The Sociobehavioural Cancer Research Network (SCRN) was established in 1994 by the National Cancer Institute of Canada (NCIC) with funding from the Canadian Cancer Society (CCS). The network was created to facilitate the development of behavioural science studies that would contribute to a fuller understanding of the cancer experience, from prevention through detection, treatment and post treatment (including palliative care). This article describes the nature of network research, the development and organization of the Sociobehavioural Cancer Research Network and the challenges it faces.
GUIDELINE QUESTIONS:1) Should dexrazoxane be used routinely in patients with advanced or metastatic cancer who are at risk of developing cardio toxicity when receiving chemotherapy containing doxorubicin or epirubicin? 2) Do the available data support the use of dexrazoxane when anthracyclines are being used in the adjuvant setting for patients at risk of developing cardiotoxicity?OBJECTIVE:To make recommendations regarding the use of dexrazoxane to prevent cardiotoxicity in patients with nonhematological malignancies who are receiving anthracycline- containing chemotherapy.OUTCOMES:Clinical and subclinical cardiotoxicity, noncardiac toxicity and impact on efficacy outcomes such as response and overall survival are considered.PERSPECTIVE (VALUES):Evidence was selected, reviewed and synthesized by 2 members of Cancer Care Ontario's Systemic Treatment Disease Site Group (STDSG), formerly the Systemic Treatment Program Committee. Drafts of this document have been circulated and reviewed by members of the STDSG. The STDSG comprises medical oncologists, pharmacists, supportive care personnel and administrators. Community representatives did not participate in the development of this guideline, but they will be included in future guidelines.QUALITY OF EVIDENCE:Seven randomized controlled trials (RCTs), 2 with placebo control, were available for analysis.BENEFITS:Data for clinical cardiotoxicity from 6 trials were pooled (n = 1070). The meta-analysis indicated that the risk of experiencing clinical cardiotoxicity was significantly reduced by dexrazoxane (risk ratio 0.24; 95% confidence interval [CI] 0.11 to 0.52; p = 0.00031). There was no significant benefit shown in individual trials for objective response or survival.HARMS:One of the RCTs revealed a significantly lower objective response rate in the dexrazoxane arm. However, a meta-analysis of objective response across 5 trials of breast cancer patients (n = 818) did not confirm this effect (odds ratio 0.85; 95% CI 0.61 to 1.18; p = 0.33). The use of dexrazoxane increased the incidence of myelosuppression and other noncardiac toxicities, but these were generally mild.PRACTICE GUIDELINE:The evidence supports the use of dexrazoxane to provide protection against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician and who have received 300 mg/m2 or more of doxorubicin. The evidence supports the use dexrazoxane to provide protection against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physicians. There are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. For doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). A similar formula could be used for epirubicin, that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in Canada is 1000 mg/m2. Preclinical studies did not show any cardioprotectant effect for dexrazoxane when used with mitoxantrone, and no clinical studies have been done. Therefore, dexrazoxane is not recommended for use with mitoxantrone. There is no evidence for or against the use of dexrazoxane in the adjuvant setting for any tumour type. Because of concerns that dexrazoxane may reduce the efficacy of anthracyclines, and because data are not yet available on long-term toxicities, further studies should be performed before the drug is used in this setting.
Since 1979, consensus guidelines have been produced for radiation treatment practice in British Columbia. These guidelines have been revised, updated and circulated to all radiation oncologists periodically. A comprehensive computer database for all patients receiving radiation treatment in the province was established in 1984. Between 1985 and 1996 inclusive, 7667 prostate cancer patients and 9748 breast cancer patients received primary radical radiation treatment or adjuvant postsurgical treatment. Palliative treatments and the treatment of other disease sites are not included in this review. Compliance of these treatments with the published guidelines is reported. Over 98% of patients completed treatment as planned and, in the last 3 years, more than 90% of patients received a guideline dose to either the prostate or the breast. Compliance was less in the treatment of the regional lymph nodes in breast cancer. Practice in prostate cancer tended to precede the changes in the guidelines. This was not the case for breast cancer.
