Patient engagement in the Continuing Professional Development programs within the department of radiation oncology at the University of Toronto (UTDRO): A qualitative study.

INTRODUCTION: There is little research regarding patient engagement (PE) in Continuing Professional Development (CPD) programs in radiation oncology. This study aims to understand the barriers and enablers to PE in the design and implementation process of CPD programs, and advance PE in these programs moving forward. METHODS: This qualitative study involved 17 semi-structured interviews, with 5 cancer patients and 12 educators, conducted from June 2019 to April 2020. Interview data identified common themes, such as: the current state of PE in CPD programming, and key barriers and recommendations on how to engage patients in meaningful and practical ways. RESULTS: Six themes were identified related to PE: the concept of PE, ethical considerations, barriers, key considerations in planning resources, and the anticipated impact of PE on curriculum planning. CONCLUSION: Both patients and educators emphasized that creating and sustaining meaningful educator-patient relationships and giving patients an active and effective role in CPD planning would improve curriculum content. The University of Toronto Department of Radiation Oncology (UTDRO) should consider building this initiative into its strategic CPD priorities and ensure the appropriate infrastructure is in place.

A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue.

PURPOSE: The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (crf) in adults. METHODS: The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of crf. The search included medline, embase, cinahl, the Cochrane Library, and other guideline and data sources to December 2009. RESULTS: Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process. CONCLUSIONS: Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care.

Patients with advanced cancer: a survey of the understanding of their illness and expectations from palliative radiotherapy for symptomatic metastases.

We conducted a pilot study to examine patients' understanding of their illness and their expectations for palliative radiotherapy for symptomatic metastases. Participants were asked to complete a survey consisting of seven questions prior to the initial consultation. Demographic details and information on extent of disease were collected. Patients were asked to score their symptom distress using the modified Edmonton Symptom Assessment System. Sixty patients participated in the pilot study between January and April 1999. Their median age was 68 years (range 46-90). The most common primary tumours were lung, prostate and breast. Twenty-one patients (35%) believed that their cancer was curable. Twelve (20%) expected that palliative radiotherapy would cure their advanced cancer and 23 (38%) believed that palliative radiotherapy would prolong their lives. Twenty-one patients (35%) had concerns about the effectiveness of radiation therapy and twenty (33%) had concerns about the side-effects of radiotherapy. Fifty-two (87%) were not familiar with the concept of radiation treatment. Forty-seven patients (78%) reported that they were not given information about the radiation treatment; 51 (85%) were not satisfied with the information that their own doctors had provided regarding radiation treatment prior to the consultation at our clinic. A significant proportion of the patients in this pilot study had misconceptions regarding their illness and unrealistic expectations from palliative radiotherapy. We plan to provide educational pamphlets for use in referring doctors' surgeries and clinics in order to inform patients of the nature, rationale and anticipated benefits and side-effects of palliative radiotherapy.

How accurate are physicians' clinical predictions of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients? A systematic review.

The purpose of this review was to examine the accuracy of physicians' clinical predictions of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients. A MEDLINE search for English language articles published between 1966 and March 2000 was performed using the following keywords: forecasting/clinical prediction, prognosis/prognostic factors, survival and neoplasm metastasis. Searches in CancerLit, EMBASE, PubMed, the Cochrane Library and reference sections of articles were performed. Studies were included if they concerned adult patients with various cancer histological diagnoses and employed clinical prediction and the readily available clinical parameters. Biochemical and molecular markers were excluded. Grading of the evidence and recommendations was performed. Twelve articles on clinical prediction and 19 on prognostic factors met the inclusion criteria. Clinical prediction tends to be incorrect in the optimistic direction but improves with repeated measurements. Performance status has been found to be most strongly correlated with the duration of survival, followed by the 'terminal syndrome', which includes anorexia, weight loss and dysphagia. Cognitive failure and confusion have also been associated with a shorter life span. Performance status combined with clinical symptoms and the clinician's estimate helps to guide an accurate prediction, as reviewed in an Italian series. There is fair evidence to support using performance status, and clinical and biochemical parameters, in addition to clinicians' judgement to aid survival prediction. However, there is weak evidence to support that clinicians' estimates alone could be specifically employed for survival prediction.

