Cancer prevention & control : CPC = Prevention & controle en cancerologie : PCC最新文献

Guideline question: Should preoperative (neoadjuvant) cisplatin-based chemotherapy with or without postoperative radiotherapy be offered to patients with technically resectable stage IIIA non-small-cell lung cancer (NSCLC) to improve survival? (Resectability should be determined preoperatively by a thoracic surgeon.)

Objective: To make recommendations about the use of preoperative cisplatin-based chemotherapy with or without postoperative radiotherapy in technically resectable stage IIIA NSCLC.

Outcomes: Survival is the primary outcome of interest. PERSPECTIVES (VALUES): Evidence was collected and reviewed by 4 members of the Lung Cancer Disease Site Group (LCDSG) of the Cancer Care Ontario Practice Guidelines Initiative. The evidence was then presented to the full LCDSG and discussed extensively at 5 of its meetings. The LCDSG comprises medical and radiation oncologists, pathologists, surgeons, epidemiologists, a psychologist and a medical sociologist. A community representative was present at one meeting during which the recommendation was discussed.

Quality of evidence: Four small randomized controlled trials (RCTs) were available for review; 2 were completed and were reported in full in the literature, 1 was published in abstract form, and 1 was closed and was reported as an interim analysis. Although the RCTs used appropriate clinical trials methodology, including planned interim analyses and early stopping rules, retrospective review revealed inconsistencies between the treatment arms for subsets of stage IIIA disease and for prognostic factors. These factors and the small samples in each study limit the interpretation of the results.

Benefits: The data from 2 of the 4 trials were not combined because the data were not mature in one case and not extractable in the other. The 2 fully published, completed trials reported a survival benefit for patients treated with preoperative chemotherapy with or without postoperative radiotherapy compared with those not given preoperative chemotherapy. One trial reported a median survival of 26 months in the treatment group versus 8 months in the control group (p < 0.001). A second trial reported an estimated median survival of 64 months versus 11 months (p < 0.008) and a 3-year survival rate of 56% versus 15% respectively. A pooled analysis of the 2-year survival data from the 2 completed RCTs yielded an odds ratio for death of 0.18 (95% confidence interval 0.06 to 0.51) in favour of preoperative chemotherapy.

Harms: There was no difference in the postoperative mortality between the trials reviewed. Toxic effects associated with the chemotherapy were limited primarily to neutropenic fever, nausea and vomiting.

Purpose: To describe the survival rates among Canadian children and teenagers with cancer diagnosed between 1985 and 1988 using population-based data, specifically for the more common forms of childhood cancer, and to assess the effect of age at diagnosis and sex as prognostic factors for selected childhood cancers.

Design: Retrospective survival study based on incident cases of cancer identified by the National Cancer Incidence Reporting System and follow-up ascertained by computer record linkage to the Canadian Mortality Database.

Subjects: A total of 4409 patients with cancer first diagnosed at 19 years of age or younger between 1985 and 1988, and followed up to Dec. 31, 1991.

Main outcome measures: Survival rates calculated at 1, 3 and 5 years according to the actuarial life table and the proportional hazards models.

Results: The 5-year survival rate for all cancers combined was 71%. Females with acute lymphoblastic leukemia and astrocytoma had markedly higher survival rates than their male counterparts (p < 0.05). Age at diagnosis was a significant predictor of survival among children with acute lymphoblastic leukemia or acute nonlymphoblastic leukemia (p < 0.01), infants having a substantially poorer prognosis than older children. Conversely, the survival rate among infants with neuroblastoma was higher than that among older children, 87% surviving for 5 years after diagnosis.

Conclusions: The survival rate among Canadian children and teenagers with cancer is favourable in relation to the rate among adults with cancer. Nonetheless, the 5-year survival rates for several childhood cancers remain poor (i.e., less than 65%). The survival rates among Canadian children with cancer are similar to those among children with cancer in other developed countries.

Purpose: Health care professionals at 2 Ontario cancer centres were surveyed to determine their familiarity with, perceptions of and interest in learning more about nonpharmacologic strategies for the management of cancer pain. Evidence-based education sessions were subsequently developed for the 5 strategies in which participants were most interested. This article presents the results of critical literature reviews concerning the effectiveness of the 5 strategies: acupuncture, massage therapy, hypnosis, therapeutic touch and biofeedback.

