The potential impact of exercise upon symptom burden in adolescents and young adults undergoing cancer treatment.

PURPOSE: Adolescents and young adults (AYAs) experience vast symptom burden resulting from cancer treatment-related toxicities (TRTs). Evidence supports integrated exercise to mitigate several TRTs in other cohorts; however, evidence in AYAs is lacking. Conventional reporting of TRTs adopts a maximum grade approach failing to recognise the trajectory over time, of persistent, or lower grade toxicities. Alternatively, longitudinal analysis of toxicities over time (ToxT) may provide clinically meaningful summaries of this data. We evaluated the longitudinal impact of an exercise intervention on TRTs in AYAs undergoing cancer treatment. METHODS: A prospective, randomised trial allocated participants to a 10-week exercise intervention (EG) or control group (CG) undergoing usual care. Detailed information on TRTs was collected throughout the intervention. All TRTs were graded per the Common Terminology Criteria for Adverse Events (CTCAE v5.0). RESULTS: Forty-three (43) participants (63% male, mean age 21.1 years) were enrolled. When categorised to reflect the maximal worst grade experienced (Grade 0, Grade 1-2 and ≥ Grade 3), the CG reported an increased incidence of severe fatigue (≥ Grade 3) compared with the EG (p = 0.05). No other differences between groups were evident (p > 0.05). ToxT analysis of the four most common toxicities (fatigue, pain, nausea and mood disturbances) demonstrated no difference in the mean grade of each over time (p > 0.05). CONCLUSION: A 10-week exercise intervention reduces the severity of fatigue in AYAs undergoing treatment. While the ToxT approach provided insight into the toxicity profile, adequately powered studies are needed to better understand these differences within a homogenous sample. TRIAL REGISTRATION: (ACTRN12620000663954) 10th June 2020.

A randomised controlled trial investigating the ability for supervised exercise to reduce treatment-related decline in adolescent and young adult cancer patients.

INTRODUCTION: Exercise is recognised as integral in mitigating a myriad negative consequences of cancer treatment. However, its benefit within adolescent and young adult (AYA) cancer cohorts remains relatively under researched, and caution should be taken in extrapolating outcomes from adult and paediatric populations given AYA distinctly different physiological and psychosocial contexts. This study sought to evaluate the impact of an exercise intervention on mitigating the expected decline in fitness, strength, physical functioning, and quality of life (QOL) in AYA undergoing cancer treatment. METHODS: This prospective, randomised controlled trial (FiGHTINGF!T) allocated 43 participants (63% male, mean age 21.1 years) to a 10-week, multimodal, bi-weekly exercise intervention (EG) or control group (CG) undergoing usual care. Pre- and post-intervention assessments included cardiopulmonary exercise tests, one-repetition maximum (1RM) strength, functional tests, and QOL patient-reported outcome measures. Data were analysed via linear mixed models and regression. RESULTS: While no significant group differences (p > 0.05) were observed, neither group significantly declined (p > 0.05) in any outcome measure over the 10-week period. No significant (p˃0.05) strength or functional improvements were observed in the CG, though the EG demonstrated significant improvements in their 1RM leg press (p = 0.004) and chest press (p = 0.032), maximal push ups (p = 0.032), and global QOL (p = 0.011). The EG reported a significant increase in fatigue (p = 0.014), while the CG reported significant positive changes in anxiety measures (p = 0.005). CONCLUSION: The exercise intervention produced superior improvements in strength and global QOL, compared with the CG. Regardless of group allocation, enrolment in the exercise study appeared to mitigate the treatment-related decline expected in AYA undergoing cancer treatment.

A supervised exercise intervention during cancer treatment for adolescents and young adults-FiGHTING F!T: study protocol of a randomised controlled trial.

