Background: Technological advancements have rapidly increased the use of point-of-care ultrasound... more Background: Technological advancements have rapidly increased the use of point-of-care ultrasound (POCUS) across various medical disciplines, leading to real-time information for clinicians at the bed side. However, literature reveals scant evidence of POCUS use in palliative care. The objective of this study was to examine the use of POCUS in a specialist palliative care setting. Methods: A retrospective chart review was conducted from January 2018 to June 2019 in Brampton, Canada, to evaluate characteristics of patients for whom POCUS was utilized. Patients were identified through pre-existing logs and descriptive information was collected from electronic health records, including demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS, and, if applicable, volume of fluid drained. Results: We identified 126 uses of POCUS in 89 unique patients. Sixty-two patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from gastrointestinal, lung, and breast pathologies. Sixty-one POCUS cases (48.4%) were in the outpatient setting. Eighty-one POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia, and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance. Conclusion: We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient and caregiver satisfaction, and health care utilization in palliative care patients receiving POCUS.
The Cancer Nutrition Rehabilitation (CNR) program at the McGill University Health Centre is an in... more The Cancer Nutrition Rehabilitation (CNR) program at the McGill University Health Centre is an interdisciplinary 8-week treatment program offering patients information, education, treatment, and support in areas such as diet, exercise, and rehabilitation, plus resources to address their psychosocial needs. The program social worker helps the patient and the patient’s family to cope with the illness, to problem-solve, and to obtain needed resources. Here, we present a description of these patients—demographics, medical diagnoses, and psychosocial needs as assessed by the Person-in-Environment standardized instrument—derived from the socialwork files of the 75 patients referred to social work in the period February 2007–December 2008. The reason most frequently reported for referral to social work was assistance with psychosocial problems. For 41.3% of the sample, these problems were assessed as high severity, and almost half the patients in the sample (47.8%) were assessed as having ...
The chapter focuses on the assessment and management of the multidimensional components, while di... more The chapter focuses on the assessment and management of the multidimensional components, while discussing the role of exercise and its impact on the physical, emotional, and psychosocial state of patients with cancer-related fatigue (CRF). It also reviews the mechanism and pathophysiology of CRF and describes the various assessment tools used in clinical practice to measure fatigue. It describes the role of counselling, education and psychosocial and other integrative interventions like mindfulness-based stress reduction (MBSR) in the management of CRF. It reviews the treatment modalities that include selecting the appropriate pharmacological psycho-stimulants and nutraceutical interventions, based on the evidence behind their use. The chapter also reviews the types of physical exercise and safety profile, lists exercise prescription, and provides the results of meta-analyses, while enlisting the future directions for a better understanding of CRF.
Given the relative novelty of cancer survivorship in Canada, much seminal work in the area has re... more Given the relative novelty of cancer survivorship in Canada, much seminal work in the area has revolved around establishing basic characteristics and program implementation groundwork. Despite commendable efforts and investments, more work is needed to understand needs and characteristics of unique or vulnerable populations. In the early 2000s, a flurry of initiatives to formally establish survivorship practice and research in Canada was undertaken. A groups of clinicians, clinician scientists, survivorship researchers, and survivors collaborating on the development of practice guidelines on survivorship services for adult populations. These were developed under the stewardship of the Cancer Journey Advisory Group of the Canadian Partnership Against Cancer (CPAC) and the Canadian Association of Psychosocial Oncology (CAPO). As the focus of cancer rehabilitation aligns closely with the principles of survivorship care, this suggests the need to more formally integrate rehabilitation s...
Summary Fifty-two patients with histologically confirmed small. cell carcinoma of the lung, 15 wi... more Summary Fifty-two patients with histologically confirmed small. cell carcinoma of the lung, 15 with disease localized to one hemithorax and 37 with extensive metastases, were studied. Only patients whose general condition was considered good enough to tolerate intensive combination chemotherapy were included in this study. The median survival time of these patients was 33 weeks (range 7 - 192 weeks) with a mean survival time of 43 weeks. Patients who responded with objective tumour improvement within 6 weeks had a median survival time of 39 weeks. Those showing disease stabilization at 6 weeks had a median survival time of 35 weeks while those having disease progression at this time had a median survival of 22 weeks. Patients without liver involvement and a normal serum albumin level at the start of treatment ha~ statistically superior survival times. S Air Med J 1986; 70: 812-814. The striking differences between small-cell carcinoma of the lung (SCCL) and non-small-cell carcinoma ...
Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain ... more Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain optimal physical, social, psychological, and vocational functioning within the limits created by the disease and its treatment. The functional autonomy of patients with cancer is compromised. The severity ranges from negligible to profound at the extremes. Owing to the nature of the cancer trajectory, rehabilitative goals have been divided into preventive, restorative, supportive, and palliative.
Journal of the National Comprehensive Cancer Network, 2018
The ideas and viewpoints expressed in this commentary are those of the author and do not necessar... more The ideas and viewpoints expressed in this commentary are those of the author and do not necessarily represent any policy, position, or program of NCCN.
95 Background: Perioperative chemotherapy improves outcomes of surgery for upper GI cancer. Some ... more 95 Background: Perioperative chemotherapy improves outcomes of surgery for upper GI cancer. Some patients have rapid recurrence. We hypothesized that any type of response to chemotherapy would predict better disease-free survival (DFS). Methods: From May 2007 to Sep 2009, 43 patients with operable adenocarcinoma of the esophagus, stomach or gastroesophageal junction went on a multicenter phase II trial. 3 cycles of docetaxel/cisplatin/5FU were given pre and post surgery. We compared DFS between responders and nonresponders after 3 cycles. Clinical response was defined as improvement of ≥ 2 points on a dysphagia score (0: normal swallowing, to 4: total obstruction), metabolic response as ≥ 35% reduction of maximum SUV by PET scan. Lack of nodal involvement or significant histologic regression (less than 50% viable tumor) was considered pathologic response. Log-rank test was used for univariate analysis, Cox regression model for multivariate analysis. All p values are double sided, me...
Medical oncology (Northwood, London, England), 2013
To determine whether metabolic or pathological response to preoperative chemotherapy can predict ... more To determine whether metabolic or pathological response to preoperative chemotherapy can predict the relapse-free survival of gastroesophageal adenocarcinoma patients treated on a perioperative chemotherapy protocol. The prospectively collected data of a recently reported phase II trial of perioperative DCF chemotherapy (docetaxel/cisplatin/5-fluorouracil) were analyzed. Median relapse-free survival (RFS) was compared with the Wilcoxon rank-sum test between responders and non-responders according to defined metabolic (reduction in maximum standard uptake value of at least 35 %) and pathological (greater than 50 % tumor regression or ypN(0) status) criteria. A double-sided p value equal or inferior to 0.05 was considered significant. Patients were followed for a median of 807 days (95 % CI: 607-896). RFS was 576 days in metabolic non-responders versus not reached in metabolic responders (p 0.009) and 562 days in ypN+ versus not reached in ypN(0) patients (p 0.045). No statistically s...
e20598 Background: Post-treatment patients with active cancer face considerable burden from the e... more e20598 Background: Post-treatment patients with active cancer face considerable burden from the effects of both disease and treatment. The Palliative Rehabilitation Program was designed to ease those challenges and to improve the patient’s functioning. The current study evaluated the changes in function scores of patients with advanced cancer upon completion of the structured program and examined the medical predictors of program completion. Methods: Referrals for 173 patients who were finished anticancer therapy were received. One hundred and thirty six patients were eligible and enrolled in the eight-week interprofessional palliative rehabilitation program. Of those, 84 completed the program. Measures of physical, nutritional, social and psychological functioning were evaluated at entry and completion of the program. Results: Significant improvements were experienced in physical performance (P =0.000), nutrition (P =0.000), symptom severity (P=0.005 to P= 0.000), symptom interfere...
The MASCC Textbook of Cancer Supportive Care and Survivorship, 2010
Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain ... more Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain optimal physical, social, psychological, and vocational functioning within the limits created by the disease and its treatment.