The patient-doctor relationship is central to medicine. From this relationship, duties and obligations are derived; within this relationship, hopes and expectations are set. Communication is essential in this relationship and evidence-based efforts directed at improving it are a key element in improving care. At an even deeper level, critical reflection reveals fundamental values operating within and beneath this discourse that must be addressed if the goals of improving communication are to be achieved in a meaningful way. This is the stuff of the ethics of patient-physician communication. Because these values are so deeply embedded in the speech and actions of physicians, insights are best provided by those who are observers of the discourse rather than by participants. Observations from the history and sociology of physician communication, literary analysis and reflections on the illness experience by women provide important insights into the values and attitudes underlying physician communication, which must be taken into account in the education of physicians if the outcome is to benefit all participants.
Medical educators at undergraduate, postgraduate and continuing medical education levels acknowledge that communication is a fundamental medical skill. Responding to patient, professional and governmental advocates, as well as to advances in research on patient-physician communication and its teaching, some medical educators are in the process of starting new communication curricula, while others are working at expanding, integrating and further developing already well-established programs. For most people working in this area, the question is no longer whether to teach and assess communication skills and attitudes but, rather, how to do so most efficiently and effectively. In order to enhance the development of communication curricula at all levels, we first provide a brief look at how communication education has become widely encouraged in many parts of the globe, and we set out the underlying assumptions that frame the teaching and learning of communication in medicine. We then summarize critical components common to many established communication curricula and identify a series of specific strategies for teaching communication skills. We include a chart that describes a sample of the wide variety of resources available to assist in the development and teaching of communication curricula in medicine. Finally, we consider gaps in current communication curricula and suggest the next steps and ideas for moving forwards.
OBJECTIVETo outline the patterns and temporal trends in leukemia, regarding incidence and mortality, in Canada since 1970.DESIGNA descriptive analysis of trends in incidence and mortality by age, sex, time period and leukemia subtype, using change-point modelling and log-linear regression.SETTINGData from all provincial and territorial cancer registries.MAIN OUTCOME MEASUREIncidence and mortality rate per population of 100,000.RESULTSThe overall age-adjusted incidence rates for all males and females increased from 12.3 and 7.3 per 100,000 in 1970-1972 to 14.6 and 9.0 in 1979-1981, then decreased to 13.2 and 8.3 in 1991-1993, respectively. The overall age-adjusted mortality rates decreased from 9.1 and 5.7 per population of 100,000 in 1970-1972 to 8.3 and 4.8 in 1993-1995 for males and females, respectively. The incidence of acute leukemias decreased between 1970 and 1993. A sharp increase in the incidence of chronic leukemias from 1978 to 1980 was observed in the older age group. Mortality rates also showed a small increase from 1979 to 1989 in seniors.CONCLUSIONThe increase in the incidence of chronic leukemias among older subjects was probably due to improvements in diagnosis and changes in registration practices, whereas the decrease in the incidence of acute leukemias was probably a real change attributable to environmental factors. Further investigation is needed to clarify whether and to what extent diagnostic practices contributed to the increased detection of chronic leukemias among elderly Canadians.
OBJECTIVEThe objective of this chart review was to determine the frequency of transfusion and prevalence of anemia (hemoglobin result < 100 g/L) in patients receiving chemotherapy.DESIGNThis study was a retrospective review of medical charts.SETTINGPatients receiving chemotherapy were included from 12 tertiary care comprehensive cancer centres across Canada.MAIN OUTCOME MEASUREThe primary study outcome measure was red blood cell transfusion rate, controlling for patient variables.RESULTSThe 616 patients included had started chemotherapy in January-June 1992. For each subject, data collection finished 4 weeks after the end of the first regimen or after a maximum follow-up period of 26 weeks. Seventy-two patients (12%; 95% confidence interval 9.5% to 14.5%) were transfused for anemia (reasons other than blood loss), and 28% (95% confidence interval 24.5% to 31.5%) of the subjects were anemic during treatment. The univariate analyses of transfusion for anemia yielded significant associations with prognostic factors. In the multivariate analyses, platinum (odds ratio [OR] = 6.69) and anthracycline (OR = 3.56) chemotherapy, baseline hemoglobin (OR = 0.96) and disease stage (OR = 1.72) were statistically significant contributors.CONCLUSIONIn this patient cohort, red blood cell transfusion was infrequent (12%). However, patient groups at high risk of transfusion could be identified, with platinum-based chemotherapy being the most significant contributing factor. The information obtained from this multicentre study may prove helpful in developing supportive care guidelines for the management of chemotherapy-related anemia requiring transfusion.
