Establishing the sensitivity and specificity of the gynaecological cancer distress screen.

OBJECTIVE: Nuanced distress screening tools can help cancer care services manage specific cancer groups' concerns more efficiently. This study examines the sensitivity and specificity of a tool specifically for women with gynaecological cancers (called the Gynaecological Cancer Distress Screen or DT-Gyn). METHODS: This paper presents cross-sectional data from individuals recently treated for gynaecological cancer recruited through Australian cancer care services, partner organisations, and support/advocacy services. Receiver operating characteristics analyses were used to evaluate the diagnostic accuracy of the DT-Gyn against criterion measures for anxiety (GAD-7), depression (patient health questionnaire), and distress (IES-R and K10). RESULTS: Overall, 373 individuals aged 19-91 provided complete data for the study. Using the recognised distress thermometer (DT) cut-off of 4, 47% of participants were classified as distressed, while a cut-off of 5 suggested that 40% had clinically relevant distress. The DT-Gyn showed good discriminant ability across all measures (IES-R: area under the curve (AUC) = 0.86, 95% CI = 0.82-0.90; GAD-7: AUC = 0.89, 95% CI = 0.85-0.93; K10: AUC = 0.88, 95% CI = 0.85-0.92; PHQ-9: AUC = 0.85, 95% CI = 0.81-0.89) and the Youden Index suggested an optimum DT cut-point of 5. CONCLUSIONS: This study established the psychometric properties of the DT-Gyn, a tool designed to identify and manage the common sources of distress in women with gynaecological cancers. We suggest a DT cut point ≥5 is optimal in detecting 'clinically relevant' distress, anxiety, and depression in this population.

Evaluation of a new emergency department avoidance model of care, the Cancer Urgent Assessment Clinic, in response to the COVID-19 pandemic.

Introduction: The Cancer Urgent Assessment Clinic (CUAC) was an emergency department (ED) avoidance/unscheduled model of care implemented in response to the COVID-19 pandemic. The aim was to reduce the risk of COVID-19 exposure and infection by providing an alternative to ED for cancer patients while undergoing anticancer treatments. Methods: The clinic incorporated a telephone triage process and face-to-face appointments 8am to 8pm, 7 days per week. CUAC operated between 23 March '20 and 31 July '20, led by a nurse practitioner candidate, oncology registrars, cancer nurse specialists, and overseen by oncology consultants. Evaluation followed a mixed-methods approach through (1) analysis of CUAC patient data, (2) comparison of ED cancer patient presentation data from a previous period (23 March 2019-31 July 2019), and (3) a patient survey. Results: In total, 400 patients were telephone triaged via CUAC, with 166 recorded as having avoided ED. There was a reduction in the number of cancer patient admissions to the ED short stay unit during the clinic period compared with the same time-period in 2019: 130 vs. 234, associated with 615 fewer hours. Patient satisfaction was positive particularly regarding ease of access, time to treatment, confidence in assessment and treatment of cancer-related concerns, and likelihood of presenting to hospital when unwell during the pandemic. Discussion: While initially being implemented to reduce the risk of COVID-19 exposure, this evaluation demonstrated the CUAC model was an efficient and potentially cost-saving model of care for the management of cancer patients with mild to moderate severity of disease and treatment-related concerns.

Screening for distress in women with gynaecological cancer: Adaptation of the distress thermometer for gynaecological oncology patients.

OBJECTIVE: Generic distress screening tools may not recognise the unique concerns reported in some cancer populations. The face and content validity of a screening tool derived from the National Cancer Comprehensive Network distress thermometer and problem list and adapted specifically for women with gynaecological cancer is presented. METHODS: Building on existing work, panels of clinicians and researchers, and focus groups with women treated for gynaecological cancer, developed a nuanced distress screening tool. RESULTS: The clinical reference group used an iterative process to reduce 54 items to 22 across four domains (practical/family/psychological/physical). These items were included in the draft tool, which was reviewed by two focus groups of long-term cancer survivors. Participants unanimously thought the tool was necessary though several changes were recommended. The final draft tool contained a global distress score and 25 items across the four domains. CONCLUSIONS: This measure provides a structured screening tool tailored to the concerns of women with gynaecological cancer, enhancing communication between clinicians and their patients about potentially identified and unrecognised sources of distress. Future research will focus on establishing sensitivity and specificity of this tool and further assessing its utility in clinical settings for all gynaecological cancers (including rare cancers like vulvar cancer).

