State of research, feasibility, safety, acceptability, and outcomes examined on remotely delivered exercises using technology for older adult with cancer: a scoping review.

INTRODUCTION: Technology-based exercise is gaining attention as a promising strategy for increasing physical activity (PA) in older adults with cancer (OACA). However, a comprehensive understanding of the interventions, their feasibility, outcomes, and safety is limited. This scoping review (1) assessed the prevalence and type of technology-based remotely delivered exercise interventions for OACA and (2) explored the feasibility, safety, acceptability, and outcomes in these interventions. METHODS: Studies with participant mean/median age ≥ 65 reporting at least one outcome measure were included. Databases searched included the following: PubMed, CINAHL, Embase, Cochrane Library Online, SPORTDiscus, and PsycINFO. Multiple independent reviewers completed screening and data abstractions of articles in English, French, and Spanish. RESULTS: The search yielded 2339 citations after removing duplicates. Following title and abstract screening, 96 full texts were review, and 15 were included. Study designs were heterogeneous, and sample sizes were diverse (range 14-478). The most common technologies used were website/web portal (n = 6), videos (n = 5), exergaming (n = 2), accelerometer/pedometer with video and/or website (n = 4), and live-videoconferencing (n = 2). Over half (9/15) of the studies examined feasibility using various definitions; feasibility outcomes were reached in all. Common outcomes examined include lower body function and quality of life. Adverse events were uncommon and minor were reported. Qualitative studies identified cost- and time-savings, healthcare professional support, and technology features that encourage engagement as facilitators. CONCLUSION: Remote exercise interventions using technology appear to be feasible and acceptable in OACA. IMPLICATIONS FOR CANCER SURVIVORS: Some remote exercise interventions may be a viable way to increase PA for OACA.

Long-term Outcomes Following Active Surveillance of Low-grade Prostate Cancer: A Population-based Study Using a Landmark Approach.

PURPOSE: Active surveillance is widely used to manage low-risk prostate cancer, but population-level long-term outcomes are limited. Our objective was to determine long-term population-level oncological outcomes in active surveillance patients. A secondary objective examined the active surveillance discontinuation rate. MATERIALS AND METHODS: In this retrospective, population-based study using linked administrative databases from Ontario, Canada, we identified low-grade prostate cancer patients managed with active surveillance or initial treatment between 2002-2014. The 10- and 15-year metastasis-free survival, overall survival, and cancer-specific survival were compared between active surveillance and initial treatment. A landmark of 24 months was selected for the primary analysis. Long-term outcomes were examined using multivariable proportional hazards models and a propensity-based approach. RESULTS: The cohort consisted of 21,282 low-grade prostate cancer patients with a median follow-up of 9.8 years. At 10-year follow-up the survival rate of remaining on active surveillance was 39%, metastasis-free survival was 94.2%, overall survival 88.7%, and cancer-specific survival 98.1%. In adjusted models active surveillance was associated with higher risk of metastasis (HR 1.34, 95%CI 1.15-1.57), overall mortality (HR 1.12, 95%CI 1.01-1.24), and prostate cancer-specific mortality (HR 1.66, 95%CI 1.15-2.39) compared to initial treatment. Survival analysis using 7,525 propensity-matched pairs was consistent with the primary analysis for metastasis-free survival, overall survival and cancer-specific survival. CONCLUSIONS: In this large population-based study of long-term outcomes in men with low-grade prostate cancer, active surveillance is associated with excellent long-term metastasis-free survival and overall survival. However, long-term cancer-specific survival was slightly inferior (1% worse at 10 years with active surveillance), and this must be balanced against known harms of overtreatment.

Opioid Use After Nephrectomy for Kidney Cancer in Ontario: A Population-Based Study.

