Prediction models in cancer care

Prediction is ubiquitous across the spectrum of cancer care from screening to hospice. Indeed, oncology is often primarily a prediction problem; many of the early stage cancers cause no symptoms, and treatment is recommended because of a prediction that tumor progression would ultimately threaten a patient's quality of life or survival. Recent years have seen attempts to formalize risk prediction in cancer care. In place of qualitative and implicit prediction algorithms, such as cancer stage, researchers have developed statistical prediction tools that provide a quantitative estimate of the probability of a specific event for an individual patient. Prediction models generally have greater accuracy than reliance on stage or risk groupings, can incorporate novel predictors such as genomic data, and can be used more rationally to make treatment decisions. Several prediction models are now widely used in clinical practice, including the Gail model for breast cancer incidence or the Adjuvant! Online prediction model for breast cancer recurrence. Given the burgeoning complexity of diagnostic and prognostic information, there is simply no realistic alternative to incorporating multiple variables into a single prediction model. As such, the question should not be whether but how prediction models should be used to aid decision‐making. Key issues will be integration of models into the electronic health record and more careful evaluation of models, particularly with respect to their effects on clinical outcomes. CA Cancer J Clin 2011. © 2011 American Cancer Society, Inc.     

Risk prediction tools for cancer in primary care

Numerous risk tools are now available, which predict either current or future risk of a cancer diagnosis. In theory, these tools have the potential to improve patient outcomes through enhancing the consistency and quality of clinical decision-making, facilitating equitable and cost-effective distribution of finite resources such as screening tests or preventive interventions, and encouraging behaviour change. These potential uses have been recognised by the National Cancer Institute as an ‘area of extraordinary opportunity'' and an increasing number of risk prediction models continue to be developed. The data on predictive utility (discrimination and calibration) of these models suggest that some have potential for clinical application; however, the focus on implementation and impact is much more recent and there remains considerable uncertainty about their clinical utility and how to implement them in order to maximise benefits and minimise harms such as over-medicalisation, anxiety and false reassurance. If the potential benefits of risk prediction models are to be realised in clinical practice, further validation of the underlying risk models and research to assess the acceptability, clinical impact and economic implications of incorporating them in practice are needed.     

Adjuvant therapy in renal cell carcinoma

Localized renal cell carcinoma (RCC) has an associated risk of recurrence after nephrectomy. Several clinical risk models attempt to predict oncologic outcomes based on clinical and pathologic features. In addition, novel gene signatures have been developed to refine risk prediction based on tumor biology. Systemic therapies targeting angiogenic pathways that are effective in metastatic RCC failed to show an improvement in overall survival in the adjuvant setting. Immune checkpoint inhibitors have shown significant antitumor activity with prolonged and durable responses in metastatic RCC, which led to an interest in evaluating these agents in the adjuvant setting. In this review, clinical risk-predictive models, novel gene signatures, major clinical trials completed in the adjuvant setting, ongoing immune checkpoint inhibitor trials, and the perspective of adjuvant treatment in RCC are discussed.     

Treatment failure prediction for head-and-neck cancer radiation therapy

PurposeTreatment outcome prediction is an important emerging topic in oncologic care. To support radiation oncologists on their decisions, with individualized, tailored treatment regimens increasingly becoming the standard of care, accurate tools to predict tumour response to treatment are needed. The goal of this work is to identify the most determinant factor(s) for treatment response aiming to develop prediction models that robustly estimate tumour response to radiation therapy in patients with head-and-neck cancer.Patients and methodsA population-based cohort study was performed on 92 patients with head-and-neck cancer treated with radiation from 2007 until 2014 at the Portuguese Institute of Oncology of Coimbra (IPOCFG). Correlation analysis and multivariate binary logistic regression analysis were conducted in order to explore the predictive power of the considered predictors. Performance of the models is expressed as the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. A nomogram to predict treatment failure was developed.ResultsSignificant prognostic factors for treatment failure, after multivariate regression, were older age, non-concomitant radiation therapy and larger primary tumour volume. A regression model with these predictors revealed an AUC of .78 for an independent data set.ConclusionFor patients with head-and-neck cancer treated with definitive radiation, we have developed a prediction nomogram based on models that presented good discriminative ability in making predictions of tumour response to treatment. The probability of treatment failure is higher for older patients with larger tumours treated with non-concomitant radiation.     

