Cancer survivorship challenges of rural older adults: a qualitative study.

BACKGROUND: Although research has advanced the field of oncologic geriatrics with survivors to assess their cancer-related needs and devise patient-centered interventions, most of that research has excluded rural populations. This study aimed to understand the survivorship challenges and recommendations in the perspective of rural older adults. METHODS: This was a qualitative study that explored the survivorship challenges and recommendations of rural older adults who have completed curative intent chemotherapy for a solid tumor malignancy in the 12 months prior to enrollment in the present study. RESULTS: Twenty-seven older adult survivors from rural areas completed open-ended semi-structured interviews. The mean age was 73.4 (SD = 5.0). Most participants were non-Hispanic White (96.3%), female (59.3%), married (63.0%), and had up to a high school education (51.9%). Rural older survivors reported a general lack of awareness of survivorship care plans, communication challenges with healthcare team, transportation challenges, financial toxicity, psychological challenges, and diet and physical challenges. Rural older survivors recommend the provision of nutritional advice referral to exercise programs, and social support groups and for their healthcare providers to discuss their survivorship plan with them. CONCLUSIONS: Although study participants reported similar survivorship challenges as urban older adult survivors, additional challenges reported regarding transportation and consideration of farm animals have not been previously reported. Heightened awareness of the survivorship needs of rural older adults may result in better survivorship care for this population.

Barriers to participation in clinical trials of rural older adult cancer survivors: A qualitative study.

BACKGROUND: Currently, 64% of cancer survivors are aged 65+. Older cancer survivors have unique complications after chemotherapy and are often excluded from cancer clinical trials. Although there is research on barriers to clinical trial participation of older adult cancer survivors, to date no research has explored barriers to clinical trial participation unique to rural older adult cancer survivors. METHODS: This study is a secondary qualitative analysis from a study exploring survivorship challenges of rural older adults. Eligible participants were rural residents over age 65 who have completed curative-intent chemotherapy in the past 12 months. Participants (n = 27) completed open-ended semi-structured interviews that included questions on barriers to clinical trial participation. Transcripts were coded independently by two coders using thematic analysis. We have adhered to the standards for reporting qualitative research. FINDINGS: Participants reported a variety of barriers that included limited knowledge and fear about clinical trials, transportation challenges, their physicians not informing them of clinical trials, and thinking they are too old to participate in clinical trials. However, participants also reported facilitators to participating in clinical trials, including acknowledging benefits to their own health and society, and understanding the importance of clinical trials. CONCLUSION: Rural older cancer survivors face numerous interpersonal, intrapersonal, and organizational barriers to clinical trial participation. Aging- and location-sensitive interventions that focus on patients, their caregivers, and health care providers may lead to improved participation of rural older adult survivors into clinical trials.

Transformed non-Hodgkin lymphoma in the rituximab era: analysis of the NCCN outcomes database.

Histological transformation (HT) is a major cause of morbidity and mortality in patients with indolent non-Hodgkin lymphoma (NHL). The multicentre National Cancer Comprehensive Network database for NHL provides a unique opportunity to investigate the natural history of HT in the rituximab era. 118 patients with biopsy-confirmed indolent lymphoma and subsequent biopsy-confirmed HT were identified. Treatments for HT included autologous stem-cell transplant (auto-SCT) (n = 50), allogeneic SCT (allo-SCT) (n = 18), and treatment without transplant (n = 50). The 2-year overall survival (OS) for the entire cohort was 68%. For auto-SCT patients aged ≤ 60 years (n = 24), the 2-year OS was 74%. For non-transplanted patients aged ≤ 60 years (n = 19), the 2-year OS was 59%. The 2-year OS of patients naïve to chemotherapy prior to HT was superior to patients who were exposed to chemotherapy prior to HT (100% vs. 35%, P = 0.03). In this largest prospective cohort of patients of strictly defined HT in the rituximab era, the natural history of HT appears more favourable than historical studies. Younger patients who were not exposed to chemotherapy prior to HT experienced a prolonged survival even without transplantation. This study serves as a benchmark for future trials of novel approaches for HT in the Rituximab era.

Ipilimumab-Induced Neutropenia in Melanoma.

