How does health literacy affect quality of life among men with newly diagnosed clinically localized prostate cancer?

BACKGROUND:

Health literacy deficits affect half of the US overall patient population, especially the elderly, and are linked to poor health outcomes among noncancer patients. Yet little is known about how health literacy affects cancer populations. The authors examined the relation between health‐related quality of life (HRQOL) and health literacy among men with prostate cancer.

METHODS:

Data analysis included 1581 men with newly diagnosed clinically localized prostate cancer from a population‐based study, the North Carolina‐Louisiana Prostate Cancer Project (PCaP). Participants completed assessment of health literacy using Rapid Estimate of Adult Literacy in Medicine (REALM) and HRQOL using the Short Form‐12 General Health Survey (SF12). Bivariate and multivariate regression was used to determine the potential association between REALM and HRQOL, while controlling for sociodemographic and illness‐related variables.

RESULTS:

Higher health literacy level was significantly associated with better mental well‐being (SF12‐Mental Component Summary [MCS]; P < .001) and physical well‐being (SF12‐Physical Component Summary [PCS]; P < .001) in bivariate analyses. After controlling for sociodemographic (age, marital status, race, income, and education) and illness‐related factors (types of cancer treatment, tumor aggressiveness, and comorbidities), health literacy remained significantly associated with SF12‐MCS scores (P < .05) but not with SF12‐PCS scores.

CONCLUSIONS:

Among patients with newly diagnosed localized prostate cancer, those with low health literacy levels were more vulnerable to mental distress than those with higher health literacy levels, but physical well‐being was no different. These findings suggest that health literacy may be important in patients managing prostate cancer and the effects of treatment, and provide the hypothesis that supportive interventions targeting patients with lower health literacy may improve their HRQOL. Cancer 2012. © 2011 American Cancer Society.     

High PSA anxiety and low health literacy skills: drivers of early use of salvage ADT among men with biochemically recurrent prostate cancer after radiotherapy?

BackgroundAlthough commonly used, early initiation of salvage androgen deprivation therapy (ADT) has not been proven to enhance survival. We evaluated whether prostate-specific antigen (PSA) anxiety or health literacy are associated with use of early salvage ADT among men with recurrent prostate cancer after radiotherapy.Patients and MethodsThe prospective Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma Registry was used to study 375 men with biochemically recurrent prostate cancer after external beam radiation or brachytherapy. Multivariable logistic regression was used to determine whether PSA anxiety and health literacy are associated with salvage ADT as initial management after biochemical recurrence.ResultsSixty-eight men (18.1%) received salvage ADT as initial management for PSA recurrence. Men with high PSA anxiety were twice as likely to receive salvage ADT compared with men who did not have high PSA anxiety on both univariable [28.8% versus 13.1%; odds ratio (OR) 2.15; 95% confidence interval (CI) 1.16–4.00; P = 0.015] and multivariable analysis [adjusted OR (AOR) 2.36; 95% CI 1.21–4.62; P = 0.012]. Furthermore, men who had higher levels of health literacy were nearly half as likely to undergo salvage ADT compared with men who had lower levels of health literacy on univariable analysis (15.2% versus 26.3%; OR 0.50; 95% CI 0.29–0.88; P = 0.016), with a trend toward this association on multivariable analysis (AOR 0.58; 95% CI 0.32–1.05; P = 0.07).ConclusionsAmong men with PSA recurrence after radiotherapy, odds of use of salvage ADT were nearly twice as great among men with high PSA anxiety or low health literacy, suggesting that these men are receiving higher rates of unproven treatment. Given that early salvage ADT is costly, worsens quality of life, and has not been shown to improve survival, quality improvement strategies are needed for these individuals.     

Do elderly people with lung cancer benefit from palliative radiotherapy?

The median age at diagnosis of patients with lung cancer is currently around 70 and is rising, yet the trials on which treatment is based included few elderly people. We conducted a prospective observational cohort study of 83 elderly patients (aged 75 and above) being treated with palliative radiotherapy for lung cancer, with a comparison group of 49 younger patients (aged 65 and under). Response to treatment was evaluated by patient-assessed symptom and quality of life scores using the EORTC QLQ-C30 and its companion lung module LC17. This is to date the largest prospective study of elderly lung cancer patients in routine practice. We found no significant differences in response or toxicity between the two groups. Elderly people with lung cancer should be offered palliative radiotherapy the same as younger patients, with the same expectation of benefit.     