Background Cancer-associated weight loss (WL) associates with increased mortality. International ... more Background Cancer-associated weight loss (WL) associates with increased mortality. International consensus suggests that WL is driven by a variable combination of reduced food intake and/or altered metabolism, the latter often represented by the inflammatory biomarker C-reactive protein (CRP). We aggregated data from Canadian and European research studies to evaluate the associations of reduced food intake and CRP with cancer-associated WL (primary endpoint) and overall survival (OS, secondary endpoint). Methods The data set included a total of 12,253 patients at risk for cancer-associated WL. Patient-reported WL history (% in 6 months) and food intake (normal, moderately, or severely reduced) were measured in all patients; CRP (mg/L) and OS were measured in N = 4960 and N = 9952 patients, respectively. All measures were from a baseline assessment. Clinical variables potentially associated with WL and overall survival (OS) including age, sex, cancer diagnosis, disease stage, and performance status were evaluated using multinomial logistic regression MLR and Cox proportional hazards models, respectively. Results Patients had a mean weight change of À7.3% (±7.1), which was categorized as: ±2.4% (stable weight; 30.4%), 2.5-5.9% (19.7%), 6.0-10.0% (23.2%), 11.0-14.9% (12.0%), ≥15.0% (14.6%). Normal food intake, moderately, and severely reduced food intake occurred in 37.9%, 42.8%, and 19.4%, respectively. In MLR, severe WL (≥15%) (vs. stable weight) was more likely (P < 0.0001) if food intake was moderately [OR 6.28, 95% confidence interval (CI 5.28-7.47)] or severely reduced [OR 18.98 (95% CI 15.30-23.56)]. In subset analysis, adjusted for food intake, CRP was independently associated (P < 0.0001) with ≥15% WL [CRP 10-100 mg/L: OR 2.00, (95% CI 1.58-2.53)] and [CRP > 100 mg/L: OR 2.30 (95% CI 1.62-3.26)]. Diagnosis, stage, and performance status, but not age or sex, were significantly associated with WL. Median OS was 9.9 months (95% CI 9.5-10.3), with median follow-up of 39.7 months (95% CI 38.8-40.6). Moderately and severely reduced food intake and CRP independently predicted OS (P < 0.0001). Conclusions Modelling WL as the dependent variable is an approach that can help to identify clinical features and biomarkers associated with WL. Here, we identify criterion values for food intake impairment and CRP that may improve the diagnosis and classification of cancer-associated cachexia.
Approximately 10% of new breast cancer patients will present with overt synchronous metastatic di... more Approximately 10% of new breast cancer patients will present with overt synchronous metastatic disease. The optimal local management of those patients is controversial. Several series suggest that removal of the primary tumour is associated with a survival benefit, but the retrospective nature of those studies raises considerable methodologic challenges. We evaluated our clinical experience with the management of such patients and, more specifically, the impact of surgery in patients with synchronous metastasis. We reviewed patients with primary breast cancer and concurrent distant metastases seen at our centre between 2005 and 2007. Demographic and treatment data were collected. Study endpoints included overall survival and symptomatic local progression rates. The 111 patients identified had a median follow-up of 40 months (range: 0.6-71 months). We allocated the patients to one ot two groups: a nonsurgical group (those who did not have breast surgery, n = 63) and a surgical group ...
Background: Technological advancements have rapidly increased the use of point-of-care ultrasound... more Background: Technological advancements have rapidly increased the use of point-of-care ultrasound (POCUS) across various medical disciplines, leading to real-time information for clinicians at the bed side. However, literature reveals scant evidence of POCUS use in palliative care. The objective of this study was to examine the use of POCUS in a specialist palliative care setting. Methods: A retrospective chart review was conducted from January 2018 to June 2019 in Brampton, Canada, to evaluate characteristics of patients for whom POCUS was utilized. Patients were identified through pre-existing logs and descriptive information was collected from electronic health records, including demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS, and, if applicable, volume of fluid drained. Results: We identified 126 uses of POCUS in 89 unique patients. Sixty-two patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from gastrointestinal, lung, and breast pathologies. Sixty-one POCUS cases (48.4%) were in the outpatient setting. Eighty-one POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia, and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance. Conclusion: We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient and caregiver satisfaction, and health care utilization in palliative care patients receiving POCUS.
The Cancer Nutrition Rehabilitation (CNR) program at the McGill University Health Centre is an in... more The Cancer Nutrition Rehabilitation (CNR) program at the McGill University Health Centre is an interdisciplinary 8-week treatment program offering patients information, education, treatment, and support in areas such as diet, exercise, and rehabilitation, plus resources to address their psychosocial needs. The program social worker helps the patient and the patient’s family to cope with the illness, to problem-solve, and to obtain needed resources. Here, we present a description of these patients—demographics, medical diagnoses, and psychosocial needs as assessed by the Person-in-Environment standardized instrument—derived from the socialwork files of the 75 patients referred to social work in the period February 2007–December 2008. The reason most frequently reported for referral to social work was assistance with psychosocial problems. For 41.3% of the sample, these problems were assessed as high severity, and almost half the patients in the sample (47.8%) were assessed as having ...
The chapter focuses on the assessment and management of the multidimensional components, while di... more The chapter focuses on the assessment and management of the multidimensional components, while discussing the role of exercise and its impact on the physical, emotional, and psychosocial state of patients with cancer-related fatigue (CRF). It also reviews the mechanism and pathophysiology of CRF and describes the various assessment tools used in clinical practice to measure fatigue. It describes the role of counselling, education and psychosocial and other integrative interventions like mindfulness-based stress reduction (MBSR) in the management of CRF. It reviews the treatment modalities that include selecting the appropriate pharmacological psycho-stimulants and nutraceutical interventions, based on the evidence behind their use. The chapter also reviews the types of physical exercise and safety profile, lists exercise prescription, and provides the results of meta-analyses, while enlisting the future directions for a better understanding of CRF.
