Olanzapine as Antiemetic Prophylaxis in Moderately Emetogenic Chemotherapy: A Phase 3 Randomized Clinical Trial.

Importance: The role of olanzapine has not been adequately evaluated in moderately emetogenic chemotherapy (MEC) regimens with or without neurokinin-1 receptor antagonists. Objective: To evaluate whether addition of olanzapine to an MEC regimen reduces nausea, vomiting, and use of nausea rescue medications among patients with solid malignant tumors. Design, Setting, and Participants: This multicenter, open-label phase 3 randomized clinical trial included patients aged 18 years or older with solid malignant tumors who were receiving oxaliplatin-, carboplatin-, or irinotecan-based chemotherapy. The trial was conducted at 3 institutes in India from March 26, 2019, to August 26, 2023; the final cutoff date for analysis was September 10, 2023. Exposure: Patients were randomized 1:1 to dexamethasone, aprepitant, and palonosetron with olanzapine (experimental group) or without olanzapine (observation group). The experimental group received 10 mg of olanzapine orally once at night on days 1 through 3 of the chemotherapy regimen. Main Outcomes and Measures: The primary end point was complete response (CR), defined as the proportion of patients with no vomiting, no significant nausea (scored as <5 on a visual analog scale of 1 to 100), and no use of rescue medications for nausea. Secondary end points included the proportion of patients experiencing nausea and chemotherapy-induced nausea and vomiting (CINV), receiving rescue medications, and experiencing adverse events. Results: A total of 560 patients (259 [64%] male; median age, 51 years [range, 19-80 years]) were randomized. The analysis included 544 patients with evaluable data (274 assigned to olanzapine and 270 to observation). Baseline characteristics were evenly matched between the 2 groups. The proportion of patients with CR was significantly greater in the group with (248 [91%]) than without (222 [82%]) olanzapine in the overall 120-hour treatment period (P = .005). Likewise, there were significant differences between the olanzapine and observation groups for nausea control (264 [96%] vs 234 [87%]; P < .001) and CINV (262 [96%] vs 245 [91%]; P = .02) during the overall assessment period, and the proportion of patients receiving rescue medications significantly increased in the observation group (30 [11%]) compared with the olanzapine group (11 [4%]) (P = .001). Grade 1 somnolence was reported by 27 patients (10%) following administration of chemotherapy and olanzapine and by no patients in the observation group. Conclusions and Relevance: In this randomized clinical trial, the addition of olanzapine significantly improved CR rates as well as nausea and vomiting prevention rates in chemotherapy-naive patients who were receiving MEC regimens containing oxaliplatin, carboplatin, or irinotecan. These findings suggest that use of olanzapine should be considered as one of the standards of care in these chemotherapy regimens. Trial Registration: Clinical Trials Registry-India (CTRI) Identifier: CTRI/2018/12/016643.

Oral Cannabis Extract for Secondary Prevention of Chemotherapy-Induced Nausea and Vomiting: Final Results of a Randomized, Placebo-Controlled, Phase II/III Trial.

