Inflammatory markers as prognostic factors of recurrence in advanced-stage squamous cell carcinoma of the head and neck.

Background: Multiple immunologic parameters have provided useful prognostic and assessment significance in various cancers, including head-and-neck squamous cell carcinoma (scc). We sought to identify whether pretreatment inflammatory markers could prognosticate recurrence in patients with advanced (stage iii or iv) head-and-neck scc who underwent therapy with curative intent in a tertiary care centre between January 2010 and December 2012. Methods: In a chart review, we recorded demographics; primary tumour characteristics; p16 status; pretreatment inflammatory markers, including body mass index (bmi), neutrophil-to-lymphocyte ratio (nlr), C-reactive protein (crp), and serum albumin; therapy received; and date of relapse, death, or last follow-up. The main outcome was relapse-free survival (rfs). Overall survival (os) was a secondary outcome. Results: From among 235 charts reviewed, 118 cases were included: 86 oropharyngeal (50 p16-positive, 18 p16-negative, 17 p16 unavailable, 1 p16 indeterminate), and 32 non-oropharyngeal (7 p16-positive, 19 p16-negative, 6 p16 unavailable). Median follow-up was 2.45 years (25%-75% interquartile range: 1.65-3.3 years). In univariate analysis, p16 status, bmi, modified Glasgow prognostic score, and crp were significant for rfs, but in multivariate analysis, only p16 status, bmi, and crp remained significant. For os, only crp and nlr were significant in both the univariate and multivariate analyses. After adjustment for p16 status, nlr did not remain significant. After adjustment for p16 status, crp remained significant for both rfs and os. Conclusions: In patients with head-and-neck scc, a stronger prognostic value is associated with human papillomavirus status than with nlr and many other factors, including bmi and albumin. However, even though few of our patients had high crp, serum crp remained significant despite p16-positive status.

Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement.

Recent guidelines concerning exercise for people with cancer provide evidence-based direction for exercise assessment and prescription for clinicians and their patients. Although the guidelines promote exercise integration into clinical care for people with cancer, they do not support strategies for bridging the guidelines with related resources or programs. Exercise program accessibility remains a challenge in implementing the guidelines, but that challenge might be mitigated with conceptual frameworks ("pathways") that connect patients with exercise-related resources. In the present paper, we describe a pathway model and related resources that were developed by an expert panel of practitioners and researchers in the field of exercise and rehabilitation in oncology and that support the transition from health care practitioner to exercise programs or services for people with cancer. The model acknowledges the nuanced distinctions between research and exercise programming, as well as physical activity promotion, that, depending on the available programming in the local community or region, might influence practitioner use. Furthermore, the pathway identifies and provides examples of processes for referral, screening, medical clearance, and programming for people after a cancer diagnosis. The pathway supports the implementation of exercise guidelines and should serve as a model of enhanced care delivery to increase the health and well-being of people with cancer.

A little help from my friends: social support in palliative rehabilitation.

Background: Social support has been shown to buffer some difficulties of living with advanced cancer. The Palliative Rehabilitation Program (prp) was an interdisciplinary outpatient program offering post-treatment palliative rehabilitation to patients with advanced cancer. Social support was directly integrated into the program. The aim of the present study was to examine the types and sources of social support that patients found most beneficial. Methods: Twelve patients participated in 30-minute semi-structured interviews. Thematic content analysis was used to explore the social support experiences of those patients in the prp. Patients were eligible to participate in the interview if they had completed the 8-week prp, spoke English, and did not have cognitive or auditory impairments affecting their ability to participate. Results: The main sources of support reported by participants were team members and spouse, family, or close friends; peers attending the program; and spiritual beliefs. Social support varied based on sex and age, such that, compared with women, men reported relying less on social support, and the supportive needs of younger (≤50 years of age) and older participants differed. Team members were endorsed as frequently as family as social support. Discussion: Emotional support was endorsed with the greatest frequency. The members of the interdisciplinary care team were also providers of emotional and informational support for patients, bolstering the support received from caregivers. Widowed or divorced women might rely on health care providers more readily than do married men, who chose their wives as support. Future rehabilitation programs might consider the importance of an interdisciplinary team, the formal integration of caregivers, and the incorporation of spirituality to meet the unique supportive needs of patients with advanced cancer.

An interdisciplinary palliative rehabilitation intervention bolstering general self-efficacy to attenuate symptoms of depression in patients living with advanced cancer.

