Five-Year Trends in Reported National Football League Injuries.

OBJECTIVE: To determine the incidence of all-cause injury and concussion in the National Football League (NFL) over a 5-season time span (2012-2016). DESIGN: Prospective descriptive epidemiological study. SETTING: National Football League Injury Report data from 2012 to 2016. PARTICIPANTS: National Football League players. INTERVENTIONS: None (descriptive study). MAIN OUTCOME MEASURES: Injury report data were collected prospectively for all NFL injuries from 5 seasons (2012-2016). The incidences of reported concussions, knee injuries, and all-cause injury were compared across the 5 seasons using the Kruskal-Wallis rank-sum test. RESULTS: A total of 10 927 injuries were identified across the 5 seasons, including 752 (6.9%) concussions. The top 3 most injured areas included the knee (17.2%), ankle (13.6%), and shoulder (8.8%). Defensive backs consistently had the highest number of all-cause injuries per season. When comparing across years, there was a significant decrease in all-cause injury in 2016 compared with 2015, a significant decrease in knee injuries in 2016 compared with 2015, and a significant increase in concussion in 2015 compared with 2014 (P < 0.05). CONCLUSIONS: Reported all-cause injury incidence and knee injury incidence is currently on the decline. However, reported concussion incidence has recently increased, perhaps due to increased awareness and rule changes implemented to aid in the detection and treatment of concussion. Strategies to reduce injury and improve injury awareness should continue to be explored.

Quality of life (QOL) and symptom burden (SB) in patients with breast cancer.

PURPOSE: The purpose of this study was to determine the quality of life (QOL) and symptom burden (SB) among breast cancer patients. METHODS: Patients with DCIS, early stage, locally advanced, or metastatic breast cancer completed the Edmonton Symptom Assessment System (ESAS) and the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B). Patients were divided into subsequent cohorts based on their last day of treatment, age at enrollment, radiation, chemotherapy, and hormone therapy. RESULTS: A total of 1513 patients were enrolled. Metastatic patients had a lower QOL and greatest SB compared to all other patient groups. Patients ≤50 years old with early stage or locally advanced breast cancer had a lower QOL and greater SB for fatigue, depression, and anxiety compared to all other age cohorts. Patients with early stage breast cancer who received chemotherapy had a lower QOL and greater SB. Patients taking selective estrogen receptor modulator (SERM) had greater SB for depression and lower QOL compared to those not on SERM. Patients 2-10 years post-treatment had a lower QOL compared to patients ≥10 years post-treatment. CONCLUSION: Patients ≤50 years old, 2-10 years post-treatment, treated with chemotherapy or SERM had increased SB and decreased QOL. Individualized interventions and programs can be developed to tailor to physical, educational, and psychosocial needs identified across the breast cancer continuum.

Quality of life and symptom burden in patients with metastatic breast cancer.

PURPOSE: The goal of this study was to examine the symptom burden (SB) and quality of life (QOL) in patients with metastatic breast cancer. METHODS: Breast cancer patients with metastases were asked to complete the Edmonton Symptom Assessment System (ESAS) and FACT-B questionnaires. Statistical analysis was performed to identify (1) any differences in SB and QOL between patients with bone metastases only and patients with visceral +/- bone metastases and (2) any associations between SB and/or QOL and various clinical factors, including treatment with bisphosphonates, participation in a clinical trial and presence of brain metastases. RESULTS: A total of 174 patients were enrolled. Treatment with bisphosphonates was significantly associated with lower ESAS well-being scores (less symptoms) in patients with bone metastases only. In this same group, receiving treatment prior to diagnosis of metastases was significantly associated with increased fatigue, anxiety and dyspnoea. The presence of brain metastases was associated with higher physical well-being scores (increased QOL). Participation in clinical trials was associated with better QOL. CONCLUSION: Breast cancer patients with metastases have different SB and QOL in relation to the type of the metastases, treatment interventions and participation in clinical trials.

Stereotactic body radiation therapy for non-spine bone metastases--a review of the literature.

