Should organs at risk (OARs) be prioritized over target volume coverage in stereotactic ablative radiotherapy (SABR) for oligometastases? a secondary analysis of the population-based phase II SABR-5 trial.

BACKGROUND AND PURPOSE: Stereotactic ablative radiotherapy (SABR) for oligometastases may improve survival, however concerns about safety remain. To mitigate risk of toxicity, target coverage was sacrificed to prioritize organs-at-risk (OARs) during SABR planning in the population-based SABR-5 trial. This study evaluated the effect of this practice on dosimetry, local recurrence (LR), and progression-free survival (PFS). METHODS: This single-arm phase II trial included patients with up to 5 oligometastases between November 2016 and July 2020. Theprotocol-specified planning objective was to cover 95 % of the planning target volume (PTV) with 100 % of the prescribed dose, however PTV coverage was reduced as needed to meet OAR constraints. This trade-off was measured using the coverage compromise index (CCI), computed as minimum dose received by the hottest 99 % of the PTV (D99) divided by the prescription dose. Under-coverage was defined as CCI < 0.90. The potential association between CCI and outcomes was evaluated. RESULTS: 549 lesions from 381 patients were assessed. Mean CCI was 0.88 (95 % confidence interval [CI], 0.86-0.89), and 196 (36 %) lesions were under-covered. The highest mean CCI (0.95; 95 %CI, 0.93-0.97) was in non-spine bone lesions (n = 116), while the lowest mean CCI (0.71; 95 % CI, 0.69-0.73) was in spine lesions (n = 104). On multivariable analysis, under-coverage did not predict for worse LR (HR 0.48, p = 0.37) or PFS (HR 1.24, p = 0.38). Largest lesion diameter, colorectal and 'other' (non-prostate, breast, or lung) primary predicted for worse LR. Largest lesion diameter, synchronous tumor treatment, short disease free interval, state of oligoprogression, initiation or change in systemic treatment, and a high PTV Dmax were significantly associated with PFS. CONCLUSION: PTV under-coverage was not associated with worse LR or PFS in this large, population-based phase II trial. Combined with low toxicity rates, this study supports the practice of prioritizing OAR constraints during oligometastatic SABR planning.

Validation of a Patient-Reported Outcome Measure for Moist Desquamation among Breast Radiotherapy Patients.

There has been an increasing interest in patient-reported outcome (PRO) measures in both the clinical and research settings to improve the quality of life among patients and to identify when clinical intervention may be needed. The primary purpose of this prospective study was to validate an acute breast skin toxicity PRO measure across a broad sample of patient body types undergoing radiation therapy. Between August 2018 and September 2019, 134 women undergoing adjuvant breast radiotherapy (RT) consented to completing serial PRO measures both during and post-RT treatment and to having their skin assessed by trained trial radiation therapists. There was high patient compliance, with 124 patients (92.5%) returning to the clinic post-RT for at least one staff skin assessment. Rates of moist desquamation (MD) in the infra-mammary fold (IMF) by PRO were compared with skin assessments completed by trial radiation therapists. There was high sensitivity (86.5%) and good specificity (79.4%) between PRO and staff-reported presence of MD in the IMF, and there was a moderate correlation between the peak severity of the MD reported by PRO and assessed by staff (rho = 0.61, p < 0.001). This prospective study validates a new PRO measure to monitor the presence of MD in the IMF among women receiving breast RT.

Predictors of Early Polymetastatic Relapse After SABR for up to 5 Oligometastases: A Secondary Analysis of the Phase II SABR-5 Trial.

