The oncology ribbon of reflection: a novel tool to encourage trainee self-reflection.

The field of oncology presents a number of emotionally challenging situations for a trainee to navigate which might not have been previously encountered in training. With the assistance of a guide, reflecting on such situations can be helpful; however, no tool exists in the literature specifically for clinical oncology situations and tailored to provide trainees guidance through the reflective process. Consequently, we present a self-guided reflection tool design using four established reflection models and improved over three iterations of feedback.

Le domaine de l'oncologie présente un certain nombre de situations émotionnellement difficiles à gérer pour un stagiaire qui n'a peut-être jamais été confronté à de telles situations au cours de sa formation. Avec l'aide d'un guide, il peut être utile de réfléchir à ces situations. Cependant, il n'existe pas dans la littérature d'outil adapté aux situations cliniques en oncologie et conçu pour guider les stagiaires tout au long du processus de réflexion. Par conséquent, nous présentons un outil d'autoréflexion conçu à partir de quatre modèles de réflexion établis et amélioré au cours de trois rondes de rétroaction.

Combination of Osimertinib and Olaparib Therapy to Treat Non-Small Cell Lung Cancer and High-Grade Serous Ovarian Carcinoma: A Case Report.

We present the case of a 75-year-old female with simultaneous EGFR-mutated stage IV lung cancer and advanced BRCA2-mutated ovarian cancer, treated with a unique regimen. In this case report, the patient was treated with alternating months of osimertinib and olaparib to control her lung and ovarian cancers, respectively. When both diseases showed progression, the patient underwent a trial of concurrent therapy with both drugs, yet this was discontinued due to patient-reported adverse side effects. Combination targeted drug therapy may be required to treat complex diagnoses such as dual malignancies. However, combination drug therapy consisting of osimertinib and olaparib has not previously been explored. This case report represents the first to demonstrate osimertinib and olaparib combination therapy as a unique treatment regimen for concurrent lung and ovarian cancers. These two drugs can either be given in an alternating way or given together, short-term, with a higher but tolerable toxicity profile.

Assessment of urine colour using a wallet card: a randomised study of a novel patient self-care tool during chemoradiation for oesophageal cancer.

BACKGROUND: Patients undergoing neoadjuvant chemoradiation for oesophageal cancer often experience dehydration from decreased fluid intake and increased losses. Despite frequent clinical visits during treatment, patients can still present with dehydration, suggesting the need for increased patient awareness and engagement around adverse event management at home. Evidence for benefits of self-monitoring may help motivate patients to engage proactively in their own care to improve their treatment experience. METHODS: We performed a randomised single-centre study of a urine colour self-monitoring card (UCC) during chemoradiation therapy for oesophageal cancer, compared with standard dietitian counselling. Primary outcome was self-efficacy as determined by the Self-Management Resource Centre Self-Efficacy for Managing Chronic Disease Scale (SMCD). Secondary outcomes included Burge thirst scores, Edmonton Symptom Assessment System scores (ESAS), patient-initiated hydrations, creatinine rise and satisfaction with the UCC. RESULTS: Thirty-five patients were randomised. UCC use was not associated with improved SMCD or ESAS scores compared with standard counselling. The card was highly rated by patients as a welcome tool for self-monitoring. CONCLUSIONS: No beneficial effect on self-efficacy or dehydration markers with UCC use was demonstrated. The study nonetheless drew attention to several factors potentially hindering its use for effective self-care: the unexpected severity of other symptoms consuming patients' attention, reduced sensitivity of urine colour due to chemotherapy, absence of active inquiry by the healthcare team and the inconvenient location of the UCC in wallet/purse. Urine colour monitoring in patients with oesophageal cancer to improve the patient experience during treatment warrants further study but supported by active healthcare provider inquiry, more accessible format of the card, and possibly home vital checks to increase its sensitivity in the clinical context.

Double Duty: Complete Pathologic Response of Two Colonic Primaries with Mosaicism of a Novel MLH1 Mutation to Neoadjuvant Pembrolizumab.

We present a fascinating case of a 57-year-old male with a novel mutation in MLH1 (MLH1:c.1288G > T, p.(Glu430*)), who presented with two synchronous colonic tumours, initially deemed unresectable, and experienced a complete pathological response on neoadjuvant pembrolizumab. Extensive genetic testing revealed post-zygotic mosaicism from the novel mutation.