BACKGROUND: Stereotactic body radiation therapy (SBRT) has the ability to deliver significantly higher biologically equivalent doses (BED) compared to conventional radiation treatment. The main goal of SBRT is to improve local tumor control while reducing pain. The side effects however may be greater than those of conventional treatment. METHODS: A review of the literature was conducted and articles pertaining to studies of SBRT in non-spine bone metastases were included. Data on outcomes and toxicities were collected in addition to inclusion and exclusion criteria for each study. RESULTS: A total of 14 studies were included in this review. Very rarely were grade 3 and 4 toxicities reported. Endpoints for the studies varied significantly, which made conclusions of overall local control and progression free survival near impossible. In studies that reported local control rates, these rates were all greater than 85%. Progression free survival varied significantly between studies. CONCLUSIONS: Due to the lack of consistency in endpoint definitions, it is difficult to compare outcomes across trials. There is a need for consensus in endpoint definitions.

Quality of life and symptom burden in patients with breast cancer treated with mastectomy and lumpectomy.

INTRODUCTION: Mastectomy (MAS) and lumpectomy (LUMP) are the two common local surgical treatments for early breast cancer. There has been a debate whether MAS or LUMP results in better quality of life (QOL). The purpose of this study was to examine the symptom burden (SB) and QOL of both MAS and LUMP patients. METHODS: Patients at the Louise Temerty Breast Cancer Centre in Toronto, Canada, were approached to complete two self-administered questionnaires, the Edmonton Symptom Assessment Score (ESAS) and the Functional Assessment of Cancer Therapy-Breast (FACT-B) cancer edition. Additionally, patient demographics were recorded from medical records. Patients were divided into two cohorts depending on their surgical treatment: MAS and LUMP. The QOL and SB, assessed by FACT-B and ESAS, respectively, of MAS and LUMP patients were compared. The analysis was repeated excluding patients with metastases. RESULTS: From January to August 2014, 614 MAS and 801 LUMP patients were accrued. The MAS patients reported a lower QOL in all categories, except social well-being. There was however no statistical difference in ESAS scores for MAS and LUMP patients with non-metastatic breast cancer. CONCLUSION: This study supports existing literature that SB of MAS and LUMP patients without metastases are similar. QOL of MAS patients including those with metastases was lower than that of LUMP patients.

Impaired timing of audiovisual events in the elderly.

Perceptual binding of multisensory events occurs within a limited time span known as the temporal binding window. Failure to correctly identify whether multisensory events occur simultaneously, what their temporal order is, or whether they should be causally bound can lead to inaccurate representations of the physical world, poor decision-making, and dangerous behavior. It has been shown that the ability to discriminate simultaneity, temporal order, and causal relationships among stimuli can become increasingly difficult as we age. In the present study, we assessed the relationship between these three attributes of temporally processing multisensory information in both younger and older adults. Performance on three tasks (temporal order judgment: TOJ, simultaneity judgment: SJ, and stream/bounce illusion) was compared using a large sample within-subjects design consisting of younger and older adults to determine aging effects as well as relationships between the three tasks. Older adults had more difficulty (larger temporal binding window) discriminating temporal order and perceived collision than younger adults. Simultaneity judgments in younger and older adults were indistinguishable. Positive correlations between TOJ and SJ as well as SJ and stream/bounce tasks were found in younger adults, which identify common (SJ) and distinct (TOJ, stream/bounce) neural mechanisms that sub-serve temporal processing of audiovisual information that is lost in older adults. We conclude that older adults have an extended temporal binding window for TOJ and stream/bounce tasks, but the temporal binding window in SJ is preserved, suggesting that age-related changes in multisensory integration are task specific and not a general trait of aging.

Minimal important differences in the EORTC QLQ-C15-PAL to determine meaningful change in palliative advanced cancer patients.

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

Quality of life after palliative radiotherapy in bone metastases: A literature review.

OBJECTIVE: To investigate the quality of life (QOL) following palliative radiotherapy for painful bone metastases. METHODS: A literature search was conducted in OvidSP Medline (1946-Jan Week 4 2014), Embase (1947-Week 5 2014), and the Cochrane Central Register of Controlled Trials (Dec 2013) databases. The search was limited to English. Subject headings and keywords included 'palliative radiation', 'cancer palliative therapy', 'bone metastases', 'quality of life', and 'pain'. All studies (prospective or retrospective) reporting change in QOL before and after palliative radiotherapy for painful bone metastases were included. RESULTS: Eighteen articles were selected from a total of 1730. The most commonly used tool to evaluate QOL was the Brief Pain Inventory. Seventeen studies collected data prospectively. An improvement in symptoms and functional interference scores following radiotherapy was observed in all studies. The difference in changes in QOL between responders and non responders was inconsistently reported. CONCLUSION: QOL improves in patients who respond to palliative radiotherapy for painful bone metastases.

