Long-Term Second Malignancies in Prostate Cancer Patients Treated With Low-Dose-Rate Brachytherapy and Radical Prostatectomy.

PURPOSE: Second malignancy is a rare but potentially lethal event after prostate brachytherapy, but data remain scarce on its long-term risk. The objective of this study is to estimate the number of pelvic second malignancies following brachytherapy compared to radical prostatectomy (RP). MATERIALS AND METHODS: We retrospectively reviewed patients treated with low-dose 125I brachytherapy and RP in British Columbia from 1999 to 2010. Kaplan-Meier estimates for pelvic (bladder and rectum), invasive pelvic, any second malignancy, and death from any second malignancy were assessed. Cox multivariable analyses were performed adjusting for initial treatment type, age, post-RP adjuvant/salvage external beam radiation therapy status, and smoking history. RESULTS: Two thousand three hundred seventy-eight brachytherapy and 9089 RP patients were included. Median age was 66 years (interquartile range [IQR] 61-71) and 63 years (IQR 58-67), respectively. Median follow-up time to event or censured was 14 years (IQR 11.5-17.3). The Kaplan-Meier estimates for pelvic second malignancy at 15 and 20 years were 6.4% and 9.8%, respectively, after brachytherapy, and 3.2% and 4.2% after RP. Time to any second malignancy and time to death from any second malignancy were not significantly different (P > .05). On Cox multivariable analysis, brachytherapy, compared to surgery, was an independent factor for pelvic (hazard ratio [HR] 1.81 [95% CI 1.45-2.26], P < .001) and invasive pelvic second malignancy (HR 2.13 [95% CI 1.61-2.83], P < .001). Increased age and smoking were also associated with higher estimates of events (P < .001). CONCLUSIONS: After adjustment for age, post-RP adjuvant/salvage external beam radiation therapy status, and smoking status, numerically higher long-term HRs of pelvic and invasive pelvic second malignancy in patients treated with brachytherapy compared to RP were noted.

Health and healthcare equity within the Canadian cancer care sector: a rapid scoping review.

BACKGROUND: Despite a publicly-funded healthcare system, alarming cancer-related health and healthcare inequities persist in Canada. However, it remains unclear how equity is being understood and taken up within the Canadian cancer context. Our objective was to identify how health and healthcare equity are being discussed as goals or aims within the cancer care sector in Canada. METHODS: A rapid scoping review was conducted; five biomedical databases, 30 multidisciplinary websites, and Google were searched. We included English-language documents published between 2008 and 2021 that discussed health or healthcare equity in the Canadian cancer context. RESULTS: Of 3860 identified documents, 83 were included for full-text analysis. The prevalence of published and grey equity-oriented literature has increased over time (2008-2014 [n = 20]; 2015-2021 [n = 62]). Only 25% of documents (n = 21) included a definition of health equity. Concepts such as inequity, inequality and disparity were frequently used interchangeably, resulting in conceptual muddling. Only 43% of documents (n = 36) included an explicit health equity goal. Although a suite of actions were described across the cancer control continuum to address equity goals, most were framed as recommendations rather than direct interventions. CONCLUSION: Health and healthcare equity is a growing priority in the cancer care sector; however, conceptual clarity is needed to guide the development of robust equity goals, and the development of sustainable, measurable actions that redress inequities across the cancer control continuum. If we are to advance health and healthcare equity in the cancer care sector, a coordinated and integrated approach will be required to enact transformative and meaningful change.

Evaluation of 18F-EF5 for detection of hypoxia in localized adenocarcinoma of the prostate.