OBJECTIVE: To compare the odds of early and prolonged post-operative opioid use in patients undergoing minimally invasive surgery (MIS) vs open surgery for nephrectomy. METHODS: For opioid-naïve patients in Ontario who underwent nephrectomy for kidney cancer (1994-2017, n = 7900), post-discharge opioid use was determined by prescriptions in the Ontario Drug Benefit database (age ≥65 years) and the Narcotics Monitoring System (all patients from 2012). Early opioid use was defined as ≥1 prescription 1-90 days after surgery. Two separate definitions of prolonged opioid use were examined: (1) prescription(s) for ≥60 days during post-operative days 90-365; (2) ≥1 prescriptions between both of: 1-90 days AND 91-180 days after surgery. Predictors of opioid use were assessed using multivariable generalized estimating equation logistic regression, accounting for surgeon clustering. RESULTS: Overall, 67.4% of patients received early opioid prescriptions; however, prolonged use was low, ranging from 1.6 to 4.4% of patients depending on the definition. In multivariable analysis, open nephrectomy was associated with higher odds of early opioid use compared to MIS nephrectomy (Odds Ratio [OR] 1.36, 95% Confidence Interval [CI] 1.19-1.55). Surgery type was not significantly associated with prolonged opioid use for either definition (OR 1.22, CI 0.79-1.89 and OR 1.06, CI 0.83-1.35). CONCLUSIONS: In this population-level study of patients undergoing nephrectomy for kidney cancer, patients who received open surgery were at increased odds of receiving early post-operative opioids compared to MIS. Prolonged opioid use was low overall and was not significantly with associated with type of surgery.

Real-World Practice Patterns and Predictors of Continuous versus Intermittent Androgen Deprivation Therapy Use for Prostate Cancer in Older Men.

PURPOSE: Phase-III randomized control trial evidence suggests intermittent androgen deprivation therapy (IADT) is not significantly inferior to continuous androgen deprivation therapy (ADT) for patients with prostate cancer (PC). However, clinical practice and guidelines differ in their recommendations. We evaluate real-world utilization and practice patterns of IADT. MATERIALS AND METHODS: Ontario men ≥65 years of age with PC who initiated ADT for ≥3 months were identified (1997-2017). Lapses in ADT ≥6 months (initial gap) and ≥3 months (subsequent gaps) were used to classify IADT. Neoadjuvant/adjuvant therapy was excluded. Disease stage adjustment was completed for patients with likely metastatic disease based on de novo presentation with ADT. Patient and physician predictors of IADT were analyzed using multivariable logistic regression. RESULTS: We identified 8,544 patients with 1,715 having previously received local therapy. Among all patients, 16.4% received IADT. This ranged from 11.4%-24.8% across health-planning regions and increased to 26.6% in those with previous local therapy. Mean followup was 8.3 years. Patients with prior local therapy (OR 1.85, 95% CI 1.59-2.17, p <0.001) and those in the highest income quintile (OR 1.32, 95% CI 1.08-1.60, p=0.005) had increased odds of receiving IADT. Radiation oncologists were more likely to use IADT than urologists (OR 1.99, 95% CI 1.59-2.50, p <0.001), as were physicians with more experience (≥10 years in practice: OR 1.44, 95% CI 1.11-1.88, p=0.007). In specialty-stratified analyses, case volume was significantly associated with IADT for radiation oncologists (highest quartile: OR 1.73, 95% CI 1.14-2.62, p=0.009). CONCLUSIONS: IADT remains underutilized for patients with PC who ≥65 years of age with only 1 in 4 to 1 in 6 eligible patients receiving this form of care. Clinical, sociodemographic and physician characteristics play an important role in treatment selection.

Long-term use of 5-alpha-reductase inhibitors is safe and effective in men on active surveillance for prostate cancer.