Use of the CAGE questionnaire for screening problem drinking in an out-patient palliative radiotherapy clinic.

To determine the positive rate of the CAGE questionnaire in an outpatient palliative radiotherapy clinic and to examine the association between problem drinking, pain control, and analgesic consumption, patients referred for palliative radiotherapy were screened with the CAGE questionnaire and asked to rate their symptom distress using the modified Edmonton Symptom Assessment System (ESAS). The latter instrument uses 11-point numeric scales (0 = best, 10 = worst). Their daily analgesic consumption in oral morphine equivalent was recorded. A total of 128 patients participated in the study. Only 9 patients answered one of the four CAGE questions affirmatively (positive group). All the rest answered negatively (negative group). The mean pain intensity at index site/overall pain was 4.97 +/- 3.31/3.27 +/- 2.76 for the negative group and 6.29 +/- 4.42/2.89 +/- 3.37 for the positive group. The mean total daily oral morphine equivalent for the negative and positive group were 112.35 +/- 233.58 mg and 36.82 +/- 58.85 mg, respectively. There was no significant difference found in other symptoms in the modified ESAS between these two groups. The positive rate of the CAGE in patients with advanced cancer attending an out-patient radiotherapy clinic was only 7%, and analyses were limited by the small sample size of those with a positive CAGE. Whether our observed low positive rate of CAGE represents the true prevalence of problem drinking or the CAGE questionnaire is an insensitive tool for screening problem drinking in an outpatient palliative radiotherapy clinic requires further investigation. We did not find a statistically significant worse pain intensity nor higher analgesic consumption in patients who screened positive for CAGE questionnaire.

Correlation of neuropathologic findings and phase-based MRI temperature maps in experimental laser-induced interstitial thermotherapy.

To investigate the correlation between the neuropathologic findings after laser-induced interstitial thermotherapy (LITT) and MRI temperature maps during laser irradiation, a total of six pig brains from cadavers were treated with a Nd:YAG laser (lambda = 1,064 nm, 3.8 W) for 15 minutes. For MRI monitoring, we used a phase-sensitive two-dimensional (2D) fast low-angle shot (FLASH) sequence on a 1.5-T Magnetom SP. Temperature maps were acquired every minute (accuracy, <1.5 degrees C). Histopathologic methods were selected (hematoxylin and eosin stain, Masson's trichrome, Bodian silver impregnation) to demonstrate the zonal architecture of LITT lesions in ex vivo specimens. They showed extensive destruction of the nervous tissue constituents, vascular changes, and lysis of erythrocytes near the track of the laser, a transitional zone, and an 1.5-mm broad margin with edema-like perinuclear vacuolization. No immunoreactivity of glial fibrillary acidic protein (GFAP) could be visualized inside the lesion. In a semiquantitative evaluation, the lesion sizes were measured microscopically (mean diameter = 12.8 mm) and their margins could be defined at temperature zones of 60 to 65 degrees C on the MRI maps.

In vivo MRI thermometry using a phase-sensitive sequence: preliminary experience during MRI-guided laser-induced interstitial thermotherapy of brain tumors.

The purpose of this study was the application of the proton-resonance-frequency method to monitor laser-induced interstitial thermotherapy (LITT) in a patient with an astrocytoma WHO II. A phase-sensitive two-dimensional (2D) fast low-angle shot (FLASH) sequence was used to determine the temperature-related phase shifts during LITT. Temperature maps were displayed during therapy with a temporal resolution of 20 seconds. Irradiation was discontinued as soon as the 60 to 65 degrees C isotherm reached the margin of the tumor. A contrast-enhanced MRI study performed immediately after therapy showed a good correlation of the size of an enhancing rim around the lesion with the 60 to 65 degrees C isotherm. The preliminary results of our study indicate that MRI guidance of LITT may be improved by temperature quantification based on the proton-resonance-frequency method.