PURPOSE: Patients with advanced cancer, post-anticancer treatment, are living longer than 10-20 years ago. This emerging population of survivors has unique palliative and rehabilitation needs. A particular concern is depression, which can impair functioning, quality of life, and survival. The interdisciplinary Palliative Rehabilitation Program offers holistic palliative rehabilitation for this population using a self-efficacy framework. The current study examined the unique impact of three program factors that have been shown to improve depression: inflammation, exercise, and self-efficacy. METHOD: Patients underwent a 2-month interdisciplinary intervention (up to six disciplines) and thorough pre-post assessments. Measures included serum C-reactive protein, 6-min walk test, General Self-efficacy Scale, and Hospital Anxiety and Depression Scale (depression subscale). Paired t tests analyzed pre-post changes in each variable, and a hierarchical linear regression analyzed the predictors' unique contributions of changes in depression in this quasi-experimental design. RESULTS: The sample included 80 patients (52.5% females), with stages 3/4 heterogeneous cancers. Results revealed that C-reactive protein (CRP) did not significantly change pre-post, from 7.39 (SD = 11.99) to 9.47 mg/L (SD = 16.41), p = 0.110, exercise significantly increased, from 372.55 (SD = 137.71) to 412.64 m (SD = 144.31), p < 0.001, self-efficacy significantly increased from 27.86 (SD = 6.16) to 31.23 units (SD = 5.77), p < 0.001, and depression scores significantly decreased, from 7.14 (SD = 3.91) to 5.95 units (SD = 3.51), p = 0.002. A hierarchical linear regression revealed that this model explained 15% of variance in changes in depression scores, p = 0.006. Change in self-efficacy accounted for 11% of change in depression scores (p < 0.001). Change in CRP and exercise did not make a significant contribution. CONCLUSIONS: A self-efficacy framework may be a helpful ingredient in interdisciplinary intervention to decrease depressive symptomatology.

Erratum: Tumour inflammatory response: adding fuel to the fire?

[This corrects the article on p. 7 in vol. 22, PMID: 25684982.].

An interprofessional palliative care oncology rehabilitation program: effects on function and predictors of program completion.

BACKGROUND: After treatment, patients with active cancer face a considerable burden from the effects of both the disease and its treatment. The Palliative Rehabilitation Program (prp) is designed to ameliorate disease effects and to improve the patient's functioning. The present study evaluated predictors of program completion and changes in functioning, symptoms, and well-being after the program. METHODS: The program received referrals for 173 patients who had finished anticancer therapy. Of those 173 patients, 116 with advanced cancer were eligible and enrolled in the 8-week interprofessional prp; 67 completed it. Measures of physical, nutritional, social, and psychological functioning were evaluated at entry to the program and at completion. RESULTS: Participants experienced significant improvements in physical performance (p < 0.000), nutrition (p = 0.001), symptom severity (p = 0.005 to 0.001), symptom interference with functioning (p = 0.003 to 0.001), fatigue (p = 0.001), and physical endurance, mobility, and balance or function (p = 0.001 to 0.001). Reasons that participants did not complete the prp were disease progression, geographic inaccessibility, being too well (program not challenging enough), death, and personal or unknown reasons. A normal level of C-reactive protein (<10 mg/L, p = 0.029) was a predictor of program completion. CONCLUSIONS: Patients living with advanced cancers who underwent the interprofessional prp experienced significant improvement in functioning across several domains. Program completion can be predicted by a normal level of C-reactive protein.

A prospective evaluation of an interdisciplinary nutrition-rehabilitation program for patients with advanced cancer.

BACKGROUND: Cancer can affect many dimensions of a patient's life, and in turn, it should be targeted using a multimodal approach. We tested the extent to which an interdisciplinary nutrition-rehabilitation program can improve the well-being of patients with advanced cancer. METHODS: Between January 10, 2007, and September 29, 2010, 188 patients with advanced cancer enrolled in the 10-12-week program. Body weight, physical function, symptom severity, fatigue dimensions, distress level, coping ability, and overall quality of life were assessed at the start and end of the program. RESULTS: Of the enrolled patients, 70% completed the program. Patients experienced strong improvements in the physical and activity dimensions of fatigue (effect sizes: 0.8-1.1). They also experienced moderate reductions in the severity of weakness, depression, nervousness, shortness of breath, and distress (effect sizes: 0.5-0.7), and moderate improvements in Six Minute Walk Test distance, maximal gait speed, coping ability, and quality of life (effect sizes: 0.5-0.7) Furthermore, 77% of patients either maintained or increased their body weight. CONCLUSIONS: Interdisciplinary nutrition-rehabilitation can be advantageous for patients with advanced cancer and should be considered an integrated part of standard palliative care.

The association between malnutrition and psychological distress in patients with advanced head-and-neck cancer.

