 0), pre-frail (score 1-2), and frail (score 3-5)) using a mixed effects model. Predictors of long-term elevated frailty (12 months > baseline) were analyzed using logistic regression.

Results: The study had 108 patients classified as non-frail (47%), 104 pre-frail (mean (SD) 1.3 (0.4), 45%), and 17 frail (3.4 (0.6); 7%). Frailty score decreased significantly for frail patients 3 months post-operatively (2.1 (1.0); P = .002) and remained significantly lower than baseline at 6 and 12 months (2.1 (1.4); P = .0008 and 2.2 (1.5); P = .005, respectively) while frailty score increased for non-frail patients at 3 months (1.1 (1.0); P < .001) and then decreased. Forty-eight patients (21%) had long-term elevated frailty, with baseline frailty and marital status identified as predictors on univariate analysis. The frail population had significantly worse QOL scores at baseline, which persisted 12 months post-operatively.

Conclusions: Frail patients demonstrate a decrease in frailty score following surgical treatment of HNC. Frail patients have significantly worse QOL scores on longitudinal assessment and would benefit from supportive services throughout their care.

Level Of Evidence: 3 Laryngoscope, 131:E2232-E2242, 2021.
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http://dx.doi.org/10.1002/lary.29375DOI Listing
July 2021

Role of the vulnerable elders survey-13 screening tool in predicting treatment plan modification for older adults with cancer.

J Geriatr Oncol 2021 06 17;12(5):786-792. Epub 2020 Dec 17.

Department of Medicine, University Health Network, Canada; Department of Medicine, University of Toronto, Canada. Electronic address:

Background: The Vulnerable Elders Survey (VES-13) is commonly used to identify older patients who may benefit from Comprehensive Geriatric Assessment (CGA) prior to cancer treatment. The optimal cut point of the VES-13 to identify those whose final oncologic treatment plan would change after CGA is unclear. We hypothesized that patients with high positive VES-13 scores (7-10)have a higher likelihood of a change in treatment compared to low positive scores (3-6).

Methods: Retrospective review of a customized database of all patients seen for pre-treatment assessment in an academic geriatric oncology clinic from June 2015 to June 2019. Various VES-13 cut points were analyzed to identify those individuals whose treatment was modified after CGA. Area under the curve (AUC) was calculated and subgroups of patients treated locally or systemically were also examined to determine if performance varied by treatment modality.

Results: We included 386 patients with mean age 81, 58% males. Gastrointestinal cancer was the most common site (31%) and 60% were planned to receive curative treatment. The final treatment plan was modified in 59% overall, with 52.7% modified with VES-13 scores 7-10, 50.8% with scores 3-6 and 28.1% with scores <3 (P = 0.002). VES-13 performance in predicting treatment modification was similar for cut points 3 (AUC 0.58), 4 (0.59), 5 (0.59), and 6 (0.59) and in those considering local treatment vs. chemotherapy.

Conclusions: A positive VES-13 score was associated with final oncologic treatment plan modification. A high positive score was not superior to the conventional cut point of ≥3.
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http://dx.doi.org/10.1016/j.jgo.2020.12.002DOI Listing
June 2021

"This is my home-based exercise": exploring environmental influences on home-based exercise participation in oncology.

Support Care Cancer 2021 Jun 23;29(6):3245-3255. Epub 2020 Oct 23.

Faculty of Kinesiology and Physical Education, University of Toronto, 55 Harbord St, Toronto, Ontario, M5S 2W6, Canada.

Purpose: Home-based exercise interventions offer many health benefits; however, the environments that constitute home-based exercise are not well-understood. The purpose of this study was to explore what constitutes the "home" for cancer survivors engaging in home-based exercise and identify factors of the environment that may impact exercise participation.

Methods: We conducted a qualitative exploratory study of cancer survivors receiving a home-based exercise prescription to manage their cancer-related impairments. Semi-structured interviews included photo elicitation to actively involve participants in the interview process and provide opportunities to visually "observe" environments utilized for home-based exercise.