Laser-induced thermal lesions in the human brain: short- and long-term appearance on MRI.

PURPOSE: The purpose of our study was to investigate with MRI the development of thermal lesions in the human brain up to almost 4 years after laser-induced interstitial thermotherapy (LITT). METHOD: Eighteen patients with brain tumors who underwent LITT entered the study. RESULTS: In all patients the acute lesion comprised five concentric zones that showed reverse signal intensities on T1- versus T2-weighted images. Lesion development over time was uniform in 89% of the lesions. In two cases variations were observed. CONCLUSION: The results of our MR follow-up studies showed that post-LITT, laser-induced lesions will shrink exponentially after an initial expansion without any pseudocystic effects.

[MR tomographic temperature quantification at 1.5 T in vitro: a comparison of fast T1 maps and a phase-sensitive sequence]. / MR-tomographische Temperaturquantifizierung bei 1.5 T in vitro: Vergleich von schnellen T1-Parameterbildern und einer phasensensitiven Sequenz.

PURPOSE: To determine the value of fast T1-maps and a phase-sensitive sequence for temperature quantification with MR imaging. MATERIAL AND METHODS: The experimental setup allowed both homogeneous heating as well as laser-induced interstitial thermotherapy (Nd:YAG, 1064 nm) of tissue specimens (pig brain, liver and muscle) in vitro. A total of 60 experiments were performed. T1-maps were calculated by means of a multi-point-turbo-FLASH sequence. Additionally, the temperature dependent phase shift was determined with a 2D-FLASH sequence. RESULTS: The T1-relaxation times of four different aqueous solutions of gadolinium-DTPA (0.125-1.0 mmol/l) varied by less than 5%. During homogeneous heating, the T1-maps revealed a linear correlation (r > 0.98) between temperature and T1-relaxation times. The temperature coefficients were 11.0 +/- 0.42 ms/degree C. Variations of the linear correlation were observed during laser irradiation. There was only slight variation of the temperature coefficients of the chemical shift during homogeneous heating of different tissues (brain: 0.0098 +/- 0.0002 ppm/degree C; muscle: 0.0109 +/- 0.0003 ppm/degree C; liver: 0.0093 +/- 0.0002 ppm/degree C). The temperatures calculated during laser therapy based on the phase shift correlated strongly (r = 0.99) to the measured temperatures. CONCLUSION: Due to the considerable tissue independence and high accuracy, the phase mapping method is superior to T1-maps for monitoring thermal therapy modalities at 1.5 T in vitro.

Determination of laser-induced temperature distributions using echo-shifted TurboFLASH.

An echo-shifted TurboFLASH sequence implemented on a clinical whole body MR scanner was used to determine thermal changes in tissue. With this snapshot-like data acquisition, temperature-related phase shifts were measured with a temporal resolution of 1.3 s. For different types of tissue (postmortem porcine brain, liver, and muscle) the temperature coefficients of the proton chemical shift were recorded during uniform heating of the specimen in a water bath. The specific temperature-dependent frequency shifts appeared similar to the proton chemical shift of free water (-0.01 ppm/degrees C). With this method, laser-induced ablation in postmortem porcine brain was monitored by temperature mapping. Comparison of the induced temperature profiles measured with NiCrNi-thermocouples with the MR calculated profiles demonstrated excellent temperature sensitivity and accuracy for this method of MR thermometry, with a maximum deviation of the determined temperatures of only 1.8 degrees C. This investigation was designed as a feasibility study for this rapid version of the phase mapping method, and no in vivo studies were performed.

Preliminary experience with the application of gadolinium-DTPA before MR imaging-guided laser-induced interstitial thermotherapy of brain tumors.