Given the relative novelty of cancer survivorship in Canada, much seminal work in the area has re... more Given the relative novelty of cancer survivorship in Canada, much seminal work in the area has revolved around establishing basic characteristics and program implementation groundwork. Despite commendable efforts and investments, more work is needed to understand needs and characteristics of unique or vulnerable populations. In the early 2000s, a flurry of initiatives to formally establish survivorship practice and research in Canada was undertaken. A groups of clinicians, clinician scientists, survivorship researchers, and survivors collaborating on the development of practice guidelines on survivorship services for adult populations. These were developed under the stewardship of the Cancer Journey Advisory Group of the Canadian Partnership Against Cancer (CPAC) and the Canadian Association of Psychosocial Oncology (CAPO). As the focus of cancer rehabilitation aligns closely with the principles of survivorship care, this suggests the need to more formally integrate rehabilitation s...
Summary Fifty-two patients with histologically confirmed small. cell carcinoma of the lung, 15 wi... more Summary Fifty-two patients with histologically confirmed small. cell carcinoma of the lung, 15 with disease localized to one hemithorax and 37 with extensive metastases, were studied. Only patients whose general condition was considered good enough to tolerate intensive combination chemotherapy were included in this study. The median survival time of these patients was 33 weeks (range 7 - 192 weeks) with a mean survival time of 43 weeks. Patients who responded with objective tumour improvement within 6 weeks had a median survival time of 39 weeks. Those showing disease stabilization at 6 weeks had a median survival time of 35 weeks while those having disease progression at this time had a median survival of 22 weeks. Patients without liver involvement and a normal serum albumin level at the start of treatment ha~ statistically superior survival times. S Air Med J 1986; 70: 812-814. The striking differences between small-cell carcinoma of the lung (SCCL) and non-small-cell carcinoma ...
Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain ... more Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain optimal physical, social, psychological, and vocational functioning within the limits created by the disease and its treatment. The functional autonomy of patients with cancer is compromised. The severity ranges from negligible to profound at the extremes. Owing to the nature of the cancer trajectory, rehabilitative goals have been divided into preventive, restorative, supportive, and palliative.
Journal of the National Comprehensive Cancer Network, 2018
The ideas and viewpoints expressed in this commentary are those of the author and do not necessar... more The ideas and viewpoints expressed in this commentary are those of the author and do not necessarily represent any policy, position, or program of NCCN.
95 Background: Perioperative chemotherapy improves outcomes of surgery for upper GI cancer. Some ... more 95 Background: Perioperative chemotherapy improves outcomes of surgery for upper GI cancer. Some patients have rapid recurrence. We hypothesized that any type of response to chemotherapy would predict better disease-free survival (DFS). Methods: From May 2007 to Sep 2009, 43 patients with operable adenocarcinoma of the esophagus, stomach or gastroesophageal junction went on a multicenter phase II trial. 3 cycles of docetaxel/cisplatin/5FU were given pre and post surgery. We compared DFS between responders and nonresponders after 3 cycles. Clinical response was defined as improvement of ≥ 2 points on a dysphagia score (0: normal swallowing, to 4: total obstruction), metabolic response as ≥ 35% reduction of maximum SUV by PET scan. Lack of nodal involvement or significant histologic regression (less than 50% viable tumor) was considered pathologic response. Log-rank test was used for univariate analysis, Cox regression model for multivariate analysis. All p values are double sided, me...
Medical oncology (Northwood, London, England), 2013
To determine whether metabolic or pathological response to preoperative chemotherapy can predict ... more To determine whether metabolic or pathological response to preoperative chemotherapy can predict the relapse-free survival of gastroesophageal adenocarcinoma patients treated on a perioperative chemotherapy protocol. The prospectively collected data of a recently reported phase II trial of perioperative DCF chemotherapy (docetaxel/cisplatin/5-fluorouracil) were analyzed. Median relapse-free survival (RFS) was compared with the Wilcoxon rank-sum test between responders and non-responders according to defined metabolic (reduction in maximum standard uptake value of at least 35 %) and pathological (greater than 50 % tumor regression or ypN(0) status) criteria. A double-sided p value equal or inferior to 0.05 was considered significant. Patients were followed for a median of 807 days (95 % CI: 607-896). RFS was 576 days in metabolic non-responders versus not reached in metabolic responders (p 0.009) and 562 days in ypN+ versus not reached in ypN(0) patients (p 0.045). No statistically s...