Results: Sixteen participants were interviewed (n = 11 women, median age = 53.5, range = 26-74 years) and three themes emerged: (1) reasons for participating in a home-based exercise program; (2) physical environmental influences and preferences; and (3) social environmental influences and preferences. The ability to self-manage exercise and accommodate competing demands, having access to exercise facilities, feeling comfortable exercising without qualified supervision, and a desire for autonomy were reasons home-based exercise programs were preferred. Participants reported that the physical environment influenced their experience with home-based exercise and sub-themes related to a dynamic environment, indoor and outdoor characteristics, and aesthetics were identified. The social environment, with sub-themes associated with the presence of people, social climate, exercise modeling, connection, and exercise support, also related to exercise behavior.

Conclusion: The findings highlight the influence of the physical and social environment on exercise prescription engagement. They further indicate the need for exercise professionals to consider the environment for exercise when delivering home-based exercise interventions.
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http://dx.doi.org/10.1007/s00520-020-05843-wDOI Listing
June 2021

The Effect of Yoga Interventions on Cancer-Related Fatigue and Quality of Life for Women with Breast Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Integr Cancer Ther 2020 Jan-Dec;19:1534735420959882

University of Toronto, Toronto, ON, Canada.

Background: Women with breast cancer (BC) are living longer with debilitating side effects such as cancer-related fatigue (CRF) that affect overall well-being. Yoga promotes health, well-being and may be beneficial in reducing CRF. Although there have been previous systematic reviews and meta-analyses, the effects of yoga on CRF and quality of life (QOL) remain unclear, particularly in comparison with other types of physical activity (PA). Our objective is to carry out a systematic review and meta-analysis of the effects of yoga on CRF and QOL in women with BC.

Methods: Electronic databases were searched (MEDLINE, Embase Classic+Embase and EMB Reviews, Cochrane Central CT) from inception to May 2018. Randomized controlled trials were included if they were full text, in English, included a yoga intervention, a comparator (including non-PA usual care or alternate PA intervention), and reported on CRF or QOL. Effects of yoga were pooled using standardized mean difference (SMD) via a random effects model.

Results: Of the 2468 records retrieved, 24 trials were included; 18 studies compared yoga to a non-PA comparator and 6 to a PA comparator. Yoga demonstrated statistically significant improvements in CRF over non-PA (SMD -0.30 [-0.51; -0.08]) but not PA (SMD -0.17 [-0.50; 0.17]) comparators. Additionally, yoga demonstrated statistically significant improvements in QOL over non-PA (SMD -0.27 [-0.46; -0.07]) but not PA (SMD 0.04 [-0.22; +0.31]) comparators.

Discussion: This meta-analysis found that yoga provides small to medium improvements in CRF and QOL compared to non-PA, but not in comparison to other PA interventions.
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http://dx.doi.org/10.1177/1534735420959882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580184PMC
August 2021

The suggested chemopreventive association of metformin with prostate cancer in diabetic patients.

Urol Oncol 2021 03 17;39(3):191.e17-191.e24. Epub 2020 Sep 17.

Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada.

Purpose: Metformin, an insulin sensitizer, is the most common first-line antidiabetic therapy. There is increasing evidence suggesting metformin can prevent the emergence of prostate cancer (CaP). We aimed to analyze the chemopreventive role of metformin, in conjunction with other putative chemopreventive medications (statins, proton-pump-inhibitors, alpha-blockers, 5-alpha-reductase inhibitors, diabetic medications) in a population-based cohort study.

Methods: Data were incorporated from the Institute for Clinical and Evaluative Sciences to identify all diabetic men aged 66 and above with prior history of a negative prostate biopsy (PB) between 1994 and 2016, who were not on any of the medications prior to study inclusion. Multivariable Cox regression models with time-dependent covariates were used to assess the association of metformin to CaP diagnosis, subsequent PB, and use of androgen deprivation therapy (ADT). All models were adjusted for age, rurality, comorbidity, and year of study inclusion.

Results: Overall, 2,332 diabetic men were included, with a median follow-up time of 9.4 years (interquartile range 5.4-13.4 years). A total of 2,036 patients (87.3%) received metformin. Compared to non-metformin users, metformin use was associated with decreased CaP diagnosis rate (HR 0.69, 95%CI 0.54-0.88, P = 0.003), lower hazard of undergoing an additional PB (HR 0.64, 95%CI 0.44-0.95, P = 0.03), and receiving ADT (HR 0.72, 95%CI 0.54-0.96, P = 0.003).

