A Feasibility Randomized Controlled Trial of Prehabilitation During Neoadjuvant Chemotherapy for Women with Breast Cancer: A Mixed Methods Study.

BACKGROUND: Limited data exist regarding the role of multimodal prehabilitation during neoadjuvant chemotherapy (NACT) for breast cancer. Determining large trial feasibility and identifying signals of prehabilitation benefit are needed. PATIENTS AND METHODS: We conducted a randomized controlled feasibility trial of multimodal prehabilitation versus usual care during NACT among women diagnosed with non-metastatic breast cancer. Intervention participants received an individualized exercise program, dietetic support, and stress management counseling during NACT. The trial assessed feasibility via rates of recruitment, attrition, adherence, and study-related adverse events. Physical fitness (Six Minute Walk Test, grip strength, anthropometrics) and patient-reported outcomes were assessed at baseline, after NACT completion, and 6 months after surgery as exploratory outcomes, and analyzed using linear mixed effects models. Qualitative data were collected from a subsample to understand feasibility and acceptability of prehabilitation. RESULTS: A total of 72 participants were enrolled from the 123 eligible patients (recruitment rate of 53%). There was a 13% attrition rate and no intervention-related adverse events. Participants in the prehabilitation group had better 6-min walk distance at the post-chemotherapy timepoint [between group difference of 49.43 m, 95% confidence interval (CI) - 118.1, 19.2] and at the post-surgery timepoint (27.3, 95% CI -96.8, 42.2) compared with the control group. Prehabilitation participants reported better quality of life, less fatigue, and improved physical activity levels compared with usual care participants. Interviews revealed that the intervention had a positive impact on the treatment experience. CONCLUSIONS: This study demonstrated feasibility and improvement in physical and psychosocial outcomes. Larger trials assessing intervention efficacy to confirm indications of prehabilitation benefit are warranted.

Exploring Tobacco Use and Smoking Cessation Best Practices From the Perspectives of Individuals With Lung Cancer and Health Care Professionals.

BACKGROUND: Lung cancer patients who continue to smoke after diagnosis are at increased risk of treatment toxicity, residual/recurrent disease, future malignancies, and all-cause mortality. Guidelines including those from National Comprehensive Cancer Network and Cancer Care Ontario advocate for screening, counseling, and access to smoking cessation services for all cancer patients; however, barriers from both patient and health care professional (HCP) perspectives contribute to lack of implementation. OBJECTIVE: The objective of this study was to identify the different perspectives among patients and HCPs in how the promotion of person-centred approaches may be used when offering smoking cessation services to patients who are receiving care within a regional cancer centre. METHODS: Qualitative data were generated using various methods, including focus groups with HCPs and interviews with patients. In total, 16 HCPs participated in three focus groups: including nine radiation therapists, five registered nurses, one registered dietitian, and one physiotherapist. Of 55 patients accrued, 19 were interviewed. Both focus groups and interviews were audio recorded, and the recordings were transcribed verbatim. Transcripts were then analyzed using narrative thematic analysis to define and identify themes. RESULTS: The identified themes were categorized into three topic areas: knowledge (eg, impact of smoking on illness and why they should not smoke); individual decision to quit (eg, motivators), and the social unacceptability of smoking (eg, the public perception of smoking over the last 40 years). HCP-identified themes included identification of smokers, triggers to start a conversation, approach, gaps and barriers to cessation, rationale for cessation, and judgment. Patient-identified themes included knowledge, individual decision to quit, and the social unacceptability of smoking. CONCLUSION: Understanding patient and HCP perspectives on smoking cessation will help influence practice to ensure that patients are not judged, assumptions are not made, and individualized and person-centred care is provided. HCP awareness of these themes and the patient perspective may challenge assumptions and values.

Catalyst for Change: Measuring the Effectiveness of Training of All Health Care Professionals to Provide Brief Intervention for Smoking Cessation to Cancer Patients.

BACKGROUND: Smoking cessation is recommended to prevent individuals from developing cancer, with additional benefits after a cancer diagnosis. Tobacco use during cancer treatments increases the risk of complications and may reduce the effectiveness of treatment; patients who quit smoking are less likely to experience recurrence. Health care professionals play a vital role in assessing and educating cancer patients on how to quit. We report on the effectiveness of peer-to-peer education of a brief smoking cessation intervention to patients. METHODS: An interprofessional team was created to implement and integrate smoking cessation best practices into daily clinical care. Health care providers were provided with peer-to-peer training to provide brief interventions of smoking cessation to patients. After training, participants were invited to complete an electronic survey to assess the effectiveness of the peer-to-peer training sessions. The survey consisted of 3 domains: confidence, comfort, and knowledge. Participants were asked to rate a series of statement questions using a Likert scale as well as to self-assess knowledge. The survey also included open-ended questions to invite respondents to share further comments and feedback. RESULTS: Approximately 90% of staff across the oncology program participated in a training session. This included nurses, radiation therapists, and patient and family support professionals. Sixty-one surveys were returned (30% response rate). Most respondents had >10 years of clinical experience (70%), 91% agreed it was important to support patients in their efforts to quit smoking, 88% agreed they have an impact on their patients' smoking cessation attempts, and 67% had opportunities in daily practice to support smoking cessation. Sixty-one percent would benefit from additional education. Fifty-three percent indicated they experienced challenges providing interventions and patients' responsiveness to the intervention. CONCLUSIONS: Peer-to-peer training for smoking cessation can increase confidence, comfort, and knowledge. Challenges include comfort level of clinician, determining the best time to ask patients, and having the confidence in knowing their scope of practice.