PURPOSE: A subset of patients with oligometastatic cancer experience early widespread cancer dissemination and do not benefit from metastasis-directed therapy such as SABR. This study aimed to identify factors associated with early polymetastatic relapse (PMR). METHODS AND MATERIALS: The SABR-5 trial was a single arm phase 2 study conducted at all 6 regional cancer centers across British Columbia (BC), Canada. SABR for oligometastases was only offered on trial. Patients with up to 5 oligometastatic lesions (total, progressing, or induced) received SABR to all lesions. Patients were 18 years of age or older, Eastern Cooperative Oncology Group 0 to 2 and life expectancy ≥6 months. This secondary analysis evaluated factors associated with early PMR, defined as disease recurrence within 6 months of SABR, which is not amenable to further local treatment. Univariable and multivariable analyses were performed using binary logistic regression. The Kaplan-Meier method and log-rank tests assessed PMR-free survival and differences between risk groups, respectively. RESULTS: Between November 2016 and July 2020, 381 patients underwent treatment on SABR-5. A total of 16% of patients experienced PMR. Worse performance status (Eastern Cooperative Oncology Group 1-2 vs 0; hazard ratio [HR] = 2.01, P = .018), nonprostate/breast histology (HR = 3.64, P <.001), and oligoprogression (HR = 3.84, P <.001) were independent predictors for early PMR. Risk groups were identified with median PMR-free survival ranging from 5 months to not yet reached at the time of analysis. Rates of 3-year overall survival were 0%, 53% (95% confidence interval [CI], 48-58), 77% (95% CI, 73-81), and 93% (95% CI, 90-96) in groups 1 to 4, respectively (P <.001). CONCLUSIONS: Four distinct risk groups for early PMR are identified, which differ significantly in PMR-free survival and overall survival. The group with all 3 risk factors had a median PMR-free survival of 5 months and may not benefit from local ablative therapy alone. This model should be externally validated with data from other prospective trials.

Progression-Free Survival and Local Control After SABR for up to 5 Oligometastases: An Analysis From the Population-Based Phase 2 SABR-5 Trial.

PURPOSE: Despite increasing utilization of SABR for oligometastatic cancer, prospective outcomes are lacking. The purpose of this study was to determine progression-free survival (PFS), local control (LC), and prognostic factors from the population-based phase 2 SABR-5 trial. METHODS AND MATERIALS: The SABR-5 trial was a single-arm phase 2 study with the primary endpoint of toxicity, conducted at the 6 regional cancer centers across British Columbia (BC), Canada, during which time SABR for oligometastases was only offered on trial. Patients with up to 5 oligometastases (total or not controlled by prior treatment and including induced oligometastatic disease) underwent SABR to all lesions. Patients were 18 years of age or older, had an Eastern Cooperative Oncology Group score of 0 to 2, and had life expectancy ≥ 6 months. The secondary outcomes of PFS and LC are presented here. RESULTS: Between November 2016 and July 2020, 381 patients underwent SABR on trial. Median follow-up was 27 months (interquartile range, 18-36). Median PFS was 15 months (95% confidence interval [CI], 12-18). LC at 1 and 3 years were 93% (95% CI, 91-95) and 87% (95% CI, 84-90), respectively. On multivariable analysis, increasing tumor diameter (hazard ratio [HR], 1.09; P < .001), declining performance status (HR, 2.13; P < .001), disease-free interval <18 months (HR, 1.52; P = .003), 4 or more metastases at SABR (HR, 1.48; P = .048), initiation or change in systemic treatment (HR, 0.50; P < .001), and oligoprogression (HR, 1.56; P = .008) were significant independent predictors of PFS. Tumor diameter (sub-hazard ratio [SHR], 1.28; P < .001), colorectal histology (SHR, 4.33; P = .002), and "other" histology (SHR, 3.90; P < .001) were associated with worse LC. CONCLUSIONS: In this population-based cohort including patients with genuine oligometastatic, oligoprogressive, and induced oligometastatic disease, the median PFS was 15 months and LC at 3 years was 87%. This supports ongoing efforts to randomize patients in phase 3 trials, even outside the original 1 to 5 metachronous oligometastatic paradigm.

A novel carbon-fibre adjustable reusable accessory (CARA) for supine breast positioning to reduce toxicity in breast adjuvant radiotherapy: a study protocol for a multicentre phase III randomized controlled trial.