Conclusion: Men receiving metformin were less likely to have suspected or diagnosed CaP, and in those with CaP, the use of ADT was less common. Ongoing prospective randomized studies will determine if these findings correspond to the suggested associations of metformin in the emergence and/or progression of CaP.
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http://dx.doi.org/10.1016/j.urolonc.2020.08.032DOI Listing
March 2021

Delirium incidence, risk factors, and treatments in older adults receiving chemotherapy: A systematic review and meta-analysis.

J Geriatr Oncol 2021 04 14;12(3):352-360. Epub 2020 Sep 14.

Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada; Department of Medicine, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, ON M5T 1P8, Canada. Electronic address:

Introduction: Older adults with cancer are at increased risk of delirium due to age, comorbidities, medications, cognitive impairment, and possibly cancer treatments. However, there is scant information on the risks of delirium with chemotherapy and approaches to prevent or treat it. We performed a systematic review and meta-analysis to summarize available evidence.

Materials And Methods: We systematically searched peer-reviewed journal articles in English, French, German, and Dutch from five databases from 1990 to May 2019 to identify studies examining delirium in adult patients receiving chemotherapy. We also attempted to identify delirium risk prediction models and prevention or treatment trials. All reviews and data extraction were performed by two independent reviewers. Summary estimates were derived from random effects models.

Results: A total of 23,389 titles and abstracts were screened, and 1272 full-text articles were reviewed. Nineteen articles reported on delirium using an acceptable diagnostic standard. Sample sizes varied from 7 to 324. The incidence of delirium ranged from 0 to 51% (weighted mean 9%, 95% confidence interval 5-16%). In a sensitivity analysis including 122 studies that used terminology suggestive of delirium but did not meet our inclusion criteria, the weighted incidence of delirium was 10% (95% confidence interval 8-12%). Age was not consistently associated with increased delirium risk. No intervention studies to prevent or treat delirium were identified.

Conclusions: Delirium may occur in 1 in 11 older adults receiving chemotherapy; however, there were substantial limitations in reported studies. This systemic review highlights key gaps in knowledge, particularly regarding risk factors, prevention, and treatments.
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http://dx.doi.org/10.1016/j.jgo.2020.08.011DOI Listing
April 2021

Never too old to learn new tricks: Surveying Canadian healthcare professionals about learning needs in caring for older adults with cancer.

J Geriatr Oncol 2021 03 3;12(2):262-273. Epub 2020 Sep 3.

Oncology and Aging Program, Jewish General Hospital, Montreal, QC, Canada.

Introduction: The number of older adults with cancer is growing but little is known about healthcare professionals' (HCPs) perceptions of their readiness to care for older adults with cancer. The Canadian Network on Aging and Cancer together with the Canadian Association of Nurses in Oncology, Oncology and Aging Special Interest Group, conducted a survey to assess geriatric oncology learning needs of Canadian HCPs and explore any differences in needs between nurses and physicians.

Methods: An online survey was distributed to Canadian HCP, which assessed respondent confidence and desire to learn about domains related to geriatric oncology, current clinical practice and sociodemographic information. Descriptive statistics and chi-square tests were used to characterize participant characteristics, learning needs and compare learning needs of physicians vs. nurses.

Results: Respondents (n = 154) were mostly physicians (n = 78, 51%) or nurses (n = 56, 36%). Respondents reported not being confident addressing mental health issues (75%), polypharmacy (71%), geriatric oncology care models (69%), and return to baseline function post-treatment (67%). Physicians reported more confidence than nurses in managing comorbidities (72% vs. 49%, p < 0.05), having difficult conversations (90% vs. 68%, p < 0.001), and addressing ageism (76% vs. 58%, p < 0.05), while nurses reported more confidence with managing mobility limitations (64% vs 42%, p < 0.05), fall prevention (72% vs. 26%, p < 0.01) and supporting caregivers (74% vs 52%, p < 0.05). Nurses wanted to learn more about geriatric oncology than physicians for 10 domains (p < 0.05).

