Like Frying Multiple Eggs in One Pan: a Qualitative Study Exploring the Understanding of Inter-speciality Training in Cancer Care.

H igh-quality cancer care is a key priority worldwide. Caring for people affected by cancer requires a range of specific knowledge, skills and experience to deliver the complex care regimens both within the hospital and within the community environment. In June 2022, the European Cancer Organisation along with 33 European cancer societies began working together to develop a curriculum for inter-speciality training for healthcare professionals across Europe. As part of the project, this research consisted of a qualitative survey distributed to the European Union societies via email. The aim of this paper is to disseminate the qualitative findings from healthcare professionals across Europe. Questionnaires were sent out to a convenience sample of 219 healthcare professionals and patient advocates with a response rate of 55% (n = 115). The findings identified that there were four key themes: 'What is inter-speciality training?', 'Barriers and challenges', 'Support throughout the cancer journey' and 'New ways of working'. These results are part of a larger needs analysis and scoping review to inform the development of a core competency framework which will be part of an inter-speciality curriculum for specialist cancer doctors, nurses and other healthcare professionals across Europe. Healthcare professionals will be able to access education and training through the virtual learning environment and workshops and by clinical rotations to other specialties.

Characterization of male breast cancer: results of the EORTC 10085/TBCRC/BIG/NABCG International Male Breast Cancer Program.

Background: Male breast cancer (BC) is rare, managed by extrapolation from female BC. The International Male BC Program aims to better characterize and manage this disease. We report the results of part I, a retrospective joint analysis of cases diagnosed during a 20-year period. Methods: Patients with follow-up and tumor samples, treated between 1990 and 2010, in 93 centers/9 countries. Samples were centrally analyzed in three laboratories (the United Kingdom, the Netherlands and the United States). Results: Of 1822 patients enrolled, 1483 were analyzed; 63.5% were diagnosed between 2001 and 2010, 57 (5.1%) had metastatic disease (M1). Median age at diagnosis: 68.4 years. Of 1054 M0 cases, 56.2% were node-negative (N0) and 48.5% had T1 tumors; 4% had breast conserving surgery (BCS), 18% sentinel lymph-node biopsy; half received adjuvant radiotherapy; 29.8% (neo)adjuvant chemotherapy and 76.8% adjuvant endocrine therapy (ET), mostly tamoxifen (88.4%). Per central pathology, for M0 tumors: 84.8% ductal invasive carcinomas, 51.5% grade 2; 99.3% estrogen receptor (ER)-positive; 81.9% progesterone receptor (PR)-positive; 96.9% androgen receptor (AR)-positive [ER, PR or AR Allred score ≥3]; 61.1% Ki67 expression low (<14% positive cells); using immunohistochemistry (IHC) surrogates, 41.9% were Luminal-A-like, 48.6% Luminal-B-like/HER-2-negative, 8.7% HER-2-positive, 0.3% triple negative. Median follow-up: 8.2 years (0.0-23.8) for all, 7.2 years (0.0-23.2), for M0, 2.6 years (0.0-12.7) for M1 patients. A significant improvement over time was observed in age-corrected BC mortality. BC-specific-mortality was higher for men younger than 50 years. Better overall (OS) and recurrence-free survival (RFS) were observed for highly ER+ (P = 0.001), highly PR+ (P = 0.002), highly AR+ disease (P = 0.019). There was no association between OS/RFS and HER-2 status, Ki67, IHC subtypes nor grade. Conclusions: Male BC is usually ER, PR and AR-positive, Luminal B-like/HER2-negative. Of note, 56% patients had T1 tumors but only 4% had BCS. ER was highly positive in >90% of cases but only 77% received adjuvant ET. ER, PR and AR were associated with OS and RFS, whereas grade, Ki67 and IHC surrogates were not. Significant improvement in survival over time was observed.

A randomised trial of secondary prophylaxis using granulocyte colony-stimulating factor ('SPROG' trial) for maintaining dose intensity of standard adjuvant chemotherapy for breast cancer by the Anglo-Celtic Cooperative Group and NCRN.