True transition to practice: a role-reversal simulation.

Implication Statement: This article explores a direct-observation simulation swapping resident and consultant roles as a measure to assess competence during the final "transition to practice" phase of residency. As indicated by the Royal College, assessment of competency in this stage should include direct observation; however, this is challenging to implement, both from the perspective of a busy clinical environment, but also logistically, as a final-stage resident is still a learner in a consultant clinic. Our suggested approach allows for both real-world experience for the resident as well as direct observation and assessment by the consultant, thus providing the resident with targeted, actionable feedback, as well as ensuring the final-stage resident is competent for practice. Énoncé des implications de la recherche: Cet article explore une simulation utilisant l'observation directe et où les rôles de résident et de consultant sont inversés comme moyen d'évaluation des compétences durant l'étape finale de la résidence, la « transition vers la pratique ¼. Le Collège royal indique qu'à ce stade, l'observation directe doit faire partie de l'évaluation des compétences; or, cette modalité d'évaluation est difficile à mettre en œuvre dans un environnement clinique animé et un contexte logistique où le résident est encore un apprenant dans une clinique de consultants. L'approche que nous proposons permet à la fois au résident d'acquérir une situation réelle et au consultant de faire une observation directe pour l'évaluation, et d'offrir une rétroaction ciblée et utile, tout en s'assurant que le résident en fin de parcours a les compétences requises pour pratiquer.

Real-World Analysis of Durvalumab after Chemoradiation in Stage III Non-Small-Cell Lung Cancer.

The 2017 PACIFIC trial heralded the incorporation of routine adjuvant durvalumab following curative-intent chemoradiation for stage III non-small-cell lung cancer (NSCLC). However, carefully selected clinical trial populations can differ significantly from real-world populations, which can have implications on treatment toxicities and outcomes, making it difficult to accurately counsel patients. Consequently, we performed a real-world, retrospective analysis of outcomes and toxicities in 118 patients with stage III NSCLC treated with durvalumab after platinum-based chemoradiotherapy. The data were collected from patients who underwent treatment at a single, tertiary-level Canadian cancer centre from May 2018 to October 2020. The variables collected included patient demographics, treatment specifics, progression-free survival, overall survival, and immune-related adverse events (IRAE) from durvalumab. Descriptive statistics were used for toxicity analysis, and progression-free survival and overall survival estimates were calculated using the Kaplan-Meier method. The statistical analyses indicated a 64.4% (n = 76) toxicity rate, with a 21% (n = 25) toxicity rate of grade 3+ IRAEs. The most common documented IRAEs were pneumonitis (n = 44; 40%), followed by rash (n = 20; 18%) and thyroid dysfunction (n = 17; 15%). FEV1 and DLCO were not found to be associated predictors of pneumonitis toxicity. The median PFS and OS were estimated to be >1.7 years and >2.7 years, respectively.

Oncology residents' experiences of decision-making in a clinical learning environment: a phenomenological study.

Oncology residents routinely engage in ethically complex decision-making discussions with patients, while observing and interacting with their teaching consultant. If clinical competency in oncology decision-making guidance is to be taught deliberately and effectively, it is necessary to understand resident experiences in this context to develop appropriate educational and faculty development initiatives. Four junior and two senior postgraduate oncology residents participated in semi-structured interviews during October and November 2021 which explored their experiences of real-world decision-making scenarios. Van Manen's phenomenology of practice was used in an interpretivist research paradigm. Transcripts were analysed to articulate essential experiential themes, and composite vocative narratives were created. Three essential themes were identified: (1) residents often endorsed different decision-making approaches than supervising consultants, (2) residents experienced inner conflict, and (3) residents struggled to find their own approach to decision-making. Residents experienced being torn between a perceived obligation to defer to consultant directives, and a desire for increasing ownership of decision-making while not feeling empowered to discuss their opinions with the consultants. Residents described their experiences around ethical position awareness during decision-making in a clinical teaching context as challenging, with experiences suggesting moral distress combined with inadequate psychological safety to address ethical conflicts and unresolved questions of decision ownership with supervisors. These results suggest the need for enhanced dialogue and more research to reduce resident distress during oncology decision-making. Future research should be aimed at discovering novel ways in which residents and consultants could interact in a unique clinical learning context including graduated autonomy, a hierarchical gradient, ethical positions, physician values, and sharing of responsibility.

