RESUMO
BACKGROUND: Increasing systemic treatment and shortages of oncology professionals in Canada require innovative approaches to the safe and effective delivery of intravenous (IV) cancer treatment. We conducted a systematic review of the clinical and scientific literature, and an environmental scan of models in Canada, the United Kingdom, Australia, and New Zealand. We then developed a framework for the organization and delivery of IV systemic treatment. METHODS: The systematic review covered the medline, embase, cinahl, and HealthStar databases. The environmental scan retrieved published and unpublished sources, coupled with a free key word search using the Google search engine. The Systemic Treatment Working Group reviewed the evidence and developed a draft framework using evidence-based analysis, existing recommendations from various jurisdictions, and expert opinion based on experience and consensus. The draft was assessed by Ontario stakeholders and reviewed and approved by Cancer Care Ontario. RESULTS: The poor quantity and quality of the evidence necessitated a consensus-derived model. That model comprises four levels of care determined by a regional systemic treatment program and three integrated structures (integrated cancer programs, affiliate institutions, and satellite institutions), each with a defined scope of practice and a specific organizational framework. INTERPRETATION: New models of care are urgently required beyond large centres, particularly in geographically remote or rural areas. Despite limited applicable evidence, the development and successful implementation of this framework is intended to create sustainable, accessible, quality care and to measurably improve patient outcomes.
RESUMO
BACKGROUND: Aluminium hydroxide (alum) is a commonly used adjuvant for specific immunotherapy of allergic diseases. While alum is traditionally associated with murine Th2 sensitization, little is known about its effects on secondary allergic responses in humans. METHODS: We investigated the in vitro effects of alum on peripheral blood mononuclear cells (PBMC) from atopic donors. PBMC from 18 grass pollen-sensitive rhinitic subjects were stimulated with Phleum pratense (Phl p) in the presence or absence of alum. After 6 days culture, cytokine production was measured by ELISA and T cell proliferation by radiolabelled thymidine incorporation. The effect of alum on the expression of human leucocyte antigen and CD80/CD86 on cultured antigen-presenting cells was assessed by flow cytometry. RESULTS: PBMC cultured with Phl p and alum showed a significant decrease in both IL-5 and IL-13 production compared with allergen alone (P<0.005 and P<0.001, respectively), but no change in IFN-gamma or IL-12 production or proliferative responses. These alum-induced changes in T helper (Th)2 cytokine production were unaffected by the addition of neutralizing antibodies to IL-4 or IL-12. Culture of PBMC with alum induced increased expression of CD86 (P=0.004) and HLA (P=0.01) on monocytes while the expression of CD80 was decreased (P=0.02). SUMMARY: Alum down-regulates allergen-driven Th2 cytokine responses while Th1 cytokines are unaffected. These data confirm that alum is a useful adjuvant for inclusion in allergen immunotherapy vaccines.