BACKGROUND: Guidelines on the use of haematopoietic colony-stimulating factors for patients having adjuvant chemotherapy for breast cancer are designed to minimise the risk of neutropaenic infection (Smith TJ, Khatcheressian J, Lyman GH et al. Update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol 2006; 3: 187-205; Aapro MS, Bohlius J, Cameron DA et al. Effect of primary prophylactic G-CSF use on systemic therapy administration for elderly breast cancer patients. Breast Cancer Res Treat 2011; 47: 8-32; Carlson RW, Allred DC, Anderson BO et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2009; 7: 122-192). Non-randomised data suggest that the achievement of planned dose intensity (DI) may have an important effect on survival. This trial compared the effects of granulocyte colony-stimulating factor, GCSF, against standard management following a first neutropaenic event (NE) in achieving planned DI. PATIENTS AND METHODS: Adult patients receiving adjuvant or neoadjuvant chemotherapy were randomised following a first NE, defined as hospitalisation due to neutropaenic fever, an absolute neutrophil count (ANC) ≤1.5 × 10(9)/l requiring treatment delay or dose reduction of 15% or more of planned dose. The study was initially planned to enrol 816 patients to detect a difference of 10%. This was difficult to achieve in the timeframe and the trial size was amended. Thus, 407 patients were randomly assigned to filgrastim for 7 days or pegfilgrastim versus standard care. The amended study was designed to have 80% power to detect an absolute difference of 14% of planned DI between the two groups. RESULTS: Most regimens were anthracycline-based many of which included a sequential taxane and/or were in clinical trials. Around 82.7% had an NE in the first three cycles. A total of 401 had calculable relative dose intensity (RDI) data. A target of 85% planned RDI was achieved in only 50% of patients in the control arm compared with 75% in the GCSF arm (P < 0.0001). A secondary end point revealed a reduction in post-randomisation NEs, 65.7% controls versus 18.2% with GCSF. CONCLUSIONS: Secondary intervention with GCSF showed a statistically significant improvement in the achievement of adequate RDI in non-intensive regimens. This may have important clinical implications for outcome.

The Minimum Competences in Non-surgical Oncology that Medical Students Need to Acquire in Order to be Safe Foundation Year 1 (F1) Doctors: A Delphi Survey.

AIMS: To develop a consensus on the minimum competences in non-surgical oncology that medical students need to acquire in order to be safe Foundation Year 1 (F1) doctors. MATERIALS AND METHODS: A two-round Delphi survey was conducted by e-mail with an expert panel of 24 consultant oncologists who had expressed an interest in undergraduate education. RESULTS: The response rate to round 1, which asked panellists to list the competences they thought were important, was 50%. The competences they generated contained 86 different concepts. These were categorised according to the learning outcomes in Tomorrow's Doctors. The panellists were then asked to rate the importance of each proposed competence between 1 and 9 on a Likert scale to give a measure of the perceived importance and consensus. The panellists generated competences in all the main categories of learning outcomes in Tomorrow's Doctors. The scores were highest and the consensus greatest for those competences related to the doctor as a practitioner and the doctor as a professional. CONCLUSION: The Delphi survey was an effective method of obtaining the judgement of an expert panel and in measuring the degree of consensus. The results of the survey were valuable in informing the design of a UK non-surgical oncology curriculum.

Training in clinical oncology: results of the Royal College of Radiologists' survey of new consultants.