Different Ways of Traveling the Cancer Road-Daytime Running Lights at Night?

This essay describes the reflections of an oncology ward attending physician and patients with cancer who are blindsided by cancer recurrence or progression.

Cancer-related fatigue-pharmacological interventions: systematic review and network meta-analysis.

INTRODUCTION: Cancer-related fatigue (CRF) is a very common symptom in patients with cancer, and one of the five areas of highest priority in cancer research. There is currently no consensus on pharmacologic interventions for treating CRF. The aim of this systematic review is to provide more clarity on which pharmacologic interventions may be most promising, for future clinical trials. The network meta-analysis provides the ability to compare multiple agents when no direct head-to-head trials of all agents have been performed. METHODS: Medline (PubMed), EMBASE and Cochrane Central Register of Controlled Trials were searched up until 5 March 2021. Studies were included if they reported on a pharmacologic intervention for CRF. Standardised mean differences and corresponding 95% CIs were computed using a random-effects maximum-likelihood model. RESULTS: This review reports on 18 studies and 2604 patients, the most comprehensive review of pharmacologic interventions for CRF at the time of this publication. Methylphenidate, modafinil and paroxetine were superior to placebo. Methylphenidate and modafinil were equivalent to one another. Paroxetine was superior to modafinil. CONCLUSION: Paroxetine should be further studied in future trials. As well, more safety data are needed on pharmacologic interventions.

Exploring the Inner Lens: Examining Oncology Consultants' Use of Competency and Assessment Frameworks in Clinical Teaching Settings.

Medical education in oncology has adopted a competency-based medical education (CBME) approach in Canada. Oncologist competencies are arranged within assessment frameworks, but it is unknown whether oncologists routinely use assessment frameworks when determining what to teach oncology trainees. Understanding oncologists' actual approaches to assessment and teaching as a form of enacted CBME could inform and focus faculty development efforts. Using a participatory action research approach, oncology faculty were interviewed regarding their teaching practices and use of assessment frameworks. Faculty suggestions regarding challenges in setting teaching goals and completing assessment within the CBME paradigm were solicited. Furthermore, teaching objectives developed by faculty in-house were assessed regarding the domains of competence targeted. Thirty-one of the 40 faculty members in the Department of Oncology, Western University, agreed to participate. Trainee factors (training level, areas of interest), faculty personal values and experience, the teaching setting, and some components of frameworks (medical expert, communicator, advocate, and professional) were articulated as determinants of teaching goals. Of the 1117 in-house objectives reviewed, 76% focused on the medical role. Faculty held widely disparate views on assessment framework features which would enable teaching and assessment. Oncology faculty members used a multifaceted approach to determine what to teach trainees. This approach contains elements both of the conventional apprenticeship models under which many faculty members themselves were trained and of the CBME paradigm. Future research should focus on exploring ways to resolve the tension between established individual teaching approaches and nationally standardized competency frameworks which are being implemented.

BMS-986012, an Anti-Fucosyl-GM1 Monoclonal Antibody as Monotherapy or in Combination With Nivolumab in Relapsed/Refractory SCLC: Results From a First-in-Human Phase 1/2 Study.

Introduction: Fucosyl-GM1 is a monosialoganglioside with limited expression in healthy tissues and high expression on SCLC cells. BMS-986012 is a nonfucosylated, first-in-class, fully human immunoglobulin G1 monoclonal antibody that binds to fucosyl-GM1. Methods: CA001-030 is a phase 1/2, first-in-human study of BMS-986012 as monotherapy or in combination with nivolumab for adults with relapsed or refractory SCLC. Safety is the primary end point. Additional end points include objective response rate, duration of response, progression-free survival, pharmacokinetics, and overall survival. Results: Patients (BMS-986012 monotherapy, n = 77; BMS-986012 + nivolumab, n = 29) were predominantly of male sex (58%), 63 years old (mean), current or past tobacco users (97%), and treated previously with first-line systemic therapy (99%). The most common treatment-related adverse event was pruritus (n = 95 [90%]). Grade 4 treatment-related adverse events were reported in 2% (n = 2) of patients. The objective response rate (95% confidence interval [CI]) was higher with BMS-986012 plus nivolumab (38% [20.7%-57.7%]) than with monotherapy (4% [0.8%-11.0%]). Median (95% CI) duration of response with BMS-986012 plus nivolumab was 26.4 (4.4-not reached) months. Progression-free survival (95% CI) at 24 weeks with monotherapy and BMS-986012 plus nivolumab was 12.2% (6.0%-20.7%) and 39.3% (21.7%-56.5%), respectively. The pharmacokinetics profile of monotherapy and BMS-986012 plus nivolumab suggested dose proportionality across the tested dose range. Median overall survival (95% CI) with monotherapy and BMS-986012 plus nivolumab was 5.4 (4.0-7.3) and 18.7 (8.2-37.3) months, respectively. Conclusions: BMS-986012 in combination with nivolumab represents a well-tolerated, potential new therapy for relapsed or refractory SCLC. BMS-986012 is currently being explored in combination with carboplatin, etoposide, and nivolumab as a first-line therapy in extensive-stage SCLC (NCT04702880).