BACKGROUND: A novel device for supine positioning in breast radiotherapy for patients with large or pendulous breasts has been developed and tested in phase II studies. This trial is designed to assess the efficacy of the device to reduce skin toxicity and unwanted normal tissue dose in comparison to the current clinical standard for supine breast support during breast radiotherapy. METHODS: Patients at high risk for moist desquamation, having infra-mammary fold or lateral ptosis, will be randomized into two arms. Patients in the control arm will receive breast radiotherapy with supine positioning using current standard of care. Patients in the experimental arm will be positioned supine with the novel device. The primary endpoint is the incidence of moist desquamation in the infra-mammary fold. We hypothesize a 20% reduction (from 50 to 30%) in the rate of moist desquamation in the study arm versus the control arm. For 80% power, two-tailed α = 0.05 and 10% loss to follow up, 110 patients will be assigned to each arm. The proportion of patients experiencing moist desquamation in the two arms will be compared using logistic regression adjusting for brassiere cup size, skin fold size, body mass index, smoking status, and dose fractionation schedule. An unadjusted comparison will also be made using the chi-square test, or Fisher's exact test, if appropriate. Secondary endpoints include dose-volume statistics for the lung and heart, skin dose and clinical parameters including setup time, reproducibility, and staff experience with setup procedures. Patient-reported pain, skin condition interference with sleep and daily activities, and comfort during treatment are also secondary endpoints. DISCUSSION: Based on results from earlier phase II studies, it is expected that the device-enabled elimination of infra-mammary fold should reduce toxicity and improve quality of life for this patient population. Earlier studies showed reduction in dose to organs at risk including lung and heart, indicating potential for other long-term benefits for patients using the device. This study is limited to acute skin toxicity, patient-reported outcomes, and clinical factors to inform integration of the device into standard breast radiotherapy procedures. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04257396 . Registered February 6 2020.

Evaluation of Patient-Reported Outcome Differences by Radiotherapy Techniques for Bone Metastases in A Population-Based Healthcare System.

We assessed whether advanced RT techniques were associated with differences in patient-reported outcomes (PROs). Patients with bone metastases who completed the brief pain inventory (BPI) before and after RT were identified, and RT technique was categorized as simple (e.g., parallel opposed pair) or advanced (e.g., 3D-conformal RT (3DCRT), intensity-modulated RT (IMRT), or stereotactic ablative RT (SABR)). Pain response and patient-reported interference on quality of life secondary to pain was compared. A total of 1712 patients completed the BPI. From 2017−2021, the rate of advanced RT technique increased significantly (p < 0.001; 2.4%, 2.4%, 9.7%, 5.5%, 9.3%), with most advanced techniques consisting of IMRT, and only 7% of advanced techniques were SABR. Comparing simple vs. advanced technique, neither the complete pain response (12.3% vs. 11.4%; p = 0.99) nor the partial pain response (50.0% vs. 51.8%; p = 0.42) was significantly different. There was no significant patient-reported difference in pain interfering with general activity, mood, walking ability, normal work, relationships, sleep, or enjoyment of life. Given that there is increasing utilization of advanced RT techniques, there is further need for randomized trials to assess their benefits given the increased cost and inconvenience to patients.

Patient-reported outcomes and complications during head and neck cancer radiotherapy before versus during the COVID-19 pandemic.

PURPOSE: This study compares patient-reported outcomes and treatment-related complications during radiotherapy before (August 2019-January 2020) versus during (March-Sept 2020) the COVID-19 pandemic. MATERIALS AND METHODS: The MD Anderson Symptom Inventory-head and neck module was used to assess curative intent in H&N cancer patients' symptoms during radiotherapy. RESULTS: There were 158 patients in the pre-pandemic cohort and 137 patients in the pandemic cohort. There was no significant difference in enteral feeding requirements between the cohorts (21% versus 30%, p = 0.07). Weight loss was higher during the pandemic (mean - 5.6% versus 6.8%, p = 0.03). On multivariate analysis, treatment during the pandemic was associated with higher symptom scores for coughing/choking while eating (2.7 versus 2.1, p = 0.013). CONCLUSIONS: Complication rates during H&N radiotherapy during the COVID-19 pandemic were similar at our institution relative to the pre-pandemic era, although weight loss was greater and patients reported more severe choking/coughing while eating.

Should Stereotactic Ablative Radiotherapy Be Used for Oligometastatic Disease?

Should SABR Be Used for Oligometastatic Disease?The efficacy of stereotactic ablative radiotherapy in the oligometastatic setting has not been shown in phase 3 randomized controlled trials for breast (or many other) cancers. We review the evidence base and propose a trial to address the question, should stereotactic ablative radiotherapy be used for oligometastatic disease?

Ninety-day mortality after radiotherapy for head and neck cancer: Population-based comparison between rural and urban patients.

