Patients with complete clinical response after neoadjuvant chemoradiotherapy for locally advanced esophageal cancer: A Markov decision analysis of esophagectomy versus active surveillance.

OBJECTIVE: Chemoradiation followed by esophagectomy is a standard treatment option for patients with locally advanced esophageal cancer (LAEC). Esophagectomy is a high-risk procedure, and recent evidence suggests select patients may benefit from omitting or delaying surgery. This study aims to compare surgery versus active surveillance for LAEC patients with complete clinical response (cCR) after neoadjuvant chemoradiotherapy (nCRT). METHODS: Decision analysis with Markov modeling was used. The base case was a 60-year-old man with T3N0M0 esophageal cancer with cCR after nCRT. The decision was modeled for a 5-year time horizon. Primary outcomes were life-years and quality-adjusted life-years (QALY). Probabilities and utilities were derived through the literature. Deterministic sensitivity analyses were performed using ranges from the literature with consideration for clinical plausibility. RESULTS: Surgery was favored for survival with an expected life-years of 2.89 versus 2.64. After incorporating quality of life, active surveillance was favored, with an expected QALY of 1.70 versus 1.56. The model was sensitive to probability of recurrence on active surveillance (threshold value 0.598), probability of recurrence being resectable (0.318), and disutility of previous esophagectomy (-0.091). The model was not sensitive to perioperative morbidity and mortality. CONCLUSIONS: Our study finds that surgery increases life expectancy but decreases QALY. Although the incremental change in QALY for either modality is insufficient to make broad clinical recommendations, our study demonstrates that either approach is acceptable. As probabilities of key factors are further defined in the literature, treatment decisions for patients with LAEC and a cCR after nCRT should consider histology, patient values, and quality of life.

Online Knowledge Translation Program Involving Video Games and University Student-Led Tutorials About Cannabis and Psychosis for Black Youth: Mixed Method Feasibility Study.

BACKGROUND: We have piloted a new online knowledge translation (KT) program created to educate youth about cannabis effects, which uniquely focuses on mental health risks for Black youth. Youth are generally unaware of the research linking underage usage and the risk of psychosis. Youth from some Black racialized communities in Ontario may be disproportionately affected and in need of this knowledge. OBJECTIVE: Because very little is known about the acceptability and feasibility of programs educating Black youth about cannabis and psychosis risk, we evaluated this KT program, which consists of tutorials facilitated by university students and video games. METHODS: This mixed methods pilot study evaluates the transfer of knowledge about cannabis and psychosis risk before and after the online KT program and, at the same time, explores participant satisfaction with the program and views about underage use. Eligible participants were youth 16-19 years of age of Black African or Caribbean descent. Trained undergraduate students from McMaster University administered a quiz (psychosis and cannabis test; PCT) to evaluate knowledge before and after the KT program. After playing the psychoeducational video games, participants attended two tutorial group sessions led by undergraduate students. The undergraduate students facilitated the online tutorials about cannabis and psychosis. The tutorials augmented the educational content embedded within the gameplay: participants discussed what they learned from the video games and their understanding of psychosis and the effects of cannabis. In addition, undergraduate students qualitatively analyzed the tutorial discussions for themes, and the prequiz and postquiz scores were analyzed for significant differences in scores. RESULTS: A total of 9 Black youth were recruited and completed this pilot study. The mean PCT scores were 5.67 (SD 1.7) and 7.78 (SD 1.8) before and after the KT program, respectively. There was a significant improvement in scores (P<.05) post-KT program. Thematic analysis of the facilitated tutorials revealed three major themes: video game satisfaction, marijuana and psychosis literacy, and help-seeking awareness. Overall, participants showed an increased awareness and understanding of the subject matter after the gameplay and tutorial intervention. CONCLUSIONS: When supplemented with tutorial sessions, the Back to Reality Series shows promise for addressing the gap in knowledge about cannabis and psychosis, and the results provide preliminary evidence that the games appeal to Black youth.