Exploring attitudes of Canadian radiation oncologists, radiation therapists, physicists, and oncology nurses regarding interprofessional teaching and learning.

The purposes of this exploratory study were to investigate the attitudes of radiation oncology professionals regarding interprofessional (IP) teaching and interprofessional education (IPE), to identify the challenges faced by radiation oncologists who teach within an IP context, and to discover new strategies to aid professionals teaching IP students. A questionnaire was developed through the review of existing literature on IPE using Medline. The proposed group of questions was selected by educators from different professions actively involved in IPE. The final revised questionnaire consisted of three main domains assessing the understanding of IP concepts, attitudes toward IP teaching and learning environments, and attitudes toward health-care teams. An open-ended comment section was included. The questionnaire was administered to health-care professionals (physicists, radiation oncologists, and radiation therapists) nationally through SurveyMonkey® (electronic survey). A total of 220 respondents provided demographic information. Half of these respondents indicated that they previously received education relating to IPE. A high level of agreement was received for nearly all the questions. There were no significant statistical differences among the three different professional respondent groups for any question. Overall, most of the respondents demonstrated a good knowledge and understanding of IP concepts and advocated IP training and collaboration.

Opinions from the experts: exploring what prostate cancer patients should know about post-operative radiotherapy.

The present study investigated health professionals' opinions about important questions that should be discussed with patients who may require post-prostatectomy radiotherapy. A 74-question survey was conducted among radiation oncologists, urologists, nurses, and radiation therapists involved in the care of prostate cancer patients. Survey questions covered six domains: understanding my situation and prostate cancer diagnosis, making a decision, radiotherapy: procedures involved, potential benefits, side effects, and my support network during radiation treatment. Respondents rated the importance of addressing these questions as either essential, important, no opinion, or avoid with a hypothetical post-prostatectomy case. The majority of questions were rated as either essential or important. There was disagreement between professions on essential questions, mostly between nurses and urologists in the side-effects domain. There was agreement between all professions regarding which questions should be avoided.

Comparing cost-effectiveness analyses of denosumab versus zoledronic acid for the treatment of bone metastases.

BACKGROUND: Bone metastases from various cancers have been traditionally treated with bisphosphonates, such as zoledronic acid (ZA), to prevent future skeletal-related events (SREs). Denosumab (Dmab) has been shown to have more advantages in preventing SREs in clinical trials than ZA, but the cost to administer Dmab is significantly higher. METHODS: A literature review was conducted to investigate the methodologies used to compare the cost-effectiveness of Dmab and ZA. MEDLINE and EMBASE were searched systematically for all cost-effectiveness analyses published between January week 1, 2006 to August week 1, 2012. Search strategies were designed to retrieve articles analyzing the cost-effectiveness and cost utility of Dmab compared to ZA in patients with bone metastases. From 12 references obtained in the initial database search, eight satisfied the predetermined criteria for full article review. Articles were analyzed for incremental costs per skeletal-related event avoided or incremental cost per quality-adjusted life year gained. RESULTS: All the studies identified received funding from Novartis Pharmaceuticals (the manufacturer of ZA) or Amgen Incorporated (the manufacturer of Dmab). The studies looked at the economic analysis using different associated costs and over various time periods, ranging from a 1-year to a lifetime time horizon. CONCLUSION: It is not clear whether the methods used across studies are consistent, which may account for the differences between estimated costs and effects. Future research is suggested to explore the cost-effectiveness between Dmab and ZA using a standardize time frame and endpoint.

An Update on the Quality of Life Measurements in Lung Cancer Patients Receiving Palliative Radiotherapy: A Literature Review.

To conduct a systematic review on validated instruments used to assess quality of life (QOL) in patients with either primary or metastatic lung neoplasms. A literature search was conducted through the Embase (1950 - 2012 week 30) and Medline (1946 - 2012 week 3 July) databases. All compiled studies utilized QOL or symptom palliation as a primary or secondary outcome for patients with advanced lung cancer. A total of 17 studies met our criteria. Four questionnaires were most commonly used: the EORTC QLQ-C-30, the EORTC QLQ-LC-13, the Rotterdam Symptom Check-list (RSCL), and the Hospital Anxiety and Depression Scale (HADS). The limited number of studies assessing QOL in patients with advanced lung cancer suggests that QOL is still an uncommon endpoint for this patient population. Nine of seventeen (53%) studies evaluated QOL in their cohorts and out of those nine, seven (77%) included the use of a lung-specific tool. In total there were eleven of seventeen (65%) studies that evaluated symptom palliation, indicating the relevance of symptom palliation as an endpoint in this population. It is encouraged that lung specific QOL questionnaires, such as the FACT-L and the EORTC QLQ LC-13, be used in tandem with general questionnaires, such as the FACT-G and the EORTC QLQ C-30, in advanced lung cancer patients undergoing radiotherapy. Clinicians should also be advised to focus more on QOL assessment.