This chapter covers important and well-studied aspects of patient-doctor communication. First the paper describes the lessons learned from studies about patients' satisfactions or dissatisfactions related to patient-doctor communication, making the point that complaints about doctors are usually due to communication problems and not technical competency issues. The next section of the chapter deals with time. It is often assumed that effective communication is inefficient. While this is not necessarily the case, the research results are complex and very interesting. The third part of the chapter covers communication in relation to patient adherence with the management plan recommended by the doctor. There is strong evidence that communication affects patient adherence and that there are four key aspects of communication that can enhance the patients' co-operation with the management plan. The final topic is patients' health. Twenty-two studies indicate the generally positive effect of key dimensions of communication on actual patient health outcomes such as pain, recovery from symptom, anxiety, functional status, and physiologic measures of blood pressure and blood glucose.
OBJECTIVE:To document the perspectives, practices and knowledge of Canadian gynecologists regarding ovarian cancer.DESIGN:A mailed survey questionnaire was followed by a reminder card and a second mailing of the questionnaire.SETTING:A sample of all gynecologists practising in Canada.MAIN OUTCOME MEASURES:Knowledge related to ovarian cancer. Practices related to the screening and detection of ovarian cancer. Attitudes towards ovarian cancer. Perceived role in the care of women at risk of, or diagnosed with, ovarian cancer. Perceived educational needs of gynecologists regarding ovarian cancer.RESULTS:A total of 504 completed questionnaires were returned, providing a response rate of 46%. Most gynecologists indicated that they knew the basic facts about ovarian cancer and risk factors. Practices related to asymptomatic, low-risk women were found to be mostly in accord with current guidelines and the lack of evidence for the effectiveness of tests. Practices regarding women with suspected early or late-stage ovarian cancer varied, particularly with regard to referral to gynecologic oncologists. Many respondents indicated that they have an important role to play in the care of women after they have been diagnosed with ovarian cancer or referred to another specialist. Respondents also expressed interest in obtaining additional information about ovarian cancer.CONCLUSIONS:This study shows that there is a need for the development and dissemination of evidence-based guidelines regarding ovarian cancer. It also pinpoints areas where educational efforts could be directed.
OBJECTIVE:To explore cancer patients' experiences with and expectations of the role of family physicians in communication about complementary therapies.DESIGN:Focus group interviews.SETTING:British Columbia Cancer Agency and the University of Calgary.PARTICIPANTS:Sample of 14 cancer patients using complementary therapies comprising 3 focus groups (2 in BC and 1 in Alberta).RESULTS:The role of family physicians in discussing complementary therapies varied from being extraneous to patients' decision making to being a partner in making decisions about cancer treatments. Patients expected their physicians to be supportive, caring, kind and to show an interest in them. They also expected their physicians to be accepting and nonjudgmental regarding complementary therapy use and to reinforce a sense of hope. Most patients did not expect their doctors to have extensive knowledge about these therapies. All patients strongly felt the need to seek information themselves. In addition, they felt that believing in the type of therapies they were using was very important.CONCLUSION:Family physicians can play an important role in exploring and discussing complementary therapies with their patients. It is important that they are made aware of their patients' needs in this area.