Methods: The databases MEDLINE (1966 to June 1997), CINAHL (1982 to June 1997) and PsychoINFO Lit (1980 to June 1997) were searched systematically for randomized controlled trials (RCTs) of the 5 nonpharmacologic strategies. The authors' personal files and reference lists of relevant papers and main texts were also searched. The quality of the trials was reviewed according to established criteria.

Results: The search yielded 1 RCT of acupuncture, 1 of massage therapy and 6 of hypnosis. The studies of hypnosis suggested that there is much support for its use in the management of cancer pain. The evidence was either lacking or less clear for the other therapies examined.

Conclusion: Because patients use a wide variety of nonpharmacologic strategies regardless of their effectiveness, clinicians need to be familiar with available research and able to discuss those strategies for which the evidence is strong, weak or nonexistent. More research on the effectiveness of nonpharmacologic strategies for pain management is needed.

The Atlantic Breast Cancer Information Project (ABCIP) is one of 5 breast cancer information exchange projects funded by Health Canada. This article describes the development of ABCIP and thereby contributes to the limited knowledge on successful partnership formation in the face of restraints but with support from enabling factors. Partnership formation is presented in the context of alliances in management, coalitions in health promotion, and social movements. The restraining factors were the inertia of the status quo, provincial structures and concerns about empowering others. The enabling factors fell into 3 categories: timely logistics, roles of individuals who participated at critical points in the process, and the evolution of a supportive cultural environment. The article outlines ABCIP's achievements to date.

This article reviews the scientific literature concerning psychosocial and spiritual aspects of palliative care for the patient with cancer. It discusses 4 separate areas: the continuum of care, communication, spiritual and psychological issues, and psychotherapeutic and behavioural management of physical symptoms. Most of the research could be classified as fundamental according to the Cancer Control Framework of the National Cancer Institute of Canada. In some areas, even fundamental research was lacking. There is a need for clearer and more relevant definitions of the desired outcomes of interventions and also for the development of appropriate quantitative and qualitative methods. We must determine which interventions can be initiated earlier in the disease trajectory and can provide benefit at the palliative phase. Given the burden of suffering that palliative care aims to address, relatively little research in this area has been conducted.

This article reviews the published literature related to families of palliative care patients with cancer within the context of the Cancer Control Framework of the National Cancer Institute of Canada. Three themes emerged: 1) the impact of terminal cancer on the family; 2) family functioning--responses to terminal cancer; and 3) quality of palliative care from the family perspective. The most substantial body of research describes family needs, family caregiving burdens, caregiving costs and the impact of the patient's terminal cancer on the health of family members. Small samples, high nonresponse rates, selection biases and a lack of standardized outcome measures have impeded the advancement of knowledge. Method development studies are warranted, including the development of instruments to measure family care constructs. Longitudinal studies to examine the long-term impact of the patient's functional status, mood, symptom distress and quality of life on family members are needed. Research should also explore the effects of family composition, socioeconomic factors, culture and spirituality on families' experiences with terminal illness. Identification of families at risk as well as development and rigorous testing of appropriate interventions should become priorities.

Guideline question: Should patients with resected stage II colon cancer receive adjuvant therapy?

Objective: To make recommendations regarding the use of adjuvant therapy in the treatment of resected stage II colon cancer.

Outcomes: Overall survival is the primary outcome of interest. Secondary outcomes are disease-free survival and adverse effects of the treatment regimens.

Perspective (values): Evidence was selected and reviewed by 2 members of the Provincial Gastrointestinal Disease Site Group (GI DSG) of the Cancer Care Ontario Practice Guidelines Initiative. The recommendations resulting from this review have been approved by the GI DSG, which comprise medical and radiation oncologists, surgeons and epidemiologists. Community representatives did not participate in the development of this practice guideline but will do so in future guidelines development.

Quality of evidence: There are 25 published randomized controlled trials (RCTs) and 1 meta-analysis. The GI DSG pooled data from 11 of the 25 RCTs that provided adequate data.

Benefits: The 25 RCTs are grouped according to the type of therapy and whether the control patients received no treatment (observation) or other adjuvant therapy after resection. Because the trials usually included patients with stage II and III cancer, the complete trial results and those for a subset of patients with stage II disease were analysed. Although the overall trial results showed a survival benefit for adjuvant treatments, the benefit was not significant for stage II patients. A meta-analysis of 11 trials comparing adjuvant treatment with observation in patients with stage II cancer indicated no significant reduction in the odds ratio (OR) for death (OR 0.83; 95% confidence interval [CI] 0.62 to 1.10). The OR for death among patients receiving chemotherapy by portal vein infusion (PVI) was 0.62 (95% CI 0.35 to 1.11).