Circulating tumor cells detected in follow-up predict survival outcomes in tri-modality management of advanced non-metastatic esophageal cancer: a secondary analysis of the QUINTETT randomized trial.

BACKGROUND: Our aim was to establish if presence of circulating tumor cells (CTCs) predicted worse outcome in patients with non-metastatic esophageal cancer undergoing tri-modality therapy. METHODS: We prospectively collected CTC data from patients with operable non-metastatic esophageal cancer from April 2009 to November 2016 enrolled in our QUINTETT esophageal cancer randomized trial (NCT00907543). Patients were randomized to receive either neoadjuvant cisplatin and 5-fluorouracil (5-FU) plus radiotherapy followed by surgical resection (Neoadjuvant) or adjuvant cisplatin, 5-FU, and epirubicin chemotherapy with concurrent extended volume radiotherapy following surgical resection (Adjuvant). CTCs were identified with the CellSearch® system before the initiation of any treatment (surgery or chemoradiotherapy) as well as at 6-, 12-, and 24-months post-treatment. The threshold for CTC positivity was one and the findings were correlated with patient prognosis. RESULTS: CTC data were available for 74 of 96 patients and identified in 27 patients (36.5%) at a median follow-up of 13.1months (interquartile range:6.8-24.1 months). Detection of CTCs at any follow-up visit was significantly predictive of worse disease-free survival (DFS;hazard ratio [HR]: 2.44; 95% confidence interval [CI]: 1.41-4.24; p=0.002), regional control (HR: 6.18; 95% CI: 1.18-32.35; p=0.031), distant control (HR: 2.93; 95% CI: 1.52-5.65;p=0.001) and overall survival (OS;HR: 2.02; 95% CI: 1.16-3.51; p=0.013). After adjusting for receiving neoadjuvant vs. adjuvant chemoradiotherapy, the presence of CTCs at any follow-up visit remained significantly predictive of worse OS ([HR]:2.02;95% [Cl]:1.16-3.51; p=0.013) and DFS (HR: 2.49;95% Cl: 1.43-4.33; p=0.001). Similarly, any observed increase in CTCs was significantly predictive of worse OS (HR: 3.14; 95% CI: 1.56-6.34; p=0.001) and DFS (HR: 3.34; 95% CI: 1.67-6.69; p<0.001). CONCLUSION: The presence of CTCs in patients during follow-up after tri-modality therapy was associated with significantly poorer DFS and OS regardless of timing of chemoradiotherapy.

The quality of life in neoadjuvant versus adjuvant therapy of esophageal cancer treatment trial (QUINTETT): Randomized parallel clinical superiority trial.