BACKGROUND: Although 5-alpha-reductase inhibitors (5ARIs) have been shown to benefit men with prostate cancer (PCa) on active surveillance (AS), their long-term safety remains controversial. Our objective is to describe the long-term association of 5ARI use with PCa progression in men on AS. MATERIALS/SUBJECTS AND METHODS: The cohort of men with low-risk PCa was derived from a prospectively maintained AS database at the Princess Margaret (1995-2016). Pathologic, grade, and volume progression were the primary end points. Kaplan-Meier time-to-event analysis was performed and Cox proportional hazards regression was used to determine predictors of progression where 5ARI exposure was analyzed as a time-dependent variable. Patients who came off AS prior to any progression events were censored at that time. RESULTS: The cohort included 288 men with median follow-up of 82 months (interquartile range: 37-120 months). Among non-5ARI users (n = 203); 114 men (56.2%) experienced pathologic progression compared with 24 men (28.2%) in the 5ARI group (n = 85), (p < 0.001). Grade and volume progression were higher in the non-5ARI group compared with the 5ARI group (n = 82; 40.4% vs. n = 19; 22.4% respectively, p = 0.003 for grade progression; n = 87; 43.1% and n = 15; 17.7%, respectively for volume progression p < 0.001). Lack of 5ARI use was independently positively associated with pathologic progression (HR: 2.65; CI: 1.65-4.24), grade progression (HR: 2.75; CI: 1.49-5.06), and volume progression (HR: 3.15; CI: 1.78-5.56). The frequency of progression to high-grade (Grade Group 4-5) tumors was not significantly different between the groups. CONCLUSIONS: Use of 5ARIs diminished both grade and volume progression without an increased risk of developing Grade Groups 4-5 disease.

Long-term recovery of quality of life and physical function over three years in adult survivors of acute myeloid leukemia after intensive chemotherapy.

We previously described impairments in quality of life (QOL) and physical function among acute myeloid leukemia (AML) survivors between diagnosis and 1 year. The aim of the current study is to describe and compare to normative data QOL and physical function recovery over 3 years from diagnosis and treatment with intensive chemotherapy (IC). At assessments done at baseline (pre-IC) and at 11 time points over 3 years, QOL, fatigue, and 3 physical performance measures (PPMs; grip strength, 6-min walk test (6MWT), and timed chair stands) were collected. Long-term recovery was defined by reaching scores within the minimum clinically important difference of normative data. Global QOL recovery was seen in 79% at 1 year, 75% at 2 years, and 86% at 3 years. At 3 years, the QLQ-C30 subscales with the greatest recovery were physical and emotional functioning. For FACT-fatigue, recovery was seen in 68% at 1 year and 77% at 3 years. Recovery on PPMs was poorer on average, with only 17% on the 6MWT and 42% in grip strength returning to normal at 3 years. The vast majority of AML survivors after IC achieve recovery in QOL and fatigue by three years. However, recovery in physical performance remained blunted.

Bone Health and Bone-targeted Therapies for Prostate Cancer: a Programme in Evidence-based Care - Cancer Care Ontario Clinical Practice Guideline.

AIMS: To make recommendations with respect to bone health and bone-targeted therapies in men with prostate cancer. MATERIALS AND METHODS: A systematic review was carried out by searching MEDLINE, EMBASE and the Cochrane Library from inception to January 2016. Systematic reviews and randomised-controlled trials were considered for inclusion if they involved therapies directed at improving bone health or outcomes such as skeletal-related events, pain and quality of life in patients with prostate cancer either with or without metastases to bone. Therapies included medications, supplements or lifestyle modifications alone or in combination and were compared with placebo, no treatment or other agents. Disease-targeted agents such as androgen receptor-targeted and chemotherapeutic agents were excluded. Recommendations were reviewed by internal and external review groups. RESULTS: In men with prostate cancer receiving androgen deprivation therapy, baseline bone mineral density testing is encouraged. Denosumab should be considered for reducing the risk of fracture in men on androgen deprivation therapy with an increased fracture risk. Bisphosphonates were effective in improving bone mineral density, but the effect on fracture was inconclusive. No medication is recommended to prevent the development of first bone metastasis. Denosumab and zoledronic acid are recommended for preventing or delaying skeletal-related events in men with metastatic castration-resistant prostate cancer. Radium-223 is recommended for reducing symptomatic skeletal events and prolonging survival in men with symptomatic metastatic castration-resistant prostate cancer. CONCLUSIONS: The recommendations represent a current standard of care that is feasible to implement, with outcomes valued by clinicians and patients.

Long-term health care costs for prostate cancer patients on androgen deprivation therapy.

