A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue.

PURPOSE: The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (crf) in adults. METHODS: The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of crf. The search included medline, embase, cinahl, the Cochrane Library, and other guideline and data sources to December 2009. RESULTS: Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process. CONCLUSIONS: Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care.

Models of care for post-treatment follow-up of adult cancer survivors: a systematic review and quality appraisal of the evidence.

PURPOSE: The impact of cancer and cancer treatment on the long-term health and quality of life of survivors is substantial, leading to questions about the most appropriate configuration of services and models of care for follow-up of post-primary treatment survivors. METHODS: A systematic review and quality appraisal of the health literature for structure of services and models of follow-up care for post-treatment survivors was identified through a search of guideline sources and empirical databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Library, CINAHL, and EBSCO from 1999 through December 2009. RESULTS: Ten practice guidelines and nine randomized controlled trials comprised the evidence base for models of care for adult cancer survivors. Although the evidence base was rated as low quality, nurse-led and primary care physician models of follow-up care were equivalent for detecting recurrence. Consensus also suggests that cancer survivors may benefit from coordinated transition planning that includes the provision of survivorship care plans as part of standard care. CONCLUSIONS: Realignment of models of care is identified as a health system priority to meet the supportive care and surveillance needs of a burgeoning survivor population. Further research is needed to evaluate the efficacy of models of care in a broader population of cancer survivors with differing needs and risks. While the evidence is limited, there is research that may be used to guide the configuration of health care services and planning.

Psychosocial health care needs assessment of adult cancer patients: a consensus-based guideline.

PURPOSE: Although recommended as an essential part of cancer care, there is limited evidence regarding the optimum approach to psychosocial health care needs assessment in this setting. To address this gap, the Cancer Journey Action Group of the Canadian Partnership Against Cancer (CPAC) and the Canadian Association of Psychosocial Oncology (CAPO) partnered to develop consensus-based recommendations regarding the routine assessment of psychosocial and supportive care needs. The purpose of this paper is to summarize the evidence that informed the guideline and disseminate the recommendations developed by the expert panel. METHODS: Clinical practice recommendations were developed by a panel comprised of psychosocial and interdisciplinary experts. Recommendations were informed by a review of oncology clinical practice guidelines, systematic reviews, and primary research, through to May 2008. Following expert consensus on the recommendations, the clinical practice guideline was externally reviewed by a purposively selected sample of national and international interdisciplinary experts. RESULTS: A total of nine clinical practice guidelines, three systematic reviews, and 14 primary studies were included in the review. Overall, this body of literature suggested that routine collection of psychosocial health care data has an influence on communication with oncologists and other study specific outcomes, but the evidence was limited by heterogeneity and methodological limitations. Based on the interpretation of this body of evidence by clinical experts, research methodologists, and external reviewers, 12 substantive recommendations were developed regarding the process and parameters of psychosocial needs assessment in adult cancer patients. CONCLUSION: Given the limitations in the current body of evidence, there remains a need for rigorous empirical research regarding the optimal approach to psychosocial needs assessment, including the specific characteristics that influence effectiveness on patient outcomes. This guideline fills an important gap in psychosocial care, regarding the routine assessment of psychosocial health care needs.

Survivorship services for adult cancer populations: a pan-Canadian guideline.

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

Enhancement of active corrosion protection via combination of inhibitor-loaded nanocontainers.

The present work reports the synthesis of layered double hydroxides (LDHs) nanocontainers loaded with different corrosion inhibitors (vanadate, phosphate, and 2-mercaptobenzothiazolate) and the characterization of the resulting pigments by X-ray diffraction (XRD) and transmission electron microscopy (TEM). The anticorrosion activity of these nanocontainers with respect to aluminum alloy AA2024 was investigated by electrochemical impedance spectroscopy (EIS). The bare metallic substrates were immersed in dispersions of nanocontainers in sodium chloride solution and tested to understand the inhibition mechanisms and efficiency. The nanocontainers were also incorporated into commercial coatings used for aeronautical applications to study the active corrosion protection properties in systems of industrial relevance. The results show that an enhancement of the active protection effect can be reached when nanocontainers loaded with different inhibitors are combined in the same protective coating system.

"This is a kind of betrayal": a qualitative study of disability after breast cancer.