Nerve-sparing techniques in open and laparoscopic prostatectomy

Open and laparoscopic radical prostatectomy is a safe and effective treatment for organ-confined prostate cancer with excellent cancer control and quality of life outcomes. We present current nerve-sparing techniques used in open, laparoscopic and robot-assisted prostatectomy to maximize postoperative potency. We review the literature and describe important anatomical landmarks and technical aspects that differentiate between approaches. Nerve trauma is inherent to the surgery and cannot be completely avoided. These techniques serve to minimize injury without compromising oncologic outcomes. In combination with postoperative pharmacological and mechanical recuperative approaches, nerve-sparing surgery has made an impact in postprostatectomy quality of life.     

Nerve-sparing techniques in open and laparoscopic prostatectomy

Open and laparoscopic radical prostatectomy is a safe and effective treatment for organ-confined prostate cancer with excellent cancer control and quality of life outcomes. We present current nerve-sparing techniques used in open, laparoscopic and robot-assisted prostatectomy to maximize postoperative potency. We review the literature and describe important anatomical landmarks and technical aspects that differentiate between approaches. Nerve trauma is inherent to the surgery and cannot be completely avoided. These techniques serve to minimize injury without compromising oncologic outcomes. In combination with postoperative pharmacological and mechanical recuperative approaches, nerve-sparing surgery has made an impact in postprostatectomy quality of life.     

Predicting clinical end points: treatment nomograms in prostate cancer

Due to the generally indolent nature of prostate cancer, patients must decide among a wide range of treatments, which will significantly affect both quality of life and survival. Thus, there is a need for instruments to aid patients and their physicians in decision analysis. Nomograms are instruments that predict outcomes for the individual patient. Using algorithms that incorporate multiple variables, nomograms calculate the predicted probability that a patient will reach a clinical end point of interest. Nomograms tend to outperform both expert clinicians and predictive instruments based on risk grouping. We outline principles for nomogram construction, including considerations for choice of clinical end points and appropriate predictive variables, and methods for model validation. Currently, nomograms are available to predict progression-free probability after several primary treatments for localized prostate cancer. There is need for additional models that predict other clinical end points, especially survival adjusted for quality of life.     

Breast cancer—The catalyst of contemporary trials design

Surgical trials in breast cancer have catalyzed contemporary trial design for solid organ cancers and are a prime example of surgeons taking the lead in clinical trial design. Surgeons have lead trials that have improved patient outcomes and quality of life without sacrificing oncologic safety. We have evolved from radical mastectomy to breast conservation and sentinel node biopsy. Contemporary trial design in breast cancer now focus on personalizing care based on tumor genomics     

Endoscopic Resection of Sinonasal Cancers

Sinonasal malignancies, a rare group of tumors, are characterized by histological heterogeneity and poor survival. As improvements in image-guidance and endoscopic technologies became incorporated into head and neck oncologic and neurosurgical practice, the application of these technologies and techniques to the surgical management of sinonasal malignancy began. Over the past decade, there has been increasing evidence regarding the safety and oncological effectiveness of these techniques. Several institutions have reported their experience with endoscopic surgery and have shown reduced morbidity, better quality of life, and survival outcomes equivalent to those of open surgery in carefully selected patients. Endoscopic cranial base surgery is a rapidly evolving field. We review the literature on oncological outcomes, safety, quality of life, and recent technological advances.     

Geriatric assessment in the management of older patients with cancer – A systematic review (update)

AimThe aim of this systematic review is to summarize all available data on the effect of a geriatric assessment in older patients with cancer, for oncologic treatment decisions, the implementation of non-oncologic interventions, patient-doctor communication, and treatment outcome. Additionally, we examined the impact of the type of assessment used.MethodsSystematic Medline and Embase search for studies on the effect of a geriatric assessment on oncologic treatment decisions, non-oncologic interventions, communication, and outcome.ResultsSixty-five publications from 61 studies were included. After a geriatric assessment, the oncologic treatment plan was altered in a median of 31% of patients (range 7–56%), with highest change rates in studies using a multidisciplinary team evaluation. Non-oncologic interventions were recommended in over 70% of patients, provided that an intervention plan or specific expertise was in place. A geriatric assessment led to more goals-of-care discussions and improved communication. The geriatric assessment also led to lower toxicity/complication rates (most strongly if the assessment outcomes were considered during decision making), improved likelihood of treatment completion, and improved physical functioning and quality of life in the majority of included studies.ConclusionA geriatric assessment can change oncologic treatment plans, leads to non-oncologic interventions, and improve communication about care planning and ageing-related issues. It can decrease toxicity/complications and improve treatment completion and patient-centred outcomes. If multidisciplinary or geriatric input is not available, having a pre-defined non-oncologic intervention plan is important. To maximize the effect on outcomes, the result of the geriatric assessment should be incorporated into oncologic decision-making.     