Safety and efficacy of telephone clinics during the COVID-19 pandemic in the provision of care for patients with cancer.

BACKGROUND: Due to the COVID-19 pandemic, telephone clinics have been utilised to reduce the risk of transmission. Evidence supporting its quality and safety is required. AIMS: Assess the efficacy and safety of telephone clinics in delivering care to established oncology patients and assess patient and health professionals' preference (telephone vs face-to-face clinics). METHODS: Retrospective chart audit in the month preceding and month following the introduction of telephone clinics at the Gold Coast University Hospital and a patient and health professional questionnaire. RESULTS: In total, 1212 clinical encounters occurred in the month post the introduction of telephone clinics (vs 1208 encounters prior). There were no statistically significant differences in 24-h (18 vs 22, P = 0.531) or 7-day admissions (50 vs 46, P = 0.665) comparing encounters in the month prior to the introduction of telephone clinics versus the month post, but there was a statistically significant difference in 30-day mortality post systemic therapy in favour of the post-telephone clinic period (7 vs 0 patients, P = 0.008). Of the 222 patients who undertook the questionnaire, 42.3% preferred telephone clinics (95% confidence interval (CI) 35.97-48.97), 25.2% preferred face-to-face clinics (95% CI 19.92-31.39) and 32.4% did not prefer one method over another. Of the 24 health professionals who undertook the questionnaire, 70.8% felt patients preferred phone clinics. CONCLUSIONS: Generally, patients and clinicians viewed telephone clinics favourably. Nevertheless, a large portion of patients still prefer face-to-face clinics. Services should be tailored to individual preferences. Although there were no 'red flags' in terms of mortality or admission rates, further longitudinal research is required.

Unmet needs in breast cancer survivors are common, and multidisciplinary care is underutilised: the Survivorship Needs Assessment Project.

PURPOSE: The transition from a breast cancer patient to a survivor can be associated with significant physical, psychological, and social challenges. Development of multidisciplinary evidence-based care during the post-treatment period is a key area of cancer research. This study examined survivorship issues, unmet needs and perceptions about care among a cohort of breast cancer survivors. METHODS: Participants were 130 women diagnosed with breast cancer for at least one year, and attending a hospital breast or oncology outpatient clinic. They completed a series of self-report questionnaires assessing demographic and clinical characteristics, unmet needs, severity of survivorship issues, use of multidisciplinary services, clinical benchmarks, survivorship care satisfaction, and suggestions for service improvements. RESULTS: There was an average of 4.9 unmet survivorship needs, with 67% of participants reporting at least one unmet need. Fear of cancer recurrence, stress, coordination of medical care and negative iatrogenic impacts of hormonal treatments were key concerns. The cancer support team typically consisted of medical and nursing staff, and family/friends, and most were satisfied with their survivorship care. There was minimal use of other multidisciplinary clinicians and support groups. Provision of additional dietary and cancer recurrence education, and a written treatment plan were identified as key areas of service improvement. CONCLUSION: Despite high satisfaction ratings, survivorship issues and unmet needs were relatively common, particularly among younger participants. Use of multidisciplinary care was inconsistent and overall underutilised. IMPLICATIONS FOR CANCER SURVIVORS: Ongoing specific evaluation and optimisation of existing models of multidisciplinary survivorship care are essential in meeting the complex needs of breast cancer survivors.

End-user perceptions of a patient- and family-centred intervention to improve nutrition intake among oncology patients: a descriptive qualitative analysis.