Computer-based sun safety instruction has many advantages that may be attractive to health educators in schools. An educational multimedia computer program on sun safety was produced on CD-ROM for children in grades 4 and 5, which was based on the "Sunny Days, Healthy Ways" sun safety curriculum (SDHW). Its effects on children's sun safety knowledge, attitudes and behaviour were evaluated with 162 students in 8 fourth and fifth grade classes in a randomized pretest-posttest 2 x 2 factorial design. Children interacting with the CD-ROM program showed significant improvements in knowledge (p = 0.007). The effect on knowledge may have indirectly improved children's sun protection (r = 0.201, p = 0.013), even though the CD-ROM program did not directly increase sun protection (p > .05) or improve attitudes (p > .05). The CD-ROM program may be a cost-effective and administratively acceptable sun safety instructional strategy, however, like many short prevention strategies, it will be most successful at conveying information on sun safety to children.
Professional caregivers have an obligation to maintain the privacy and confidentiality of all personal information given to them by their patients or clients. Such information is to be released to a party who is not participating in the care of the patient only with the express consent of the patient. The question is whether or not the express consent of a client of an organized cancer screening program is ethically required before the client's personal information is entered into a centralized database. The arguments in favour of express consent are grounded largely in a desire to respect clients' privacy and autonomy fully. The arguments for the reliance on nonexpress, implied or tacit consent are based chiefly on the desire to provide clients with the full benefits of screening. It is suggested here that neither extreme position is satisfactory. A novel, balanced approach that would be sensitive to both electronic data storage and a preventive care situation is needed. Progress on this issue requires focused empirical research, a debate in both professional and public forums, and further critical analysis.
OBJECTIVE To determine the feasibility and the economic impact of tumour EGFR, erbB-2 and cathepsin-D measurements in women with node-negative breast cancer. DESIGN Consecutive tumour samples received at a regional steroid receptor laboratory from patients with node-negative breast cancer were evaluated with commercially available kits to determine EGFR, erbB-2 and cathepsin-D levels. SETTING All node-negative patients whose tumours were submitted to the steroid receptor laboratory from November 1992 to March 1994 were included (n = 142). A control group of concurrent node-negative breast cancer patients from the London Regional Cancer Centre (LRCC) database were also evaluated to determine the representativeness of our sample. MAIN OUTCOME MEASURE To determine the proportion of patients who were positive for the 3 newer prognostic factors relative to their risk of relapse. RESULTS We found 75 positive values in 69 patients (48.6%). We demonstrated that each factor identified a different high-risk subgroup. Epidermal growth factor receptor (EGFR) positivity (> 10 fmol/mg protein) was found in 16.3% of patients, with 19.9% of patients positive for erbB-2 (> 250 units/mg protein) and 17.3% positive for cathepsin D (> 70 pmol/mg protein). Between 10% and 23.2% more node-negative patients currently seen in a regional cancer centre could be offered systemic adjuvant chemotherapy based on a single positive new factor. CONCLUSIONS These tumour evaluations are straightforward using material already available in a regional steroid receptor laboratory or on tumour tissue available to pathologists. The economic impact is minimal; the 1995 cost of performing all 3 evaluations is Can$425-616 (US$304-440) per patient treated depending on the number of assays per run. Prospective clinical trials incorporating tumour EGFR, erbB-2 and cathepsin D are feasible and economically viable.