Are medical oncologists biased in their treatment of the large woman with breast cancer?

Purpose. Obesity and breast cancer are common conditions that often coexist. Concerns of relative overdosing of chemotherapy in the large cancer patient have led clinicians to apply empiric dose reductions, cap the body surface area (BSA) at 2m², or use ideal rather than actual body weight to calculate BSA. There are no data supporting or refuting these practices and their prevalence is unknown. We sought to determine the distribution of body size and prevalence of obesity in the breast cancer population of our cancer centre, and to determine clinician chemotherapy dosing practices in the era of modern adjuvant chemotherapy. Patients and methods. Women with invasive breast cancer receiving systemic therapy at our institution between 1980 and 1998 were identified and their recorded height and weight were used to calculate BSA and body mass index (BMI). We reviewed the first cycle adjuvant chemotherapy dosing practices from 1990–1998. The ideal dose of chemotherapy was calculated based on calculated BSA, and then contrasted with the actual dose received at cycle one. Discrepancies were recorded and categorized, using the largest single drug reduction if more than one drug was reduced. Results. Mean BMI in the systemic therapy population was 26.4±5.3kg/m², 54% were overweight, 2% severely obese and 18% moderately so. Their mean BSA was 1.7±0.2m² and only 5% had a BSA2m². In the adjuvant chemotherapy subgroup, most patients received >85% of their ideal dose. The mean dose reduction was 5.3±11.3% versus 9.9±11.3% in the BSA <2 and >2m² groups, respectively (p=0.02), and 4.3±8.2% versus 6.7±13.1% in the BMI <25 and 25kg/m² groups, respectively (p=0.008). While only 24% of chemotherapy dose reductions of 15% were in the BSA 2m² group, 76% were in the BMI 25kg/m² group. Conclusions. Obesity is prevalent in this breast cancer population. BSA is not a sensitive index of large body size. We consistently detected more frequent empiric dose reductions at cycle one of adjuvant chemotherapy, with reductions of greater magnitude in the largest women (BSA 2m²) and those who were overweight (BMI 25kg/m²).     

Is sex associated with the outcome of patients treated with radiation for nonsmall cell lung cancer?

BACKGROUND:

Lung cancer is the leading cause of cancer death for both men and women, but the disease course differs between the sexes. To the authors' knowledge, sex‐based differences in outcomes among the population of nonsmall cell lung cancer (NSCLC) patients receiving radiation have not been well defined.

METHODS:

Data for 831 patients (319 women and 512 men) with stage I to III NSCLC and treated with ≥45 Gray of radiation between March 1985 and November 2003 were retrospectively analyzed (grading determined according to the 1997 American Joint Committee on Cancer grading system).

RESULTS:

Women were more likely to have earlier stage disease, to have smoked <50 pack‐years, and to have adenocarcinoma or large‐cell carcinoma (all P ≤ .001). For each stage, treatment did not differ between women and men. Five‐year survival rates were significantly better for women than for men: overall survival (OS), 28.6% versus 16.1% (P < .001); disease‐free survival, 31.2% versus 20.1% (P = .02); and distant metastasis–free survival, 48.8% versus 37.6% (P < .02). Among patients with medically inoperable stage I NSCLC, women had improved 5‐year OS compared with men (30.0% vs 13.1%; P = .004). On multivariate analysis, male sex, weight loss, age ≥65 years, and stage III disease were found to be associated with poorer OS (all P < 0.02).

CONCLUSIONS:

Although women are more likely to have earlier stage disease, among patients with medically inoperable stage I NSCLC, women still have a better OS. Along with known prognostic factors, including age, weight loss, and stage, sex remained significant on multivariate analysis of OS, suggesting that sex is a determinant of outcome in NSCLC patients receiving radiation. Cancer 2009. © 2009 American Cancer Society.     

Are endometrial cancer radiotherapy results age related?

Objective

To analyze the impact of age on radiotherapy results based on cancer-specific survival (CSS), vaginal-cuff relapses (VCR) and complications analysis in 438 patients with endometrial carcinoma (EC) receiving postoperative radiotherapy (PRT) divided into three age groups for analysis.