BACKGROUND: This study assesses whether 90-day mortality differs between patients living in rural and urban areas, as lower access to supportive care services in rural areas could result in higher mortality. METHODS: All patients with head and neck cancer (HNC) treated between 1998 and 2014 with radiotherapy in British Columbia were included. Patients were divided into rurality areas according to the Modified Statistics Canada (mSC) definition, which classifies a population <30 000 as rural and ≥30 000 as urban. RESULTS: Five thousand five hundred and fifty-four patients were included in this study, of which 68% lived in urban centers. The 90-day mortality for rural versus urban patients were 3.0% and 3.9% (p = 0.09), respectively. Univariate and multivariate analyses showed no association with 90-day mortality and rurality. CONCLUSION: After controlling for potentially confounding factors, we did not find a significant association between 90-day mortality and rurality in patients who were treated with radiotherapy for HNC in British Columbia.

Is SABR Cost-Effective in Oligometastatic Cancer? An Economic Analysis of the SABR-COMET Randomized Trial.

PURPOSE: The phase 2 randomized study SABR-COMET demonstrated that in patients with controlled primary tumors and 1 to 5 oligometastatic lesions, SABR was associated with improved progression-free survival (PFS) compared with standard of care (SoC), but with higher costs and treatment-related toxicities. The aim of this study was to assess the cost-effectiveness of SABR versus SoC in this setting. METHODS AND MATERIALS: A Markov model was constructed to perform a cost-utility analysis from the Canadian health care system perspective. Utility values and transition probabilities were derived from individual-level data from the SABR-COMET trial. One-way, 2-way, and probabilistic sensitivity analyses were performed. Costs were expressed in 2018 CAD. A separate analysis based on US payer's perspective was performed. An incremental cost-effectiveness ratio (ICER) at a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was used. RESULTS: In the base case scenario, SABR was cost-effective at an ICER of $37,157 per QALY gained. This finding was most sensitive to the number of metastatic lesions treated with SABR (ICER: $28,066 per QALY for 2, increasing to $64,429 per QALY for 5), difference in chemotherapy use (ICER: $27,173-$53,738 per QALY), and PFS hazard ratio (HR) between strategies (ICER: $31,548-$53,273 per QALY). Probabilistic sensitivity analysis revealed that SABR was cost-effective in 97% of all iterations. Two-way sensitivity analysis demonstrated a nonlinear relationship between the number of lesions and the PFS HR. To maintain cost-effectiveness for each additional metastasis, the HR must decrease by approximately 0.047. The US cost analysis yielded similar results, with an ICER of $54,564 (2018 USD per QALY) for SABR. CONCLUSIONS: SABR is cost-effective for patients with 1 to 5 oligometastatic lesions compared with SoC.

The Usefulness of Patient-Reported Outcomes and the Influence on Palliative Oncology Patients and Health Services: A Qualitative Study of the Prospective Outcomes and Support Initiative.

BACKGROUND: Through the British Columbia, Prospective Outcomes and Support Initiative (POSI), registered nurses collect patient-reported outcome (PRO) data during telephone follow-up with palliative oncology patients. OBJECTIVE: The research objective was to describe the usefulness and influence of the nursing care provided through POSI follow-up on palliative patients and health services. METHODS: We used a qualitative interpretive description approach involving the collection and analysis of semistructured interview data with 20 palliative patients and 12 oncology nurses. All participant data were subjected to an inductively derived coding framework. Analytic categories were identified and iteratively revised through constant comparative techniques to develop representative themes. RESULTS: The accounts of patients and nurses suggest that telephone follow-up with PROs enabled the nurses to (1) focus on the priorities of patients experiencing complex health challenges, (2) manage complex symptoms, (3) ease the patient's transition home, and (4) improve access to and use of health services. Suggestions for improving POSI nurse follow-up centered on flexibility in the timing of the follow-up, creating dedicated POSI work assignments, and having additional time to personalize assessments and nursing care beyond the PRO questionnaires. CONCLUSIONS: Nursing care employing PROs via telephone follow-up can improve palliative cancer patients' quality of life and health service use. IMPLICATIONS FOR PRACTICE: Nurses are optimally positioned to use PROs following cancer treatment completion but require organizational resources and support to optimize patient and system outcomes.

Hypofractionated Adjuvant Radiation Therapy Is Effective for Patients With Lymph Node-Positive Breast Cancer: A Population-Based Analysis.