Gait Speed vs. VES-13: A Pilot Study Comparing Screening Tools to Determine the Need for a Comprehensive Geriatric Assessment in Senior Women with Breast Cancer.

BACKGROUND/OBJECTIVES: Patients aged 70 years and older may be suboptimally treated with cancer therapy because of the lack of clinical trial data in this population. The Comprehensive Geriatric Assessment can be time consuming, and access to geriatricians is limited. This study aims to determine whether gait speed (GS) analysis is equivalent to the widely accepted Vulnerable Elders Survey 13 (VES-13) in identifying vulnerable or frail patients in need of a Comprehensive Geriatric Assessment. METHODS: A pilot prospective cohort study was carried out at a tertiary cancer centre in Toronto, Canada, in a radiation oncology breast follow-up clinic. GS analysis and VES-13 were completed by each patient at the same clinic visit. GS of <1 meter/second (m/s) and VES-13 score ≥3 were considered abnormal. Sensitivity, specificity, positive and negative predictive values, and Kappa characteristic were calculated for GS compared with VES-13. RESULTS AND DISCUSSION: Twenty-nine participants aged 70 years and older with any stage of breast cancer were included. The GS was 67% sensitive and 95% specific for abnormal VES-13 scores. The GS had an 86% positive predictive value and 86% negative predictive value for abnormal scores on VES-13. Overall, the GS showed a substantial strength of agreement with the VES-13 (kappa 0.66, P < .0001). CONCLUSION: The GS analysis compared very well with VES-13 scores, and this may be a reasonable alternative to VES-13 screening. This pilot data warrant further study in a larger group of patients.

Prehabilitation for surgical oncology patients: empowering patient volition.

Prehabilitation is the improvement of patient health in anticipation of a physiological stressor, such as major surgery. Prehabilitation optimizes health by taking a proactive approach to promoting exercise, nutrition, and lifestyle modifications. Engaging patients in the pre-operative phase provides an opportunity to positively impact their recovery and return to functional baseline by reducing post-operative deconditioning. At the Odette Cancer Centre at Sunnybrook Health Sciences Centre in Toronto, Canada, the Interprofessional Multidisciplinary Prehabilitation Assessment Consultation Team (IMPACT-Surgical Oncology) was developed. The program was initiated in January 2015 and assesses approximately 3-5 patients/week (with a total of over 250 patients so far). This program offers patients individualized pre-operative assessments, including medical optimization, functional, and nutritional assessments, as well as counseling for mood-related issues, smoking/alcohol cessation, and preparing for surgery (such as ensuring adequate home supports/functional equipment prior to surgery). By providing holistic, person-centered, individualized pre-operative optimization strategies, patients and families feel empowered, motivated, and in control of their own health.

Adverse Health Outcomes Associated with Postdiagnosis Smoking in Prostate Cancer Patients: A Literature Review.

This literature review presents what is currently known about the association between postdiagnosis smoking and adverse health outcomes in prostate cancer. A literature search was conducted using Ovid Embase and Ovid MEDLINE. Information from 36 studies was summarized. There is strong evidence across the included studies of higher overall mortality and biochemical recurrence in current smokers diagnosed with prostate cancer. In addition, enhanced adverse effects following surgery, radiation, and hormone therapy have also been identified in current smokers of this population.

The Perceptions and Expectations of Older Women in the Establishment of the Senior Women's Breast Cancer Clinic (SWBCC): a Needs Assessment Study.

This study explored older women's perceptions and expectations of the prospective Senior Women's Breast Cancer Clinic (SWBCC) at Sunnybrook Odette Cancer Centre (SOCC) in Toronto, Ontario, Canada. In our previous studies, older breast cancer patients had expressed a greater need for informational, decisional, and post-treatment support. This study also assessed women's perspectives on the involvement of geriatricians and incorporation of geriatric assessment in their cancer care. Twelve breast cancer patients aged 68 years or older who were treated at the SOCC participated in the study. We recorded and transcribed 11 interviews and analyzed them using qualitative thematic analysis methods to identify major themes; one interview was excluded due to recording defect. Eight major themes were identified: transportation issues, service, communication between patient and healthcare professionals, communication between healthcare professionals, support during treatment, support after treatment, informational resources, and patient suggestions. Important issues were raised by participants, such as difficulties in arranging transportation to the clinic, barriers in accessing family physician service, and communication breakdown that result in treatment delay and unaddressed complications. In conclusion, there were important gaps in the cancer care of older women with breast cancer that could be detected earlier and better addressed in the new multidisciplinary SWBCC. The participating women were highly supportive of the initiative and made several suggestions on how the clinic could better accommodate their specific needs during and after breast cancer treatment.

Caring for the bereaved parent: Guidelines for practice.

PURPOSE: The purpose of this research review was to create practical guidelines for the primary care practitioner in comforting, counseling, and educating bereaved parents and their significant supporters. DATA SOURCES: The authors used an extensive review of the literature for original research reports of bereaved parents' self-identified needs for comfort from their friends, family, and healthcare practitioners. Insight gained from the authors' clinical work with bereaved parents added further understanding. CONCLUSIONS: Parents express strong preferences and needs regarding support from both social relationships and healthcare personnel. Specific guidelines were created for use by both friends/family members and health professionals. IMPLICATIONS FOR PRACTICE: Nurse practitioners have an important role in supporting bereaved parents, and educating their friends and family on the most helpful behaviors during this painful time.