Comparison and Literature Review of Occupational Stress in a Palliative Radiotherapy Clinic's Interprofessional Team, the Radiation Therapists, and the Nurses at an Academic Cancer Centre.

PURPOSE: The purpose of this study was to assess the predisposing factors for occupational stress within the Rapid Response Radiotherapy Program (RRRP), radiation therapists (RTs), and registered nurses (RNs) at the Odette Cancer Centre (OCC). MATERIALS AND METHODS: All RRRP team members (n = 15, including radiation oncologists, residents, and students), RTs (n = 130), and ambulatory care nurses (n = 80) at the OCC were asked to complete a demographics form on professional background and three validated surveys designed to evaluate stress. The Maslach Burnout Inventory (MBI) was used to assess burnout in the workplace through assessment of personal accomplishment, emotional exhaustion, and depersonalization; the General Health Questionnaire (GHQ-12) assessed psychological morbidity; and the Professional Quality of Life Scale (ProQOL) assessed compassion satisfaction, compassion fatigue, and burnout. Univariate general linear regression was used to determine significant demographic predictors for occupational stress, and one-way analysis of variance was used to compare stress among the three groups. RESULTS: The overall response rate was 28%: 80% for RRRP, 20% for RTs, and 31% for RNs. Females were more likely to report greater personal accomplishment (P = .0393). Being younger (P = .0041), male (P = .0056), having less professional experience (P = .008), and being in the RRRP (P = .0019) was associated with greater depersonalization. Greater self-reported spirituality was predictive of higher compassion satisfaction (P = .0064); those reporting no or lower spirituality experienced higher levels of burnout (P = .0053). Higher GHQ-12 scores (greater stress) were reported by participants that spend more of their work time with palliative patients, and lower GHQ-12 scores (less stress) was reported in participants that participated in stress-relieving activities. A significant difference between groups was only seen in the MBI scale assessing depersonalization (P = .0077), with the RRRP experiencing greater depersonalization. For burnout subscales, 59.0% (RNs), 40.0% (RRRP), and 58.3% (RTs) reported low levels of personal accomplishment; 50% (RNs), 20% (RRRP), and 25% (RTs) reported high levels of emotional exhaustion; and 86.3% (RNs), 53.3% (RRRP), and 66.7% (RTs) reported low levels of depersonalization. CONCLUSION: Greater psychological stress was seen in respondents that worked primarily with palliative patients. Individuals that identified themselves as being spiritual had higher professional satisfaction with work, whereas a detached response to professional practice was associated with being younger, male, having less work experience, and being a member of the RRRP team. Future initiatives should place emphasis on promoting stress-relieving activities, the necessity for stress management courses, and the overall importance of increasing awareness of the potential signs and causes of occupational stress.

Do elderly patients with metastatic cancer have worse quality of life scores?

PURPOSE: The purpose of this study is to compare self-reported quality of life (QOL) scores in old and young patients with metastatic cancer using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C15-PAL questionnaire. MATERIALS AND METHODS: Patients receiving palliative radiotherapy (RT) for bone metastases and brain metastases completed the QLQ-C15-PAL questionnaire prior to treatment. Using multiple linear regression analysis, a parametric test, the QLQ-C15-PAL scores were compared using 65 and 70 years as cutoff ages. RESULTS: A total of 340 patients were referred for palliative RT for bone metastases (n = 190) or brain metastases (n = 150). Physical functioning and appetite were worse in the older group using either 65 or 70 years as the cutoff age. Age-related differences in the QLQ-C15-PAL scores varied as a function of age cutoff used and location of metastatic site irradiated. CONCLUSION: Based on the (EORTC) QLQ-C15-PAL, elderly advanced cancer patients have a different QOL profile. Similar observations have been reported with the (EORTC) QLQ-C30 questionnaire.

Fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic as screened by the Edmonton Symptom Assessment System.