Prophylactic dexamethasone effectively reduces the incidence of pain flare following spine stereotactic body radiotherapy (SBRT): a prospective observational study.

PURPOSE: The purpose of this study was to determine the incidence of pain flare (PF) in patients receiving spine stereotactic body radiotherapy (SBRT) treated with prophylactic oral dexamethasone (DEX) 1 h before and for 4 days following SBRT. METHODS: Forty-seven patients were accrued on this prospective observational study. The first cohort of 24 patients was treated with 4 mg, while a second cohort of 23 patients treated with 8 mg of DEX. The Brief Pain Inventory (BPI) was used to score pain and functional interference each day during SBRT and for 10 days following. Comparisons between the 4 and 8 mg cohorts, in addition to our previously reported steroid naïve patients post SBRT (n = 41), were also performed. RESULTS: The total incidence of PF was 19 % (9/47). The incidence in the 4 and 8 mg cohorts was 25 % (6/24) and 13 % (3/23), respectively, and the difference was not statistically significant (p = 0.46). Comparing functional interference, the 4 mg cohort had better profile in walking ability (p < 0.005) and relationships with others (p < 0.035) compared to the 8 mg cohort. Compared to our previously reported steroid naïve cohort, prophylactic DEX significantly reduced the incidence of PF (68 vs. 19 %, p < 0.0001, respectively), patients had lower worst pain scores, and improved general activity interference outcome. CONCLUSION: We recommend prophylactic DEX for patients treated with spine SBRT. Our current practice is based on the 4 mg protocol primarily due to the improved functional interference outcomes. A randomized trial is required to finalize the optimal regimen and schedule.

Minimal clinically important differences in the EORTC QLQ-BN20 in patients with brain metastases.

INTRODUCTION: Quality of life (QOL) is an important treatment endpoint in advanced cancer patients with brain metastases. In clinical trials, statistically significant changes can be reached in a large enough population; however, these changes may not be clinically relevant. OBJECTIVE: The objective of this study was to determine the minimal clinically important difference (MCID) for the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire brain module (EORTC QLQ-BN20) in patients with brain metastases. METHODS: Patients undergoing radiotherapy for brain metastases completed the EORTC QLQ-BN20 and QLQ-C30/C15-PAL at baseline and 1-month follow-up. MCIDs were calculated for both improvement and deterioration using anchor- and distribution-based approaches. The anchor of overall QOL (as assessed by question 30 or question 15 on the QLQ-C30 and QLQ-C15-PAL, respectively) was used to determine meaningful change. RESULTS: A total of 99 patients were included. The average age was 61 years, and the most common primary cancer sites were the lung and breast. Statistically significant meaningful differences were seen on two scales. A decrease of 6.1 (95 % confidence interval (CI) 0.8 to 11.4) units and 13.8 (0.2 to 27.4) units was required to represent clinically relevant deterioration of seizures and weakness of legs, respectively. Distribution-based MCID estimates tended to be closer to 0.5 SD on the EORTC QLQ-BN20. CONCLUSION: Understanding MCIDs allows physicians to determine the impact of treatment on patients' QOL and allows for determination of sample sizes for clinical trials. Future studies should be conducted to validate our findings in a larger population of patients with brain metastases.

Symptom clusters of gastrointestinal cancer patients undergoing radiotherapy using the Functional Living Index-Emesis (FLIE) quality-of-life tool.

OBJECTIVE: The Functional Living Index-Emesis (FLIE) instrument is a validated nausea and vomiting specific quality of life (QOL) tool originally created as a 3-day test of the impact of chemotherapy-induced nausea and vomiting on cancer patients' daily life. The primary objective of the present study was to retrospectively explore the use of the FLIE from data obtained in a previously published study of patients with gastrointestinal radiation-induced nausea and vomiting (RINV) and compare the extracted symptom clusters on a weekly basis for the entirety of gastrointestinal cancer patients' radiotherapy treatments. METHODS: QOL was assessed on a weekly basis using the 18-item FLIE questionnaire for patients' radiotherapy treatments. A principal component analysis with varimax rotation was performed at each visit. The internal consistency and reliability of the derived clusters was assessed with Cronbach's alpha. Robust relationship and correlation among symptoms was displayed with biplot graphics. RESULTS: A total of 460 FLIE assessments were completed for the 86 gastrointestinal patients who underwent radiotherapy. Two components were consistently identified except for week 5 where only one component was identified. Component 1 contained the items "Q10-Q18" which included all vomiting items. Component 2 included all nausea items from "Q1 to Q9". All the variables were well accounted for by two components for most weeks of treatment with excellent internal consistency. Biplots indicate that the two symptom clusters were evident at each week, with the exception of the first week of treatment. Strong correlations were seen between the effect of nausea on patients' ability to make meals, patients' ability to do tasks within the home, and patients' willingness to spend time with family and friends. CONCLUSION: The high internal consistency at all timepoints indicates that the FLIE QOL instrument is useful for the RINV population.