PURPOSE: The aim of this randomized, placebo-controlled, two-stage, phase II/III trial was to determine the efficacy of an oral cannabis extract in adults with refractory nausea and/or vomiting during moderately or highly emetogenic, intravenous chemotherapy despite guideline-consistent antiemetic prophylaxis. Here, we report results of the prespecified combined analysis including the initial phase II and subsequent phase III components. PATIENTS AND METHODS: Study treatment consisted of oral capsules containing either tetrahydrocannabinol 2.5 mg plus cannabidiol 2.5 mg capsules (THC:CBD) or matching placebo, taken three times a day from days -1 to 5, in addition to guideline-consistent antiemetics. The primary measure of effect was the difference in the proportions of participants with no vomiting or retching and no use of rescue medications (a complete response) during hours 0-120 after the first cycle of chemotherapy on study (cycle A). RESULTS: We recruited 147 evaluable of a planned 250 participants from 2016 to 2022. Background antiemetic prophylaxis included a corticosteroid and 5-hydroxytryptamine antagonist in 97%, a neurokinin-1 antagonist in 80%, and olanzapine in 10%. THC:CBD compared with placebo improved the complete response rate from 8% to 24% (absolute difference 16%, 95% CI, 4 to 28, P = .01), with similar effects for absence of significant nausea, use of rescue medications, daily vomits, and the nausea scale on the Functional Living Index-Emesis quality-of-life questionnaire. More frequent bothersome adverse events of special interest included sedation (18% v 7%), dizziness (10% v 0%), and transient anxiety (4% v 1%). There were no serious adverse events attributed to THC:CBD. CONCLUSION: THC:CBD is an effective adjunct for chemotherapy-induced nausea and vomiting despite standard antiemetic prophylaxis, but was associated with additional adverse events. Drug availability, cultural attitudes, legal status, and preferences may affect implementation. Future analyses will evaluate the cost-effectiveness of THC:CBD.

Multidisciplinary team meeting Chairs' attitudes and perceived facilitators, barriers and ideal improvements to meeting functionality: A qualitative study.

AIM: Oncology care provision by multidisciplinary teams (MDTs) is widely acknowledged as best practice. Formal team meetings, led by chairpersons, coordinate decisions on diagnosis, staging, treatment planning, and review. This study addresses a gap in meeting Chairs' perspectives on factors affecting functionality across the meeting cycle, from pre-meeting patient list triage to post-meeting dissemination of recommendations. METHODS: Semi-structured interviews were conducted in person with Chairs within two urban geographical regions in New South Wales, Australia as part of a larger project. Though the population of oncology MDT Chairs in Australia is small, the richness and depth of data from nine Chairs were considered to be valuable knowledge in support of extant literature on meeting functionality. An integrated deductive-inductive approach was applied to data analysis. RESULTS: Perceived facilitators, barriers, and ideals relating to pre-meeting, in-meeting, and post-meeting functionality were identified across five pre-determined analytic categories: the team; meeting infrastructure; meeting organization and logistics; patient-centered clinical decision-making, and; team governance. Key barriers included inadequate information technology, limited support staff, and lack of dedicated time for Chair duties. Corresponding facilitators included robust Information Technology infrastructure and support, provision of clinically knowledgeable MDT meeting coordinators, and formal employment recognition of Chairs' responsibilities and skill sets. CONCLUSION: Chairs across various tumor streams develop workarounds to overcome barriers and ensure quality meeting outcomes. With more robust support they could enhance value by sharing evidence, conducting audits, and engaging in research. The findings highlight the need for healthcare systems to support tumor stream clinical networks by allocating greater resources to prioritize multidisciplinary meetings and cancer care decision-making.

Experience of patients considering or using checkpoint inhibitors in cancer treatment: a systematic review of qualitative research.

Increasing numbers of patients with cancer are considering or undergoing immunotherapy, however, little is known about patients' perspectives on this treatment. We undertook a systematic review for use by clinicians and researchers, consolidating published qualitative research studies on patient experience of checkpoint inhibitor therapy. A search of Medline, Embase, and PsycINFO was carried out for publications in English to 30 June 2022. Publications were selected if they reported a qualitative study of patient experience with checkpoint inhibitor therapy for cancer, either by patients or their families or carers. Quality was appraised using the Johanna Briggs Institute quality assessment tool for qualitative studies. A thematic synthesis was conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses standard was followed. We identified 17 eligible studies published between 2017 and 2022, 9 using mixed methods, and 8 solely using qualitative methods. Most studies reported on the experiences of patients with advanced stage melanoma and were using the earliest approved checkpoint inhibitors for cancer therapy. Studies met most formal quality criteria but varied in the extent of their qualitative explorations of data; some mixed methods studies had limited reporting of qualitative results. Through thematic synthesis, we categorized study findings into four domains: (1) treatment decision-making; (2) success with immunotherapy; (3) treatment-related adverse events (AEs); and (4) quality of life on immunotherapy. Our review identified several areas with potential for improving the care system. These include, for example: routinely linking patients to peers who have experienced this therapy; improving the capacity of patients and carers to identify and report AEs faster; and supporting patients and carers to live with changed circumstances after successful treatment. Most studies focused on patients who had successful treatment, effectively excluding those who do not respond or who discontinue due to serious side effects; future research targets are suggested.