OBJECTIVE: Malnutrition and psychological distress are often seen in patients with head-and-neck cancer, but little is known about the interrelationships between those two symptoms. The present study examined the relationship between malnutrition and psychological distress in patients with advanced head-and-neck cancer. METHODS: Using the Patient-Generated Subjective Global Assessment, 99 patients with advanced-stage head-and-neck cancer were screened for nutrition status. The patients were also screened for psychosocial distress (using the Distress Thermometer) and for psychosocial issues (using the Problem Checklist). Any relationship between malnutrition and psychosocial distress was determined by regression and correlation analysis. We also used t-tests to compare distress levels for patients with and without specific nutrition-related symptoms. RESULTS: The study group included 80 men and 19 women [mean age: 58.4 ± 10.9 years (range: 23-85 years)]. The correlation between poorer nutrition status and level of psychological distress was significant r = 0.37 (p < 0.001). Specifically, reduced food intake and symptoms were both positively associated with distress: r = 0.27 and r = 0.29 respectively, both significant at p < 0.01. After controlling for the effects of psychosocial problems and pain, nutrition status remained a significant predictor of distress, explaining 3.8% of the variance in the distress scores of the patients (p < 0.05). CONCLUSIONS: Malnutrition and symptoms were strongly related to distress in patients with advanced head-and-neck cancer. Our results suggest the need for further research into the complex relationship between nutrition status and distress and into the management of both nutrition and distress in cancer care.

Perioperative DCF chemotherapy protocol for patients with gastroesophageal adenocarcinoma: correlation between response to treatment and outcome.

To determine whether metabolic or pathological response to preoperative chemotherapy can predict the relapse-free survival of gastroesophageal adenocarcinoma patients treated on a perioperative chemotherapy protocol. The prospectively collected data of a recently reported phase II trial of perioperative DCF chemotherapy (docetaxel/cisplatin/5-fluorouracil) were analyzed. Median relapse-free survival (RFS) was compared with the Wilcoxon rank-sum test between responders and non-responders according to defined metabolic (reduction in maximum standard uptake value of at least 35 %) and pathological (greater than 50 % tumor regression or ypN(0) status) criteria. A double-sided p value equal or inferior to 0.05 was considered significant. Patients were followed for a median of 807 days (95 % CI: 607-896). RFS was 576 days in metabolic non-responders versus not reached in metabolic responders (p 0.009) and 562 days in ypN+ versus not reached in ypN(0) patients (p 0.045). No statistically significant RFS difference was seen between low and high pathologic responders classified according to tumor regression criteria, although a trend was observed in favor of high pathologic responders. Simple metabolic and pathologic criteria used for the assessment of response to the preoperative part of perioperative chemotherapy can help to estimate the outcome of gastroesophageal adenocarcinoma patients.

Excision of the primary tumour in patients with metastatic breast cancer: a clinical dilemma.

BACKGROUND: Approximately 10% of new breast cancer patients will present with overt synchronous metastatic disease. The optimal local management of those patients is controversial. Several series suggest that removal of the primary tumour is associated with a survival benefit, but the retrospective nature of those studies raises considerable methodologic challenges. We evaluated our clinical experience with the management of such patients and, more specifically, the impact of surgery in patients with synchronous metastasis. METHODS: We reviewed patients with primary breast cancer and concurrent distant metastases seen at our centre between 2005 and 2007. Demographic and treatment data were collected. Study endpoints included overall survival and symptomatic local progression rates. RESULTS: The 111 patients identified had a median follow-up of 40 months (range: 0.6-71 months). We allocated the patients to one ot two groups: a nonsurgical group (those who did not have breast surgery, n = 63) and a surgical group (those who did have surgery, n = 48, 29 of whom had surgery before the metastatic diagnosis). When compared with patients in the nonsurgical group, patients in the surgical group were less likely to present with T4 tumours (23% vs. 35%), N3 nodal disease (8% vs. 19%), and visceral metastasis (67% vs. 73%). Patients in the surgical group experienced longer overall survival (49 months vs. 33 months, p = 0.01) and lower rates of symptomatic local progression (14% vs. 44%, p < 0.001). CONCLUSIONS: In our study, improved overall survival and symptomatic local control were demonstrated in the surgically treated patients; however, this group had less aggressive disease at presentation. The optimal local management of patients with metastatic breast cancer remains unknown. An ongoing phase iii trial, E2108, has been designed to assess the effect of breast surgery in metastatic patients responding to first-line systemic therapy. If excision of the primary tumour is associated with a survival benefit, then the preselected subgroup of patients who have responded to initial systemic therapy is the desired population in which to put this hypothesis to the test.