BACKGROUND: Comparing relative costs for androgen deprivation therapy (adt) protocols in prostate cancer (pca) requires an examination of all health care resources, not only those specific to pca. The objective of the present study was to use administrative data to estimate total health care costs in a population-based cohort of pca patients. METHODS: Patients in Ontario with pca who started 90 days or more of adt at age 66 years or older during 1995-2005 were selected from cancer registry and health care administrative databases. We classified patients (n = 21,818) by regimen (medical castration, orchiectomy, anti-androgen monotherapy, medical castration with anti-androgen, orchiectomy with anti-androgen) and indication (neoadjuvant, adjuvant, metastatic disease, biochemical recurrence, primary nonmetastatic). Using nonparametric regression methods, with inverse probability weighting to adjust for censoring, and bootstrapping, we computed mean 1-year, 5-year, and 10-year longitudinal total direct medical costs (2009 Canadian dollars). RESULTS: Mean first-year costs were highest for metastatic disease, ranging from $24,400 for orchiectomy to $32,120 for anti-androgen monotherapy. Mean first-year costs for all other indications were less than $20,000. Mean 5-year and 10-year costs were lowest for neoadjuvant treatment: approximately $43,000 and $81,000 respectively, with differences of less than $4,000 between regimens. Annual costs were highest in the first year of adt. Orchiectomy was the least costly regimen for most time periods, but was limited to primary and metastatic indications. Outpatient drugs, including pharmacologic adt, accounted for 17%-65% of total first-year costs. CONCLUSIONS: Compared with combined therapies, the adt monotherapies, particularly orchiectomy when clinically feasible, are more economical. Our methods exemplified the use of algorithms to elucidate clinical information from administrative data. Our approach can be adapted for other cancers to expand the range of studies using Canadian administrative data.

The prevalence and nature of supportive care needs in lung cancer patients.

PURPOSE: In the present work, we set out to comprehensively describe the unmet supportive care and information needs of lung cancer patients. METHODS: This cross-sectional study used the Supportive Care Needs Survey Short Form 34 (34 items) and an informational needs survey (8 items). Patients with primary lung cancer in any phase of survivorship were included. Demographic data and treatment details were collected from the medical charts of participants. The unmet needs were determined overall and by domain. Univariable and multivariable regression analyses were performed to determine factors associated with greater unmet needs. RESULTS: From August 2013 to February 2014, 89 patients [44 (49%) men; median age: 71 years (range: 44-89 years)] were recruited. The mean number of unmet needs was 8 (range: 0-34), and 69 patients (78%) reported at least 1 unmet need. The need proportions by domain were 52% health system and information, 66% psychological, 58% physical, 24% patient care, and 20% sexuality. The top 2 unmet needs were "fears of the cancer spreading" [n = 44 of 84 (52%)] and "lack of energy/tiredness" [n = 42 of 88 (48%)]. On multivariable analysis, more advanced disease and higher MD Anderson Symptom Inventory scores were associated with increased unmet needs. Patients reported that the most desired information needs were those for information on managing symptoms such as fatigue (78%), shortness of breath (77%), and cough (63%). CONCLUSIONS: Unmet supportive care needs are common in lung cancer patients, with some patients experiencing a very high number of unmet needs. Further work is needed to develop resources to address those needs.

Enablers and barriers in delivery of a cancer exercise program: the Canadian experience.

BACKGROUND: Exercise is an important therapy to improve well-being after a cancer diagnosis. Accordingly, cancer-exercise programs have been developed to enhance clinical care; however, few programs exist in Canada. Expansion of cancer-exercise programming depends on an understanding of the process of program implementation, as well as enablers and barriers to program success. Gaining knowledge from current professionals in cancer-exercise programs could serve to facilitate the necessary understanding. METHODS: Key personnel from Canadian cancer-exercise programs (n = 14) participated in semistructured interviews about program development and delivery. RESULTS: Content analysis revealed 13 categories and 15 subcategories, which were grouped by three organizing domains: Program Implementation, Program Enablers, and Program Barriers. ■ Program Implementation (5 categories, 8 subcategories) included Program Initiation (clinical care extension, research project expansion, program champion), Funding, Participant Intake (avenues of awareness, health and safety assessment), Active Programming (monitoring patient exercise progress, health care practitioner involvement, program composition), and Discharge and Follow-up Plan.■ Program Enablers (4 categories, 4 subcategories) included Patient Participation (personalized care, supportive network, personal control, awareness of benefits), Partnerships, Advocacy and Support, and Program Characteristics.■ Program Barriers (4 categories, 3 subcategories) included Lack of Funding, Lack of Physician Support, Deterrents to Participation (fear and shame, program location, competing interests), and Disease Progression and Treatment. CONCLUSIONS: Interview results provided insight into the development and delivery of cancer-exercise programs in Canada and could be used to guide future program development and expansion in Canada.