BACKGROUND: A common feature of solid tumours that are resistant to therapy is the presence of regions with low oxygen content (i.e., hypoxia). Oxygen electrode studies suggest that localized prostate adenocarcinoma is commonly hypoxic, although conflicting data have been reported between immunohistochemical detection of hypoxia-induced proteins in biopsy specimens and positron emission tomography (PET) imaging of 18F-labeled hypoxia reporters. Although the 2-nitroimidazole 18F-EF5 is well-established to label hypoxic tumour cells in pre-clinical tumour models and clinical trials of multiple primary tumour sites, it has yet to be tested in prostate cancer. The purpose of this study was to evaluate the feasibility of using 18F-EF5 to detect hypoxia in clinical prostate tumours. MATERIAL AND METHODS: Patients with localized adenocarcinoma of the prostate were recruited for pre-treatment 18F-EF5 PET scans. Immunohistochemistry was conducted on diagnostic biopsies to assess the expression of glucose transporter 1 (GLUT1), osteopontin (OPN), and carbonic anhydrase IX (CAIX). Immunoreactivity scores of staining intensity and frequency were used to indicate the presence of tumour hypoxia. RESULTS: We found low tumour-to-muscle ratios of 18F-EF5 uptake that were not consistent with tumour hypoxia, causing early termination of the study. However, we observed GLUT1 and OPN expression in all prostate tumour biopsies, indicating the presence of hypoxia in all tumours. CONCLUSION: Our data do not support the use of 18F-EF5 PET to detect hypoxia in prostate adenocarcinoma, and suggest the use of immunohistochemistry to quantify expression of the hypoxia-inducible proteins GLUT1 and OPN as indications of prostate tumour hypoxia.

Acute Effect of Popular High-Intensity Functional Training Exercise on Physiologic Markers of Growth.

ABSTRACT: Kliszczewicz, B, Markert, CD, Bechke, E, Williamson, C, Clemons, KN, Snarr, RL, and McKenzie, MJ. Acute effect of popular high-intensity functional training exercise on physiologic markers of growth. J Strength Cond Res 35(6): 1677-1684, 2021-Constantly evolving, high-intensity functional training (HIFT) exercise consists of various modalities, orders, weights, and repetition schemes. High-intensity functional training has gained popularity among the general population, but lacks empirical evidence regarding acute adaptive responses. The purpose of this study was to describe the acute effects of 2 representative bouts of HIFT on physiologic markers of growth. For convenience, the bouts are designated "short" (<5 minutes) and "long" (∼15 minutes), although duration was not the only difference between bouts. Ten apparently healthy men (28.1 ± 5 years) performed 2 HIFT bouts in a randomized crossover design. Blood was collected at 5 time points (Pre, Post, 1, 3, and 6 hours) to examine growth hormone (GH), insulin-like growth factor (IGF-1), insulin-like growth factor binding proteins 1 and 2 (IGFBP-1 and IGFBP-2), and vascular endothelial growth factor (VEGF). Blood lactate concentration ([La]) was analyzed at the Pre and Post time points. A repeated-measures analysis of variance (ANOVA) revealed no trial differences among the markers (IGF-1, IGFBP-1, IGFBP-2, and VEGF) except GH at Post, where the long bout produced a greater effect (p = 0.005). Mean GH levels (pg·ml-1) in the short bout increased from 68.4 to 106.5, and in the long bout, mean GH levels increased from 38.5 to 286.4. The repeated-measures ANOVA revealed a main time effect in GH (p = 0.037), while a post hoc t-test demonstrated elevated GH at 1 hour (p = 0.018) when compared with Pre. No time-dependent change (p > 0.05) was observed in IGF-1, IGFBP-1, IGFBP-2, or VEGF. Mean blood [lactate] increased more than tenfold in both bouts. The findings of this descriptive study suggest that, other than GH, there are no acute differences in markers of skeletal muscle or vascular growth between these 2 specific HIFT bouts.

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings.

PURPOSE: Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www.prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics. METHODS: We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement. RESULTS: In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations. CONCLUSIONS: Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.

Canadian patterns of practice for intracranial germ cell tumors in adolescents and young adults.