OBJECTIVE: We proposed to document the effect of arm morbidity and disability in 40 Canadian women who were 12-24 months post breast cancer surgery. METHODS: We completed 40 qualitative interviews as one component of a multidisciplinary national longitudinal study of arm morbidity after breast cancer (n = 745) involving four research sites (Fredericton/Saint John, Montreal, Winnipeg, Surrey). During semi-structured interviews, participants who had reported arm morbidity and disability in earlier surveys were asked to discuss the effects of these conditions on everyday life. RESULTS: The interviewees reported making major adjustments to paid and unpaid work, which often involved the assistance of family members, thus demonstrating the effect of disability. Interview data resulted in the creation of a model that addresses arm morbidity and disability, and that holds implications for health care professionals. CONCLUSIONS: Based on the interview findings, we conclude that a robust measure of disability after breast cancer should be developed. In the absence of a validated measure of the effect of disability, evaluating qualitative responses to questions about everyday activities could provide the impetus for provision of physical therapy and emotional support.

Family physicians and cancer care. Palliative care patients' perspectives.

OBJECTIVE: To explore factors that affect the integrity of palliative cancer patients' relationships with family physicians and to ascertain their perceptions of their FPs' roles in their care. DESIGN: Qualitative study using grounded-theory methods, taped semistructured interviews, and chart reviews. SETTING: Two palliative care hospital wards in Winnipeg, Man. PARTICIPANTS: A purposeful sample of 11 men and 14 women. METHOD: Qualitative content analysis of interview transcripts. MAIN FINDINGS: Cancer care is organized in a sequential, parallel, or shared manner between FPs and cancer specialists, with sequential care a common outcome if patients' relationships with their FPs wane. Cancer patients can lose contact with FPs because of patient or physician relocation, distrust over delays in diagnosis, failure to perceive a need for FPs, poor communication between FPs and specialists, and a lack of FP involvement in the hospital. People with cancer value FPs for being accessible through prompt appointments and telephone contact; for providing emotional and family support; and for referral, triage, and general medical care. CONCLUSION: Family physicians can enhance care of cancer patients. Contact with FPs can be maintained by ensuring good communication between specialists and FPs, defining a clear role for FPs, addressing concerns about delays in diagnosis, and referring patients back to FPs, particularly after hospitalization.

Preventing sexual risk behaviors among gay, lesbian, and bisexual adolescents: the benefits of gay-sensitive HIV instruction in schools.

OBJECTIVES: This study compared sexual risk behaviors of gay, lesbian, and bisexual (GLB) and heterosexual adolescents and evaluated associations between gay-sensitive HIV instruction and risk behaviors of GLB youths. METHODS: A random sample of high school students and HIV education teachers completed surveys. Self-reported risk behaviors of heterosexual and GLB adolescents were compared, with control for student and community demographic characteristics. Sexual risk behaviors of GLB youths in schools with and without gay-sensitive instruction were compared. RESULTS: GLB youths reported more substance use, high-risk sexual behaviors, suicidal thoughts or attempts, and personal safety issues than did heterosexual youths (P < .001). Among those who were sexually active, GLB youths reported more lifetime and recent sexual partners than did heterosexuals (P < .001), and more of them reported alcohol use before last sex (P < .01) and a history of pregnancy (P < .001). GLB youths in schools with gay-sensitive instruction reported fewer sexual partners, less recent sex, and less substance use before last sex than did GLB youths in other schools (P < .05). CONCLUSIONS: The findings document increased risk behaviors among GLB youths and demonstrate the potential benefits of providing gay-sensitive HIV instruction in schools.

Falling through the cracks. Women's experiences of ineligibility for genetic testing for risk of breast cancer.