GUIDELINE QUESTION:Is there a role for the use of gemcitabine in the treatment of patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC)?OBJECTIVE:To make recommendations about the use of gemcitabine in the management of medically appropriate patients with stage IIIB-IV NSCLC.OUTCOMES:The outcomes of interest were survival, response rate, symptomatic response, response duration and toxicity.PERSPECTIVE (VALUES):Evidence was selected and reviewed by 2 members of the Provincial Lung Cancer Disease Site Group (DSG) of the Cancer Care Ontario Practice Guidelines Initiative. The practice guideline report was reviewed by the Provincial Lung Cancer DSG and by the Systemic Treatment Disease Site Group. These committees comprise medical and radiation oncologists, surgeons, pathologists, nurses, a psychologist, a medical sociologist and administrators. One community representative participated in the development of this practice guideline.QUALITY OF EVIDENCE:Five phase II studies of single-agent gemcitabine in advanced NSCLC were reviewed. Four of these are published as full reports. Two randomized phase II studies comparing single-agent gemcitabine with etoposide plus cisplatin were also reviewed. One of these studies is fully published. Seven phase II studies of gemcitabine in combination with cisplatin and I phase II study of gemcitabine in combination with ifosfamide were reviewed. Three randomized controlled trials (RCTs) and 1 randomized phase II study, published in abstract form, compared gemcitabine combination chemotherapy with cisplatin combination chemotherapy. An additional phase II study, published in abstract form, of gemcitabine as salvage therapy in previously treated patients was also included.BENEFITS:Four phase II studies of single-agent gemcitabine at a dose of 1000 mg/m2 or more showed a combined response rate of 19% (intention-to-treat analysis; 95% confidence interval [CI] 15% to 24%) or 21% (efficacy analysis; 95% CI 17% to 26%) in advanced NSCLC. Median survival ranged from 7 to 9 months. Improvement from baseline in cough, hemoptysis and dyspnea was comparable to what would be expected with radiation therapy and with standard combination chemotherapy regimens. Improvement from baseline in their performance status was reported in 52% of treated patients. The 2 randomized phase II studies reported equivalent response rates for gemcitabine compared with etoposide plus cisplatin; the response data were pooled, which resulted in a nonsignificant benefit for gemcitabine (common odds ratio [OR] 0.90; 95% CI 0.43 to 1.90; p = 0.78). Gemcitabine has most frequently been combined with cisplatin, yielding a combined response rate of 44% (intention-to-treat; 95% CI 36% to 47%) or 45% (efficacy; 95% CI 39% to 51%) from 7 phase II studies. Median survival times ranged from 10 to 14 months. One phase II randomized study compared gemcitabine-cisplatin-vinorelbine vs. cisplatin-epirubicin-vindesine plus lonidamine and demonstrated a higher response rate (62% vs. 35%) in favour of the gemcitabine combination. Three RCTs demonstrated increased response rates for the combination of gemcitabine-cisplatin over either cisplatin alone or other combination regimens [(gemcitabine-cisplatin 35% vs. etoposide-cisplatin 12%; p = 0.001), (gemcitabine-cisplatin 31% vs. cisplatin 9%; p = 0.0001), (gemcitabine-cisplatin 40% vs. mitomycin, ifosfamide, cisplatin 28%; p = 0.03)].HARMS:The major dose-limiting toxicity is neutropenia. Despite this, infection rates are low. Significant adverse effects that have an impact on the patient's quality of life or require the discontinuance of treatment are reported to be less than with any other single agent or combination of agents. Grade 3 or 4 dyspnea has been reported to occur in fewer than 2% of cases and may be drug related. (ABSTRACT TRUNCATED)
OBJECTIVE:To describe the knowledge, practices and perspectives of Canadian family physicians regarding ovarian cancer.DESIGN:A mailed survey questionnaire was followed by a reminder card, a second mailing of the questionnaire and a final reminder card.SETTING:A national sample of family physicians was drawn randomly from the membership database of the College of Family Physicians of Canada.MAIN OUTCOME MEASURES:Knowledge related to ovarian cancer. Practices related to the screening and detection of ovarian cancer. Attitudes towards screening for ovarian cancer. Perceived role in the care of women at risk of, or diagnosed with, ovarian cancer. Perceived educational needs of physicians.RESULTS:A total of 1079 completed questionnaires were returned, providing a response rate of 56.6%. Although most family physicians were aware of the basic facts about ovarian cancer, there were knowledge limitations related to risk factors, familial ovarian cancer syndromes and symptoms. Practices related to asymptomatic women were found to be mostly in accord with current guidelines and recognized the prevailing lack of evidence for the effectiveness of tests. Areas that were troublesome included the role of screening in high-risk women and knowledge about available tests. Most family physicians indicated that they have an important role to play in the care of women after they have been diagnosed with ovarian cancer. They also expressed a high level of interest in obtaining additional information related to ovarian cancer.CONCLUSIONS:This study clearly shows that there is a need for additional research to assist with the development of evidence-based guidelines for women at increased risk of ovarian cancer and for women at no known risk. Pending more definitive evidence, interim guidelines could provide assistance to physicians currently having to make decisions in a context of massive uncertainty. Canadian family physicians would be interested in and would benefit from continuing medical education (CME) initiatives concerning ovarian cancer.