Harms: The toxic effects of 5-fluorouracil (5-FU) with either levamisole or leucovorin, or both, were mild to moderate and consisted mostly of stomatitis, diarrhea and myelosuppression; 5% of patients required hospital admission. 5-FU plus levamisole was associated with transient neurotoxic effects in 18% of patients. Toxic effects associated with PVI were mild, rare and mostly consisted of leukopenia and diarrhea; 1% of patients experienced bowel perforation.

Practice guideline: Adjuvant therapy is not recommended at this time for the routine management of patients with resected stage II colon cancer. Patients with stage II disease and high-risk factors (bowel obstruction, tumour adhesion, invasion, perforation or aneuploidy) have a poorer prognosis, similar to that of patients with stage III colon cancer. For individual management, these patients should be made aware of their prognosis; treatment can be considered

This paper offers a critique of the National Cancer Institute of Canada's (NCIC) framework for cancer control. The critique has been prepared by researchers who used the framework to review the literature in 5 substantive areas. These reviews, published in the current and previous issues of CPC, were designed to begin to outline a research agenda for the Sociobehavioural Cancer Research Network. In this paper, the authors reflect on the strengths and limitations of the framework. Perceived strengths are that the framework (a) facilitates systematic thinking about research options and priorities, (b) helps foster clear communication, (c) links science and practice, (d) may assist grant review panels to place proposed studies in context and (e) emphasizes important values. Perceived concerns include the following: (a) potential users are not familiar with the framework, (b) lack of clarity of definitions and classification criteria, (c) the utility of the framework is not immediately self-evident to potential users, (d) the framework lacks emphasis on environmental and policy interventions and (e) it is not clear how the values espoused are to be integrated with other dimensions of the framework. The concerns were seen as remediable. In short, the framework was seen to be valuable in its current form; refinement may enhance its value.

Guideline questions: 1) Does the use of postoperative, adjuvant radiotherapy or chemotherapy, alone or in combination, improve survival rates among patients with completely resected, pathologically confirmed stage II or IIIA non-small-cell lung cancer (NSCLC)? 2) Does the use of radiotherapy reduce the risk of local recurrence among patients with completely resected stage II or IIIA NSCLC?

Objective: To make recommendations about the use of postoperative adjuvant radiotherapy and chemotherapy in the treatment of patients with completely resected stage II or IIIA NSCLC.

Outcomes: Overall survival and disease-free survival are the primary outcomes of interest. A secondary outcome of interest is local disease control. PERSPECTIVES (VALUES): Evidence was collected and reviewed by 4 members of the Lung Cancer Disease Site Group (Lung Cancer DSG) of the Cancer Care Ontario Practice Guidelines Initiative. The evidence-based recommendation resulting from this review was approved by the Lung Cancer DSG, which comprises medical oncologists, radiation oncologists, pathologists, surgeons and a medical sociologist. A community representative was present at 1 meeting during which the recommendation was discussed.

Quality of evidence: One meta-analysis and 22 randomized controlled trials (RCTs) were published between 1962 and 1996. The RCTs compared surgery plus radiotherapy with surgery alone; surgery plus adjuvant chemotherapy with surgery alone; surgery plus radiotherapy with surgery plus both chemotherapy and radiotherapy. Many studies included patients with stage IIIB NSCLC; some included patients with incompletely resected stage I NSCLC or with small cell lung cancer (maximum 10%). Older studies used chemotherapy or radiation that would now be considered inferior according to current standards of practice.

Benefits: There was no survival benefit with adjuvant radiotherapy alone, although 3 RCTs reported a reduction in the rate of local recurrence among patients treated with adjuvant radiotherapy. The meta-analysis showed that postoperative, cisplatin-based chemotherapy alone reduced the relative risk of death by 13% (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.74 to 1.02); in combination with radiotherapy it resulted in a 6% reduction in the relative risk of death (HR 0.94, 95% CI 0.79 to 1.11).

Harms: Postoperative adjuvant chemotherapy with alkylating agents was found in the meta-analysis to increase the relative risk of death by 15%. A study involving prolonged adjuvant chemotherapy (busulfan or cytoxan daily for 2 years) reported that 4 of 726 patients had hematologic malignancies. In 1 study, only 53% of patients received all 4 cycles of chemotherapy with cyclophosphamide-doxorubicin-cisplatin (CAP); in another, 22% of patients refused therapy with CAP because of nausea and vomiting.

Practice