BACKGROUND: We compared the health-related quality of life (HRQOL) in patients undergoing trimodality therapy for resectable stage I-III esophageal cancer. METHODS: A total of 96 patients were randomized to standard neoadjuvant cisplatin and 5-fluorouracil chemotherapy plus radiotherapy (neoadjuvant) followed by surgical resection or adjuvant cisplatin, 5-fluorouracil, and epirubicin chemotherapy with concurrent extended volume radiotherapy (adjuvant) following surgical resection. RESULTS: There was no significant difference in the functional assessment of cancer therapy-esophageal (FACT-E) total scores between arms at 1 year (p = 0.759) with 36% versus 41% (neoadjuvant vs. adjuvant), respectively, showing an increase of ≥15 points compared to pre-treatment (p = 0.638). The HRQOL was significantly inferior at 2 months in the neoadjuvant arm for FACT-E, European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ-OG25), and EuroQol 5-D-3 L in the dysphagia, reflux, pain, taste, and coughing domains (p < 0.05). Half of patients were able to complete the prescribed neoadjuvant arm chemotherapy without modification compared to only 14% in the adjuvant arm (p < 0.001). Chemotherapy related adverse events of grade ≥2 occurred significantly more frequently in the neoadjuvant arm (100% vs. 69%, p < 0.001). Surgery related adverse events of grade ≥2 were similar in both arms (72% vs. 86%, p = 0.107). There were no 30-day mortalities and 2% vs. 10% 90-day mortalities (p = 0.204). There were no significant differences in either overall survival (OS) (5-year: 35% vs. 32%, p = 0.409) or disease-free survival (DFS) (5-year: 31% vs. 30%, p = 0.710). CONCLUSION: Trimodality therapy is challenging for patients with resectable esophageal cancer regardless of whether it is given before or after surgery. Newer and less toxic protocols are needed.

Functional Lung Avoidance for Individualized Radiation Therapy: Results of a Double-Masked, Randomized Controlled Trial.

PURPOSE: To determine whether functional lung avoidance based on 3He magnetic resonance imaging (MRI) improves quality of life (QOL) for patients undergoing concurrent chemoradiotherapy (CCRT) for advanced non-small cell lung cancer. METHODS AND MATERIALS: Patients with stage III non-small cell lung cancer (or oligometastatic disease treated with curative intent) undergoing CCRT with at least a 10 pack-year smoking history were eligible. Patients underwent pretreatment 3He MRI to measure lung ventilation and had 2 radiation therapy (RT) plans created before randomization: a standard plan, which did not make use of the 3He MRI, and an avoidance plan, preferentially sparing well-ventilated lung. All participants were masked to assignment except the physicist responsible for exporting the selected plan. The primary end point was patient-reported QOL measured at 3-months post-RT by the FACT-L lung cancer subscale (LCS); secondary end points included other QOL metrics, toxicity, and survival outcomes. Target accrual was 64. RESULTS: Twenty-seven patients were randomized before the trial was closed due to slower-than-expected accrual, with 11 randomized to the standard arm and 16 to the avoidance arm. Baseline patient characteristics were well-balanced. At 3 months post-RT, the mean ± SD LCS scores were 17.4 ± 2.8 versus 17.3 ± 6.1 for the standard and avoidance arms, respectively (P = .485). A clinically meaningful, prespecified decline of ≥3 points in the LCS score was observed in 50% (4/8) in the standard arm and 33% (4/12) in the avoidance arm (P = .648). Two patients in each arm developed grade ≥2 radiation pneumonitis, with no grade ≥4 toxicities. CONCLUSIONS: Although this trial did not reach full accrual, QOL scores were very similar between arms. Due to the scarcity of 3He MRI, other, more commonly available methods to measure functional lung, such as 4-dimensional computed tomography ventilation mapping, may be considered in the assessment of functional lung avoidance RT, and a larger, multicenter approach would be needed to accrue sufficient patients to test such approaches.

Exploitation of treatment induced tumor lysis to enhance the sensitivity of ctDNA analysis: A first-in-human pilot study.

INTRODUCTION: Blood-based liquid biopsies examining circulating tumour DNA (ctDNA) have increasing applications in non-small cell lung cancer (NSCLC). Limitations in sensitivity remain a barrier to ctDNA replacing tissue-based testing. We hypothesized that testing immediately after starting treatment would yield an increased abundance of ctDNA in plasma because of tumor lysis, allowing for the detection of genetic alterations that were occult in baseline testing. METHODS: Three prospective cohorts of patients with stage III/IV NSCLC were enrolled. Cohort 1 (C1) contained patients starting platinum doublet chemoradiation (n = 10) and cohort 2 (C2) initiating platinum doublet cytotoxic chemotherapy ± immunotherapy (n = 10). Cohort 3 (C3) contained patients receiving palliative radiation. Two baseline samples were collected. In C1 and C2, subsequent samples were collected 3, 6, 24 and 48 h post initiation of chemotherapy. Patients in C3 had samples collected immediately prior to the next three radiotherapy fractions. Samples were analyzed for ctDNA using the 36-gene amplicon-based NGS Inivata InVisionFirst®-Lung assay. RESULTS: A total of 40 patients were enrolled. Detectable ctDNA was present at baseline in 32 patients (80%), 4 additional patients (50%) had detectable ctDNA in post-treatment samples. Seven patients with detectable ctDNA at baseline (23%) had new genetic alterations detected in post-treatment samples. Mutant molecule numbers increased with treatment in 24 of 31 (77%) pts with detectable ctDNA. ctDNA levels peaked a median of 7 h (IQR:2-26 h) after the initiation of chemotherapy and a median of 2 days (IQR:1-3 days) after radiation was commenced. CONCLUSION: ctDNA levels increase in the hours to days after starting treatment. ctDNA testing in the acute post-treatment phase can yield results that were not evident in pre-treatment testing. Application of this principle could improve ctDNA utility as an alternate to tissue-based testing and improve sensitivity for the detection of treatment-resistant clones.(NCT03986463).