Conclusion: There is a need for interprofessional educational initiatives that address differences between nurses and physicians in clinical areas of confidence and learning needs.
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http://dx.doi.org/10.1016/j.jgo.2020.08.010DOI Listing
March 2021

The deleterious association between proton pump inhibitors and prostate cancer-specific mortality - a population-based cohort study.

Prostate Cancer Prostatic Dis 2020 12 8;23(4):622-629. Epub 2020 Jul 8.

Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada.

Background: Proton pump inhibitors (PPIs) are commonly prescribed medications that have been shown to have contradicting effects on cancer. We aimed to investigate the effect of pantoprazole and other PPIs on prostate cancer (PCa) specific mortality (PCSM), use of androgen deprivation therapy (ADT), and PCa diagnosis using a large Canadian population-based cohort.

Methods: We identified 21,512 men aged ≥ 66, with a history of a single negative prostate biopsy and no previous use of any of the analyzed medications between 1994 and 2016. Multivariable Cox regression models with time-dependent covariates were used to assess the associations of PPIs with PCa outcomes. All models included other medications with a putative chemopreventative effect on PCa-outcomes, and were adjusted for age, rurality, comorbidity, and study inclusion year.

Results: Over a mean follow-up of 8.06 years (SD 5.44 years), 10,999 patients (51.1%) used a PPI, 5187 patients (24.1%) had PCa, 2043 patients (9.5%) were treated with ADT, and 805 patients (3.7%) died from PCa. For every 6 months of cumulative use, pantoprazole was associated with a 3.0% (95% CI 0.3-6.0%) increased rate of ADT use, while any use of other PPIs was associated with a 39.0% (95% CI 18.0-64.0%) increased risk of PCSM. No association was found with PCa diagnosis.

Conclusions: Upon validation of the potentially negative association of PPIs with PCa, PPI use may need to be reassessed in PCa patients.
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http://dx.doi.org/10.1038/s41391-020-0248-9DOI Listing
December 2020

The Suggested Unique Association Between the Various Statin Subgroups and Prostate Cancer.

Eur Urol Focus 2021 May 30;7(3):537-545. Epub 2020 Jun 30.

Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada.

Background: The chemopreventive effect of various medications in prostate cancer (PCa) has gained interest. Specifically, the potential impact of statins on PCa incidence has been studied, but solely as a "drug family" overlooking the distinctive pharmacological properties of its two main subgroups: hydrophilic and hydrophobic statins.

Objective: To assess the impact of statin subgroups on PCa-specific mortality (PCSM), PCa diagnosis, and undergoing another prostate biopsy.

Design, Setting, And Participants: This is a population-based cohort study in Ontario identifying all men aged ≥66 yr with a history of a single negative prostate biopsy (representing healthy men at risk for PCa) between 1994 and 2016, who were not on any of the analyzed medications prior to the study, with a median follow-up of 9.42 yr (interquartile range 8.03 yr).

Outcome Measurements And Statistical Analysis: Using multivariable cause-specific hazard models with time-dependent covariates, the association of hydrophobic and hydrophilic statins with all study outcomes was analyzed. Other putative chemopreventive medications (including alpha-blockers, 5-alpha-reductase inhibitors, and proton-pump inhibitors), age, rurality, comorbidities, and study inclusion year were included in the models.

Results And Limitations: Overall, 21 512 men were identified. Statins were taken by 11 401 patients (50.3%), 5184 men (24.1%) were diagnosed with PCa, and 805 (3.7%) died from it. Overall, 7556 patients (35.1%) underwent another biopsy. Any use of hydrophilic statins was associated with a 32.4% (95% confidence interval [CI] 12.9-47.5%), a 20% (95% CI 10-28%), and an 18% (95% CI 6.1-27.3%) decreased risk of PCSM, undergoing another prostate biopsy, and being diagnosed with PCa, respectively. Hydrophobic statins were associated with 17% (95% CI 2-31%) decreased PCSM. The study is limited by its retrospective nature, selection bias, and accompanying health-administrative database inaccuracies.

Conclusions: Use of any statin may be associated with a lower hazard of PCSM, with hydrophilic statins showing a greater association with decreased PCa diagnosis rates. Preferentially prescribing one statin subgroup over another in men needs further exploration.