AIMS: To seek the views of consultants appointed less than 2 years ago on the appropriateness of their training in fitting them to carry out their present posts, the FRCR examination, experience of research and the prevalence and value of out of programme experience and acting up as a consultant. MATERIALS AND METHODS: All the consultants identified from the Royal College of Radiologists' database as having been appointed to a consultant post in the last 2 years were emailed inviting them to take part in a web-based survey. RESULTS: The response rate was 60% (32 of 53 consultants). Ninety-four per cent agreed or strongly agreed that training had equipped them for clinical work as a consultant, but only 44% agreed or strongly agreed that training had equipped them to fulfil the management roles. Free text answers stressed the importance of management skills, getting involved with trial set-up and producing publications early in their career. Ninety-four per cent agreed or strongly agreed that they had adequate opportunity to develop skills in systemic therapy and radiotherapy planning, but only 56% thought this was the case for intensity-modulated radiotherapy and image-guided radiotherapy. Although 87% agreed or strongly agreed they had sufficient opportunity to develop teaching skills, this was only the case in 62% with regard to research skills. They published a median number of three papers in peer-reviewed journals. Twenty-five per cent of respondents studied for research degrees; 69% of consultants had undertaken out of programme experience and 50% had acted up as a consultant and these were generally found to be valuable experiences. There was strong support for the FRCR examination. CONCLUSIONS: Consultants appointed in the last 2 years are generally satisfied with their training. Training in intensity-modulated radiotherapy and image-guided radiotherapy should be improved and the advanced specialist training requires reviewing to better fit consultants for subspecialisation, management and research.

What is valuable for specialist registrars to learn in order to become good consultant clinical oncologists?

AIMS: Given the pressures for change in training, it is important that what is valuable for specialist registrars to learn in order to become good consultant clinical oncologists is identified to aid in curricular design. MATERIALS AND METHODS: A qualitative, one-to-one, semi-structured interview study was undertaken with 12 clinical oncologists who had been appointed as consultants within the last 2 years. RESULTS: They described the 'shock' on realising that they had entered foreign territory. The three main themes that emerged were surviving, navigating and moving forward. CONCLUSIONS: It was not enough to be a competent clinician. The newly appointed consultant could only carry out their clinical work adequately and develop as clinicians, researchers and educators if they could navigate the maze of emotions, relationships and management structures contained in the clinical and organisational contexts of their work.

'Losing my touch': decline in self-reported confidence in performing practical procedures in consultant oncologists.

This study aimed to compare the confidence of oncology consultants and specialist registrars (SpRs) in the performance of practical procedures, to contrast this with confidence in other areas of practice and to determine at what grade they felt most confident. Questionnaires were sent to all 57 oncology consultants and SpRs in the South-West region. Respondents scored confidence on a five-point Likert scale. The response rate was 70%. SpRs were significantly more confident in cardiopulmonary resuscitation (p = 0.003) and central line insertion (p = 0.006). Consultants were significantly more confident in developing management plans (p = 0.001) and performing committee work (p = 0.002). Only 6% of consultants felt most confident performing practical procedures as a consultant, and were less confident about these than other tasks (p = 0.001). Some 86% of SpRs considered they were more confident performing practical procedures as senior house officers (SHOs). In conclusion, self-reported confidence in performing practical procedures declines during career progression in oncology. This raises questions about the teaching and supervision of these procedures. If there is a greater emphasis on a consultant-provided service, their educational needs will need to be recognized and retraining or outsourcing of these procedures to other specialties may be necessary.

The effect of combined modality treatment with ionising radiation and TPPS-mediated photodynamic therapy on murine tail skin.

The effect on normal skin of combined modality treatment with 300 kV X-rays and photodynamic therapy (PDT) using the photosensitising drug meso-tetra (sulphonatophenyl) porphine (TPPS) was studied using the mouse tail necrosis assay. Prior treatment with a tolerance dose of PDT produced a significant increase in the probability of necrosis following graded doses of ionising radiation. A tolerance dose of X-rays administered prior to graded doses of PDT also produced a significant rise in the necrosis rate. TPPS appeared to have a radiosensitising effect but, as the animals were kept in subdued light, the low dose of PDT they therefore received may provide an alternative explanation. The effect of prolonging the interval between the modalities on the necrosis rate did not appear to be related to the time course of either the changes in blood flow produced by each modality, measured by xenon clearance studies or the development of the skin reaction following X-ray irradiation.

Quantitative histological changes in murine tail skin following photodynamic therapy.