BACKGROUND: High-quality evidence supports the integration of exercise to mitigate treatment-related side effects in a wide range of paediatric and adult cancer cohorts. However, the implementation of exercise in adolescent and young adult (AYA) cancer patients is yet to be explored in depth. FiGHTINGF!T is a randomised controlled cross over trial designed to determine if a supervised, structured, and progressive exercise programme can reduce the decline in physical fitness (V02peak) associated with cancer treatment in AYAs from diagnosis. METHODS/DESIGN: A total of 40 AYAs recently diagnosed and due to commence systemic treatment (± 2 weeks) for a primary haematological malignancy or solid tumour will be recruited and randomised to either an immediate exercise intervention or usual care (delayed exercise) for 10 weeks. This randomised controlled crossover trial will see both groups engage in a supervised exercise intervention from either diagnosis (baseline assessment) for 10 weeks (0-10 weeks) or following an interim assessment to 20 weeks (10-20 weeks). The bi-weekly tailored exercise programme will combine aerobic and resistance exercises and be supervised by an Accredited Exercise Physiologist. Participants will complete a range of assessments at 0, 10, and 20 weeks including cardiopulmonary exercise tests, 1 repetition maximum strength measures, physical functioning, and self-reported quality of life measurements. Patient-reported treatment-related toxicities will be recorded on a weekly basis. DISCUSSION: The FiGHTINGF!T trial will provide insight into the potential benefits of a supervised exercise programme in AYAs undergoing cancer treatment. This trial will contribute to the evidence supporting the necessary integration of exercise during cancer treatment, specifically in the under-reported AYA cohort. TRIAL REGISTRATION: This trial was registered retrospectively with the Australia New Zealand Clinical Trial registry ( ACTRN12620000663954 ). Registered on 10 June 2020.

Personalised cancer care in the era of precision medicine.

BACKGROUND: Advances in cancer treatment have not benefited all patients equally, underscoring the need for a personalised approach to care. OBJECTIVE: The aim of this article is to outline the key elements of personalised cancer care, including delivery of goal-directed care, self-management and self-management support, care integration, focus on access and equity, reduction in cost and promotion of health literacy and e-health literacy. DISCUSSION: Achievement of personalised cancer care requires a system-wide approach that targets the patient, healthcare provider and healthcare system with data informing practice. Primary care providers, including general practitioners (GPs) and practice nurses, play an important and growing part in the provision of personalised cancer care through support, advocacy, coordination, holistic care and health promotion. Cancer care systems can facilitate GPs' involvement in care through early input into multidisciplinary management, timely communication, rapid access to acute care and training opportunities.

Diffuse large B cell lymphoma within an anal fistula: a case report with an intriguing possible aetiology.

Described is a case of diffuse large B cell lymphoma that presented within a typical fistula tract, possibly secondary to oxidative stress within the fistula tract itself and consequent malignant change rather than a fistula as a consequence of necrosis in a lymphoma. If so it would be unique in the world literature. A 42-year-old fitness instructor presented with a typical appearing left lateral anal fistula. Biopsy of the fistulous tract revealed B cell lymphoma, graded 1E. Although chemotherapy cured the lymphoma, surgical treatment by ligation of the inter-sphincteric fistula tract was required to heal the fistula. At 3-year follow-up, there has been no recurrence of the lymphoma or the fistula. Neoplasia arising secondary to oxidative stress within an anal fistula is a well-established phenomenon. Early diagnosis of rare conditions associated with anal fistula can only be accomplished by routine biopsy of every fistula tract.

Mycosis fungoides and Sézary syndrome: Australian clinical practice statement.

Primary cutaneous lymphomas represent a heterogeneous group of T- and B-cell lymphomas with distinct clinical presentations, histopathologic features, treatment approaches and outcomes. The cutaneous T-cell lymphomas, which include mycosis fungoides and Sézary syndrome, account for the majority of the cutaneous lymphomas. This Clinical Practice Statement is reflective of the current clinical practice in Australia. An expanded form of the Clinical Practice Statement (and updates), along with helpful patient resources and access to support groups, can be found at the following (http://www.australasianlymphomaalliance.org.au).

An international multicenter retrospective analysis of patients with extranodal marginal zone lymphoma and histologically confirmed central nervous system and dural involvement.