OBJECTIVE: To describe experiences of women seeking information about their risk of hereditary breast cancer who fail to meet strict eligibility criteria for genetic counseling and testing. DESIGN: Qualitative descriptive study. SETTING: Hereditary cancer program in western Canada. PARTICIPANTS: Women who had received notification of their ineligibility for referral for hereditary breast cancer risk assessment (n = 20) and some of their referring physicians (n = 10). Of 28 attempted contacts, five women had moved, one declined the invitation to participate, and two could not be interviewed because of scheduling conflicts. Ten of 20 physicians declined the invitation to participate. METHOD: In-depth, open-ended telephone interviews were conducted. Transcribed interviews were systematically analyzed to identify salient themes. MAIN FINDINGS: Three themes emerged. The first theme, "It's always on your mind," points to the profound concern about breast cancer that underlies women's experiences in seeking genetic testing. The second theme, "A test is a test," reflects women's beliefs that the test was relatively simple and similar to other medical tests in that it would provide a definitive answer. The third theme, "Falling through the cracks," captures the experience of ineligibility. Women reacted with a range of emotional responses and were left frustrated in their search for more specific information about their personal risk for breast cancer. Although women were encouraged to contact their physicians, few did. CONCLUSION: These findings point to the psychological consequences in women who seek genetic testing for risk of breast cancer when they are told they are ineligible and they are not given adequate information and support.

The effects of type of surgery and time on psychological adjustment in women after breast cancer treatment.

BACKGROUND: The aim of the present study was to examine whether type of surgery, age, and time since surgery influenced psychological distress and quality of life (QOL) in women treated for breast cancer. METHODS: We surveyed 183 women who had undergone surgery for breast cancer. Psychological distress was measured with the Mental Health Inventory and QOL was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. RESULTS: After controlling for stage of disease, radiation treatment, and age, there was a statistically significant interaction between type of surgery and time since surgery for the Mental Health Inventory total score, and a marginal interaction between type of surgery and time since surgery for the Global health status/QOL score. Women who had breast conservation surgery experienced significantly greater levels of psychological distress and marginally worse QOL from 40 months after surgery onward than did women who received a mastectomy. CONCLUSIONS: The effects of different surgical treatments for breast cancer on psychological distress and QOL become apparent only after a period of several years. Women, therefore, need counseling on the potentially positive and negative psychological implications of different surgical treatments for breast cancer.

Effects of oleoresin capsicum pepper spray on human corneal morphology and sensitivity.

PURPOSE: To examine the potential harmful effects on corneal structure, innervation, and sensitivity of a spray containing the neurotoxin capsaicin (oleoresin capsicum, OC). METHODS: Ten police officers who volunteered for the study were exposed to OC. Clinical signs were assessed. Corneal sensitivity was measured using a Cochet-Bonnet or a noncontact esthesiometer that provides separate measurements of mechanical, chemical, and thermal sensitivity. Tear fluid nerve growth factor (NGF) was measured. Corneal cell layers and subbasal nerves were examined by in vivo confocal microscopy. The subjects were examined before application and 30 minutes, 1 day, 1 week, and 1 month after OC exposure. RESULTS: OC spray produced occasional areas of focal epithelial cell damage that healed within 1 day. Each eye showed conjunctival hyperemia and in two subjects, mild chemosis. All except one eye had unchanged best corrected visual acuity (BCVA). A transient decrease (day 1) of mechanical sensitivity was observed with the Cochet-Bonnet esthesiometer. With the gas esthesiometer, mechanical sensitivity remained below normal values for 7 days. Chemical sensitivity to CO2 was high for as much as 1 day and decreased below normal 1 week later, whereas sensitivity to cold was unaffected. Two subjects had measurable tear NGF that increased after exposure. Basal epithelial cell morphology suggested temporary corneal epithelial swelling, whereas keratocytes, endothelial cells, and subbasal nerves remained unchanged. CONCLUSIONS: Although OC causes immediate changes in mechanical and chemical sensitivity that may persist for a week, a single exposure to OC appears harmless to corneal tissues. The changes are possibly associated with damage of corneal nerve terminals of mainly unmyelinated polymodal nociceptor fibers.

Infusion versus bolus contrast echocardiography: a multicenter, open-label, crossover trial.