Materials and methods

From 2003 to 2015, 438 patients with EC were treated with PRT and divided into three age groups: Group-1: 202 patients <?65 years; Group-2: 210 patients ≥?65 and <?80 years; Group-3: 26 patients ≥?80 years. Vaginal toxicity was assessed using the objective LENT-SOMA criteria and RTOG scores were recorded for the rectum, bladder, and small bowel. Statistics: Chi square and Student’s t tests, Kaplan–Meier survival study for analysis of CSS.

Results

The mean follow-up was 5.6 years in Group-1, 5.6 years in Group-2 and 6.3 years in Group-3 (p?=?0.38). No differences were found among the groups in distribution of stage, grade, myometrial invasion, Type 1 vs. 2 EC and VLSI (p?=?0.97, p?=?0.52, p?=?0.35, p?=?0.48, p?=?0.76, respectively). There were no differences in rectal, bladder and vagina late toxicity (p?=?0.46, p?=?0.17, p?=?0.75, respectively). A better CSS at 5 years was found in Group-1 (p?=?0.006), and significant differences were found in late severe small bowel toxicity in Group-3 (p?=?0.005). VCR was increased in Group-3 (p?=?0.017).

Conclusions

Patients ≥?65 years had a worse outcome in comparison to younger patients. Late vaginal, rectal and bladder toxicities were similar in the three groups, although an increase of severe late small bowel toxicity led to IMRT in patients ≥?80 years. Further larger studies are needed including quality of life analysis in patients ≥?80 years.

     

Are there socio-economic inequalities in age of resection of colorectal cancer in people with HNPCC?

The relationship between socio-economic status and health has been consistently reported and is thought to be causal. Socio-economic inequalities are present in the incidence of and mortality from cancer in general, but not in the incidence of colorectal cancer in particular. However, there are socio-economic gradients in mortality from colorectal cancer. The socio-economic distribution of incidence of and mortality from colorectal cancer in individuals with hereditary non-polyposis colon cancer (Lynch syndrome) is not known. It is possible that increased awareness of and access to screening for colorectal cancer amongst this group of individuals reduces the socio-economic gradients seen in the population as a whole. We investigated the relationship between socio-economic status and age of resection of colorectal cancer in a cohort of individuals with hereditary non-polyposis colon cancer. More affluent individuals tended to undergo surgical resection for colorectal cancers earlier in their lives than less affluent individuals. This relationship was bordering on statistical significance. This trend probably represents socio-economic variations in access to treatment. In addition, age based diagnostic criteria for hereditary non-polyposis colon cancer may, inadvertently, accentuate socio-economic inequalities in outcome.     

Are the UK oncology trainees adequately informed about the needs of older people with cancer?

Background:

Outcomes for older people with cancer are poorer in the United Kingdom compared with that in other countries. Despite this, the UK oncology curricula do not have dedicated geriatric oncology learning objectives. This cross-sectional study of UK medical oncology trainees investigates the training, confidence level and attitudes towards treating older people with cancer.

Methods:

A web-based survey link was sent to the delegates of a national medical oncology trainee meeting. Responses were collected in October 2011.

Results:

The response rate was 93% (64 out of 69). The mean age of the respondents was 32.3 years (range 27–42 years) and 64.1% were female. A total of 66.1% of the respondents reported never receiving training on the particular needs of older people with cancer, 19.4% reported to have received this training only once. Only 27.1% of the trainees were confident in assessing risk to make treatment recommendations for older patients compared with 81.4% being confident to treat younger patients. Even fewer were confident with older patients with dementia (10.2%).

Conclusion:

This first study of the UK medical oncology trainees highlights the urgent need for change in curricula to address the complex needs of older people with cancer.     

Where should teenagers with cancer be treated?