2023 updated MASCC/ESMO consensus recommendations: controlling nausea and vomiting with chemotherapy of low or minimal emetic potential.

PURPOSE: Review the literature to update the MASCC guidelines from 2016 for controlling nausea and vomiting with systemic cancer treatment of low and minimal emetic potential. METHODS: A working group performed a systematic literature review using Medline, Embase, and Scopus databases between June 2015 and January 2023 of the management of antiemetic prophylaxis for anticancer therapy of low or minimal emetic potential. A consensus committee reviewed recommendations and required a consensus of 67% or greater and a change in outcome of at least 10%. RESULTS: Of 293 papers identified, 15 had information about managing systemic cancer treatment regimens of low or minimal emetic potential and/or compliance with previous management recommendations. No new evidence was reported that would change the current MASCC recommendations. No antiemetic prophylaxis is recommended for minimal emetic potential therapy, and single agents recommended for low emetic potential chemotherapy for acute emesis, but no prophylaxis is recommended for delayed emesis. Commonly, rescue medication includes antiemetics prescribed for the next higher level of emesis. CONCLUSION: There is insufficient data to change the current guidelines. Future studies should seek to more accurately determine the risk of emesis with LEC beyond the emetogenicity of the chemotherapy to include patient-related risk assessment.

2023 MASCC/ESMO consensus antiemetic guidelines related to integrative and non-pharmacological therapies.

PURPOSE: Review the literature to propose suggestions or recommendations for controlling nausea and vomiting through integrative and non-pharmacological treatments for the MASCC/ESMO 2023 update of its antiemetic guidelines. METHODS: The authors identified available systematic reviews and/or meta-analyses for 12 integrative therapies, including acupressure, acupuncture, auricular therapy, electrical stimulation of point PC6, ginger use (i.e., Zingiber officinale), guided imagery, hypnosis, inhalation aromatherapy, music therapy, food-based interventions, progressive muscle relaxation, and reflexology. Reviews were assessed for quality through the AMSTAR2 tool. A consensus committee reviewed recommendations as per MASCC/ESMO established processes. RESULTS: Thirty-nine systematic reviews and/or meta-analyses were used. There were major methodological flaws for many of the trials used as the bases for the reviews. No recommendation for ingested ginger could be made because of conflicting evidence. Recommendations were possible for acupuncture/electroacupuncture treatments, food-based interventions, and progressive muscle relaxation training alone or combined with guided imagery. No recommendations could be reached for a number of food-based approaches, inhalation aromatherapy, hypnosis in adults, music therapy, and reflexology. CONCLUSION: While a limited number of suggestions are provided, there is a need for significantly higher quality trials in many of the therapeutic approaches assessed, before stronger recommendations and a wider range of approaches are made.

Voluntary Assisted Dying/Euthanasia: Will This Have an Impact on Cancer Care in Future Years?