e20598 Background: Post-treatment patients with active cancer face considerable burden from the e... more e20598 Background: Post-treatment patients with active cancer face considerable burden from the effects of both disease and treatment. The Palliative Rehabilitation Program was designed to ease those challenges and to improve the patient’s functioning. The current study evaluated the changes in function scores of patients with advanced cancer upon completion of the structured program and examined the medical predictors of program completion. Methods: Referrals for 173 patients who were finished anticancer therapy were received. One hundred and thirty six patients were eligible and enrolled in the eight-week interprofessional palliative rehabilitation program. Of those, 84 completed the program. Measures of physical, nutritional, social and psychological functioning were evaluated at entry and completion of the program. Results: Significant improvements were experienced in physical performance (P =0.000), nutrition (P =0.000), symptom severity (P=0.005 to P= 0.000), symptom interfere...
The MASCC Textbook of Cancer Supportive Care and Survivorship, 2010
Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain ... more Cancer rehabilitation is a process that assists the individual with a cancer diagnosis to obtain optimal physical, social, psychological, and vocational functioning within the limits created by the disease and its treatment.
Background Cancer-associated weight loss (WL) associates with increased mortality. International ... more Background Cancer-associated weight loss (WL) associates with increased mortality. International consensus suggests that WL is driven by a variable combination of reduced food intake and/or altered metabolism, the latter often represented by the inflammatory biomarker C-reactive protein (CRP). We aggregated data from Canadian and European research studies to evaluate the associations of reduced food intake and CRP with cancer-associated WL (primary endpoint) and overall survival (OS, secondary endpoint). Methods The data set included a total of 12,253 patients at risk for cancer-associated WL. Patient-reported WL history (% in 6 months) and food intake (normal, moderately, or severely reduced) were measured in all patients; CRP (mg/L) and OS were measured in N = 4960 and N = 9952 patients, respectively. All measures were from a baseline assessment. Clinical variables potentially associated with WL and overall survival (OS) including age, sex, cancer diagnosis, disease stage, and performance status were evaluated using multinomial logistic regression MLR and Cox proportional hazards models, respectively. Results Patients had a mean weight change of À7.3% (±7.1), which was categorized as: ±2.4% (stable weight; 30.4%), 2.5-5.9% (19.7%), 6.0-10.0% (23.2%), 11.0-14.9% (12.0%), ≥15.0% (14.6%). Normal food intake, moderately, and severely reduced food intake occurred in 37.9%, 42.8%, and 19.4%, respectively. In MLR, severe WL (≥15%) (vs. stable weight) was more likely (P < 0.0001) if food intake was moderately [OR 6.28, 95% confidence interval (CI 5.28-7.47)] or severely reduced [OR 18.98 (95% CI 15.30-23.56)]. In subset analysis, adjusted for food intake, CRP was independently associated (P < 0.0001) with ≥15% WL [CRP 10-100 mg/L: OR 2.00, (95% CI 1.58-2.53)] and [CRP > 100 mg/L: OR 2.30 (95% CI 1.62-3.26)]. Diagnosis, stage, and performance status, but not age or sex, were significantly associated with WL. Median OS was 9.9 months (95% CI 9.5-10.3), with median follow-up of 39.7 months (95% CI 38.8-40.6). Moderately and severely reduced food intake and CRP independently predicted OS (P < 0.0001). Conclusions Modelling WL as the dependent variable is an approach that can help to identify clinical features and biomarkers associated with WL. Here, we identify criterion values for food intake impairment and CRP that may improve the diagnosis and classification of cancer-associated cachexia.
Approximately 10% of new breast cancer patients will present with overt synchronous metastatic di... more Approximately 10% of new breast cancer patients will present with overt synchronous metastatic disease. The optimal local management of those patients is controversial. Several series suggest that removal of the primary tumour is associated with a survival benefit, but the retrospective nature of those studies raises considerable methodologic challenges. We evaluated our clinical experience with the management of such patients and, more specifically, the impact of surgery in patients with synchronous metastasis. We reviewed patients with primary breast cancer and concurrent distant metastases seen at our centre between 2005 and 2007. Demographic and treatment data were collected. Study endpoints included overall survival and symptomatic local progression rates. The 111 patients identified had a median follow-up of 40 months (range: 0.6-71 months). We allocated the patients to one ot two groups: a nonsurgical group (those who did not have breast surgery, n = 63) and a surgical group ...
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