INTRODUCTION: The study objectives were to describe patterns of practice for intracranial germ cell tumors (IGCT) in adolescents and young adults (AYA) and to determine factors associated with practice patterns. METHODS: A survey was written containing questions on the management of two 17-year old males, one with localized pineal germinoma and the other with localized pineal non-germinomatous germ cell tumor (NGGCT). An invitation to participate anonymously in the survey was e-mailed to 119 oncologists who treat brain tumors across Canada. RESULTS: Seventy-two (61%) of the 119 oncologists participated in the study. For the germinoma case, the most common treatment approaches were whole ventricular radiotherapy (WVRT) and chemotherapy (CH) (56%), WVRT alone (15%), and craniospinal radiotherapy (CSRT) alone (10%); for physicians recommending WVRT + CH, most frequently selected whole ventricular doses were 24 Gy (57%) and 18 Gy (20%). Chemotherapy was included in the treatment of germinoma by 96% of pediatric physicians vs. 54% of adult physicians (P = 0.001). The most common treatment approaches for NGGCT were CSRT + CH (44%), WVRT + CH (21%), and pineal gland RT + CH (15%). The selection of craniospinal vs. smaller-volume RT was not associated with the physicians' specialty, percentage of practice treating brain tumors, number of IGCTs seen, or size of institution. CONCLUSIONS: There is wide variation in the management of IGCT in AYA across Canada. A 17-year old male with a localized pineal germinoma is highly likely to receive chemotherapy if managed by a pediatric oncologist, while the same patient is much less likely to receive chemotherapy if managed by an adult oncologist.

Long-Term Prostate Specific Antigen Stability and Predictive Factors of Failure after Permanent Seed Prostate Brachytherapy.

PURPOSE: Defining biochemical failure as nadir + 2 may overestimate cure after radiotherapy. We assessed long-term prostate specific antigen stability after low dose rate prostate brachytherapy and predictors of biochemical failure when prostate specific antigen was slowly rising below the nadir + 2 ng/ml threshold. MATERIALS AND METHODS: A total of 2,339 patients with low or intermediate risk prostate cancer received 125iodine brachytherapy from 1998 to 2010 with a minimum 3-year followup. In addition, 49.7% of the patients received 6 months of androgen deprivation. Clinical, dosimetric and prostate specific antigen data were retrieved from a prospective database. Biochemical results were classified as stable or rising prostate specific antigen (0.2 ng/ml or greater and increased 0.1 ng/ml or greater during the preceding 2 years), or biochemical failure (defined as nadir + 2). Multivariate analysis was done to identify predictors of failure used to create logistic regression models. RESULTS: At a median followup of 89 months (range 37 to 199) prostate specific antigen was stable (nadir 0.03 ng/ml and at 60 months 0.04 ng/ml) in 2,004 patients (86%) and rising (nadir 0.16 ng/ml and at 60 months 0.29 ng/ml) in 145 (6%) while biochemical failure (nadir 0.51 ng/ml, p <0.001) was noted in 190 (8%). When there was no prior androgen deprivation therapy, the prostate specific antigen nadir and prostate specific antigen at 60 months were the strongest predictors of failure (OR 20.6 and 18.3, respectively, each p <0.0001). The logistic regression model had 85% sensitivity and 98% specificity, and predicted failure in 8 of 82 men (9.8%). A second model was created for the group with androgen deprivation therapy and rising prostate specific antigen using the predictive factors prostate specific antigen at 60 months (OR 53.9, p <0.0001) and T stage (OR 0.25, p = 0.0008). This model predicted biochemical failure in 30 of 56 men (54%) with 85% sensitivity and 93% specificity. The 2 predictive models yield an anticipated 90% cure rate in the entire cohort. CONCLUSIONS: Brachytherapy is highly curative with stable prostate specific antigen at a surgical ablation level in 86% of patients. Rising prostate specific antigen is rare at a 6% incidence and often innocuous.

Effects of high-intensity interval training on cardiometabolic risk in overweight and obese African-American women: a pilot study.

OBJECTIVE: Little is known about high-intensity interval training (HIIT) in African-American (AA) women. The purpose of this pilot study was to evaluate the effects of HIIT and steady-state (SS) exercise on cardiometabolic risk factors in young AA women. DESIGN: A 16-week exercise intervention was conducted 3x/week. Twenty-seven AA women were randomized to SS (n = 11; 32 continuous minutes of treadmill walking at 60-70% of maximum heart rate (HRmax)), or HIIT (n = 16; 32 min of treadmill HIIT alternating 3 min at 60-70% of HRmax with 1 min at 80-90% of HRmax). Two-way repeated measures ANOVA with intention-to-treat analysis was used to identify changes between groups. Significance was accepted at P ≤ 0.05. RESULTS: Of the 27 women who entered the study (age: 30.5 ± 6.8 years; BMI: 35.1 ± 5.1 kg/m2; 5274 ± 1646 baseline steps/day), 14 completed the intervention. HIIT significantly decreased waist circumference (107.0 ± 11.3 to 105.1 ± 11.9 cm) compared to SS, which showed no change. There was a significant time effect for steps where HIIT increased steps/day (5334 ± 1586 to 7604 ± 1817 steps/day), and SS had no change. There were no significant changes in either group for any other measurements. CONCLUSION: HIIT was more effective at reducing waist circumference and increasing daily steps/day than SS treadmill exercise over 16 weeks. Further research in a larger sample is indicated to evaluate the effects of each protocol on cardiometabolic risk factors.