OPINION STATEMENT: In considering the impact of medically hastened death (MHD) on cancer care, a wide range of variables needs to be considered including demographic factors, diagnoses, local cultural factors, and the legislative frameworks in place. Here, we present a synthesis of recently available published literature and empirical data collected following legislative change to enable MHD in Victoria, Australia to explore in detail the potential impact of MHD on cancer care with a focus on patients/families and professional groups. Our findings reveal that for patients and families, both physical and existential distress frequently underlie MHD requests, with the latter less readily recognised by health professionals. The responses of those around the patient making the request may have a very significant impact on relationships within families and upon the nature of the subsequent bereavement. For palliative care, while differing views may remain, it appears that there has been some accommodation of MHD into or alongside practice over time. The recognition of a shared commitment to relief of suffering of palliative care and MHD appears a helpful means of establishing how these practices may co-exist. In cancer practice more broadly, as individual professionals reflect upon their own roles, new relationships and pathways of patient movement (or referral) must be established in response to patients' requests. Our findings also highlight many unanswered questions in understanding the impact of MHD, including that upon those dying who choose not to access MHD, First Nations peoples, the participating health professionals' longer term, and the relief of suffering itself. A systematic approach to the evaluation of MHD legislation must be adopted in order to understand its full impact. Only then could it be determined if the aspirations for such legislative change were being met.

Hypothesis-free discovery of novel cancer predictors using machine learning.

BACKGROUND: Cancer is a leading cause of morbidity and mortality worldwide, and better understanding of the risk factors could enhance prevention. METHODS: We conducted a hypothesis-free analysis combining machine learning and statistical approaches to identify cancer risk factors from 2828 potential predictors captured at baseline. There were 459,169 UK Biobank participants free from cancer at baseline and 48,671 new cancer cases during the 10-year follow-up. Logistic regression models adjusted for age, sex, ethnicity, education, material deprivation, smoking, alcohol intake, body mass index and skin colour (as a proxy for sun sensitivity) were used for obtaining adjusted odds ratios, with continuous predictors presented using quintiles (Q). RESULTS: In addition to smoking, older age and male sex, positively associating features included several anthropometric characteristics, whole body water mass, pulse, hypertension and biomarkers such as urinary microalbumin (Q5 vs. Q1 OR 1.16, 95% CI = 1.13-1.19), C-reactive protein (Q5 vs. Q1 OR 1.20, 95% CI = 1.16-1.24) and red blood cell distribution width (Q5 vs. Q1 OR 1.18, 95% CI = 1.14-1.21), among others. High-density lipoprotein cholesterol (Q5 vs. Q1 OR 0.84, 95% CI = 0.81-0.87) and albumin (Q5 vs. Q1 OR 0.84, 95% CI = 0.81-0.87) were inversely associated with cancer. In sex-stratified analyses, higher testosterone increased the risk in females but not in males (Q5 vs. Q1 ORfemales 1.23, 95% CI = 1.17-1.30). Phosphate was associated with a lower risk in females but a higher risk in males (Q5 vs. Q1 ORfemales 0.94, 95% CI = 0.90-0.99 vs. ORmales 1.09, 95% CI 1.04-1.15). CONCLUSIONS: This hypothesis-free analysis suggests personal characteristics, metabolic biomarkers, physical measures and smoking as important predictors of cancer risk, with further studies needed to confirm causality and clinical relevance.

A review of the utility of prognostic tools in predicting 6-month mortality in cancer patients, conducted in the context of voluntary assisted dying.

BACKGROUND: Eligibility to access the Victorian voluntary assisted dying (VAD) legislation requires that people have a prognosis of 6 months or less (or 12 months or less in the setting of a neurodegenerative diagnosis). Yet prognostic determination is frequently inaccurate and prompts clinician discomfort. Based on functional capacity and clinical and biochemical markers, prognostic tools have been developed to increase the accuracy of life expectancy predictions. AIMS: This review of prognostic tools explores their accuracy to determine 6-month mortality in adults when treated under palliative care with a primary diagnosis of cancer (the diagnosis of a large proportion of people who are requesting VAD). METHODS: A systematic search of the literature was performed on electronic databases Medline, Embase and Cinahl. RESULTS: Limitations of prognostication identified include the following: (i) prognostic tools still provide uncertain prognoses; (ii) prognostic tools have greater accuracy predicting shorter prognoses, such as weeks to months, rather than 6 months; and (iii) functionality was often weighted significantly when calculating prognoses. Challenges of prognostication identified include the following: (i) the area under the curve (a value that represents how well a model can distinguish between two outcomes) cannot be directly interpreted clinically and (ii) difficulties exist related to determining appropriate thresholds of accuracy in this context. CONCLUSIONS: Prognostication is a significant aspect of VAD, and the utility of the currently available prognostic tools appears limited but may prompt discussions about prognosis and alternative means (other than prognostic estimates) to identify those eligible for VAD.