INTRODUCTION: Advanced cancer patients present with a variety of physical and psychological symptoms. Fatigue is one such symptom which reduces overall quality of life and is difficult to manage. The purpose of this study was to report the presence, severity, and correlating factors of fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic. MATERIALS/METHODS: Patients referred to the Rapid Response Radiotherapy Program between January 1999 and October 2009 completed the Edmonton Symptom Assessment System (ESAS) prior to consultation. Demographic information including age, Karnofsky Performance Status (KPS), gender, and primary cancer sites were collected. Ordinal logistic regression analysis was conducted to determine relationships between demographic information, other ESAS items, and levels of fatigue. Multivariate ordinal logistic regression analysis was used to determine the most significant predictors of fatigue. A p value of <0.05 was considered statistically significant. RESULTS: A total of 1,397 patients completed the ESAS prior to consultation. Median age was 68 years (range, 21-95), median KPS was 60 (range, 10-100), and slightly more males completed the ESAS (53.0%). Common primary cancers were of the lung (35.8%), breast (20.7%), and prostate (17.7%). Only 179 (12.8%) patients reported no fatigue; the majority of patients reported moderate (31.8%) or severe (34.4%) fatigue. A low KPS (p < 0.0001), being female (p = 0.0056), or being referred for bone metastases (p = 0.0185) significantly correlated with higher levels of fatigue. Patients with a genitourinary primary cancer (p = 0.0078) and/or referred for malignant spinal cord compression (p = 0.0004) reported less fatigue. All other ESAS items were significantly related to fatigue. The most significant predictors of fatigue were pain (p < 0.0001, odds ratio (OR) = 1.07), nausea (p = 0.0010, OR = 1.10), depression (p < 0.0001, OR = 1.10), drowsiness (p < 0.0001, OR = 1.33), dyspnea (p = 0.0003, OR = 1.08), and overall well-being (p < 0.0001, OR = 1.19). CONCLUSION: Moderate fatigue was reported in over 66% of our advanced cancer patients prior to radiotherapy. Since radiotherapy inherently causes fatigue, proactive and multidisciplinary management is required for these patients. Similar rates of fatigue severity, in lengthier, fatigue-specific tools, suggest that the ESAS may be a good tool for screening the advanced cancer population.

EORTC QLQ-C15-PAL quality of life scores in patients with advanced cancer referred for palliative radiotherapy.

PURPOSE: Symptom control and improved quality of life (QOL) are primary goals of treatment in palliative oncology. The present study assessed and compared patient demographics, baseline Karnofsky Performance Status (KPS) and QOL using the QLQ-C15-PAL questionnaire prior to palliative radiotherapy (RT) for bone, brain, or lung disease. Few studies have used this questionnaire, an abbreviated version that was developed by the European Organization for Research and Treatment of Cancer specifically for patients with advanced cancer to decrease the burden of completing the longer, more time-consuming QLQ-C30. METHODS: Patients referred to an outpatient palliative RT clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain, or lung cancer sites. The associations between baseline QLQ-C15-PAL functional/symptom scales, patient demographics, and clinical variables including KPS were explored. RESULTS: When data from all 369 patients were analyzed, higher KPS scores correlated significantly with better overall QOL and higher physical and emotional functioning. The QLQ-C15-PAL provided more detailed information regarding how symptom burden varied depending on disease site. Patients with bone metastases had worse QLQ-C15-PAL scores for pain, while those with brain and lung disease had worse scores for fatigue. Other health-related QOL scores measured by the QLQ-C15-PAL varied as a function of age and gender. CONCLUSION: As the QLQ-C15-PAL provides detailed and often critical information regarding symptom burden, it may eventually be recognized as a universal core questionnaire to assess QOL in this patient population with advanced cancer while relieving the survey burden.

Health Care Professionals' Evaluation of Quality of Life Issues in Patients With Brain Metastases.

BACKGROUND: The Functional Assessment of Cancer Therapy - Brain (FACT-Br) is a brain specific Quality of life (QOL) tool used for patients in the primary and metastatic cancer population. The purpose of this report is to evaluate the QOL issues health care professionals (HCPs) find most important when caring for brain metastases patients. METHODS: HCPs were asked to rate whether each of the 23 FACT-Br subscale items were relevant to patients or not. In the survey, HCPs indicated the 5 to 10 top issues affecting the QOL of patients with brain metastases. Demographic information such as gender, years of experience, and health care specialty were recorded. RESULTS: A total of 46 HCPs participated in the study, 89% of HCPs ranked the need for help in caring for themselves as the most relevant item for patients with brain metastases. Other highly relevant items included the concern of getting headaches (81%) and weakness in arms or legs (78%). The lowest rated items included the ability to put thoughts together (8%), ability to write as they used to (11%) and also the ability to read as they used to (14%). CONCLUSION: It is very important to determine the issues that HCPs think are most important to patients in an attempt to harmonize these with those of patients. Future studies should compare the items that HCPs rate as most relevant to those that patients rate to ensure agreeability.