A phase II exercise randomized controlled trial for patients with acute myeloid leukemia undergoing induction chemotherapy.

Curative treatment for acute myeloid leukemia (AML) involves induction chemotherapy (IC) which is associated with bed rest and toxicities, leading to worsening quality of life (QOL), fatigue, and fitness. Exercise during IC may ameliorate declines but has not been rigorously tested. We examined the efficacy of supervised exercise during IC on QOL, fatigue, and fitness. Eighty-three inpatients age 18-80 scheduled to receive IC for newly diagnosed or relapsed AML were randomized 2:1 (exercise intervention:control group). Study measures were completed at baseline, post-IC, and following the first cycle of consolidation. The intervention consisted of a supervised mixed-modality, moderate-intensity exercise program (4-5 days per week, 30-60min per session) throughout admission. Recruitment was good (56%), retention excellent (96%), and adherence was 54%. Global QOL improved similarly in both groups from baseline to post-IC (between-group difference 3.0 points, p=0.62). Fatigue improved in the exercise group from baseline to post-IC (potentially clinically important between-group difference of 3.6 points, p=0.23). Aerobic fitness, lower body strength, and grip strength improved in the exercise group (between-group differences p=0.005, p<0.001, p=0.03, respectively). Supervised exercise for patients with AML undergoing IC is feasible, safe, and appears effective at improving fitness and possibly fatigue. A larger trial is warranted.

The effect of bicycling on PSA levels: a systematic review and meta-analysis.

BACKGROUND: Recent literature has suggested that bicycling may be associated with increases in serum PSA levels, a diagnostic and prognostic marker for prostate cancer. To further investigate this relationship, we conducted a systematic review and meta-analysis of current literature in this field. METHODS: MEDLINE, CENTRAL, CINAHL and SPORTDiscus were searched using MeSH terms and keywords for English publications related to bicycle riding and PSA. Studies were included if PSA was measured relative to cycling activity in healthy men who were free of any prostatic condition. Case studies were excluded. RESULTS: Eight studies met our inclusion criteria, comprising 912 participants that engaged in, or self-reported, bicycling activity. Six studies investigated the acute pre-post change in PSA following bicycling activity that ranged from a single cycling bout of 15 min to a 4-day cycling event. Following cycling activity, two studies reported total PSA increased from baseline by up to 3.3-fold, free PSA increased in one study by 0.08±0.18 ng ml(-)(1) and did not change in four studies. One study compared PSA in elite/professional cyclists versus non-cyclists and demonstrated no significant difference in PSA measurements between groups. Data from six studies were meta-analyzed and demonstrated no significant increase in PSA associated with cycling from pre to post (mean change +0.027 ng ml(-)(1), s.e.m.=0.08, P=0.74, 95% confidence interval (CI)=-0.17-0.23). CONCLUSIONS: Our findings suggest that there is no effect of cycling on PSA; however, the limited number of trials and the absence of randomized controlled trials limit the interpretation of our results. Additionally, the median sample size only consisted of 42 subjects. Therefore, our study may have low statistical power to detect a difference in PSA. Although, a higher sample size may demonstrate statistical significance, it may not be clinically significant. Studies of higher empirical quality are needed.

A systematic review and quality appraisal of international guidelines for early breast cancer systemic therapy: Are recommendations sensitive to different global resources?