Cancer in teenagers is relatively uncommon. Few health professionals in oncology are familiar with caring for teenagers, although most would acknowledge them as a characterisable clientele with specific needs different to those of others with cancer, whether younger or older. Many of those diagnosed with cancer between 13 and 20 years of age will be cured, often after intensive, toxic and life-changing treatment. The provision of the highly specialised medical and nursing care needed for cancer treatment must go alongside meeting the specific needs associated with this age group, an age of transition from childhood to adulthood. Care provision for teenagers must therefore address the treatment, information, educational, social and other support requirements of teenagers and their families. This must be done through the work of a highly specialised, experienced multidisciplinary team. A dedicated Teenage Cancer Unit (TCU) provides an appropriate environment in which teenagers may feel comfortable and from which such a multidisciplinary team can function. Such units cannot provide every aspect of a teenager's care throughout their cancer journey so must work in harmony with other agencies, particularly those in the community. TCUs are most successful when they are of sufficient size to ensure a critical mass of staff and experience. Not all teenagers with cancer will be treated on a TCU and other models that can meet both medical and age-specific needs are required.     

Is the coronary artery calcium score associated with acute coronary events in breast cancer patients treated with radiotherapy?

Background and purpose

The main objective of this study was to test whether pre-treatment coronary artery calcium (CAC) was associated with the cumulative incidence of acute coronary events (ACE) among breast cancer (BC) patients treated with postoperative radiotherapy (RT).

Do surgical oncologists achieve lower rates of local‐regional recurrence in node positive breast cancer treated with mastectomy alone?

BACKGROUND AND OBJECTIVE: Adjuvant radiotherapy for node positive breast cancer postmastectomy has been recommended by two previously published randomized controlled trials (RCT). The local-regional recurrence rates in the control arms, however, were considered by some critics to be excessive (> 25% at 10 years). Inadequate surgery, as evidenced by the low number of axillary nodes reported, may have resulted in the high local-regional recurrence rates, allowing for the benefits seen with radiotherapy. Fellowship trained surgical oncologists might provide "better quality" surgery, resulting in lower recurrence rates and thus making adjuvant radiotherapy unnecessary. Our objective was to establish the local-regional control rate postmastectomy in node positive breast cancer patients operated on by surgical oncologists, and to determine if treatment recommendations from previous RCTs are generalizable. METHODS: Node positive stage IIb and IIIa breast cancer patients treated with mastectomy at the Medical College of Virginia Hospitals by surgical oncologists, without adjuvant radiotherapy, and entered into adjuvant chemotherapy trials between 1978 and 1993 were identified retrospectively. Pathology and follow-up records were reviewed. RESULTS: One hundred and thirty-seven patients were identified. A median of 18 axillary nodes was reported with a median of 4 positive nodes. The locoregional recurrence at 10-years was 27% (95% confidence interval, 19-35%). CONCLUSION: Despite some evidence of "better quality" surgery, there was no clinically significant difference in the local-regional recurrence rate in this case series compared to controls in two previous RCTs. Recommendations for postmastectomy radiotherapy should be considered for node positive breast cancers, even if operated upon by surgical oncologists.     

Does prone positioning reduce small bowel dose in pelvic radiation with intensity-modulated radiotherapy for gynecologic cancer?

PURPOSE: Intensity-modulated radiotherapy (IMRT) has been shown to reduce the radiation dose to small bowel in pelvic RT in gynecology patients. Prone positioning has also been used to decrease small bowel dose by displacement of small bowel from the RT field in these patients. The purpose of this study was to determine whether the combination of both IMRT and prone positioning on a belly board can reduce small bowel dose further in gynecologic cancer patients undergoing pelvic RT. METHODS AND MATERIALS: IMRT plans for pelvic RT were computed in 16 patients with gynecologic cancer who had undergone planning CT scans in both the supine and the prone positions on a belly board. For the gross tumor volume, the uterus, cervix, and tumor (or postoperative region) were traced. The clinical target volume was defined as the vessels and lymph nodes from the obturator level to the aortic bifurcation, presacral region, and upper 4 cm of the vagina, in addition to gross tumor volume. The planning target volume was defined as a 2-cm margin in addition to the gross tumor volume and upper 4 cm of the vagina, and 1.5 cm for lymph nodes and vessels. Normal tissue regions of interest included small bowel, large bowel, and bladder. IMRT plans using (1) the limited arc technique (180 degrees arc length) and (2) the extended arc technique (340 degrees arc length) were computed. Dose-volume histograms for normal tissue structures and target were compared between the supine and prone IMRT plans using the paired t test. RESULTS: Prone positioning on a belly board decreased the small bowel dose in gynecologic pelvic IMRT, and the magnitude of improvement depended on the specific IMRT technique used. With the limited arc technique, prone positioning significantly decreased the irradiated small bowel volume at the 25-50-Gy dose levels compared with supine positioning. Small bowel volumes receiving > or =45 Gy decreased from 19% to 12.5% (p = 0.005) with prone positioning. With the extended arc technique, the decrease in irradiated small bowel volume was less marked, but remained detectable in the 35-45-Gy dose levels. Small bowel volumes receiving > or =45 Gy decreased from 13.6% to 10.1% (p = 0.03) with prone positioning. The effect of prone positioning on large bowel and bladder was variable. Large bowel volumes receiving > or =45 Gy increased with prone positioning from 16.5% to 20.6% (p = 0.02) in the limited arc technique and was unaffected in the extended arc technique. CONCLUSION: These preliminary data suggest that prone positioning on a belly board can reduce the small bowel dose further in gynecology patients treated with pelvic RT, and that the dose reduction depends on the IMRT technique used.     

