Remote, proactive, telephone based management of toxicity in outpatients during adjuvant or neoadjuvant chemotherapy for early stage breast cancer: pragmatic, cluster randomised trial.

OBJECTIVE: To evaluate the effectiveness of remote proactive management of toxicities during chemotherapy for early stage breast cancer. DESIGN: Pragmatic, cluster randomised trial. SETTING: 20 cancer centres in Ontario, Canada, allocated by covariate constrained randomisation to remote management of toxicities or routine care. PARTICIPANTS: All patients starting adjuvant or neoadjuvant chemotherapy for early stage breast cancer at each centre. 25 patients from each centre completed patient reported outcome questionnaires. INTERVENTIONS: Proactive, standardised, nurse led telephone management of common toxicities at two time points after each chemotherapy cycle. MAIN OUTCOME MEASURES: The primary outcome, cluster level mean number of visits to the emergency department or admissions to hospital per patient during the whole course of chemotherapy treatment, was evaluated with routinely available administrative healthcare data. Secondary patient reported outcomes included toxicity, self-efficacy, and quality of life. RESULTS: Baseline characteristics of participants were similar in the intervention (n=944) and control arms (n=1214); 22% were older than 65 years. Penetration (that is, the percentage of patients who received the intervention at each centre) was 50-86%. Mean number of visits to the emergency department or admissions to hospital per patient was 0.91 (standard deviation 0.28) in the intervention arm and 0.94 (0.40) in the control arm (P=0.94); 47% (1014 of 2158 patients) had at least one visit to the emergency department or a hospital admission during chemotherapy. Among 580 participants who completed the patient reported outcome questionnaires, at least one grade 3 toxicity was reported by 48% (134 of 278 patients) in the intervention arm and by 58% (163 of 283) in the control arm. No differences in self-efficacy, anxiety, or depression were found. Compared with baseline, the functional assessment of cancer therapy trial outcome index decreased by 6.1 and 9.0 points in the intervention and control participants, respectively. CONCLUSIONS: Proactive, telephone based management of toxicities during chemotherapy did not result in fewer visits to the emergency department or hospital admissions. With the rapid rise in remote care because of the covid-19 pandemic, identifying scalable strategies for remote management of patients during cancer treatment is particularly relevant. TRIAL REGISTRATION: ClinicalTrials.gov NCT02485678.

Adherence to surveillance guidelines after curative resection for stage II/III colorectal cancer.

PURPOSE: Our aims were to determine adherence to American Society of Clinical Oncology (ASCO) guidelines on colorectal cancer (CRC) surveillance and to evaluate differences in practice patterns and clinical outcomes between an academic institution (Princess Margaret Hospital [PMH]) and a community cancer hospital (Credit Valley Hospital [CVH]). PATIENTS AND METHODS: Patients with stage II/III CRC who were diagnosed between January 1, 1999, and December 31, 2001, were identified, and their records were retrospectively reviewed. RESULTS: A total of 244 and 97 patients were eligible at PMH and CVH, respectively. Surveillance patterns, including blood tests, imaging studies, and colonoscopies, were inconsistent with ASCO recommendations in a significant proportion of patients. Clinic visits occurred more frequently and imaging studies were more commonly ordered at PMH than at CVH (P < .001). In contrast, CVH performed a higher median number of blood count and liver function tests (P = .001) per patient than PMH. The rates of carcinoembryonic antigen monitoring and surveillance colonoscopies were not statistically different between centers (P = .67 and P = .43, respectively). There were a total of 70 CRC recurrences: 53 (75.7%) were detected by surveillance (44 at PMH and 9 at CVH) and 17 (24.3%) by patient symptoms (9 at PMH and 8 at CVH). For recurrences detected by surveillance, 38% were resectable, whereas only 18% of those detected by symptoms were resectable. CONCLUSION: Colorectal cancer surveillance revealed noticeable departures from ASCO guidelines, with the academic institution using a more intensive surveillance strategy with imaging studies than the community cancer center. Surveillance was associated with a higher proportion of resectable tumor recurrences than was detection by patient symptoms.