Ipilimumab is a human monoclonal IgG1 antibody against CTLA-4 that has been shown to prolong the overall survival of advanced melanoma. The most common adverse events associated with ipilimumab are immune-related. Severe hematological toxicity is rare. We report a case of severe neutropenia following ipilimumab therapy that fully resolved after the administration of prednisone, cyclosporine, and anti-thymocyte globulin therapies.

High-dose therapy and autologous stem cell transplant for transformed non-Hodgkin lymphoma in the rituximab era.

The impact of rituximab on the outcome of high-dose therapy and autologous stem cell transplant (HD-ASCT) for transformed non-Hodgkin lymphoma (NHL) has not been previously described. We analyzed 18 consecutive patients with indolent NHL who transformed to diffuse large B-cell lymphoma (DLBCL), received rituximab-containing therapy either before or after transformation and underwent subsequent HD-ASCT. With a median follow-up of 40 months, the 2-year progression-free survival (PFS) was 59% and the 2-year overall survival (OS) was 82%. Six patients did not receive rituximab pre-transformation. This group had a significantly better PFS at 2 years post-HD-ASCT compared to 12 patients who were exposed to rituximab pre-transformation (p = 0.03). HD-ASCT remains an effective therapeutic option for transformed NHL in the rituximab era. However, patients exposed to rituximab pre-transformation appear to have inferior HD-ASCT outcomes, and thus may benefit from novel conditioning and maintenance regimens in the setting of HD-ASCT.

Heparin induced thrombocytopenia and thrombosis in a tertiary care hospital.

UNLABELLED: Heparin-induced thrombocytopenia (HIT) results from development of an antibody to a complex of heparin and platelet factor 4 (PF4) resulting in thrombocytopenia and a prothrombotic state with serious clinical consequences. The diagnosis depends on a combination of both the clinical presentation and laboratory detection of an appropriate antibody. OBJECTIVE: To determine the frequency, clinical characteristics and laboratory correlates of HIT in a tertiary care hospital. METHODS: A retrospective review of all case of HIT over a thirty month period in a tertiary care hospital was conducted. RESULTS: HIT was diagnosed in 136 patients including 114/28,091 (0.48%) of those receiving only unfractionated heparin, 22/6,559 (0.33%) of those that received both unfractionated and low-molecular-weight heparin (LMWH) and in 2/2498 (0.08%) of those receiving only LMWH (P=0.02 compared to those receiving only unfractionated heparin). HIT occurred in 62/16,939 patients (0.39%) of patients receiving subcutaneous (SC) heparin or LMWH compared to 69/11,152 (0.62%) of patients receiving intravenous (IV) therapy (P=0.003). Of all patients with exposure to heparin products, 41/34,650 (0.1%) developed symptomatic thrombosis. The optical density (OD) of the ELISA was significantly higher in patients with HIT and thrombosis (1.2 +/- 0.8) compared to those without thrombosis (0.9 +/- 0.6, P=0.03). CONCLUSION: HIT develops in approximately 0.4% of all patients exposed to heparin at a tertiary care hospital but is significantly less frequent in those treated with LMWH only than in those who receive unfractionated heparin. A higher antibody titer is associated with the development of thrombosis. The occurrence of HIT could be decreased by reducing exposure to unfractionated heparin, and the diagnosis could be improved by reporting the OD of the ELISA test result.

Diffuse large B cell lymphoma presenting as a cardiac mass and odynophagia.

Cardiac involvement as an initial presentation of malignant lymphoma is a rare occurrence. We describe the case of a 77-year-old man who had initially been diagnosed with a left atrial mass on an echocardiogram, presenting with progressive dyspnea, dysphagia, odynophagia and fevers. The cardiac mass had been managed as an outpatient with full anticoagulation for the suspicion of clot. On admission, cardiac magnetic resonance imaging revealed a large mediastinal mass invading the left atrium that originated from the oesophagus. A barium oesophagram revealed an apple core lesion involving the distal third of the oesophagus. A subsequent computed tomography scan demonstrated a large mediastinal soft tissue mass and paratracheal lymphadenopathy. A flexible upper endoscopy revealed an oesophageal mass that was approximately 10 cm in length, irregular at the margins, and with a very necrotic appearance. This was biopsied, revealing findings consistent with high grade diffuse large B cell lymphoma. This case illustrates lymphoma presenting with dyspnea, odynophagia and a left atrial mass. To our knowledge, there are no reported cases of diffuse large B cell lymphoma presenting as odynophagia and a cardiac mass.