Patterns of pain and functional improvement in patients with bone metastases after conventional external beam radiotherapy and a telephone validation study.

Patients experiencing lower body pain resulting from bone metastases have greater levels of functional interference than those with upper body pain. The purpose of this study was to assess the levels of interference caused by pain after treatment with conventional radiotherapy using the Brief Pain Inventory (BPI) and to validate this tool for telephone use. After radiotherapy, a total of 159, 129, and 106 patients completed the BPI over the telephone at months 1, 2, and 3, respectively. Cronbach's alpha, confirmatory factor analysis, and discriminant validity tests were performed to assess the validity of the BPI. One-way ANOVA was used to compare BPI scores. There was no statistically significant difference in functional interference among patients after treatment. Internal consistency of the BPI was high. Functional interference may be inherently higher in patients with pain in the lower body. Telephone use of the BPI is reliable and recommended in this population.

Functional Interference due to Pain Following Palliative Radiotherapy for Bone Metastases Among Patients in Their Last Three Months of Life.

BACKGROUND: To compare the self-reported ratings of functional interference caused by pain between patients who did and did not respond to palliative radiotherapy for bone metastases during their last three months of life. METHODS: A prospectively gathered Brief Pain Inventory (BPI) database compiled from patients receiving palliative radiotherapy for painful bone metastases was reviewed. Demographic and clinical data, pain response rates and self-reported ratings of functional interference caused by pain were analyzed for those patients who died within three months of beginning radiotherapy. RESULTS: From 400 patients in the database, 83 died within 3 months of beginning radiotherapy. There were 54 male and 29 female patients. Their median age was 69 years and their median KPS was 70. The three most common primary cancers were lung (40%), gastrointestinal (16%) and breast (14%). For patients with available follow-up information the 1-month overall pain response rate was 78% and the 2-month rate was 83%, which include both complete and partial responses as defined by the International Bone Metastases Consensus. At 1 month, patients responding to treatment reported significantly less interference by pain on their general activity, walking ability, normal work, sleeping, and enjoyment of life than did patients not responding to treatment. CONCLUSIONS: Patients that responded to treatment reported less functional interference due to pain than did patients who did not respond. Despite being very near the end of life, patients responding to palliative radiotherapy for painful bone metastases may benefit from more than pain relief alone.

Quality of Life in Patients Treated with Palliative Radiotherapy for Advanced Lung Cancer and Lung Metastases.

BACKGROUND: The purpose of this study was to investigate quality of life (QOL) in patients receiving palliative radiotherapy (RT) for advanced lung cancer/lung metastases using the EORTC QLQ-LC13 and the EORTC QLQ-C15-PAL questionnaires. METHODS: Patients who received palliative RT for lung metastases or advanced lung cancer between November 2007 and October 2010 completed the EORTC QLQ-LC13 and the QLQ-C15-PAL at baseline prior to RT, 1, 2, 4, 8 and 12 weeks post-treatment. The Wilcoxon Signed Rank test was used to compare QOL scores between baseline and each follow-up period. RESULTS: Thirty-one patients with advanced lung disease were included in this study; 61% of participants were male and 39% were female. The median age was 69 years (range 38 - 85), and median KPS and PPS scores at baseline were both 70 (range 30 - 90). All patients received radiotherapy to the lung. None of the QLQ-LC13 scores significantly improved or deteriorated at any follow-up. Of the QLQ-C15-PAL scales, fatigue, pain, insomnia and physical functioning significantly improved at their respective follow-ups. CONCLUSIONS: This was the first study to use the EORTC QLQ-LC13 in conjunction with the EORTC QLQ-C15-PAL questionnaires. Future studies should continue to incorporate quality of life assessment tools specific to disease characteristics in advanced cancer patients.

Gender Difference in Symptom Presentations Among Patients With Bone Metastases in Gender-Specific and Gender-Neutral Primary Cancers.