Patient Summary: Use of any statin may be associated with a lower probability of dying from prostate cancer. Hydrophilic statins (rosuvastatin and pravastatin) may also be more positively associated with a lower risk of undergoing an additional prostate biopsy and being diagnosed with prostate cancer in men aged ≥66 yr.
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http://dx.doi.org/10.1016/j.euf.2020.06.005DOI Listing
May 2021

Pilot prospective study of Frailty and Functionality in routine clinical assessment in allogeneic hematopoietic cell transplantation.

Bone Marrow Transplant 2021 01 30;56(1):60-69. Epub 2020 Jun 30.

Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.

A Frailty and Functionality evaluation for alloHCT was implemented using existing resources. We describe the implementation of this evaluation across all ages and at first consultation, and correlate results with posttransplant outcomes in 168 patients. The evaluation consists of: Clinical Frailty Scale (CFS), Instrumental Activities of Daily Living (IADL), grip strength (GS), timed up and go test (TUGT), self-rated health question (SRH), Single question of Falls, albumin and C-Reactive Protein (CRP) levels. Median time to perform the evaluation was 5-6 min. Median age was 58 years (range: 19-77) and median follow-up was 5.3 months. TUGT > 10 s (HR 2.92; p = 0.003), raised CRP (HR 4.40; p < 0.001), and hypoalbuminemia (HR 2.10; p = 0.043) were significant risk factors for worse overal survival (OS). CFS ≥ 3 (HR 3.11; p = 0.009), TUGT > 10 s (HR 3.47; p = 0.003), GS (HR 2.56; p = 0.029), SRH ( 10 s and raised CRP were significant predictors for worse OS and NRM. SRH (
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http://dx.doi.org/10.1038/s41409-020-0979-1DOI Listing
January 2021

Key Perspectives on Managing Older Patients with Prostate Cancer: What We Know About the Fit and What We Need to Know About the Frail.

Eur Urol Oncol 2020 08 16;3(4):410-411. Epub 2020 Jun 16.

Department of Medicine, University Health Network, University of Toronto, Toronto, Canada.

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http://dx.doi.org/10.1016/j.euo.2020.05.006DOI Listing
August 2020

Exercise before, during, and after Hospitalization for Allogeneic Hematological Stem Cell Transplant: A Feasibility Randomized Controlled Trial.

J Clin Med 2020 Jun 14;9(6). Epub 2020 Jun 14.

Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada.

People with cancer who undergo allogeneic hematological stem cell transplant (allo-HSCT) experience significant deconditioning that can compromise quality of life. Exercise has shown to be beneficial before or after allo-HSCT; however, little is known about exercise therapy delivered across the continuum of care. We conducted a feasibility randomized controlled trial of exercise delivered prior to admission, during the inpatient stay, and after discharge versus control in people with planned allo-HSCT. Feasibility was assessed via recruitment and retention rates, the incidence of adverse events, and adherence to the exercise prescription. Estimates of efficacy were measured at baseline, one week prior to hospital admission, and 100 days and one year after transplant. The recruitment and retention rates were 20% and 33%, respectively. One serious adverse event occurred during the baseline six-minute walk test that precluded participation in the study and no adverse events were associated with the intervention. From baseline to pre-transplant, the intervention group improved six-minute walk test distances by 45 m (95% CI: -18.0 to 108.7)-a finding that warrants further investigation with an adequately powered trial. Our study contributes important feasibility considerations and pilot data for future exercise intervention research in allo-HSCT recipients.
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http://dx.doi.org/10.3390/jcm9061854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355733PMC
June 2020

Cannabis and cannabinoids in cancer pain management.

Curr Opin Support Palliat Care 2020 06;14(2):87-93

Department of Anesthesiology and Pain Medicine, University of Toronto.

Purpose Of Review: An increasing number of patients are turning to cannabis and cannabinoids for management of their palliative and nonpalliative cancer pain and other cancer-related symptoms. Canadians have a legal framework for access to medical cannabis, which provides a unique perspective in a setting lacking robust clinical evidence. This review seeks to delineate the role of cannabis and cannabinoids in cancer pain management and offers insight into the Canadian practice.