Quality of life after rectal resection and multimodality therapy

Modern management of locally advanced rectal cancer requires a multimodality approach. This includes radical surgery, pelvic radiotherapy, and systemic chemotherapy. It can require a permanent colostomy and result in significant bowel, sexual, and urinary dysfunction. In order to determine the effectiveness of various multimodality regimens it is important to not only assess conventional oncologic outcomes but also the impact on patient's quality of life.     

The influence of self‐efficacy and resilient coping on cancer patients’ quality of life

The objective of this study was to analyse whether general self‐efficacy and resilient coping are negatively impacted when people are sick with cancer (compared with people from the general population), and whether these resource variables predict quality of life outcomes in that patient group. A sample of 959 patients recruited in an oncologic rehabilitation clinic was examined once while hospitalised and once again six months thereafter. The outcome variables were quality of life (EORTC QLQ‐C30) and distress (PHQ‐4). The resource variables were self‐efficacy (General Self‐Efficacy Scale) and resilient coping (Brief Resilient Coping Scale). Representative samples of the general population served as controls. Self‐efficacy (d = 0.08) and resilient coping (d = 0.28) were only slightly lower in the patients’ sample than in the general population. Both resource variables were associated with quality of life, but self‐efficacy (and not resilient coping) was the only independent predictor of quality of life functioning scales and distress scores when the baseline values of the dependent variables were also taken into account. Strengthening patients’ belief in their own ability to cope with the disease may help them retain and/or regain a higher level of quality of life.     

Quality assessment in oncology

The movement to improve healthcare quality has led to a need for carefully designed quality indicators that accurately reflect the quality of care. Many different measures have been proposed and continue to be developed by governmental agencies and accrediting bodies. However, given the inherent differences in the delivery of care among medical specialties, the same indicators will not be valid across all of them. Specifically, oncology is a field in which it can be difficult to develop quality indicators, because the effectiveness of an oncologic intervention is often not immediately apparent, and the multidisciplinary nature of the field necessarily involves many different specialties. Existing and emerging comparative effectiveness data are helping to guide evidence-based practice, and the increasing availability of these data provides the opportunity to identify key structure and process measures that predict for quality outcomes. The increasing emphasis on quality and efficiency will continue to compel the medical profession to identify appropriate quality measures to facilitate quality improvement efforts and to guide accreditation, credentialing, and reimbursement. Given the wide-reaching implications of quality metrics, it is essential that they be developed and implemented with scientific rigor. The aims of the present report were to review the current state of quality assessment in oncology, identify existing indicators with the best evidence to support their implementation, and propose a framework for identifying and refining measures most indicative of true quality in oncologic care.     

Current philosophy on the management of cancer of the base of the tongue

Cancer of the base of the tongue is a challenging disease for the head and neck surgeon, radiation oncologist and medical oncologist. However, over the last 10-15 years, improved treatment strategies have evolved which offer patients high probability of loco-regional control, survival, and good quality of life. The ability to offer patients good oncologic and functional outcomes serves as a paradigm for the successful application of multidisciplinary care, and the emphasis on quality of life in head and neck cancer treatment. This review provides an overview of the treatment options that exist, their advantages and disadvantages, and hopefully provides proper guidelines for the current management of this challenging disease.     

La plateforme régionale « Cancer et fertilité »: un projet pilote du réseau ONCOPACA-Corse

Global improvements in patient prognosis and impetus gained fromthe two French cancer plans have lead to reconsider the importance of quality of life on survival, and especially of fertility preservation as an essential part of oncologic supportive care. Post treatment, patients should have the opportunity to enjoy and plan parenthood in keeping with their expectations. The regional cancer network ONCOPACA-Corse has implemented coordinated actions to promote rapid access to this specific care. This platform will provide access to emerging techniques, in particular for the female and the paediatric population, and patients’ followup. Delivering specific information to oncologic staffs is essential to reach this objective.     