Marginal zone lymphoma of the central nervous system (CNS MZL) is rare. The clinical features, treatment, and prognosis are not well characterized. We performed a multicenter retrospective study of CNS MZL. Twenty-six patients were identified: half with primary and half with secondary CNS involvement. The median age was 59 years (range 26-78), 62% female and 79% with ECOG performance status ≤ 1. The most common disease site was the dura (50%). Treatment was determined by the treating physician and varied substantially. After a median follow up of 1.9 years, the estimated 2-year progression-free (PFS) and overall survival (OS) rates were 59% and 80%, respectively. Secondary CNS MZL was associated with 2-year OS of 58%. CNS MZL is rare, but relative to other forms of CNS lymphoma, outcomes appear favorable, particularly among the subset of patients with dural presentation and primary CNS presentation.

Clinical Oncology Society of Australia position statement on cancer survivorship care.

BACKGROUND: Cancer survivors often experience long­term negative consequences of their cancer and cancer treatment. With increasing numbers of survivors and duration of survival, a sustainable model of care is required to better meet the needs of cancer survivors. OBJECTIVE: The aim of this article is to outline the Clinical Oncology Society of Australia Model of Survivorship Care, summarising the critical components of cancer survivorship care. DISCUSSION: Recommendations include: a systematic, multidisciplinary care approach that optimises self-management and enhances coordinated and integrated survivor-centred care from diagnosis; stratified care pathways based on survivors' needs, capacity to self-manage and anticipated treatment sequelae; a focus of care on wellness, healthy lifestyle, symptom management and prevention of life-altering and life threatening late effects in addition to cancer surveillance; development of a treatment summary and care plan; and equitable, timely access to services, while minimising unnecessary use of healthcare services.

Peripheral T-Cell Lymphoma Arising in Patients With Chronic Lymphocytic Leukemia.

OBJECTIVES: To describe three further cases of anaplastic large cell lymphoma (ALCL) occurring in patients with preexisting chronic lymphocytic leukemia (CLL). We also reviewed the literature of previously published cases. METHODS: We discuss the clinical features, histopathology, and outcomes for three patients with ALCL and CLL from Perth, Australia. The cases were also included in a literature review of existing cases and comparisons were made with our cohort. RESULTS: The three patients included two men (aged 77 and 74 years) and one woman (aged 66 years). All had a history of untreated CLL with diagnosis established 4 to 16 years before. They had lymphadenopathy and/or cutaneous/soft tissue lesions that proved to be ALCL, ALK+ (one case) or ALCL, ALK- (two cases). CONCLUSIONS: Further research is required in this area to establish prognostic and management recommendations. Increasing numbers of cases are being described. Positron emission tomography with computed tomography was not useful in our cohort for diagnosing progression.

Prognostic factors and the impact of frontline therapy in peripheral T-cell lymphoma: 10 years of 'real-world' experience from Western Australia.

We present an analysis of 98 consecutive patients with peripheral T-cell lymphoma (PTCL) treated over a 10-year period within Western Australia. The most common frontline therapies were CHO(E)P (47%), HyperCVAD (21%), and reduced intensity therapy or supportive care alone (19%). Median and 4-year overall survival (OS) for the whole cohort were 1.59 years and 34%. Amongst CHO(E)P and HyperCVAD-treated patients, elevated LDH, advanced stage, IPI >1, and non-ALK + ALCL histology predicted inferior progression-free survival (PFS). Inferior OS was predicted by elevated LDH, age >60, IPI >1, and non-ALK + ALCL histology. Response rates and PFS were not significantly different between patients treated with CHO(E)P or HyperCVAD. OS was longer in the HyperCVAD group, however this was not significant on multivariable analysis and appears to relate to the younger age and more aggressive therapy at relapse in this group. Our data confirmed the prognostic utility of the IPI in patients with PTCL and do not demonstrate a clear benefit of HyperCVAD.

Care After Lymphoma (CALy) trial: A phase II pilot pragmatic randomised controlled trial of a nurse-led model of survivorship care.