Autonomic response to a short and long bout of high-intensity functional training.

The evaluation of Autonomic Nervous System (ANS) recovery following exercise provides insight into the transient stress placed on the cardiovascular system. High-Intensity Functional Training (HIFT) is a form of intense exercise that is prescribed in various modalities and durations; however, little is known about the influence of HIFT duration on ANS recovery. Ten apparently healthy males (28.1 ± 5.4 yrs) performed two HIFT sessions (<5-minute and 15-minute) in a crossover fashion. ANS activity was measured using plasma Epinephrine (E) and Norepineprine (NE); Heart Rate Variability markers of the log transformed Root Mean Square of Successive Differences (lnRMSSD) and High-Frequency power (lnHF). No trial dependent differences were observed in lnRMSSD (p = 0.822), lnHF (p = 0.886), E (p = 0.078), or NE (p = 0.194). A significant main time effect was observed in both trials with a depression in lnRMSSD and lnHF following the trials (p < 0.05) and recovering by 2-hours post (p = 0.141, p > 0.999) respectively. A trial dependent increase in E and NE occurred immediately post (p < 0.05) and recovered by 1-hour post (p > 0.999, p > 0.999) respectively. The HIFT bouts examined within this study demonstrated similar transient strain of the ANS.

Visual Outcomes and Local Control After Fractionated Stereotactic Radiotherapy for Optic Nerve Sheath Meningioma.

PURPOSE: To review the outcomes of patients with optic nerve sheath meningiomas (ONSM) treated with fractionated stereotactic radiotherapy. METHODS: Patient characteristics, treatment, and outcomes were analyzed for all patients with primary and secondary ONSM treated from 2001 to 2012. Clinically significant visual acuity change was defined as a 2-line change on the Snellen eye chart from pre-fractionated stereotactic radiotherapy. RESULTS: Forty-one patients were treated: 23 patients with primary ONSM and 18 patients with secondary ONSM. The median age at diagnosis was 56 years. The median visual follow up was 3.8 years and the median radiologic follow up was 4.4 years. At diagnosis, 36% had normal vision (20/20-20/40), 10% had mild impairment (<20/40-20/60), 20% had moderate visual impairment (<20/60-20/200), 27% had severe impairment (<20/200), and 7% had no light perception. Common acute side effects were headache (32%) and nausea (15%); 15% of patients required corticosteroids during stereotactic radiotherapy. Chronic toxicities included retinopathy (7%), pituitary dysfunction (13%), chronic ocular pain (5%), and cataracts (2%). Visual acuity was stable in 65%, improved in 27%, and decreased in 8% of patients. Visual fields were stable in 70%, improved in 21%, and reduced in 9%. Actuarial 5-year local control rates were 100% for primary ONSM and 88% for secondary ONSM. Actuarial 5-year visual preservation rates were 100% for primary ONSM and 86% for secondary ONSM. CONCLUSIONS: Fractionated stereotactic radiotherapy for primary and secondary ONSM was well tolerated and provides excellent local control and visual preservation. Longer follow up is required to determine the risk of late ocular and pituitary sequelae.

Oncologist Experience Implementing Goals of Care Discussions in Everyday Ambulatory Oncology Practice: Implications for Education.

Despite evidence that Goals of Care (GOC) discussions should occur early in the disease trajectory, the majority occur close to end of life. In a pilot, oncologists routinely initiated GOC discussions with all patients in their everyday ambulatory practice. Following the pilot, 9 of 12 eligible oncologists participated in semi-structured interviews about their experiences. Analysis resulted in the identification of seven principles of good GOC discussions embedded in the oncologists' interviews, four barriers to engaging in GOC discussions and foundational education needs. Participants believed that the appropriate trigger for a GOC discussion is a diagnosis of advanced cancer, not simply a diagnosis of cancer, and supported the importance of selective and strategic targeting of GOC discussions. The findings have informed the development of an education-based model for culture change within a province-wide cancer care system.