PURPOSE: This study evaluated long-term, population-based, breast cancer-specific outcomes in patients treated with radiation therapy (RT) to the breast/chest wall plus regional nodes using hypofractionated (HF) (40-42.5 Gy/16 fractions) versus conventionally fractionated (CF) regimens (50-50.4 Gy/25-28 fractions). METHODS AND MATERIALS: A prospective provincial database was used to identify patients with lymph node-positive breast cancer treated with curative-intent breast/chest wall + regional nodal RT from 1998 to 2010. The effect of RT fractionation on locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) was assessed for the entire cohort and for high-risk subgroups: grade 3, ER-/HER2-, HER2+, and ≥4 positive nodes. Multivariable analysis and 2:1 case-match comparison of HF versus CF were also performed. RESULTS: A total of 5487 patients met the inclusion criteria (4006 HF and 1481 CF). Median age was 55 years, and median follow-up was 12.7 years. On multivariable analysis, no statistically significant differences were identified in 10-year LRRFS (hazard ratio [HR] 0.87; 95% confidence interval [CI], 0.59-1.27; P = .46), DRFS (HR 0.90; 95% CI, 0.76-1.06; P = .19), or BCSS (HR 0.92; 95% CI, 0.76-1.10; P = .36) between the HF and CF cohorts. There was no statistical difference in breast cancer-specific outcomes in the high-risk subgroups. On analysis of 2962 HF cases matched to 1481 CF controls, no statistical difference was observed in LRRFS (HR 0.98; 95% CI, 0.71-1.33; P = .87), DRFS (HR 0.97; 95% CI, 0.85-1.11; P = .68), or BCSS (HR 1.00; 95% CI, 0.87-1.16; P = .92). CONCLUSIONS: This large, population-based analysis with long-term follow-up after locoregional RT demonstrated that modest HF provides similar breast cancer-specific outcomes compared with CF. HF is an effective option for patients with stage I to III breast cancer receiving nodal RT.

Association between nutritional risk index and outcomes for head and neck cancer patients receiving concurrent chemo-radiotherapy.

BACKGROUND: Patients receiving chemoradiotherapy for head and neck cancer (HNC) are often malnourished. We assessed the utility of nutritional risk index (NRI) in HNC patients undergoing chemoradiotherapy. METHODS: A population-based retrospective review of HNC patients treated with curative chemoradiation was performed. Demographics, anthropometrics, overall survival (OS), and the composite treatment complication rate (G-tube dependence, radiation incompletion, 90-day mortality, and unplanned hospitalization) were collected. RESULTS: Two hundred ninety-two patients were identified. Average pretreatment and posttreatment NRI were 110 (SD 3) and 99 (SD 12), respectively (P < .01). Pretreatment NRI risk category, age, ECOG status, and tumor subsites were associated with OS on multivariate analysis. Pretreatment NRI risk category was associated with risk of treatment related complications. CONCLUSIONS: There was a significant decrease between pretreatment and posttreatment NRI in HNC patients receiving chemoradiation. Pretreatment NRI risk category may predict OS and composite treatment complications. Investigation of NRI as a prognostic factor is warranted.

Radiation Oncology Resident and Program Director Perceptions of the Job Market and Impact on Well-being.

Background Radiation oncology graduates occasionally experience difficulties obtaining employment. The purpose of this study was to explore the perceptions of radiation oncology residents (RORs) and program directors (PDs) about the job market and the potential impact on their well-being. Methods RORs and PDs from 13 Canadian training programs were invited to participate. Semi-structured interviews were conducted from March 2014 to January 2015. Knowledge/perception of the job market, impact on personal/professional life, as well as opinions regarding possible contributing factors/solutions to the job market were assessed. A conventional content analysis of each transcript was performed with the clustering of conceptually similar expressions into themes. Demographic information was summarized with descriptive statistics. Results Twenty RORs and four PDs participated. All the participants described delayed retirement and over-training as contributors to the job shortage. The majority of trainees interviewed were concerned about the job market (60%) and reported that it impacted their personal (60%) and professional (55%) relationships. PDs described the job market as negatively impacting their job satisfaction. Resident morale was ranked as poor by both groups. Conclusions Job market shortages can negatively impact the personal and professional well-being of trainees and PDs. Attention to manpower planning is important to maintaining a high-quality workforce. The cyclical undersupply and oversupply of residents occur in several countries, which makes our findings potentially relevant to residency training programs internationally.

Patterns of Radiotherapy Utilization for Lung Cancer Patients with Brain Metastases: A Population-based Analysis.