PURPOSE: Post-treatment follow-up for lymphoma potentially fails to address the supportive care needs of survivors. A nurse-led lymphoma survivorship model of care was developed and tested in a phase II pilot pragmatic randomised controlled trial (RCT). The intervention comprised three face-to-face appointments, delivery of tailored resources and an individualised survivorship care plan and treatment summary (SCPTS), shared with the general practitioner (GP). METHOD: Three months' post-treatment completion, eligible lymphoma patients were randomised 1:1 to usual care (control) or usual care plus intervention. Survivorship unmet needs (Short-Form Survivor Unmet Needs Survey), distress (Depression Anxiety Stress Scale 21), adjustment to cancer (Mini-Mental Adjustment to Cancer scale) and self-empowerment (Patient Empowerment Scale) were assessed at baseline, three and six months. Univariate and multivariate analyses examined changes within and between groups at the three time points. A GP evaluation survey sought information on the perceived utility of the SCPTS. RESULTS: Statistical significance was set at 0.05 (2-tailed). Although not statistically significant, by study completion, intervention participants (n = 30), reported less unmet needs (M = 21.41 vs M = 25.72, p = .506), less distress ((M = 13.03 vs M = 15.14, p = .558) and an increase in empowerment (M = 50.21 vs M = 47.21, p = .056) compared with control participants (n = 30). The SCPTS was rated good to very good by a majority of GPs (n = 13, 81%). CONCLUSIONS: The nurse-led lymphoma survivorship model of care may be a helpful intervention for lymphoma patients who had completed treatment. Survivors require individualised and tailored support and resources. A tailored SCPTS may promote survivor self-management and increase GP engagement.

The Benefit of Physical Activity in Adolescent and Young Adult Cancer Patients During and After Treatment: A Systematic Review.

Cancer and its associated therapies can severely impact the physical and psychosocial functioning of adolescent and young adults (AYAs), both during treatment and well into survivorship. Physical activity during and after cancer treatment could be beneficial to the AYA population, although this cohort has received little scientific attention. A systematic search of the literature was conducted to investigate current exercise interventions in AYA-specific populations. Studies were eligible for inclusion if >50% of the study population was aged between 15 and 25 years and the study included a physical activity intervention during or after cancer treatment. Studies were critically appraised using the Cochrane Risk of Bias tool. Six articles were identified as meeting the criteria, of which 2 were nonrandomized controlled studies and 4 were pilot studies, comprising a total of 135 AYA participants. The quality of studies was variable across all assessed domains. Direct comparison on intervention outcomes was not possible due to the heterogeneity of the studies; however, trends emerged on the feasibility, acceptability, and potential positive impact of physical activity in this cohort. This review highlights the lack of high-quality studies aimed to improve physical and psychosocial functioning in AYA patients across the cancer continuum. Physical activity interventions in this cohort appear to be feasible; however, larger randomized controlled trials are warranted to investigate the direct impact of interventions on health outcomes in this cohort.

The effect of tyrosine kinase inhibitor interruption and interferon use on pregnancy outcomes and long-term disease control in chronic myeloid leukemia.

The management of CML in pregnancy is challenging with the need to balance disease control against potential teratogenic effects of TKI therapy. In this multi-center case-cohort study of 16 women in chronic phase, CML ceased TKI treatment pre- or post-conception during their first pregnancy. Thirteen patients were on imatinib; 9 ceased their TKI prior to conception and 7 ceased at pregnancy confirmation. Twelve patients had achieved either MMR or better at time of TKI cessation. Eleven women lost MMR during pregnancy and two patients lost CHR. Fourteen women reestablished MMR on TKI recommenced. The depth molecular response prior to conception appeared to correlate well with restoration of disease control on TKI recommencement though duration of MMR did not appear to be as important. While interruption of TKI treatment for pregnancy usually leads to loss of molecular response, loss of hematological response is uncommon and disease control is reestablished with resumption of therapy in the majority of women.

'It is a journey of discovery': living with myeloma.

PURPOSE: Although multiple myeloma (MM) is incurable, many people live with the disease for a number of years. Thus, understanding the effect of the disease and its therapies on the lives of those with MM is important. This qualitative study explores the impact of MM and its treatments on patients. METHODS: People with newly diagnosed or relapsed MM were recruited from a tertiary institution. Participants were interviewed using a semi-structured approach. The questions were designed to obtain insight into how participants viewed their diagnosis, treatment, and symptoms and how these had impacted on their lives. Data were analysed using a phenomenological approach. RESULTS: Fifteen people with MM with a mean age of 62 were recruited. Participants' mean time since diagnosis was 2.7 years and they had received a mean of 1.7 lines of therapy. The first major theme to emerge was lifestyle changes. Interviewees described MM as causing changes to all aspects of their lives, including substantial functional changes, as well as changes to employment, relationships, and their sense of self. The second major theme was 'adjust, adjust, adjust'. Alongside challenging life changes, participants described a range of practical, psychological, and relational approaches to adjusting to living with MM. CONCLUSION: This study highlights the importance of and the need for improved supportive care in patients with MM, ideally with a multidisciplinary approach. It also identifies the potential for further investigation of patient approaches to adjusting to MM and development of support strategies.