BACKGROUND: People with cancer are at high risk of malnutrition. Nutrition education is an effective strategy to improve patient outcomes, however, little is known regarding the impact of family and/or carer involvement in nutrition education and requires investigation. The purpose of the study was to evaluate PIcNIC (Partnering with families to promote nutrition in cancer care) intervention acceptability from the perspective of patients, families and health care providers. METHODS: A descriptive qualitative study was undertaken at an inpatient and an outpatient hospital setting in Australia and an outpatient/home setting in Hong Kong. A patient-and-family centred intervention including nutrition education, goals setting/nutrition plans, and food diaries, was delivered to patients and/or families in the inpatient, outpatient or home setting. Semi-structured interviews were used to explore perceptions of the intervention. 64 participants were interviewed; 20 patients, 15 family members, and 29 health care professionals. Data were analysed using deductive and inductive content analysis. RESULTS: Two categories were identified; 1) 'context and intervention acceptability'; and 2) 'benefits of patient- and family-centred nutrition care'. Within each category redundant concepts were identified. For category 1 the redundant concepts were: the intervention works in outpatient settings, the food diary is easy but needs to be tailored, the information booklet is a good resource, and the intervention should be delivered by a dietitian, but could be delivered by a nurse. The redundant concepts for category 2 were: a personalised nutrition plan is required, patient and family involvement in the intervention is valued and the intervention has benefits for patients and families. Converging and diverging perceptions across participant groups and settings were identified. CONCLUSIONS: In this paper we have described an acceptable patient- and family-centred nutrition intervention, which may be effective in increasing patient and family engagement in nutrition care and may result in improved nutrition intakes. Our study highlights important contextual considerations for nutrition education; the outpatient and home setting are optimal for engaging patients and families in learning opportunities.

Adaptations to cognitive problems reported by breast cancer survivors seeking cognitive rehabilitation: A qualitative study.

OBJECTIVE: Qualitative studies have elucidated cancer survivors' experiences of cognitive changes associated with cancer and cancer treatment. This study specifically explored experiences of women treated for breast cancer who were seeking cognitive rehabilitation. The objective was to characterise the frequency and nature of cognitive changes and adaptations to cognitive change reported by these participants to better understand treatment needs of this group. METHOD: Australian women who had completed primary treatments for breast cancer (surgery, chemotherapy, and/or radiotherapy) and volunteered to participate in one of two cognitive rehabilitation intervention studies were interviewed via telephone. Interview responses regarding cognitive changes and adaptations to cognitive change were transcribed by the interviewers, then coded and analysed by two researchers using content analysis. RESULTS: Among the 95 participants (age M=54.3 years, SD=9.6), the most commonly reported cognitive change was memory (79% of participants) and 61% reported more than one type of cognitive change. Adaptations to change were reported by 87% of participants, with written or electronic cues the most common (51%). Most often, participants reported using a single type of adaptation (48%) with only 39% reporting multiple types of adaptations. CONCLUSIONS: Women treated for breast cancer, who were seeking cognitive rehabilitation, most commonly reported memory changes, which were mainly managed through a single type of adaptation. These results suggest that there is considerable scope for increasing the range of cognitive adaptations to improve the quality of life of cancer survivors who experience adverse cognitive changes.

Maintaining Dose Intensity of Adjuvant Chemotherapy in Older Patients With Breast Cancer.

INTRODUCTION: Maintaining the relative dose intensity (RDI) of adjuvant chemotherapy at ≥ 85% has been associated with improved treatment outcomes in early-stage breast cancer (ESBC). Increasing evidence has suggested that patients aged ≥ 65 years can maintain the optimal RDI for standard chemotherapy regimens. The present study investigated the RDI of newer adjuvant chemotherapy regimens in this demographic. PATIENTS AND METHODS: We retrospectively analyzed the data from 281 patients aged ≥ 65 years with a diagnosis of ESBC who had received adjuvant chemotherapy across 3 sites in Queensland, Australia from 2010 to 2015. The primary endpoint was the proportion of patients who had received an RDI of ≥ 85%. RESULTS: The median age at diagnosis was 68 years (range, 65-85 years), with 36.3% aged > 70 years. The patient characteristics included tumor stage T3 or T4 in 17% and node-positive disease in 60%. The common chemotherapy regimens included docetaxel/cyclophosphamide (23%), 5-fluorouracil/epirubicin/cyclophosphamide plus docetaxel or paclitaxel (17%); Adriamycin/cyclophosphamide/weekly paclitaxel (38%); and docetaxel/carboplatin/trastuzumab (11%). Primary (15%) and secondary (54%) granulocyte colony-stimulating factor (G-CSF) was used. An RDI of ≥ 85% was achieved in 63% of the patients. Significant associations were noted between a reduced RDI and age ≥ 70 years (P < .001), Charlson comorbidity index ≥ 1 (P = .043), initial dose reductions (P = .01), secondary G-CSF use (P = .45), hospital admission (P < .001), and febrile neutropenia (P = .007). Treatment-related toxicities were the most common reason for noncompletion, with high rates of hospital admissions (46%) and febrile neutropenia (22%). CONCLUSION: Our findings suggest that patients aged ≥ 65 years with ESBC can maintain an optimal RDI with modern chemotherapy regimens. Appropriate geriatric assessment and the use of supportive measures such as G-CSF could better assist select groups to maintain an optimal dose intensity.