Mice were treated by an intravenous injection of 2 mg of the photosensitising drug meso-tetra (sulphonatophenyl) porphine (TPPS) and 24 h later a 2.5 cm length of their tails was exposed to visible light (photodynamic therapy, PDT). Using cross-sections from the centre of the treatment field, the absolute areas occupied by epidermis, dermis, hypodermis, tendon and bone, and also the total number and area of the blood vessels in the dermis and hypodermis, were compared between control and PDT-treated animals. There was a significant increase in the mean cross-sectional area of the epidermis, dermis and hypodermis following both 90J cm-2 (a dose expected to produce a low incidence of tail necrosis) and 180J cm-2 (expected to produce a 100% tail necrosis rate), on day 1 and day 5 following light exposure. The cross-sectional area of the vascular compartment was also significantly increased by day 5 at both dose levels. Differences were observed between the two doses when the total number of blood vessels were compared. There was a significant increase in the number of blood vessels by day 5 following 90 J cm-2 in both the dermis and hypodermis, but not following 180J cm-2. This appeared to be due to a significant increase in blood vessels with a cross-sectional area of less than 100 microns2 by day 5 at the lower dose. It is concluded that angiogenesis plays an important role in vascular recovery following PDT.

The effect of fractionation of light treatment on necrosis and vascular function of normal skin following photodynamic therapy.

Sparing of normal tissue, mouse tail skin, by fractionation of light treatment in photodynamic therapy has been demonstrated in BDF1 mice injected with 2 mg tetrasodium-meso-tetra(4-sulphophenyl)porphine dodecahydrate i.v. When the time between 2 fractions of 67.5 J cm-2 and 90 J cm-2 was increased to 2 and 4 days respectively the incidence of necrosis fell to that expected after a single fraction. Blood flow in the tail skin 5 days after the second light fraction, as measured by the clearance of an intradermally injected solution of 133xenon in 0.9% saline, returned to control values when the time between 2 fractions was 2 days with 67.5 J cm-2 fractions, and 3 days with 90 J cm-2 fractions. The time course of recovery of normal mouse tail skin from photodynamic therapy, as shown by these split dose experiments, was found to be similar to the time course for the recovery of blood flow following a single light treatment.

Vascular function and the probability of skin necrosis after photodynamic therapy: an experimental study.

The clearance of an intradermally-injected solution of 133Xenon in 0.9% saline has been used to study the impairment and recovery of blood flow in mouse tail for 5 days following photodynamic therapy (PDT) with 2mg TPPS i.v. per mouse and a range of doses of white light. Impairment of blood flow was observed within 10 min of light exposure. Blood flow increased between day 1 and day 5 at light doses less than 151J cm-2 and had returned to control levels by day 5 at light doses less than 129J cm-2. In mice treated with a light dose that caused a 50% incidence of necrosis, there was no significant difference in the initial xenon clearance half-time (measured at 10 min and 1 day after PDT) between those mice which developed tail necrosis and those which healed. However, the latter showed significantly greater improvement in vascular function on days 2, 3 and 4. This suggests that the timing and extent of recovery of blood flow determined the risk of necrosis in individual mice.

Stage III carcinoma of cervix. The importance of increasing age and extent of parametrial infiltration.

The relative importance of a number of potential prognostic factors was analysed for a sequential group of 296 patients with stage III carcinoma of the cervix who had been treated in a mature prospective clinical trial. Using a log-rank analysis of survival curves generated by the life-table method increasing age (p = 0.05) and extent of parametrial infiltration (p = 0.001) were found to be significantly related to prognosis. These two factors were further demonstrated to be independent variables and, of the two, parametrial extension (p = 0.002) was more significant than increased age (p = 0.035). Involvement of the lower third of the vagina, the presence of bullous oedema and the histological differentiation of the disease were not prognostically significant in this study. It is suggested that tumour volume as defined by extent of parametrial infiltration is a sufficiently good prognostic factor to be incorporated into a revised staging system.