Review of psychological interventions in patients with cancer.

OBJECTIVE: Cancer is one of the leading causes of mortality in the world and also causes morbidity and deterioration in the mental health of patients and their caregivers. The most commonly reported psychological symptoms include anxiety, depression, and the fear of recurrence. The purpose of this narrative review is to elaborate and discuss the effectiveness of the different interventions employed and their utilities in clinical practice. METHODS: Scopus and PubMed databases were searched, with a timeframe from 2020 to 2022, to identify randomised controlled trials, meta-analyses, and reviews and reported using PRISMA guidelines. Articles were searched by the following keywords: "cancer, psychology, anxiety, and depression". An additional search was performed with the keywords "cancer, psychology, anxiety, depression, and [intervention name]". The most popular psychological interventions were included in these search criteria. RESULTS: A total of 4829 articles were retrieved by the first preliminary search. After reducing duplicates, 2964 articles were assessed for inclusion according to eligibility criteria. After the full-text screening, 25 final articles were chosen. To systematise psychological interventions as described in the literature, the authors have divided them into 3 broad categories, each type targeting a specific domain of mental health: cognitive-behavioural, mindfulness, and relaxation. CONCLUSION: The most efficient psychological therapies, as well as therapies which require more extensive research, were outlined in this review. The authors discuss the necessity of primary assessment of patients and whether they require the help of a specialist. With the limitations of the potential risk of bias, an overview of different therapies and interventions targeting various psychological symptoms is outlined.

Age-related experiences of colorectal cancer diagnosis: a secondary analysis of the English National Cancer Patient Experience Survey.

OBJECTIVE: The incidence of colorectal cancer (CRC) in people aged <50 years has been increasing dramatically in the past three decades and such patients are known to face difficulties in diagnosis. The objective of this study was to better understand the diagnostic experiences of patients with CRC and explore age-related differences in the proportion with positive experiences. METHOD: A secondary analysis of the English National Cancer Patient Experience Survey (CPES) 2017 was conducted on the responses of patients with CRC, restricted to those likely to have been diagnosed in the preceding 12 months via pathways other than routine screening. Ten diagnosis-related experience questions were identified, with responses to them categorised as positive, negative or uninformative. Age group-related difference in positive experiences were described and ORs estimated, both raw and adjusted for selected characteristics. Sensitivity analysis was performed by weighting survey responses to 2017 cancer registrations by strata defined by age group, sex and cancer site, to assess whether differential response patterns by these characteristics affected the estimated proportion of positive experiences. RESULTS: The reported experiences of 3889 patients with CRC were analysed. There was a significant linear trend (p<0.0001) for 9 of 10 experience items, with older patients consistently displaying higher rates of positive experiences and patients aged 55-64 showing rates of positive experience intermediate between younger and older age groups. This was unaffected by differences in patient characteristics or CPES response rates. CONCLUSION: The highest rates of positive diagnosis-related experiences were reported by patients aged 65-74 or 75 years and older, and this is robust.

Feasibility and pilot testing of a personalized eHealth intervention for pain science education and self-management for breast cancer survivors with persistent pain: a mixed-method study.