Percutaneous Cryoablation of Recurrent Pancreatic Mass for Life-Threatening Pancreatic VIPoma Syndrome: A Case Report.

We present the case of a 73-year-old female who underwent percutaneous cryoablation for recurrent life-threatening pancreatic vasoactive intestinal polypeptide-producing tumor (VIPoma) following a pancreaticoduodenectomy and chemotherapy 5 years earlier. She presented with profuse watery diarrhea causing severe electrolyte and acid-base abnormalities, along with acute kidney injury. Cryoablation was successful in treating her profound symptoms, completely reversing her clinical course. The patient has made a successful recovery for the last 1.5 years since the procedure.

Quality of written feedback given to medical students after introduction of real-time audio monitoring of clinical encounters.

BACKGROUND: Direct observation is necessary for specific and actionable feedback, however clinicians often struggle to integrate observation into their practice. Remotely audio-monitoring trainees for periods of time may improve the quality of written feedback given to them and may be a minimally disruptive task for a consultant to perform in a busy clinic. METHODS: Volunteer faculty used a wireless audio receiver during the second half of students' oncology rotations to listen to encounters during clinic in real time. They then gave written feedback as per usual practice, as did faculty who did not use the listening-in intervention. Feedback was de-identified and rated, using a rubric, as strong/medium/weak according to consensus of 2/3 rating investigators. RESULTS: Monitoring faculty indicated that audio monitoring made the feedback process easier and increased confidence in 95% of encounters. Most students (19/21 respondents) felt monitoring contributed positively to their learning and included more useful comments. 101 written evaluations were completed by 7 monitoring and 19 non-monitoring faculty. 22/23 (96%) of feedback after monitoring was rated as high quality, compared to 16/37 (43%) (p < 0.001) for monitoring faculty before using the equipment (and 20/78 (26%) without monitoring for all consultants (p < 0.001)). Qualitative analysis of student and faculty comments yielded prevalent themes of highly specific and actionable feedback given with greater frequency and more confidence on the part of the faculty if audio monitoring was used. CONCLUSIONS: Using live audio monitoring improved the quality of written feedback given to trainees, as judged by the trainees themselves and also using an exploratory grading rubric. The method was well received by both faculty and trainees. Although there are limitations compared to in-the-room observation (body language), the benefits of easy integration into clinical practice and a more natural patient encounter without the observer physically present lead the authors to now use this method routinely while teaching oncology students.

Near Miss or Standard of Care? DPYD Screening for Cancer Patients Receiving Fluorouracil.

5-fluorouracil (5-FU) and its pro-drug capecitabine are widely used anticancer agents. Most 5-FU catabolism is dependent on dihydropyrimidine dehydrogenase (DPD) encoded by the DPYD gene, and DPYD variants that reduce DPD function increase 5-FU toxicity. Most DPD deficient patients are heterozygous and can be treated with reduced 5-FU dosing. We describe a patient with a genotype associated with near complete absence of DPD function, and severe and likely fatal toxicity with 5-FU treatment. The patient was treated effectively with alternative systemic therapy. Routine pretreatment DPYD genotyping is recommended by the European Medicines Agency, and guidelines for use of 5-FU in DPD deficient patients are available. However, outside the province of Quebec, routine pretreatment screening for DPD deficiency remains unavailable in Canada. It is likely our patient would have died from 5-FU toxicity under the current standard of care, but instead provides an example of the potential benefit of DPYD screening on patient outcomes.