OBJECTIVE:To describe the perspectives of Canadian women living with ovarian cancer regarding their experiences with the disease.DESIGN:A cross-sectional survey of a convenience sample of Canadian women with ovarian cancer.SETTING:Survey questionnaires were sent to physicians in 26 cancer programs that treat women with ovarian cancer and to ovarian cancer self-help groups for subsequent distribution to women.PARTICIPANTS:Women diagnosed with ovarian cancer and able to read English or French.MAIN OUTCOME MEASURES:A variety of individual items in the survey related to information received, communication, physical and psychosocial symptoms, impact of illness and quality of life.RESULTS:A total of 315 women returned the survey. The average age of the respondents is 59 years. Each province and territory is represented in the sample. Over one-half of the women received a diagnosis of ovarian cancer within a month of seeking help for a concern and 85% had multiple treatment modalities. The majority of the women felt adequately informed (80%) and were satisfied with communication with their physicians (mean of 4.1 to 4.5 on a 5-point scale). A majority (62%) said that their lifestyle had changed as a result of their disease. Problems were experienced most frequently regarding side effects (58%), fear of recurrence (54%), sleeping difficulties (46%), bowel difficulties (44%), fear of dying (36%) and difficulty concentrating (32%). Many who experienced problems reported receiving inadequate help for them (16% to 49%). Quality of life was reported as significantly lower following the diagnosis and treatment of ovarian cancer (p = 0.0001).CONCLUSION:This study provides an important foundation for further investigation. There is a pressing need for research regarding the early identification of ovarian cancer and issues of support and coping. Care for women with ovarian cancer requires the expertise of a range of disciplines and community-based agencies working collaboratively as a team.
OBJECTIVE To document the attitudes, practices and knowledge of 3 groups of complementary practitioners (naturopathic doctors, chiropractors and massage therapists) regarding women's cancers in general and ovarian cancer specifically. DESIGN A mailed survey questionnaire was followed by a reminder card and a second mailing of the questionnaire. SETTINGS National samples were obtained for naturopathic doctors and chiropractors. The massage therapist sample was drawn from Ontario only because of the absence of a national listing of massage therapists. MAIN OUTCOME MEASURES Practitioners reported response to patients' suspicious symptoms. Practitioners' perceptions of patients' motivations for seeking treatment. Practitioners' satisfaction with interactions with conventional practitioners. Practitioners' perceptions of their role in the care of women at risk of, or diagnosed with, cancer. Practitioners' perceptions of their knowledge regarding women's cancers. Practitioners' knowledge specific to ovarian cancer. RESULTS A total of 894 completed questionnaires were returned, providing a response rate of 56%. The vast majority of practitioners who saw women with symptoms possibly related to cancer referred them to a family physician or a cancer specialist. Motivations that practitioners most frequently heard expressed by women seeking complementary treatments were "maximizing quality of life," "seeking natural approaches to healing" and "looking to stay well when disease is in remission." Most respondents were dissatisfied with patient-related communication with both family physicians and cancer specialists. The majority of complementary practitioners indicated that they have an important role to play in the postdiagnostic care of women with cancer. Considerable interest was expressed in further education concerning ovarian cancer. CONCLUSIONS Whereas the professions reached through this survey differ in important ways from each other, they share an interest in being involved in the care of women with cancer, as well as an enthusiasm for the development of continuing professional education programs to help them better serve their clients.