New biphenyl iminium salt catalysts for highly enantioselective asymmetric epoxidation: role of additional substitution and dihedral angle.

New biaryl iminium salt catalysts for enantioselective alkene epoxidation containing additional substitution in the heterocyclic ring are reported. The effects upon conformation and enantioselectivity of this additional substitution, and the influence of dihedral angle in these systems, has been investigated using a synthetic approach supported by density functional theory. Enantioselectivities of up to 97% ee were observed.

Pharmacist Screening for Risk of Osteoporosis in Elderly Veterans.

OBJECTIVE: To assess the effect of pharmacist screening for osteoporosis risk with increased bone mineral density (BMD) testing. DESIGN: Prospective, quasi-experiment. SETTING: Veterans Affairs medical center Community Living Centers (CLC), home-based primary care, and outpatient geriatric clinic. PARTICIPANTS: Patients with a routine pharmacist interaction were included. Exclusion criteria included hospice, dialysis, and respite care. INTERVENTIONS: Risk assessment with recommendations communicated by progress notes to consider BMD testing or interventions in the settings described. A second phase of the project was conducted in CLC patients to evaluate the effect of an interdisciplinary team with the inclusion of a physician to assess clinical appropriateness of interventions. MAIN OUTCOME MEASURE(S): Proportion of patients meeting guidelines for BMD testing and change in proportion of patients with BMD testing ordered after intervention. Secondary measures included response to recommendations and initiation of osteoporosis pharmacotherapies. RESULTS: A total of 219 patients were included in the first phase of the project, with 120 (54.8%) identified as candidates for BMD testing with recommendations documented. Of this population, 5 patients without previous dual-energy absorptiometry results had BMD testing ordered (P = 0.6). In the second phase, 22 high-risk patients in the CLC met criteria for BMD testing, with 14 determined to have reasons for not pursuing BMD testing. CONCLUSION: Most patients in the settings described met guidelines for BMD testing. Pharmacist recommendations to consider BMD testing did not increase the rate of testing. Including a physician on an interdisciplinary team appeared to help determine appropriateness and improve the rate of testing, though the increase in testing was not statistically significant.

The Vancouver rapid access clinic for palliative lung radiation, providing more than just rapid access.

PURPOSE: The Vancouver Rapid Access (VARA) clinic aimed to deliver urgent palliative radiotherapy (RT) and holistic care to patients with newly diagnosed incurable lung cancer. The purpose of this paper is to describe the 9-month pilot phase of the clinic and to compare its efficacy to standard practice. METHODS: A multidisciplinary team performed the initial consult, and if appropriate, the patient received RT the same day and was connected with supportive services as required. Patient and treatment details were prospectively collected. A retrospective chart review of similar patients in standard practice 1 year prior to VARA was performed. Variables compared between VARA and standard practice included RT wait times and supportive service referrals. RESULTS: During the pilot phase, 58 patients were assessed. Forty percent were inpatients, and 62% had an ECOG 2 or higher. Fifty-four patients received RT; the majority (72%) received RT on the same day as their consultation, compared to 41% in standard practice (p < 0.001). The most common sites treated were the bone (42%), lung (34%), and brain (14%). More than half of VARA patients (54%) were referred to an additional health service such as home care nursing compared to 31% of standard practice patients (p = 0.01). The VARA clinic decreased the proportion of patients double-booked into an oncologists schedule from 23 to 13% (p < 0.001). CONCLUSIONS: The VARA clinic has improved wait times for palliative RT, increased patient access to supportive services, and improved the workload for lung radiation oncologists. This clinic could serve as a model for other patients with incurable cancer.

Stereotactic Radiosurgery for Metastases in Eloquent Central Brain Locations.