The breast cancer incidence in low and middle income countries (LMCs) is increasing globally, and patient outcomes are generally worse in these nations compared to high income countries (HICs). This is partly due to resource constraints associated with implementing recommended breast cancer therapies. Clinical practice guideline (CPG) adherence can improve breast cancer outcomes, however, many CPGs are created in HICs, and include costly recommendations that may not be feasible in LMCs. In addition, the quality of CPGs can be variable. The aim of this study was to perform a systematic review of CPGs on early breast cancer systemic therapy with potential international impact, to evaluate their content, quality, and resource sensitivity. A MEDLINE and gray literature search was completed for English language CPGs published between 2005 and 2010, and then updated to July 2014. Extracted guidelines were evaluated using the AGREE 2 instrument. Guidelines were specifically analyzed for resource sensitivity. Most of the extracted CPGs had similar recommendations with regards to systemic therapy. However, only one, the Breast Health Global Initiative, made recommendations with consideration of different global resources. Overall, the CPGs were of variable quality, and most scored poorly in the quality domain evaluating implementation barriers such as resources. Published CPGs for early breast cancer are created in HICs, have similar recommendations, and are generally resource-insensitive. Given the visibility and influence of these CPGs on LMCs, efforts to create higher quality, resource-sensitive guidelines with less redundancy are needed.

Bone health management in men undergoing ADT: examining enablers and barriers to care.

UNLABELLED: The study determined prostate cancer specialists' knowledge and concordance to guidelines regarding the diagnosis, management, and prevention of androgen deprivation therapy-induced osteoporosis. Despite high knowledge regarding bone health, most respondents did not routinely measure bone mineral density or use fracture risk assessment tools, suggesting a significant gap in the screening/monitoring of bone health. INTRODUCTION: The purpose of this study was to determine prostate cancer specialists' knowledge, practices, self-perceived competencies and barriers to providing guideline-concordant care in the diagnosis, prevention, and management of androgen deprivation therapy (ADT)-induced osteoporosis (OP). METHODS: A number of 73 Canadian radiation oncologists and 83 urologists completed questionnaires assessing (i) knowledge regarding OP and consensus guidelines for bone health management in men receiving ADT, (ii) self-assessed competencies regarding bone health management, (iii) current practices regarding OP prevention and management, and (iv) self-perceived barriers to providing guideline-concordant care. RESULTS: The majority of respondents were able to correctly identify the guideline-concordant frequency of repeat dual-energy X-Ray absorptiometry (DXA) scans (76.3%), vitamin D (70.3%), and calcium (53.2%) intake and that bisphosphonates/denosumab should always be considered for patients with a history of one low-trauma fracture (57.6%). Just under 1/3 (32.5%) reported routinely measuring bone mineral density (BMD) prior to starting ADT and routinely measuring BMD 1-2 years following the initiation of ADT (36.6%). Only 4.6% of respondents routinely used a validated fracture risk assessment tool. Lowest self-assessed competency levels were reported in providing self-management education to patients to foster the uptake of healthy bone behaviors (HBBs) and managing patients who present with or develop osteopenia and OP. The most significant barriers to providing OP prevention and management were lack of time and lack of supporting structures. CONCLUSIONS: Despite high knowledge about appropriate bone health care among prostate cancer specialists, there remain significant gaps in screening and monitoring of bone health, suggesting the need to develop innovative strategies to overcome barriers to implementation.

Diagnostic prostate biopsy performed in a non-academic center increases the risk of re-classification at confirmatory biopsy for men considering active surveillance for prostate cancer.

