Watch and Wait in Rectal Cancer After a Complete Response to Chemoradiotherapy – Is It Safe and Are We Doing Enough?

AimsTo summarise current understanding and the associated outcomes of the watch and wait approach after a clinical complete response (cCR) of rectal cancer to chemoradiotherapy.Materials and methodsA contemporary and comprehensive literature review was carried out using focused searches of the MEDLINE and Google Scholar databases.ResultsThe watch and wait approach is now an established and oncologically safe option for patients who develop a cCR. Long-term survival is equivalent to primary rectal resection and quality of life outcomes are demonstrably superior. The tumour regrowth rate of 25–33% is higher than local recurrence rates after total mesenteric excision. Therefore, intensive surveillance protocols are required to enable early salvage surgery. Salvage is feasible in more than 84% of cases, with equivalent survival outcomes to primary resection.DiscussionCurrent evidence focuses on patients with locally advanced disease, but there are superior rates of cCR and organ preservation in earlier stages of rectal cancer. A shift towards planning for cCR and maximising cCR rates is the logical next step for rectal preservation. Emerging evidence attempts to predict those who will achieve a complete response and allow more tailored management plans, and earlier cancers may represent the optimal targets.     

Wait times for breast cancer care

Measurement of care time intervals is complex, being influenced by many factors. The definition of the care interval monitored can also bias the detection of changes in waits. The implications of using different care interval definitions to report wait times and identify delays in care provision were examined using a retrospective chart review of 637 women with surgically treated breast cancer who were referred to a cancer centre between September 1999 and 2000 or September 2003 and 2004. Overall waits between detection and adjuvant treatment increased by 12 days over the two periods, but their exact location and cause(s) could not be determined at such a low-resolution interval. At higher resolutions of care intervals, reporting the comprehensive sequence of care events, the prolongation was mainly associated with delayed access to surgery (4 days) and delivery of adjuvant chemotherapy (4 days). The latter went unnoticed when waits were reported at intermediate (referral to adjuvant treatment) and low (detection to adjuvant treatment) resolutions. Disease stage and type of first adjuvant treatment consistently and significantly influenced the length of waits. Comprehensive monitoring of the entire care path is essential to effectively prioritize interventions, assess their outcomes and optimise access to cancer care.     

The Cost-effectiveness of Watch and Wait for Rectal Cancer

The existing literature suggests with a high degree of certainty that watch and wait is more cost-effective than initial total mesorectal excision. However, it is heavily reliant on poor-quality health-related quality of life data. Furthermore, the cost-effectiveness of organ preservation from a broader societal perspective has not been studied. Finally, the cost-effectiveness of emerging adjuncts to watch and wait for organ preservation, such as contact X-ray brachytherapy, local excision and total neoadjuvant therapy, need to be characterised.     

直肠癌新辅助放化疗后的非手术治疗

新辅助放化疗目前已成为临床Ⅱ、Ⅲ期直肠癌的标准辅助治疗方式。接受新辅助治疗的患者部分可达到病理完全缓解,即切除的样本中不存在癌细胞。达到临床完全缓解的患者,取消手术治疗后仍获得较好的生存率。临床是否可以通过筛选取消部分患者的手术治疗,以避免术中及术后可能存在的风险及不良反应成为值得探讨的问题。     

Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.     

Wait Times and Survival in Lung Cancer Patients across the Province of Quebec,Canada

Lung cancer is the leading cause of cancer death worldwide, with a five-year survival of 22% in Canada. Guidelines recommend rapid evaluation of patients with suspected lung cancer, but the impact on survival remains unclear. We reviewed medical records of all patients with newly diagnosed lung cancer in four hospital networks across the province of Quebec, Canada, between 1 February and 30 April 2017. Patients were followed for 3 years. Wait times for diagnosis and treatment were collected, and survival analysis using a Cox regression model was conducted. We included 1309 patients, of whom 39% had stage IV non-small cell lung cancer (NSCLC). Median wait times were, in general, significantly shorter in patients with stage III–IV NSCLC or SCLC. Surgery was associated with delays compared to other types of treatments. Median survival was 12.9 (11.1–15.7) months. The multivariate survival model included age, female sex, performance status, histology and stage, treatment, and the time interval between diagnosis and treatment. Longer wait times had a slightly protective to neutral effect on survival, but this was not significant in the stage I–II NSCLC subgroup. Wait times for the diagnosis and treatment of lung cancer were generally within targets. The shorter wait times observed for advanced NSCLC and SCLC might indicate a tendency for clinicians to act quicker on sicker patients. This study did not demonstrate the detrimental effect of longer wait times on survival.     