Impact of radiotherapy on bone health in women with rectal cancer – A prospective cohort study

IntroductionPelvic radiotherapy (RT) increases the risk of pelvic insufficiency fractures. The aim was to investigate if RT is associated with changes in serum bone biomarkers in women with rectal cancer, and to examine the incidence of radiation-induced bone injuries and the association with bone biomarkers.Material and methodsWomen diagnosed with rectal cancer stage I-III, planned for abdominal surgery ± preoperative (chemo) RT, were prospectively included and followed one year. Serum bone biomarkers comprised sclerostin (regulatory of bone formation), CTX (resorption), BALP and PINP (formation). A subgroup was investigated with annual pelvic magnetic resonance imaging (MRI). The association between RT and bone biomarkers was explored in regression models.ResultsOf 134 included women, 104 had surgery with preoperative RT. The formation markers BALP and PINP increased from baseline to one year in the RT-exposed group (p < 0.001, longitudinal comparison). In the adjusted regression analysis, the mean increase in PINP was higher in the RT-exposed than the unexposed group (17.6 (3.6–31.5) μg/L, p = 0.013). Sclerostin and CTX did not change within groups nor differed between groups. Radiation-induced injuries were detected in 16 (42%) of 38 women with available MRI. At one year, BALP was higher among women with than without bone injuries (p = 0.018, cross-sectional comparison).ConclusionsPreoperative RT was associated with an increase in the formation marker PINP, which could represent bone recovery following RT-induced injuries, commonly observed in participants evaluated with MRI. These findings should be further explored in larger prospective studies on bone health in rectal cancer patients.     

Do antioxidants interfere with radiation therapy for cancer?

Despite recent comprehensive review articles concluding that supplemental antioxidants do not undermine the effectiveness of cytotoxic therapies, the use of antioxidants during cancer treatment remains controversial. Many oncologists take the position that antioxidants by their nature undermine the free radical mechanism of chemotherapy and radiotherapy and should therefore generally be avoided during treatment. For their part, many integrative practitioners believe that antioxidants taken during cancer treatment not only alleviate some of the adverse effects of that treatment but also enhance the efficacy of cancer therapy. Until recently, research attention has focused primarily on the interaction of antioxidants with chemotherapy; relatively little attention has been paid to the interaction of antioxidants with radiotherapy. This article reviews the clinical literature that has addressed whether antioxidants do in fact interfere with radiation therapy. Studies have variously investigated the use of alpha-tocopherol for the amelioration of radiation-induced mucositis; pentoxifylline and vitamin E to correct the adverse effects of radiotherapy; melatonin alongside radiotherapy in the treatment of brain cancer; retinol palmitate as a treatment for radiation-induced proctopathy; a combination of antioxidants (and other naturopathic treatments) and external beam radiation therapy as definitive treatment for prostate cancer; and the use of synthetic antioxidants, amifostine, dexrazoxane, and mesna as radioprotectants. With few exceptions, most of the studies draw positive conclusions about the interaction of antioxidants and radiotherapy. Although further studies are needed, the preponderance of evidence supports a provisional conclusion that dietary antioxidants do not conflict with the use of radiotherapy in the treatment of a wide variety of cancers and may significantly mitigate the adverse effects of that treatment.