BACKGROUND: In current practice, contrast echocardiography is performed with single or multiple bolus injections, which often result in an uncontrolled period of attenuation followed by transient left ventricular opacification (LVO). Because a "slow bolus" appears to reduce attenuation and prolong LVO, we hypothesized that a controlled infusion of contrast might provide a more uniform contrast effect with less attenuation and longer contrast duration. METHODS AND RESULTS: We sought to test the hypothesis by using an infusion of contrast (DEFINITY [perflutren], The DuPont Pharmaceuticals Co, Medical Imaging, North Billerica, Mass) that is stable when diluted in saline in a randomized, multicenter, controlled, crossover trial. Sixty-four patients with poor noncontrast images were recruited at 3 centers and randomly assigned to 2 single "slow" bolus injections of contrast (10 microL/kg each over a period of 30 to 60 seconds) or an infusion (1. 3 mL in 50 mL normal saline initially at 4.0 mL/min) of contrast. Patients then returned within 24 to 72 hours for the alternative form of contrast delivery. Three independent experienced echocardiographers viewed 30 seconds of videotape for all optimal baseline and optimal contrast images to score LVO and qualitatively assessed endocardial border evaluability. The duration of adequate LVO then was independently assessed by review of the entire videotape. Three independent sonographers traced single-frame, digitally captured images to measure the length of the contiguous endocardial border visualized. Both bolus and infusion administration demonstrated improved LVO (>90% by all blinded readers, P <.01) and endocardial border visualized (mean increase of 1.8 to 4.7 cm at both end-diastole and end-systole, all P <.05) as compared with baseline images. However, contrast infusion resulted in a longer duration of LVO (range of mean durations for each reader, 158 to 174 seconds longer, P <.05) and a shorter duration of attenuation (18 to 54 seconds, P <.05) compared with either bolus injection. There were no severe adverse events with contrast infusion. CONCLUSIONS: Contrast echocardiography delivered as an infusion optimizes the contrast effect by decreasing the attenuation period, extending the LVO duration, and providing a uniform contrast effect that may be useful in obtaining multiple echocardiographic views, stress echocardiography, myocardial perfusion imaging, and applications in which blood flow must be quantified.

Leadership: the Winnipeg Community and Long-Term Care Authority.

The Winnipeg Community and Long Term Care Authority (WCA) was established in 1998 under the Regional Health Authorities Act of the Province of Manitoba. The WCA's role is to provide for the successful integration of Winnipeg's community-based healthcare delivery services through its three main portfolios: Community Care and Public Health, Home Care and Mental Health, and Long Term Care and Specialized Services. The WCA is dedicated to building a quality health future for Winnipeg. Various initiatives undertaken in the pursuit of quality are described.

Physical and psychological morbidity after axillary lymph node dissection for breast cancer.

PURPOSE: Alternatives to axillary lymph node dissection (ALND) are being developed amid controversy surrounding the therapeutic benefit and overall utility of this routine surgical procedure. Although potential negative side effects associated with ALND are known, we set out to examine whether these side effects contribute significantly to patient reports of quality of life and mental health. PATIENTS AND METHODS: We surveyed 222 women who had received an ALND as part of breast cancer surgery. All women underwent a physical therapy assessment of range of arm/shoulder motion and completed the Modified Post-operative Pain Questionnaire, the Pain Disability Index, the McGill Pain Questionnaire (short form), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Mental Health Inventory. RESULTS: Seventy-two percent of the women experienced arm/shoulder pain, weakness, or numbness in the week before the interview, and range of motion of the affected arm/shoulder was impaired in 73% of the women. Severity of pain was reported to be low to moderate, and younger patients experienced greater pain than older patients. Pain severity correlated positively with the number of lymph nodes removed and receipt of chemotherapy and was not significantly related to length of time since surgery or receipt of radiation therapy. Generally high levels of cancer-specific quality of life and mental health were reported. Quality of life was significantly predicted by the McGill Pain Questionnaire, and mental health was significantly predicted by the Pain Disability Index and the physical therapy assessment. CONCLUSION: Surgery-related symptoms after ALND persist for a majority of women with breast cancer and are not significantly related to time since surgery or receipt of radiation therapy. These symptoms and associated disability are significantly predictive of cancer-specific quality of life and mental health.

Coping with breast cancer: a cluster analytic approach.

The aim of this study was to generate distinct clusters of women with breast cancer, and to evaluate differences between clusters with respect to decisional control, psychological adjustment, and frustration expression. Thirty-seven Stage I and 33 Stage II newly diagnosed breast cancer patients from two medical oncology clinics participated. A cluster analysis of the coping data produced three distinct patient clusters. The primary finding was that women from the low avoidance coping cluster were significantly better adjusted than women from the remaining clusters. Women from the low avoidance coping cluster also preferred more active involvement in treatment decision-making. Further research is needed to prospectively detail the mechanisms by which cognitive avoidance hampers psychological adjustment to cancer.