Analysis of Wait Times and Costs During the Peri-Diagnostic Period for Non-Small Cell Lung Cancer

Purpose

To determine the wait times and healthcare costs around the time of non-small cell lung cancer (NSCLC) diagnosis for a large, population-based cohort of patients.

Methods

Data on baseline demographics, diagnostic and staging tests, timelines of investigations, and frequency of physician visits and hospital admissions were obtained from a provincial cancer registry and health administrative databases for 2852 patients, who were diagnosed with NSCLC from 1996 to 2000 in Manitoba, Canada. Dates between investigations were used to determine wait times surrounding diagnosis and fee codes for physician and hospital services were used to estimate costs.

Results

The median wait times from chest x-ray to chest computed tomography (CT) scan and from CT scan to definitive histological diagnosis were 8 (inter-quartile range 1-25) and 18 (inter-quartile range 3-42) days, respectively. At least 25% of patients waited more than 55 days from initial suspicion on chest x-ray to final diagnosis of NSCLC. The mean cost per case of NSCLC diagnosis was $6,978 (in Canadian dollars) where the majority of expenses was attributed to hospital admissions and repeated physician visits before a diagnosis was confirmed.

Conclusions

Despite clinical suspicion for NSCLC, a significant number of patients wait more than 8 weeks for a definitive diagnosis. Substantial costs are incurred by the Canadian universal healthcare system in the months surrounding diagnosis. Establishment of more efficient and cost-effective healthcare delivery in the peri-diagnostic time period may benefit the system as well as the patients.     

The Utility of Publicly Reported Cancer Treatment Wait Time Information for Patients and Health Care Providers

AimsTo determine the utility of web-based radiation wait time information for patients and health care providers in decision-making. To revise the information using a simulated laboratory environment and to re-evaluate the new web-based information.Materials and methodsAn online ‘pop-up’ survey on the Cancer Care Ontario (CCO) website measured user satisfaction. Qualitative data were gathered through patient focus groups and physician interviews. On the basis of the analysis, the website was revised and usability testing conducted. The information was re-evaluated by end-users through survey methodology.ResultsThe majority accessing the wait time website were patients and family members. The modal age of use of the website was 31–50 years. Patients found the information more helpful after redesign than health professionals, but both found the language less easy to understand, highlighting the need to continuously evaluate the effectiveness of the website. Patients did not identify themselves as consumers of wait time information. Their expectation was that physicians would determine the urgency for treatment and would ensure timely access to care. Physicians reported that they did not use the CCO website on wait times and would not use the data for decision-making. Referrals were based on urgency of care and usual referral patterns. Referral patterns did not shift to centres with shorter wait times.ConclusionsThe results of this study did not confirm the usefulness of the web-based wait time information for patients and physicians as a resource on how to obtain timely access to radiation treatment. Patients relied on their physician to manage their access to treatment according to the urgency of their clinical condition. Physicians preferred their established referral process rather than referring their patients to centres with shorter wait times. As patients become more computer savvy, it will be interesting to see if they increasingly become consumers of web-based wait time information.     

Can tamoxifen relieve motion sickness?

Motion sickness (MS) is an unpleasant and sometimes disablingcondition in response to the perception of certain kind of motions.Its pathogenesis is incompletely understood; interactions betweenendocrine mechanisms and the vestibular apparatus are likely,as suggested by a higher incidence and severity of MS in femalesand pregnancy, the reported changes