BACKGROUND: To examine stereotactic radiosurgery (SRS) following whole brain radiotherapy for metastases in eloquent, central brain locations: brainstem, thalamus, and basal ganglia. METHODS: We conducted a retrospective review of patients with metastases in eloquent, central brain locations who were treated with SRS between January 2000 and April 2012. All patients had whole brain radiotherapy. Patients eligible for SRS had one to three brain metastases, metastasis size ≤4 cm, and Karnofsky performance status ≥70. Local progression-free survival and overall survival were calculated using the Kaplan-Meier method. RESULTS: For 24 patients, the median age was 50 years (range, 36-73). Metastases by location were: 11 brainstem, 9 thalamus, and 5 basal ganglia. The median metastasis size was 15 mm (range, 2-33) and the median SRS dose prescription was 15 Gy (range, 12-24). The median local progression-free survival was 13.7 months and median overall survival was 16.4 months. Compared with a cohort of 188 patients with noneloquent brain metastases receiving a median dose of 24 Gy, overall survival of 10.8 months was not significantly different (p=0.16). The only symptomatic complication was grade 2 headache in 8.3%. Asymptomatic adverse radiologic events were radionecrosis in two (8.3%), peritumoural edema in four (16.7%), and hemorrhage in one patient (4.2%). CONCLUSIONS: Lower SRS marginal doses do not appear to compromise survival in patients with eloquently located brain metastases compared with higher doses for other brain metastases, with minimal symptomatic complications.

The value of prostate cancer support groups: a pilot study of primary physicians' perspectives.

BACKGROUND: In Canada, prostate cancer (PCa) is the most common male cancer, and prostate cancer support groups (PCSGs) have prevailed for more than 20 years providing support to men with PCa and their families. While the format, focus and benefits of attending PCSGs have been reported little is known about primary physicians' (PPs) perceptions of these groups. This article describes Canadian primary physicians' views about face-to-face and web-based PCSGs. METHODS: Canadian based primary physicians (n = 140) attending a 2012 Continuing Medical Education Conference participated in a pilot survey questionnaire study. The 56-item questionnaire used in this study included six sets of attitudinal items to measure primary physicians' beliefs about positive and negative influences of PCSGs, reasons for attending PCSGs, the attributes of effective PCSGs, and the value of face-to-face and web-based PCSGs. RESULTS: Results showed that PCSGs were positively valued, particularly for information sharing, education and psychosocial support. Poor inclusivity, privacy, and accessibility were identified as potential barriers, and recommendations were made for better marketing and web-based PCSGs to increase engagement with potential attendees. CONCLUSIONS: Findings suggest PPs highly valued the role and potential benefits of PCSGs. Information provision and an educational role were perceived as key benefits amid the need to improve local and provincial marketing of PCSGs. The potential for web-based PCSGs to help in the support of PCa patients was also recognized.

Direct Medical Spending on Young and Average-Age Onset Colorectal Cancer before and after Diagnosis: a Population-Based Costing Study.

BACKGROUND: Despite a better understanding of the increasing incidence of young-onset colorectal cancer (yCRC; age at diagnosis <50 years), little is known about its economic burden. Therefore, we estimated direct medical spending on yCRC before and after diagnosis. METHODS: We used linked administrative health databases in British Columbia, Canada, to create a study population of yCRC and average-age onset colorectal cancer (aCRC; age at diagnosis ≥50 years) cases, along with cancer-free controls. Over the 1-year period preceding a colorectal cancer diagnosis, we estimated direct medical spending on hospital visits, healthcare practitioners, and prescription medications. After diagnosis, we calculated cost attributable to yCRC and aCRC, which additionally included the cost of cancer treatments (e.g., chemotherapy and radiotherapy) across phases of care. RESULTS: We included 1,058 yCRC (45.4% females; age at diagnosis 42.4 ± 6.2 years) and 12,619 aCRC (44.8% females; age at diagnosis of 68.1 ± 9.2 years) cases. Direct medical spending on the average yCRC and aCRC case during the year before diagnosis was $6,711 and $8,056, respectively. After diagnosis, the overall average annualized cost attributable to yCRC significantly differed in comparison with aCRC for the initial ($50,216 vs. $37,842; P < 0.001), continuing ($8,361 vs. $5,014; P < 0.001), and end-of-life cancer phase ($86,125 vs. $61,512; P < 0.001) but not end-of-life non-cancer phase ($77,273 vs. $23,316; P = 0.372). CONCLUSIONS: Reported cost estimates may be used as inputs for future economic evaluations pertaining to yCRC. IMPACT: We provided comprehensive cost estimates for healthcare spending on young-onset colorectal cancer.