Audio-taping the oncology treatment consultation: a literature review.

An increased amount of research has been conducted to evaluate interventions for improving the quality of communication between cancer patients and health care providers. One of these interventions involves providing patients with audiotapes of their consultations with oncologists. Given that effective patient-physician communication has been linked to beneficial health outcomes, an examination of studies that have evaluated the effects of audiotape provision appears warranted. This article provides a critical review of this literature. The audiotape intervention has been examined in uncontrolled studies and randomized trials, and the primary outcome variables have included psychological well-being, information recall, and patient satisfaction. The empirical literature is unclear as to the efficacy of providing patients with taped recordings of cancer consultations. Overall, the findings suggest that the majority of patients benefit from receiving the audiotape, but the utility of this intervention in improving patient-physician communication requires further examination. Replication studies and well-controlled experimental designs applied to a variety of health care providers in diverse oncology settings are needed to confirm the validity of the empirical findings to date, and to facilitate further development of interventions aimed at enhancing patient-physician communication.

Phase III multicenter trial comparing the efficacy of 2% dodecafluoropentane emulsion (EchoGen) and sonicated 5% human albumin (Albunex) as ultrasound contrast agents in patients with suboptimal echocardiograms.

OBJECTIVES: This study was performed to compare the safety and efficacy of intravenous 2% dodecafluoropentane (DDFP) emulsion (EchoGen) with that of active control (sonicated human albumin [Albunex]) for left ventricular (LV) cavity opacification in adult patients with a suboptimal echocardiogram. BACKGROUND: The development of new fluorocarbon-based echocardiographic contrast agents such as DDFP has allowed opacification of the left ventricle after peripheral venous injection. We hypothesized that DDFP was clinically superior to the Food and Drug Administration-approved active control. METHODS: This was a Phase III, multicenter, single-blind, active controlled trial. Sequential intravenous injections of active control and DDFP were given 30 min apart to 254 patients with a suboptimal echocardiogram, defined as one in which the endocardial borders were not visible in at least two segments in either the apical two- or four-chamber views. Studies were interpreted in blinded manner by two readers and the investigators. RESULTS: Full or intermediate LV cavity opacification was more frequently observed after DDFP than after active control (78% vs. 31% for reader A; 69% vs. 34% for reader B; 83% vs. 55% for the investigators, p < 0.0001). LV cavity opacification scores were higher with DDFP (2.0 to 2.5 vs. 1.1 to 1.5, p < 0.0001). Endocardial border delineation was improved by DDFP in 88% of patients versus 45% with active control (p < 0.001). Similar improvement was seen for duration of contrast effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to affect patient management. There was no difference between agents in the number of patients with adverse events attributed to the test agent (9% for DDFP vs. 6% for active control, p = 0.92). CONCLUSIONS: This Phase III multicenter trial demonstrates that DDFP is superior to sonicated human albumin for LV cavity opacification, endocardial border definition, duration of effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to influence patient management. The two agents had similar safety profiles.

[Small-cell sarcoma of the esophagus as a fourth malignancy. Its palliative therapy with argon gas coagulation]. / Kleinzelliges Sarkom des Osophagus als viertes Malignom. Palliative Therapie mit Argongaskoagulation.

HISTORY: A prostatic carcinoma, an early gastric carcinoma and a colon carcinoma had occurred over 15 years in a now 82-year-old patient. He was now admitted because of severe dysphagia. INVESTIGATIONS: Gastroscopy revealed an exophytic tumour of the oesophagus, histologically identified as a small-cell sarcoma. It had caused a 12 cm long severe eccentric stenosis of the oesophagus. Tissue from the previous three tumours were examined immunohistochemically for p-53 gene mutation, but only the oesophageal sarcoma gave positive results. TREATMENT AND COURSE: After part of exophytic tumour had been ablated by argon gas coagulation a prosthetic tube was implanted. Bleeding from erosion of a large metastasis in the gastric fundus was successfully treated by argon gas coagulation 4 months after the previous discharge, but the patient died of the malignancy 1/1 and half months later. CONCLUSIONS: The consecutive occurrence of four different malignant tumours is rare even in advanced age. In this case the malignancies were presumably unrelated and it demonstrates the possibility of removing an eccentric tumour stenosis by argon gas coagulation before implanting a prosthesis.