The purpose of this study was to investigate the potential value of i.v. gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA) applied before MRI-guided laser-induced interstitial thermotherapy (LITT) of brain tumors without original enhancement, especially in defining total lesion size during therapy. MRI-guided LITT was performed on two patients with astrocytoma WHO II. For both patients, Gd-DTPA was administered intravenously after a first irradiation period and LITT was continued after pulling back the light guide to coagulate the upper parts of the tumor. In both patients, the whole irreversible damaged zone of the second irradiation period after Gd-DTPA showed an intense increase of signal intensity. The spatial expansion correlated with the diameter of an enhancing rim after Gd-DTPA on follow-up studies. Our preliminary results indicate that the application of Gd-DTPA before MRI-guided LITT may be of value in defining exactly the size of the irreversible damaged zone during therapy in nonenhancing brain tumors.

1H T1 and T2 measurements of the MR imaging contrast agents Gd-DTPA and Gd-DTPA BMA at 1.5T.

We report in vitro T1 and T2 relaxation studies for the open-chain complexes Gd-DTPA and Gd-DTPA BMA. Measurements were performed on phantoms containing aqueous and plasma solutions of different concentrations by MR imaging in a 1.5T superconducting whole-body scanner. Longitudinal relaxation times T1 were evaluated from serial turbo-FLASH experiments for concentrations less than 1 mM, whereas for larger concentrations the values were obtained from a standard inversion recovery (IR) sequence. Transverse relaxation times T2 were determined using multi-echo spin-echo MRI protocols. The T1 and T2 relaxivities of the nonionic Gd-DTPA BMA are similar to those of the Gd-DTPA. The temperature dependencies of the relaxivities were determined over a temperature interval ranging from 21 to 50 degrees C and were found to be slightly different for the two contrast agents. In the case of Gd-DTPA BMA a larger deviation of the expected temperature behavior of the relaxivities was observed as compared with Gd-DTPA. Deviations from a strictly linear dependence of relaxation times on temperature were found at lower concentrations in aqueous solutions. In plasma solutions a high T1/T2 ratio was observed for low concentrations, which decreased monotonically with increasing concentrations.

[Laser-induced interstitial induced hyperthermia of cerebral tumors with nuclear magnetic resonance tomography control]. / Laserinduzierte interstitielle Thermotherapie von zerebralen Tumoren unter kernspintomographischer Kontrolle.

PURPOSE: The purpose of our study was to determine the value of MRI in monitoring laser-induced interstitial thermotherapy (LITT) of cerebral neoplasms. MATERIALS AND METHODS: Sixteen patients with brain tumors were treated with LITT. The laser irradiation was performed within the MR unit and monitored with a temperature-sensitive T1-weighted 2D-FLASH sequence. RESULTS: During irradiation a gradually increasing central zone of high signal intensity was surrounded by an increasing area of reduced signal intensity. After therapy, the diameter of an enhancing rim at the outer border of the peripheral zone indicated total lesion size. On T2-weighted images the signal intensities were reversed. Total lesion size decreased during follow-up. CONCLUSION: MRI is suitable for monitoring LITT. However, the role of LITT in the treatment of brain tumors has still to be defined.

Mapping of the cortical motor hand area with functional MR imaging and MR imaging-guided laser-induced interstitial thermotherapy of brain tumors. Work in progress.

PURPOSE: To localize the cortical motor hand area with functional magnetic resonance (MR) imaging before and after MR imaging--guided laser-induced interstitial thermotherapy of tumors in the precentral brain region to control energy delivery and to improve safety. MATERIALS AND METHODS: Functional MR images were obtained in eight patients (five men, three women; aged 27-63 years) while they flexed their fingers. MR imaging--guided laser-induced interstitial thermotherapy was terminated when there was less than 8-12 mm between the border of the laser-induced lesion and the motor hand area anterior aspect. RESULTS: Seven patients had a statistically significant localized change in signal intensity in the central region of the contralateral hemisphere. This area was a spotlike circumscribed focus in three patients and scattered over a larger zone in four patients. Persistent deficits did not occur after thermotherapy in any patient. In three patients, onset of reversible perifocal edema in the motor hand area coincided with the development of hemiparesis, which completely resolved. No patient had activity within the tumor on functional MR images. CONCLUSION: Functional MR imaging findings can be used to prevent neurologic damage during MR imaging--guided laser-induced interstitial thermotherapy.