Partnering with families to promote nutrition in cancer care: feasibility and acceptability of the PIcNIC intervention.

BACKGROUND: Malnutrition is frequent in patients with cancer, particularly those in advanced stages of the disease. The aim of the present study was to test the feasibility of a family-centred nutritional intervention, based on the Family Systems theory and past research. METHODS: This was a single-arm trial assessing feasibility (eligibility, recruitment and retention rates); acceptability by patients, family caregivers and health professionals; intervention fidelity, and energy/protein intake (in one site only). Two sites were involved; one each in Australia (AUS) and Hong Kong (HK), with one site delivering the intervention to oncology patients receiving curative treatments in the hospital, and the other to advanced cancer patients in the home. RESULTS: The sample included 53 patients (23 from AUS and 30 from HK), 22 caregivers (3 from AUS and 19 from HK) and 30 health professionals (20 from AUS and 10 from HK). Recruitment was difficult in the acute inpatient oncology care setting (AUS) and feasibility criteria were not met. Sufficient recruitment took place in the home care setting with advanced cancer patients in HK. Patients, family members and health professionals found the intervention helpful and acceptable, and patients and families indicated they would take part in the future in a similar study. Energy and protein intake improved from baseline to end of intervention (mean 22 kcal/kg/day to 26 and 0.9 g/kg/day to 1.0 respectively). CONCLUSION: The new intervention is feasible in a home setting when delivered to patients with advanced cancer, acceptable to patients and families, and has the potential to improve nutritional status in patients. A large randomised trial is warranted in the future.

Heterogeneity of breast cancer clinical characteristics and outcome in US black women--effect of place of birth.

Breast cancer mortality in black women is disproportionately high; reasons for this phenomenon are still unclear. In addition to socioeconomic factors, the biology of the tumor may play a role. We analyzed 1,097 incident invasive breast cancer cases diagnosed between 2000 and 2010 in black US women from Long Island and Brooklyn. Thirty-five percent of women had an estrogen receptor (ER) negative tumor, 46% a progesterone receptor (PR) negative tumor. ER, PR negative tumors were diagnosed at an earlier age (55.8 versus 55.3 years), at a later stage (p = 0.06), were larger in size (p = 0.04), and more frequently treated with neo-adjuvant chemotherapy (p = 0.06) than ER, PR positive tumors. Determinants of shorter survival were: ER, PR negativity (HR: 2.2, 95% CI: 1.4-3.4), age, and stage at diagnosis (HR: 2.0; 95% CI: 1.5-2.7). ER, PR negative breast cancer born outside of the US experienced a significantly worse survival than ER, PR negative women who were born in the US. ER, PR negative tumors in black women born outside the US, mainly in the Caribbean, are biologically more aggressive than the same size and age-matched tumors in black women born in the US. Our study suggests that environmental exposures in the country of origin may impact on host cancer interactions and cancer outcome.

A critical analysis of prognostic factors in North American patients with human T-cell lymphotropic virus type-1-associated adult T-cell leukemia/lymphoma: a multicenter clinicopathologic experience and new prognostic score.