Recent Findings: A cohort study using nabiximols on advanced cancer pain in patients already optimized on opioids, over 3 weeks, demonstrated improved average pain score. A large observational study of cancer patients using cannabis over 6 months demonstrated a decreased number of patients with severe pain and decreased opioid use, whereas the number of patients reporting good quality of life increased.

Summary: Good preclinical animal data and a large body of observational evidence point to the potential efficacy of cannabinoids for cancer pain management. However, there are relatively weak data pointing to clinical efficacy from clinical trial data to date. In Canada, the burgeoning cannabis industry has driven the population to embrace a medicine before clinical evidence. There remains a need for high-quality randomized controlled trials to properly assess the effectiveness and safety of medical cannabis, compared with placebo and standard treatments for cancer-related symptoms.
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http://dx.doi.org/10.1097/SPC.0000000000000493DOI Listing
June 2020

Variability and limitations in home-based exercise program descriptions in oncology: a scoping review.

Support Care Cancer 2020 Sep 16;28(9):4005-4017. Epub 2020 Apr 16.

Faculty of Kinesiology and Physical Education, The University of Toronto, 55 Harbord St., Toronto, Ontario, M5S 2W6, Canada.

Background: The literature reflects considerable heterogeneity in what constitutes home-based exercise interventions. The variability for where and what "home-based" exercise can represent challenges interpretation of findings and appropriate advocacy, referral, or development of these models of care. Therefore, the objective of this review was to provide a comprehensive summary of how home-based exercise is defined and reported in the literature and summarize the range of supportive elements utilized in home-based exercise trials.

Methods: We followed methodology for scoping reviews. Relevant research databases were searched from inception to March 2019. Two reviewers independently screened articles to determine eligibility and extracted terminology used to describe home-based exercise and intervention details for intervention delivery.

Results: Of the 9432 records identified, 229 articles met inclusion criteria. Across the literature, exercise interventions were described as home-based if they were completed at-home, outdoors in the neighbourhood, and in community facilities; or in self-selected environments; or if they were unsupervised. Supportive elements for home-based models ranged with respect to the amount of supervision and resources utilized, including the provision of print materials, exercise equipment, telephone support, home visits, and technology.

Conclusions: This review provides a comprehensive summary of strategies previously utilized to deliver home-based exercise interventions in oncology, along with the various definitions of the home-based environment for exercise reported by researchers. Specific recommendations to improve the prescription and reporting of home-based exercise interventions are provided in order to facilitate the delivery, evaluation, and translation of findings into clinical practice.
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http://dx.doi.org/10.1007/s00520-020-05453-6DOI Listing
September 2020

Age differences in patterns and confidence of using internet and social media for cancer-care among cancer survivors.

J Geriatr Oncol 2020 07 10;11(6):1011-1019. Epub 2020 Mar 10.

Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Pediatric Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada. Electronic address:

Objectives: The internet and social media provide information and support to cancer survivors, and adolescent and young adults (AYA, age < 40 years), adults, and older (age 65+ years) cancer survivors may have different needs. We evaluated the impact of age on cancer-related internet and social media use and confidence in evaluating online information for cancer-care decision making.

Materials And Methods: Cancer survivors completed a convenience cross-sectional survey evaluating their cancer-related internet and social media use and their confidence in using these resources for decision making. Multivariable regression models evaluated the impact of age on usage patterns and confidence.

Results: Among 371 cancer survivors, 58 were older adults and 138 were AYA; 74% used the internet and 39% social media for cancer care; 48% felt confident in using online information for cancer-care decisions. Compared to adult survivors, there was a non-significant trend for older survivors to be less likely to use the internet for cancer-care information(aOR = 0.49, 95% CI[0.23-1.03], P = .06), while AYA were more likely to use social media for cancer-care (aOR = 1.79[1.08-2.99], P = .03). Although confidence at using online information for cancer-care decision making did not differ between age groups, increasing age had a non-significant trend towards reduced confidence (aOR = 0.99 per year [0.97-1.00], P = .09). Most commonly researched and desired online information were causes/risk factors/symptoms, treatment options, and prognosis/outcomes.