Living With Multiple Myeloma: A Focus Group Study of Unmet Needs and Preferences for Survivorship Care.

PURPOSE: To describe the unmet informational, psychological, emotional, social, practical, and physical needs and preferences for posttreatment survivorship care of individuals living with multiple myeloma to inform the development of relevant, person-centered, survivorship services. METHODS: An exploratory, descriptive study using 2 focus groups with 14 participants, 6 to 49 months postdiagnosis. RESULTS: Thematic analysis revealed 7 key themes: information needs, experience with health-care professionals, coping with side effects, communicating with family and friends, dealing with emotions, support needs, and living with the chronicity of myeloma. Participants described key characteristics of survivorship care relevant to their needs and indicated they would like a more whole of person approach to follow-up when the main treatment phases had completed. CONCLUSION: Participants in this study described unmet needs across a breadth of domains that varied over time. The development of flexible, person-centered approaches to comprehensive survivorship care is needed to address the considerable quality-of-life issues experienced by people living with multiple myeloma. Nurse-led care may offer 1 viable model to deliver enhanced patient experience-providing the vital "link" that people described as missing from their survivorship care.

A qualitative study of the post-treatment experiences and support needs of survivors of lymphoma.

PURPOSE: To explore the post-treatment experiences and preferences for follow-up support of lymphoma survivors. METHODS: Two focus groups were conducted with 17 participants to explore informational, psychological, emotional, social, practical and physical needs, 6-30 months post-treatment for lymphoma. Perceptions regarding a potential model of survivorship care were also elicited. RESULTS: Thematic content analysis revealed five key themes: Information; Loss and uncertainty; Family, support and post-treatment experience; Transition, connectivity and normalcy, and Person-centred post-treatment care. Participants described a sense of loss as they transitioned away from regular interaction with the hospital at the end of treatment, but also talked about the need to find a "new normal". Establishing post-treatment support structures that can provide individualised information, support, reassurance and referrals to community and peer support were identified as a helpful way to navigate the transition from patient to post-treatment survivor. CONCLUSIONS: Participants in our study articulated a need for a flexible approach to survivorship care, providing opportunities for individuals to access different types of support at different times post-treatment. Specialist post-treatment nurse care coordinators working across acute and community settings may offer one effective model of post-treatment support for survivors of haematological malignancies.

A pilot study of routine screening for distress by a nurse and psychologist in an outpatient haematological oncology clinic.

AIM: To explore the: 1) prevalence of distress, type of problems experienced by haematological patients, and referrals for supportive care; 2) effect of demographic and clinical variables on distress, and 3) effect on the time of health professionals conducting the screening in the ambulatory chemotherapy setting. METHODS: Participants completed the National Comprehensive Cancer Network Distress Thermometer and Problem List and had a follow-up screening discussion with a health professional. RESULTS: Of 68 participants, 40% reported significant distress (≥4) on the Distress Thermometer (mean 3.2, SD 2.4). All patients reported physical problems and 72% reported emotional problems-the major contributors to distress and to time spent with the health professional. Distress was unrelated to age, gender or cancer type. Patients were less likely to have significant distress at the end of treatment than at the beginning (OR=0.15, 95% CI: 0.03; 0.72,). Forty patients (59%) were referred to supportive services. The psychologist spent less time with patients compared to the nurse (18 vs 48min, p<0.001). The more emotional problems reported, the greater the time spent with the patient (rs=0.34, p=0.009). CONCLUSIONS: Nurses can appropriately screen for distress and address significant distress reported by haematology patients undergoing chemotherapy without over burdening the nurse or patient.