BACKGROUND: Studies have assessed gender differences on symptoms commonly experienced by cancer patients at various stages in their disease trajectory using heterogeneous cancer populations with different tumor types. The purpose of our study was to evaluate the effect of gender on symptoms among patients with bone metastases while controlling for gender-specific malignancies. METHODS: A retrospective review of patients receiving palliative radiotherapy for bone metastases was conducted on patients that completed the Brief Pain Inventory (BPI) or Edmonton Symptom Assessment System (ESAS) questionnaires from 1999 - 2004. Baseline and follow-up BPI and ESAS symptom scores were compared between males and females, with and without controlling for gender-specific tumors. RESULTS: A total of 900 patients completed baseline questionnaires: ESAS (n = 508) or BPI (n = 392). The most common tumor types were lung (26%), breast (25%) and prostate (24%). In all ESAS patients, females had significantly greater severity of tiredness, nausea, depression, anxiety and breathlessness. In the subgroup analysis when gender-specific primary cancers were removed (i.e., breast, prostate and gynecological), no significant differences in ESAS symptoms were found between genders. The BPI functional item of walking ability was significantly worse for females in both the overall and subgroup analyses. Females had worse symptoms at follow-up prior to the removal of gender-specific primaries in both ESAS and BPI. CONCLUSIONS: Gender-specific cancers may significantly bias gender studies of cancer-related symptoms when primary tumor type is not taken into account. Gender differences are best assessed in gender-neutral primaries.

What QLQ-C15-PAL Symptoms Matter Most for Overall Quality of Life in Patients With Advanced Cancer?

BACKGROUND: Few studies have evaluated the QLQ-C15-PAL health-related quality of life (QOL) questionnaire, an abbreviated version of the QLQ-C30 questionnaire that was designed specifically for patients with advanced cancer. The present study assessed whether certain symptoms or functional domains from the QLQ-C15-PAL predicted overall QOL when rated prior to palliative radiation treatment (RT). PATIENTS AND METHODS: Patients attending an outpatient palliative radiotherapy clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain or lung disease. Pearson correlations were computed between the QLQ-C15-PAL functional/symptom scores and overall QOL scores. Multiple linear regressions were used to evaluate the relative importance of functional/symptom scales in association with overall QOL. RESULTS: Data from 369 patients were analyzed. The QLQ-C15-PAL domains of physical and emotional functioning, pain, and appetite loss were significant predictors of overall QOL in these patients with advanced cancer. Appetite loss was the only significant independent predictor of overall QOL in the subgroup of patients with advanced lung cancer (n = 29). Both appetite loss and emotional functioning were independently predictive of overall QOL in patients with bone metastases (n = 190). In patients with brain metastases (n = 150), independent predictors of overall QOL included physical and emotional functioning as well as fatigue. CONCLUSION: The QLQ-C15-PAL domains of physical and emotional functioning, pain and appetite loss were significant predictors of overall QOL in this cohort of patients with advanced cancer. Different functional and symptom scales predicted overall QOL in patients with bone metastases, brain metastases or advanced lung cancer.

Poor Accrual in Palliative Research Studies: An Update From the Rapid Response Radiotherapy Program.

BACKGROUND: In June 2003, the Rapid Response Radiotherapy Program (RRRP) implemented changes to recruitment strategies in attempts to increase patient accrual to research studies. Such modifications included the use of a dedicated research assistant to screen for and identify eligible study patients, the introduction of more appropriate inclusion criteria, and the switch towards telephone interviews to minimize patient burden. The purpose of this study is to provide an update on patient accrual in the RRRP. METHODS: All patients seen in the RRRP from January 2002 to December 2009 were recorded in a prospective database. Reasons for referral, eligibility for clinical trials, reasons for non-accrual, and various demographics information were recorded. Descriptive statistics summarized findings. RESULTS: A total of 4726 patient visits were recorded from January 1st, 2002 to December 31st, 2009. Prior to changes, the overall rate of accrual into research studies was 14.9% versus 48.1% after changes were implemented. Patients were not accrued onto studies mainly to due ineligibility according to study protocol. Other reasons such as language barrier (12.1%), physician objection (3.5%), patient declining participation (11.3%) and lack of a research assistant (9.3%) were cited. CONCLUSIONS: Changes in clinical structure and study design can significantly impact accrual patterns in palliative radiotherapy studies. Despite these changes however, the majority of patients are still not enrolled in studies. Therefore additional efforts need to be made to maximize patient accrual and minimize attrition.