PURPOSE: Here, we describe the development and pilot study of a personalized eHealth intervention containing a pain science education program and self-management support strategies regarding pain and pain-related functioning in female survivors of breast cancer. First, we aimed to evaluate the eHealth intervention's acceptability, comprehensibility, and satisfaction; second, we aimed to assess its preliminary efficacy. METHODS: A mixed-method study design was used. Breast cancer survivors with persistent pain were recruited. After 6 weeks of engagement with the eHealth intervention, acceptability, comprehensibility, and satisfaction were measured quantitatively with a self-constructed questionnaire and described qualitatively using focus groups. A joint display was used to present the meta-interferences between data. Efficacy was assessed via mixed effects models with repeated measures (outcomes assessed at baseline, 6 weeks, and 12 weeks). RESULTS: Twenty-nine women with persistent pain after breast cancer surgery participated. Overall, the eHealth program was well received and experienced as easy to use and helpful. The eHealth intervention seems useful as an adjunct to comprehensive cancer aftercare. Efficacy estimates suggested a significant improvement in pain-related functioning, physical functioning, and quality of life. CONCLUSION: A personalized eHealth intervention appears valuable for persistent pain management after breast cancer surgery. A large controlled clinical trial to determine effectiveness, and a full process evaluation, seems warranted.

Metabolic profile predicts incident cancer: A large-scale population study in the UK Biobank.

BACKGROUND AND AIMS: Analyses to predict the risk of cancer typically focus on single biomarkers, which do not capture their complex interrelations. We hypothesized that the use of metabolic profiles may provide new insights into cancer prediction. METHODS: We used information from 290,888 UK Biobank participants aged 37 to 73 years at baseline. Metabolic subgroups were defined based on clustering of biochemical data using an artificial neural network approach and examined for their association with incident cancers identified through linkage to cancer registry. In addition, we evaluated associations between 38 individual biomarkers and cancer risk. RESULTS: In total, 21,973 individuals developed cancer during the follow-up (median 3.87 years, interquartile range [IQR] = 2.03-5.58). Compared to the metabolically favorable subgroup (IV), subgroup III (defined as "high BMI, C-reactive protein & cystatin C") was associated with a higher risk of obesity-related cancers (hazard ratio [HR] = 1.26, 95 % CI = 1.21 to 1.32) and hematologic-malignancies (e.g., lymphoid leukemia: HR = 1.83, 95%CI = 1.44 to 2.33). Subgroup II ("high triglycerides & liver enzymes") was strongly associated with liver cancer risk (HR = 5.70, 95%CI = 3.57 to 9.11). Analysis of individual biomarkers showed a positive association between testosterone and greater risks of hormone-sensitive cancers (HR per SD higher = 1.32, 95%CI = 1.23 to 1.44), and liver cancer (HR = 2.49, 95%CI =1.47 to 4.24). Many liver tests were individually associated with a greater risk of liver cancer with the strongest association observed for gamma-glutamyl transferase (HR = 2.40, 95%CI = 2.19 to 2.65). CONCLUSIONS: Metabolic profile in middle-to-older age can predict cancer incidence, in particular risk of obesity-related cancer, hematologic malignancies, and liver cancer. Elevated values from liver tests are strong predictors for later risk of liver cancer.

Treating persistent pain after breast cancer: practice gaps and future directions.

This paper discusses the growing problem of persisting pain after successful treatment of breast cancer and presents recommendations for improving pain-related outcomes for this group. We discuss the dominant treatment approach for persisting pain post-breast cancer treatment and draw contrasts with contemporary treatment approaches to persistent pain in non-cancer-related populations. We discuss modern application of the biopsychosocial model of pain and the notion of variable sensitivity within the pain system, moment by moment and over time. We present the implications of increasing sensitivity over time for treatment selection and implementation. By drawing on transformative changes in treatment approaches to persistent non-cancer-related pain, we describe the potentially powerful role that an intervention called pain science education, which is now recommended in clinical guidelines for musculoskeletal pain, may play in improving pain and disability outcomes after successful breast cancer treatment. Finally, we present several research recommendations that centre around adaptation of the content and delivery models of contemporary pain science education, to the post-breast cancer context.

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia.

BACKGROUND: The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers. METHODS: The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127). RESULTS: Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body. CONCLUSION: Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Examining social class as it relates to heuristics women use to determine the trustworthiness of information regarding the link between alcohol and breast cancer risk.