INTRODUCTION: Brain metastases occur in 15%-20% of lung cancer patients. Recently, studies have suggested that whole-brain radiotherapy (WBRT) may not prolong survival for a subset of patients, and is associated with significant side-effects. Furthermore, it is hypothesized that radiotherapy is often given near the end-of-life when the potential for benefit is minimal. Therefore, this study investigates how frequently radiotherapy for brain metastases is given near the end-of-life in a population-based cohort. MATERIALS AND METHODS: All lung cancer patients who received radiotherapy in British Columbia for brain metastases in 2014-2015 were identified. Patient and treatment characteristics were collected and analyzed to assess associations with death within 90 days of first radiation treatment. RESULTS: In total, 740 patients were identified, with a total of 826 courses of brain radiation. The 90-day mortality rate was 40% (n=330). Multivariable analysis demonstrated higher odds for age (odds ratio (OR) = 1.04, 95% confidence interval (CI) 1.02-1.05), Eastern Cooperative Oncology Group (ECOG) performance score of 2 or higher (OR = 1.59, 95% CI 1.09-2.31) and squamous cell carcinoma (OR = 2.10, 95% CI 1.13-3.90) and lower odds for initial systemic therapy (OR = 0.48, 95% CI 0.34-0.68), more than five fractions of radiotherapy (OR = 0.25, 95% CI 0.16-0.39) and stereotactic radiation (OR = 0.29, 95% CI 0.13-0.65). CONCLUSION: In our population-based study, WBRT is given in 86% of radiotherapy courses for brain metastases from lung cancer. Of these patients, 40% received treatment near the end-of-life. We identified several factors associated with shortened survival. Using these factors and already established prognostic tools, WBRT utilization should be decreased in the future, improving individualized treatment for patients with brain metastases from lung cancer.

Urban and rural differences in outcomes of head and neck cancer.

OBJECTIVES/HYPOTHESIS: To assess for potential urban and rural disparities in head and neck cancer (HNC) outcomes within a single-payer healthcare system. STUDY DESIGN: A large retrospective population-based cohort analysis of consecutive HNC patients treated in British Columbia, Canada between 2001 and 2010 was conducted. METHODS: All patients diagnosed with HNC from 2001 to 2010 and referred to any one of five British Columbia Cancer Agency centers for management were reviewed. Based on census data, patients were classified into: 1) rural, 2) small urban, 3) moderate urban, and 4) large urban areas. Kaplan-Meier methods and Cox regression models were used to correlate site of residence with overall survival (OS), controlling for prognostic factors that included sociodemographic and other tumor and treatment-related characteristics. RESULTS: We identified 3,036 patients; the median age was 64 years, 26% were women, and 32% had Eastern Cooperative Oncology Group (ECOG) 0 or 1. The majority resided in large urban areas (55%) followed by rural (22%), moderate urban (13%), and small urban (10%). In regression analyses, smoking (hazard ratio [HR]: 2.10, 95% confidence interval [CI]: 1.28-3.45, P < .001), ECOG 2 + (HR: 3.44, 95% CI: 2.26-5.22, P < .001), oral cavity (HR: 1.54, 95% CI: 1.03-2.32, P = .04) and hypopharyngeal tumors (HR: 2.31, 95% CI: 1.42-3.77, P = .00), and large tumor size (HR: 1.69, 95% CI: 1.08-2.64, P = .02) were correlated with inferior OS, but site of residence was not. When stratified by type of treatment, OS remained similar irrespective of urban or rural residence. CONCLUSIONS: Urban-rural differences in HNC survival outcomes were not observed. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:852-858, 2018.

The Opioid Crisis and the Certified Registered Nurse Anesthetist: Caring for Patients With Opioid Use Disorder in Drug-Free Recovery.

Opioid Use Disorder (OUD), the diagnostic term for opioid addiction, is estimated to affect millions of Americans and cost those who suffer it enormously. Given that opioid analgesics are a common component of anesthesia, how can we deliver safe and effective care to those who are in drug-free remission? This editorial will provide a background of this disorder, and will focus specifically on recommendations and guidelines available to the nurse anesthetist on the appropriate anesthetic care for the surgical patient population with OUD in recovery and not on maintenance therapy.

Provincial development of a patient-reported outcome initiative to guide patient care, quality improvement, and research.