Psychometric validation of the Brain Symptom and Impact Questionnaire (BASIQ) version 1.0 to assess quality of life in patients with brain metastases.

OBJECTIVE: To test the reliability, clinical and psychometric validity of the Brain Symptom and Impact Questionnaire (BASIQ) in patients with brain metastases. METHODS: Brain metastases patients were interviewed using the BASIQ, Functional Assessment of Cancer-Brain (FACT-Br) and FACT-General (FACT-G) at baseline, with a follow-up assessment at 1 month. RESULTS: Forty patients had complete one data and the median age was 64 years. Patients with higher KPS, ECOG of 2, primary breast cancer, or >3 brain metastases, scored higher on the symptom scale of the BASIQ. All subscales showed no significant change in patient symptoms from baseline to follow-up. CONCLUSION: This study supports that the reliability, clinical and psychometric validity of BASIQ to be used in brain metastases patients.

Breakthrough cancer pain: a comparison of surveys with European and Canadian patients.

INTRODUCTION: Breakthrough cancer pain is defined as a transient exacerbation of pain that occurs spontaneously or in response to a trigger, despite stable and controlled background pain. Breakthrough pain often causes significant functional impairments for patients and can decrease quality of life. OBJECTIVE: The objective of the study was to determine differences between breakthrough cancer pain incidence and management in Canada and Europe. METHODS: Data collected from previous studies of breakthrough cancer pain in Canada and Europe was compared. A standard survey with identical inclusion/exclusion criteria was utilized for both patient populations. RESULTS: Both groups of patients had a similar number and duration of breakthrough pain episodes, and similar pain intensity and pain interference with their daily activities. European patients reported better analgesic efficacy and satisfaction with management, and a greater percentage of European patients were prescribed a transmucosal fentanyl formulation (19.1 vs 2.9 %). More European patients (55 %) than Canadian patients (32.5 %) took their rescue medication every time they had a breakthrough pain episode. CONCLUSIONS: Breakthrough cancer pain in both Canadian and European patients greatly impacts their daily living, and both groups of patients had similar experiences with breakthrough cancer pain. Currently, this pain is not adequately managed for many patients. The role for new analgesic treatments in management of breakthrough cancer pain needs further study.

Student Accomplishments in the Rapid Response Radiotherapy Program: A 10-Year Review.

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

Validation of the long-term quality of life breast cancer scale (LTQOL-BC) by health care professionals.

INTRODUCTION: Quality of life has become an important measure of treatment success and is currently being explored not only for patients on active treatment, but also for long-term breast cancer survivors. The long-term quality of life breast cancer scale (LTQOL-BC) is a tool to assess QOL in breast cancer survivors. This study aimed to validate the tool with health care professionals (HCPs). METHODS: Six HCPs with extensive experience working with breast cancer survivors were selected. HCPs completed the LTQOL-BC and were asked to assess the relevance of each included item to the disease-free breast cancer population. They were also instructed to identify items that could be upsetting for patients, irrelevant to this population, and to assess the tool's breadth of coverage. RESULTS: Feedback indicated that some items such as the body image and sexual functioning questions were potentially upsetting to patients and should be rephrased or removed. The overall breadth of coverage of the tool was inadequate, with employment status, economic situation, ability to meet needs of family, health care insurance coverage, and overall sense of well-being not being addressed by the LTQOL-BC. HCPs also identified that certain items should be edited including those specifying pain in the lower body and the item containing the term "homemaker". CONCLUSION: The LTQOL-BC may need to be modified to take into the recommendations provided by HCPs.

Development, characteristics and validity of the EORTC QLQ-PR25 and the FACT-P for assessment of quality of life in prostate cancer patients.