Conclusions: Age may influence the use of internet and social media for cancer-care, and older cancer survivors may be less confident at evaluating online information for cancer-care decision making. Future research should explore other strategies at meeting the informational needs of older cancer survivors.
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http://dx.doi.org/10.1016/j.jgo.2020.02.011DOI Listing
July 2020

Associations between self-reported physical activity, quality of life, and emotional well-being in men with prostate cancer on active surveillance.

Psychooncology 2020 06 18;29(6):1044-1050. Epub 2020 Mar 18.

Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada.

Objective: The relationship between physical activity (PA) and quality of life (QOL) relative to active treatment for prostate cancer (PCa) has been well-studied; however, little is known about this relationship during active surveillance (AS). Moreover, whether PA is associated with better emotional well-being (EWB) in men with low-risk PCa requires further investigation. Accordingly, we examined the association between self-reported PA and the average change in QOL and EWB over time during AS.

Methods: A total of 630 men on AS were included in this retrospective, longitudinal study from AS initiation until AS discontinuation. Generalized estimated equations were used to determine the association between self-reported PA (independent variable) and QOL and EWB (dependent variables) over time, adjusting for participants' age.

Results: QOL was higher over time in active ( (95%CI) = 1.14 (0.11, 2.16), P = .029) and highly active participants ( (95%CI) = 1.62 (0.58, 2.67), P = .002) compared to their inactive counterparts. Highly active participants had 55% greater odds of experiencing high EWB relative to inactive participants (OR (95%CI) = 1.55 (1.11, 2.16), P = .010). In men with low EWB at baseline (median = 3 months after diagnosis), the highest levels of PA (>1000 metabolic equivalent-minutes per week) were associated with high EWB over time (OR (95%CI) = 2.17 (1.06, 4.46), P = .034).

Conclusions: These data further support the importance of PA as a supportive care strategy for men on AS. Our findings suggest that engaging in higher volumes of PA post-diagnosis may be beneficial particularly for men exhibiting low emotional well-being early on during AS.
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http://dx.doi.org/10.1002/pon.5375DOI Listing
June 2020

Effects of six months of aerobic and resistance training on metabolic markers and bone mineral density in older men on androgen deprivation therapy for prostate cancer.

J Geriatr Oncol 2020 09 3;11(7):1074-1077. Epub 2020 Mar 3.

Department of Supportive Care, University Health Network, Toronto, ON M5G 2C4, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto ON M5S 1A1, Canada; Faculty of Medicine, University of Toronto, Toronto ON M5S 1A8, Canada.

Background: Androgen deprivation therapy (ADT) for prostate cancer (PCa) is associated with metabolic perturbations and declines in bone mineral density (BMD). Exercise interventions provide multiple health benefits to older men on ADT; however, their effect on metabolic biomarkers and BMD remains unclear.

Methods: A secondary analysis of a phase II randomized controlled trial was conducted to assess the effect of a six-month moderate-intensity aerobic and resistance exercise program on metabolic biomarkers and BMD in men on ADT. Participants were randomized to three different exercise delivery models: personal training; supervised group exercise; or home-based exercise. Analysis of metabolic biomarkers (lipid profile and glucose) was conducted at baseline, six and twelve months. BMD of the lumbar spine, femoral neck and hip were assessed at baseline and twelve months. Both within- and between-group analyses of change scores adjusted for baseline values were performed.

Results: Forty-eight men (mean age 69.8y) were enrolled. Baseline values of metabolic biomarkers and BMD were comparable between groups and the three groups were combined for the primary analysis. At six months, no changes in metabolic biomarkers were found; however, at twelve months low-density lipoprotein (+0.28 mmol/L; 95%CI, 0.04 to 0.51) and total cholesterol (+0.31 mmol/L; 95%CI, 0.00 to 0.61) were significantly increased from baseline. No changes were found in BMD. In a secondary between-group analysis, no improvements were observed for any metabolic biomarker or BMD measurement.

Conclusions: Different exercise prescription parameters (modality and intensity) or combined diet/exercise interventions may be needed to foster favorable metabolic and skeletal adaptations during ADT.
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http://dx.doi.org/10.1016/j.jgo.2020.02.013DOI Listing
September 2020

The long-term outcomes of Gleason grade groups 2 and 3 prostate cancer managed by active surveillance: Results from a large, population-based cohort.