The BC Cancer Agency Radiotherapy (RT) program started the Prospective Outcomes and Support Initiative (POSI) at all six centres to utilize patient-reported outcomes for immediate clinical care, quality improvement, and research. Patient-reported outcomes were collected at time of computed tomography simulation via tablet and 2 to 4 weeks post-RT via either tablet or over the phone by a registered nurse. From 2013 to 2016, patients were approached on 20,150 attempts by POSI for patients treated with RT for bone metastases (52%), brain metastases (11%), lung cancer (17%), gynecological cancer (16%), head and neck cancer (2%), and other pilots (2%). The accrual rate for all encounters was 85% (n = 17,101), with the accrual rate varying between the lowest and the highest accruing centre from 78% to 89% ( P < .001) and varying by tumour site ( P < .001). Using the POSI database, we have performed research and quality improvement initiatives that have changed practice.

Asian and non-Asian disparities in outcomes of non-nasopharyngeal head and neck cancer.

OBJECTIVES/HYPOTHESIS: To evaluate disparities in overall survival (OS) between Asian and non-Asian patients diagnosed with non-nasopharyngeal head and neck cancer (HNC). STUDY DESIGN: This was a population-based, retrospective study of patients diagnosed with non-nasopharyngeal HNC of squamous cell carcinoma histology between 2001 and 2010 in British Columbia, Canada. METHODS: Using Kaplan-Meier methods and Cox regression models, we examined the relationship between race and OS. RESULTS: A total of 3,036 patients were included in the study. Median age was 64 years, 74% were men, and 7% were Asians. Asians had worse Eastern Cooperative Oncology Group (ECOG) status (29% vs. 23%, P = .07) and larger tumors (33% vs. 21%, P = .02), and were more likely to be diagnosed with oral cavity cancers (38% vs. 25%, P < .001) than non-Asians. Asians were also less likely to receive multimodality therapy than non-Asians (90% vs. 95%, P = .02). Asians were more likely to have never smoked (49% vs. 15%, P < .001) and to be married or with a partner (80% vs. 69%, P = .02). Multivariate models showed that Asians had better OS than non-Asians (hazard ratio [HR] = 0.50, 95% confidence interval [CI] = 0.25-0.99, P = .05). Three-year OS did not differ significantly between Asians and non-Asians (41% vs. 42%, P = .18); however, 5-year OS did (22% vs. 19% P = .03). Stratifying by treatment type, outcomes were comparable in both groups except for radiotherapy alone, where Asians showed significantly better OS (HR = 0.71, 95% CI = 0.51-0.99, P = .04). Advanced age, worse ECOG, greater tumor size, and lack of treatment also correlated with inferior OS. CONCLUSIONS: Despite several worse prognostic features and less aggressive treatment, Asians tended to exhibit better OS than non-Asians. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:2528-2533, 2017.

Impact of Travel Distance and Urban-Rural Status on the Multidisciplinary Management of Rectal Cancer.

OBJECTIVES: Optimal treatment of rectal cancer (RC) requires multidisciplinary care. We examined whether distance to treatment center or community size impacts access to multimodality care and population-based outcomes in RC. METHODS: Patients diagnosed with stage II/III RC from 1999 to 2009 and treated at 1 of 6 regional cancer centers in British Columbia were reviewed. Distance to treatment center was determined for each patient. Communities were classified as rural, small, medium, and large population centers. Logistic and Cox regression models assessed associations of distance and community size with treatment received as well as cancer-specific (CSS) and overall survival (OS). RESULTS: Of 3,158 patients, 93.6% underwent surgery, 86.3% received radiotherapy, and 51.3% were treated with adjuvant chemotherapy (AC). Median time from diagnosis to oncologic consultation was longer for those >100 km from a treatment center or residing in medium/rural communities. Logistic regression demonstrated no correlation between distance or community size and receipt of treatment modality. Univariate analysis showed similar CSS (P = .18, .88) and OS (P = .36, .47) based on community size and distance, respectively. In multivariate analysis, distance >100 km had inferior CSS (Hazard Ratio [HR] 1.39, 95% CI: 1.03-1.88; P = .031). There was no consistent trend between decreasing community size and outcomes; however, living in a small center was associated with improved OS (HR 0.58, 95% CI: 0.38-0.88; P = .011) and CSS (HR 0.42, 95% CI: 0.25-0.70; P = .001). CONCLUSIONS: In this population-based study, there were no urban-rural differences in access to multidisciplinary care, but increased distance may be associated with worse cancer-specific outcomes.