BACKGROUND: To examine whether diagnostic biopsy (B1), for patients on active surveillance (AS) for prostate cancer, performed at an outside referral centre (external) compared with our in-house tertiary center (internal), increased the risk of re-classification on the second (confirmatory) biopsy (B2). METHODS: Patients on AS were identified from our tertiary center database (1997-2012) with PSA<10, Gleason sum (GS) ⩽6, clinical stage ⩽cT2, ⩽3 positive cores, <50% of single core involved, age ⩽75 years and having a B2. Patients who had <10 cores at B1 and delay in B2 >24 mo were excluded. Depending on center where B1 was performed, men were dichotomized to internal or external groups. All B2 were performed internally. Multivariate logistic regression examined if external B1 was a predictor of re-classification at B2. RESULTS: A total of 375 patients were divided into external (n=71, 18.9%) and internal groups (n=304, 81.1%). At B2, more men in the external group re-classified (26.8%) compared with the internal group (13.8%) (P=0.008). On multivariate analysis, external B1 predicted grade-related re-classification (odds ratio (OR) 4.14, confidence interval (CI) 2.01-8.54, P<0.001) and volume-related re-classification (OR 3.43, CI 1.87-6.25, P<0.001). Other significant predictors for grade-related re-classification were age (OR 2.13 per decade, CI 1.32-3.57, P<0.001), PSA density (OR 2.56 per unit, CI 1.44-4.73, P<0.001), maximum % core involvement (OR 1.04 per percentage point, CI 1.01-1.09, P=0.02) and time between B1 and B2 (OR 1.43 per 6 months, CI 1.21-1.71, P<0.001). CONCLUSION: At our institution, patients on AS who had their initial B1 performed externally were more likely to have adverse pathological features and re-classify on internal B2.

Health care costs for prostate cancer patients receiving androgen deprivation therapy: treatment and adverse events.

BACKGROUND: Serious adverse events have been associated with androgen deprivation therapy (adt) for prostate cancer (pca), but few studies address the costs of those events. METHODS: All pca patients (ICD-9-CM 185) in Ontario who started 90 days or more of adt or had orchiectomy at the age of 66 or older during 1995-2005 (n = 26,809) were identified using the Ontario Cancer Registry and drug and hospital data. Diagnosis dates of adverse events-myocardial infarction, acute coronary syndrome, congestive heart failure, stroke, deep vein thrombosis or pulmonary embolism, any diabetes, and fracture or osteoporosis-before and after adt initiation were determined from administrative data. We excluded patients with the same diagnosis before and after adt, and we allocated each patient's time from adt initiation to death or December 31, 2007, into health states: adt (no adverse event), adt-ae (specified single adverse event), Multiple (>1 event), and Final (≤180 days before death). We used methods for Canadian health administrative data to estimate annual total health care costs during each state, and we examined monthly trends. RESULTS: Approximately 50% of 21,811 patients with no pre-adt adverse event developed 1 or more events after adt. The costliest adverse event state was stroke ($26,432/year). Multiple was the most frequent (n = 2,336) and the second most costly health state ($24,374/year). Costs were highest in the first month after diagnosis (from $1,714 for diabetes to $14,068 for myocardial infarction). Costs declined within 18 months, ranging from $784 per 30 days (diabetes) to $1,852 per 30 days (stroke). Adverse events increased the costs of adt by 100% to 265%. CONCLUSIONS: The economic burden of adverse events is relevant to programs and policies from clinic to government, and that burden merits consideration in the risks and benefits of adt.

Do quality of life or physical function at diagnosis predict short-term outcomes during intensive chemotherapy in AML?

BACKGROUND: Intensive chemotherapy (IC) used to treat acute myeloid leukemia (AML) is associated with toxicity, particularly in older adults. Emerging data suggest that baseline quality of life (QOL) and physical function may predict outcomes in oncology, although data in AML are limited. We investigated the association between baseline QOL and physical function with short-term treatment outcomes in adults and elderly AML patients. MATERIALS AND METHODS: We conducted a prospective, longitudinal study of adults (age 18+) AML patients undergoing IC. Before starting IC, patients completed the European Organisation for the Research and Treatment of Cancer (EORTC) 30-item questionnaire (QLQ-C30) and Functional Assessment of Cancer Therapy Fatigue subscale (FACT-Fatigue) in addition to physical function tests (grip strength, timed chair stands, 2-min walk test). Outcomes included 60-day mortality, intensive care unit (ICU) admission and achievement of complete remission (CR). Logistic regression was carried out to evaluate each outcome. RESULTS: Of the 239 patients (median age 57.5 years), 56.7% were male and median Charlson comorbidity score was 0. Sixty-day mortality, ICU admission and CR occurred in 9 (3.7%), 15 (6.3%) and 167 (69.9%) patients, respectively. Using univariate regression, neither QOL nor physical function at presentation was predictive of 60-day mortality (all P > 0.05), whereas ICU admission (P < 0.001) and remission status at 30 days (P = 0.007) were. Fatigue (P = 0.004) and role functioning (P = 0.003) were predictors of ICU admission; QOL and physical function were not. A higher Charlson score predicted ICU admission (P = 0.01) and remission status (P = 0.002). The cytogenetic risk group was associated with achievement of CR (P = 0.02); QOL and physical function were not (all P > 0.05). Findings were similar when patients age 60+ were examined. Relationships between fatigue and role functioning with ICU admission deserve further exploration. CONCLUSIONS: Baseline QOL and physical function tests in this prospective study were not associated with short-term mortality, ICU admission or achievement of CR after the first cycle of chemotherapy.

Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis.

OBJECTIVE: To systematically review the evidence of pre-operative exercise, known as 'prehabilitation', on peri- and postoperative outcomes in adult surgical populations. DESIGN: Systematic review and meta-analysis. DATA SOURCES: CENTRAL, Medline, EMBASE, CINAHL, PsycINFO and PEDro were searched from 1950 to 2011. METHODS: Two reviewers independently examined relevant, English-language articles that examined the effects of pre-operative total-body exercise with peri- and postoperative outcome analysis. Given the nascence of this field, controlled and uncontrolled trials were included. Risk of bias was assessed using the Cochrane Risk of Bias Assessment tool. Only data on length of stay were considered eligible for meta-analysis due to the heterogeneity of measures and methodologies for assessing other outcomes. RESULTS: In total, 4597 citations were identified by the search strategy, of which 21 studies were included. Trials were generally small (median=54 participants) and of moderate to poor methodological quality. Compared with standard care, the majority of studies found that total-body prehabilitation improved postoperative pain, length of stay and physical function, but it was not consistently effective in improving health-related quality of life or aerobic fitness in the studies that examined these outcomes. The meta-analysis indicated that prehabilitation reduced postoperative length of stay with a small to moderate effect size (Hedges' g=-0.39, P=0.033). Intervention-related adverse events were reported in two of 669 exercising participants. CONCLUSION: The literature provides early evidence that prehabilitation may reduce length of stay and possibly provide postoperative physical benefits. Cautious interpretation of these findings is warranted given modest methodological quality and significant risk of bias.

An update on a systematic review of the use of geriatric assessment for older adults in oncology.

BACKGROUND: Our previous systematic review of geriatric assessment (GA) in oncology included a literature search up to November 2010. However, the quickly evolving field warranted an update. Aims of this review: (i) provide an overview of all GA instruments developed and/or in use in the oncology setting; (ii) evaluate effectiveness of GA in predicting/modifying outcomes (e.g. treatment decision impact, treatment toxicity, mortality, use of care). MATERIALS AND METHODS: Systematic review of literature published between November 2010 and 10 August 2012. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of GA instruments were included. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL and Cochrane Library. Two researchers independently reviewed abstracts, abstracted data and assessed the quality using standardized forms. A meta-analysis method of combining proportions was used for the outcome impact of GA on treatment modification with studies included in this update combined with those included in our previous systematic review on the use of GA. RESULTS: Thirty-five manuscripts reporting 34 studies were identified. Quality of most studies was moderate to good. Eighteen studies were prospective, 11 cross-sectional and 5 retrospective. Three studies examined treatment decision-making impact and found decisions changed for fewer than half of assessed patients (weighted percent modification is 23.2% with 95% confidence interval (20.3% to 26.1%). Seven studies reported conflicting findings regarding predictive ability of GA for treatment toxicity/complications. Eleven studies examined GA predictions of mortality, and reported that instrumental activities of daily living, poor performance status and more numerous GA deficits were associated with increased mortality risk. Other outcomes could not be meta-analyzed. CONCLUSION: Consistent with our previous review, several domains of GA are associated with adverse outcomes. However, further research examining effectiveness of GA on treatment decisions and oncologic outcomes is needed.

Factors influencing adherence to cancer treatment in older adults with cancer: a systematic review.

BACKGROUND: Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer. PATIENTS AND METHODS: Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011. RESULTS: Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies. CONCLUSION: Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.