Exploring the value of structured narrative feedback within the Serious Illness Conversation-Evaluation Exercise (SIC-Ex): a qualitative analysis.

OBJECTIVES: The Serious Illness Conversation Guide (SICG) has emerged as a framework for conversations with patients with a serious illness diagnosis. This study reports on narratives generated from open-ended questions of a novel assessment tool, the Serious Illness Conversation-Evaluation Exercise (SIC-Ex), to assess resident-led conversations with patients in oncology outpatient clinics. DESIGN: Qualitative study using template analysis. SETTING: Three academic cancer centres in Canada. PARTICIPANTS: 7 resident physicians (trainees), 7 patients from outpatient cancer clinics, 10 preceptors (raters) consisting of medical oncologists, palliative care physicians and radiation oncologists. INTERVENTIONS: Each trainee conducted an SIC with a patient, which was videotaped. The raters watched the videos and evaluated each trainee using the novel SIC-Ex and the reference Calgary-Cambridge Guide (CCG) initially and again 3 months later. Two independent coders used template analysis to code the raters' narrative comments and identify themes/subthemes. OUTCOME MEASURES: How narrative comments aligned with elements of the CCG and SICG. RESULTS: Template analysis yielded four themes: adhering to SICG, engaging patients and family members, conversation management and being mindful of demeanour. Narrative comments identified numerous verbal and non-verbal elements essential to SICG. Some comments addressing general skills in engaging patients/families and managing the conversation (eg, setting agenda, introduction, planning, exploring, non-verbal communication) related to both the CCG and SICG, whereas other comments such as identifying substitute decision maker(s), affirming commitment and introducing Advance Care Planning were specific to the SICG. CONCLUSIONS: Narrative comments generated by SIC-Ex provided detailed and nuanced insights into trainees' competence in SIC, beyond the numerical ratings of SIC-Ex and the general communication skills outlined in the CCG, and may contribute to a more fulsome assessment of SIC skills.

Population-based 10-year oncologic outcomes after low-dose-rate brachytherapy for low-risk and intermediate-risk prostate cancer.

BACKGROUND: The objective of this study was to report the rates of disease-free survival (DFS), cause-specific survival (CSS), and overall survival after low-dose-rate (LDR) prostate brachytherapy (PB). METHODS: Data from 1006 consecutive patients with prostate cancer who received LDR-PB and underwent implantation on or before October 23, 2003 were extracted from a prospective database on November 11, 2011. The selected patients had low-risk (58%) or intermediate-risk (42%) disease according to National Comprehensive Cancer Network criteria. The Phoenix threshold was used to define biochemical relapse. Sixty-five percent of patients received 3 months of neoadjuvant androgen-deprivation therapy (ADT) and 3 months of concomitant ADT. Univariate and multivariate analyses are reported in relation to patient, tumor, and treatment variables. RESULTS: The median follow-up was 7.5 years. By using Fine and Gray competing risks analysis, the 5-year and 10-year actuarial DFS rates were 96.7% (95% confidence interval, 95.2%-97.7%) and 94.1% (95% confidence interval, 92%-95.6%), respectively. When applied to the whole cohort, none of the usual prognostic variables, including dose metrics, were correlated with DFS. However, in both univariate and multivariate models, increasing dose was the only covariate that correlated with improved DFS for the subset of men (N = 348) who did not receive ADT (P = .043). The actuarial 10-year CSS rate was 99.1% (95% confidence interval, 97.3%-99.7%). The overall survival rate was 93.8% at 5 years (95% confidence interval, 92%-95.1%) and 83.5% at 10 years (95% confidence interval, 79.8%-86.6%). Only age at implantation (P = .0001) was correlated with overall survival in multivariate analysis. CONCLUSIONS: In a consecutive cohort of 1006 men with National Comprehensive Cancer Network low-risk and intermediate-risk prostate cancer, the actuarial rate of recurrent disease after LDR-PB was approximately 3% at 5 years and 6% at 10 years.