Can Urol Assoc J 2020 Jun;14(6):174-181

Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada.

Introduction: Active surveillance (AS) is an accepted management strategy for low-risk prostate cancer (PCa), but its role in the management of favorable intermediate-risk PCa remains controversial. Most reports studying the role of AS for these men generally lack long-term followup and include small numbers of patients. Our objective was to report the outcomes of men diagnosed with Gleason grade groups (GGG) 2 and 3 PCa who were managed expectantly.

Methods: Using administrative datasets and pathology reports, we identified all men who were diagnosed with GGG 2 and 3 PCa and managed expectantly between 2002 and 2011 in Ontario, Canada. Outcomes and associated factors were estimated using cumulative incidence function methods and multivariable Cox regression models, respectively.

Results: We identified 926 men who were managed expectantly (AS [n=374] or watchful waiting [n=552]). The eight-year cancer-specific survival was 94% and 89% for the AS and watchful waiting cohorts, respectively. Among AS men, 266 (71%) received treatment after a followup of approximately eight years. Cumulative AS discontinuation rates at one and five years were 30.5% and 65.1%, respectively.

Conclusions: Expectant management of GGG 2 and 3 PCa may be an option for certain men. Notably for AS patients, the cancer-specific mortality at eight years was 6%, and over 65% of men underwent treatment within five years. Further studies are required to evaluate which patients, based on disease-specific features and competing health risks, would benefit most from a conservative strategy.
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http://dx.doi.org/10.5489/cuaj.6328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654679PMC
June 2020

Local Failure in High-grade Prostate Cancer: An Elusive but Important Outcome and Target for Clinical Trials.

Eur Urol 2020 02 29;77(2):209-210. Epub 2019 Nov 29.

Radiation Medicine Program, University Health Network, University of Toronto, Toronto, Canada.

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http://dx.doi.org/10.1016/j.eururo.2019.11.013DOI Listing
February 2020

Downstream consequences of abnormal cognitive screening in older adults seen pretreatment in a geriatric oncology clinic.

J Geriatr Oncol 2020 06 8;11(5):784-789. Epub 2019 Nov 8.

Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada. Electronic address:

Introduction: Although screening for cognitive impairment (CI) is an important part of a comprehensive geriatric assessment (CGA), little is known about the downstream work-up of abnormal screening or its impact on cancer treatment. We characterized the downstream workup in diagnosing CI and its impact on cancer treatment decision-making.

Methods: Patients who underwent a pre-treatment CGA at an academic Geriatric Oncology (GO) clinic between July 2015 and June 2018 and had a positive Mini-Cog (≤ 3 out of 5) screen were included. Data were collected from medical charts and database review. Analyses were primarily descriptive.

Results: Of 82 patients seen in the pre-treatment setting, 46 (56.1%) had a positive Mini-Cog screen. Of those, 12 (26.1%) were diagnosed with dementia, 8 (17.4%) were diagnosed with mild cognitive impairment and 10 (21.7%) had CI not otherwise specified. Although 46 patients had a positive screen, only 30 patients (65.2%) were classified as cognitively "abnormal" in the GO team final assessment. Change to oncologic treatment due to CI was seen in 12 (40.0%) cases. Increased delirium risk was identified in 9 (75.0%) of 12 surgical cases; however, delirium prevention was only recommended in 5 cases (55.6%). Strategies to optimize patients with CI included targeting falls prevention (n = 13), home/personal safety (n = 7), medication safety (n = 7), and nutrition (n = 6). Pharmacotherapy for cognition was not recommended in any case.

Conclusion: Undiagnosed CI is prevalent in the GO setting and influenced treatment in 40.0% of cases. Gaps were identified in clinician and patient/caregiver education around delirium risk. Addressing these issues may improve patient care.
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http://dx.doi.org/10.1016/j.jgo.2019.10.022DOI Listing
June 2020

Vitamin B12 Therapy in Older Adults and Misconception of Its Inappropriateness.

JAMA Intern Med 2019 11;179(11):1606

Division of General Internal Medicine and Geriatrics, University Health Network, Sinai Health System, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1001/jamainternmed.2019.4926DOI Listing
November 2019
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