This review aims to compare and contrast the development, characteristics and validity of two widely used quality of life assessment tools in patients with prostate cancers: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-PR25) and Functional Assessment of Chronic Illness Therapy (FACT-P). Both questionnaires present several strengths as well as some limitations in measuring the quality of life of prostate cancer patients. Each tool may be selected accordingly based on study design and needs.

Validation of the Brain Symptom and Impact Questionnaire (BASIQ) to assess symptom and quality of life in brain metastases.

OBJECTIVE: To validate the Brain Symptom and Impact Questionnaire (BASIQ) version 1.0 for brain metastases. METHODS: Patients with brain metastases and their healthcare professionals (HCPs) assessed the relevance of the BASIQ on a 0-10 scale with 10 as extremely relevant. RESULTS: A total of 52 patients and 20 HCPs participated in this study. In total, 95% of HCPs and 85% of patients found all items relevant. Balance and walking ability were rated relevant by 100% of patients and HCPs. Headache, nausea, energy, memory and ability to do housework were also rated relevant by 100% of HCPs. Over 95% of patients determined the items of ability to do housework, tiredness, energy, vision, memory and putting ideas into words as relevant. There were no items rated below 7 by patients or below 5 by HCPs. CONCLUSION: This study indicates that BASIQ version 1.0 has valid content items encompassing disease-related symptom and impact on daily living.

Overall response rates to radiation therapy for patients with painful uncomplicated bone metastases undergoing initial treatment and retreatment.

INTRODUCTION: Radiation therapy has been shown to successfully palliate bone metastases. A number of systematic reviews and large clinical trials have reported response rates for initial treatment and retreatment. OBJECTIVE: To determine overall response rates of patients with painful uncomplicated bone metastases undergoing initial treatment and retreatment. METHODS: Intent-to-treat and evaluable patient statistics from a systematic review of palliative radiotherapy trials for initial treatment of bone metastases and a randomized clinical trial of retreatment were pooled and analyzed to determine the overall response rates for patients receiving initial treatment and retreatment. RESULTS: In the intent-to-treat calculation, 71-73% of patients had an overall response to radiation treatment and in the evaluable patient population; 85-87% of patients did so. Response rates varied slightly whether patients underwent single or multiple fractions in initial treatment or retreatment. CONCLUSIONS: Single and multiple fraction radiation treatment yielded very similar overall response rates. Patients treated with a single fraction for both initial and repeat radiation experience almost identical overall response to those patients treated with multiple fraction treatment. It is therefore recommended that patients with uncomplicated painful bone metastases be treated with a single 8 Gy fraction of radiation at both the initial treatment and retreatment.

Comparison of the EORTC QLQ-BN20 and the FACT-Br quality of life questionnaires for patients with primary brain cancers: a literature review.

PURPOSE: This review compares and contrasts the development, validity, and characteristics of two quality of life (QOL) assessment tools used in patients with primary brain cancers: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Brain Cancer Module (EORTC QLQ-BN20) and the Functional Assessment of Cancer Therapy-Brain (FACT-Br). METHODS: A literature search was conducted using the Cochrane Central Register of Controlled Trials (June 2013), Ovid EMBASE (1947 to 2013, week 27), and Ovid MEDLINE (1946 to July 2013, week 1) to identify studies that discussed the development, characteristics, validity, and reliability of the EORTC QLQ-BN20 or the FACT-Br. RESULTS: The EORTC QLQ-BN20 consists of 20 items that assess future uncertainty, visual disorder, motor dysfunction, and communication deficit. Items are presented as questions on a scale ranging from 1 = "not at all" to 4 = "very much." Reliability and validity testing of the QLQ-BN20 revealed a Cronbach's alpha coefficient that ranged from 0.71 to 0.90. The FACT-Br consists of 23 items that assess general well-being and brain cancer-specific concerns that include concentration, memory, seizures, eyesight, hearing, speech, personality, expression of thoughts, weakness, coordination, and headaches. These items are presented as statements on a scale ranging from 0 = "not applicable" to 4 = "extremely relevant." The FACT-Br underwent validity as well as test-retest reliability testing with 101 and 46 patients, respectively. Validity testing found low to moderate correlation with the FACT-G questionnaire, while reliability testing for the brain subscale revealed an acceptable correlation coefficient (r = 0.66; p < 0.001). CONCLUSIONS: The QLQ-BN20 and the FACT-Br are both valid and reliable tools that have been used extensively in the primary brain cancer population. Choice between the two tools should consider each instrument's individual strengths and weaknesses.