BACKGROUND: High rates of alcohol consumption by midlife women, despite the documented risks associated with breast cancer, varies according to social class. However, we know little about how to develop equitable messaging regarding breast cancer prevention that takes into consideration class differences in the receipt and use of such information. OBJECTIVE: To explore the heuristics used by women with different (inequitable) life chances to determine the trustworthiness of information regarding alcohol as a modifiable risk factor for breast cancer risk. METHODS AND MATERIALS: Interviews were conducted with 50 midlife (aged 45-64) women living in South Australia, diversified by self-reported alcohol consumption and social class. Women were asked to describe where they sought health information, how they accessed information specific to breast cancer risk as it relates to alcohol, and how they determined whether (or not) such information was trustworthy. De-identified transcripts were analysed following a three-step progressive method with the aim of identifying how women of varying life chances determine the trustworthiness of alcohol and breast cancer risk information. Three heuristics were used by women: (1) consideration of whose interests are being served; (2) engagement with 'common sense'; and (3) evaluating the credibility of the message and messenger. Embedded within each heuristic are notable class-based distinctions. CONCLUSIONS: More equitable provision of cancer prevention messaging might consider how social class shapes the reception and acceptance of risk information. Class should be considered in the development and tailoring of messages as the trustworthiness of organizations behind public health messaging cannot be assumed.

The complexities, coordination, culture and capacities that characterise the delivery of oncology services in the common areas of ambulatory settings.

BACKGROUND: Relatively little is understood about real-world provision of oncology care in ambulatory outpatient clinics (OPCs). This study aimed to: 1) develop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of this care; and 2) identify barriers to, and facilitators of, the delivery of this care in OPC common areas. METHODS: A purpose-designed ethnographic study was employed in four public hospital OPCs. Informal field scoping activities were followed by in-situ observations, key informant interviews and document review. A view of OPCs as complex adaptive systems was used as a scaffold for the data collection and interpretation, with the intent of understanding 'work as done'. Data were analysed using an adapted "Qualitative Rapid Appraisal, Rigorous Analysis" approach. RESULTS: Field observations were conducted over 135 h, interviews over 6.5 h and documents were reviewed. Analysis found six themes. Staff working in OPCs see themselves as part of small local teams and as part of a broader multidisciplinary care team. Professional role boundaries could be unclear in practice, as duties expanded to meet demand or to stop patients "falling through the cracks." Formal care processes in OPCs were supported by relationships, social capital and informal, but invaluable, institutional expertise. Features of the clinic layout, such as the proximity of departments, affected professional interactions. Staff were aware of inter- and intra-service communication difficulties and employed strategies to minimise negative impacts on patients. We found that complexity, coordination, culture and capacity underpin the themes that characterise this care provision. CONCLUSIONS: The study advances understanding of how multidisciplinary care is delivered in ambulatory settings and the factors which promote or inhibit effective care practice. Time pressures, communication challenges and competing priorities can pose barriers to care delivery. OPC care is facilitated by: self-organisation of participants; professional acumen; institutional knowledge; social ties and relationships between and within professional groups; and commitment to patient-centred care. An understanding of the realities of 'work-as-done' may help OPCs to sustain high-quality care in the face of escalating service demand.

Interventions to support adherence to oral anticancer therapies: research challenges, lessons learned, and strategies to overcome them from Australia and Switzerland.

Not monitoring adherence to oral anticancer therapies (OAT) can lead to poor clinical outcomes, including premature death as reported by Foulon et al. (Acta Clin Belg 66(2):85-96, 2011) and Greer et al. (Oncologist 21(3):354-76, 2016). Barriers to the implementation of supportive cancer care interventions in medication adherence occur with multiple hospital sites, cancer diagnoses, and numerous healthcare professionals. This commentary describes challenges and strategies from two OAT adherence trials in Australia and Switzerland to assist researchers in the design and implementation of future interprofessional trials.