Risk prediction models for postoperative outcomes of colorectal cancer surgery in the older population - a systematic review

BackgroundAn increasing number of patients with Colorectal Cancer (CRC) is 65 years or older. We aimed to systematically review existing clinical prediction models for postoperative outcomes of CRC surgery, study their performance in older patients and assess their potential for preoperative decision making.MethodsA systematic search in Pubmed and Embase for original studies of clinical prediction models for outcomes of CRC surgery. Bias and relevance for preoperative decision making with older patients were assessed using the CHARMS guidelines.Results26 prediction models from 25 publications were included. The average age of included patients ranged from 61 to 76. Two models were exclusively developed for 65 and older. Common outcomes were mortality (n = 10), anastomotic leakage (n = 7) and surgical site infections (n = 3). No prediction models for quality of life or physical functioning were identified. Age, gender and ASA score were common predictors; 12 studies included intraoperative predictors. For the majority of the models, bias for model development and performance was considered moderate to high.ConclusionsPrediction models are available that address mortality and surgical complications after CRC surgery. Most models suffer from methodological limitations, and their performance for older patients is uncertain. Models that contain intraoperative predictors are of limited use for preoperative decision making. Future research should address the predictive value of geriatric characteristics to improve the performance of prediction models for older patients.     

Local therapy in prostate cancer—surgery versus radiation

Many patients with localized prostate cancer are eligible for more than one treatment option. Currently, both radical prostatectomy (RP) and radiotherapy (RT) are the key treatment options in organ-confined disease. In this review, we provide an overview about oncologic outcomes of both therapy modalities. Additionally, we review studies about patients’ quality of life after therapy as well as common side effects of both therapeutic options.     

Local excision for early rectal cancer: transanal endoscopic microsurgery and beyond

The goal of treatment for early stage rectal cancer is to optimize oncologic control while minimizing the long-term impact of treatment on quality of life. The standard of care treatment for most stage I and II rectal cancers is radical surgery alone, specifically total mesorectal excision (TME). For early rectal cancers, this procedure is usually curative but can have a substantial impact on quality of life, including the possibility of permanent colostomy and the potential for short and long-term bowel, bladder, and sexual dysfunction. Given the morbidity associated with radical surgery, alternative approaches to management of early rectal cancer have been explored, including local excision (LE) via transanal excision (TAE) or transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). Compared to the gold standard of radical surgery, local procedures for strictly selected early rectal cancers should lead to identical oncological results and even better outcomes regarding morbidity, mortality, and quality of life.     

Minimally Invasive Surgery for Rectal Cancer: Current Trends

Purpose of the Review

The literature regarding minimally invasive surgical approaches to rectal adenocarcinoma is reviewed, and techniques introduced over recent decades are assessed for oncological and patient-centered outcomes.

Recent Findings

Total mesorectal excision (TME) is the gold standard for surgical treatment of rectal adenocarcinoma, and while laparoscopic TME is safe and feasible, with acceptable oncologic outcomes, its non-inferiority with regard to completeness of TME specimen when compared to open surgery could not be established in two recent randomized trials. Long-term follow-up for these trials is pending with regard to ultimate oncologic outcomes. Robotic TME is also safe and feasible when performed by experienced surgeons, but has high costs, and results of the only randomized trial comparing the technique to laparoscopy are yet to be published. Laparoscopic and robotic approaches appear to offer short-term benefits in patient recovery and quality of life. The latest innovation is transanal TME (TaTME). This is performed at select centers, and early on, has been associated with acceptable resection quality and short-term outcomes. Organ-preserving transanal and endoscopic resections for early-stage disease have acceptable results, and a non-operative/watch-and-wait strategy may be appropriate in selected patients with a complete clinical response.

Summary

There are multiple surgical options for rectal adenocarcinoma, depending on patient and disease characteristics. In the appropriate setting, minimally invasive approaches to TME offer short-term benefits to patients and acceptable oncologic results. Organ-preserving strategies in selected patients may avoid morbidity associated with radical resection.

     

Geriatric oncology and palliative medicine

People age 65 years and older are the fastest growing segment of the US population. Cancer is one of the leading causes of death in the elderly. Geriatric oncology has developed since most cancer cases are diagnosed in elderly patients and the majority of cancer deaths occur in elderly patients. Little is known on how to best treat elderly patients with cancer and deal with treatment side effects and palliative care. Most recommendations have focused on the need for clinical trials specifically for the elderly with cancer, and a short, easy tool to predict chemotherapy toxicity. The focus of geriatric oncologists has been to integrate geriatric assessment into the care of the elderly cancer patient and find new assessment tools to predict chemotherapy tolerance, toxicity, and outcomes. Understanding the importance of supportive management during antineoplastic treatment and developing an intentional approach to palliative care issues (which are an important part of treating elderly patients with cancer) will help patients complete a full treatment course and maintain quality of life.