BACKGROUND: To define the clinicopathologic and prognostic features of patients with human T-cell lymphotropic virus type-1 (HTLV-1)-associated adult T-cell leukemia/lymphoma (ATLL) in North America, standard criteria were used to identify patients with ATLL. METHODS: Statistical analyses used included descriptive statistics, Kaplan-Meir survival analysis, and recursive partitioning. RESULTS: Eighty-nine patients were identified between August 1992 and May 2007, including 37 (41.6%) males and 52 (58.4%) females with a median age of 50 years (range, 22-82 years). All but 6 patients had immigrated to the United States from the Caribbean, Latin America, or Africa. The acute subtype predominated (68.5%). The majority of patients received a combination-alkylator-based chemotherapy regimen in the front-line setting (72.6%). The most common regimen was cyclophosphamide, doxorubicin, vincristine, and prednisone at standard doses or attenuated and/or with methotrexate (CHOP-like), which produced an overall response rate of 64.1%. Despite initial responses to therapy, the median overall survival for all subtypes was 24 weeks (range, 0.9-315 weeks). Although the International Prognostic Index and Prognostic Index for peripheral T-cell lymphoma unspecified identified subsets of patients, these models were not completely predictive. A recursive partitioning analysis was performed on the data, which successfully identified 3 prognostic categories based on Eastern Cooperative Oncology Group performance status, stage, age, and calcium level at diagnosis. CONCLUSIONS: This series proposed a new prognostic model for patients with HTLV-1-associated ATLL and confirmed a poor outcome for these patients in North America.

Small cell carcinoma of the breast.

We report the case of an 81-year-old woman with limited-stage small cell carcinoma of the left breast who presented with multiple painful nodules in the left breast. The patient was treated with systemic chemotherapy and consolidation radiation therapy without undergoing surgery. To our knowledge, this is the first report in the literature of small cell carcinoma of the breast managed definitively with chemotherapy and local-regional irradiation for which the details of treatment are explicitly described.

Treatment of AIDS-associated anaplastic large-cell lymphoma with dose-adjusted EPOCH chemotherapy.

Anaplastic large-cell lymphoma (ALCL) has rarely been described in patients with acquired immunodeficiency syndrome (AIDS). Reports of treatment of ALCL in the setting of AIDS are rare as well. Dose-adjusted EPOCH (DA-EPOCH; etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin) has been shown to be well tolerated and effective in the treatment of AIDS-related aggressive B-cell lymphomas. Treatment of AIDS-associated ALCL with DA-EPOCH has not been reported. This report describes two patients with AIDS-associated ALCL treated with DA-EPOCH chemotherapy. Both patients presented with advanced disease. Excellent clinical response was observed in both patients. The first patient completed six cycles of chemotherapy and remains in complete remission at 12 months of follow up. The second patient has received 2 cycles of chemotherapy thus far. She had an excellent response with rapid improvement of cutaneous disease and lymphadenopathy starting three days after the first cycle. Repeat imaging after two cycles of chemotherapy showed marked radiologic improvement as well. Chemotherapy was well tolerated by both patients. Our experience suggests that DA-EPOCH is an effective treatment for AIDS-associated ALCL.

Thrombotic thrombocytopenic purpura in a patient with acquired immunodeficiency syndrome at 28 weeks gestation.

An increased incidence of thrombotic thrombocytopenic purpura has been reported among human immunodeficiency virus-infected patients or those with acquired immunodeficiency syndrome (AIDS). Despite this association, hitherto only a single case of thrombotic thrombocytopenic purpura has been reported in an HIV-infected patient during pregnancy. We describe a young multiparous patient with long-standing AIDS who presented with lower abdominal pain. Following findings of thrombocytopenia, microangiopathic hemolytic anemia, renal failure, low-grade fever, and mental status changes, thrombotic thrombocytopenic purpura was diagnosed after initially considering the diagnosis of severe preeclampsia, and the patient was delivered by cesarean section. The patient required multiple plasma exchanges during a protracted postpartum course, and was discharged in good health. This first report of thrombotic thrombocytopenic purpura and AIDS in pregnancy demonstrates that when encountering preeclampsia in patients with AIDS, thrombotic microangiopathy should be strongly considered. In addition, these patients may exhibit an attenuated response to plasma exchange therapy and despite previous reports in nonobstetric patients, a favorable outcome is attainable in these critically ill patients.