Biomedical subjects

Rebecca K S Wong

Publications and source records attributed to Rebecca K S Wong.

15 recordsLinked to original sources

PubMed2026

Older adults with resectable gastric cancer undergoing perioperative chemotherapy or preoperative chemoradiotherapy plus perioperative chemotherapy: A secondary analysis of the AGITG TOPGEAR phase III trial.

PURPOSE: To evaluate treatment adherence, adverse events, and survival in older (≥70 years) adults undergoing perioperative treatment for gastric cancer. METHODS: Patients with resectable gastric/gastro-esophageal junction adenocarcinoma (ECOG 0-1) enrolled in the phase III TOPGEAR trial were randomized to perioperative chemotherapy (ECF/ECX or FLOT) alone or perioperative chemotherapy plus preoperative chemoradiotherapy (45 Gy in 25 fractions with concurrent fluoropyrimidine). In this exploratory analysis, treatment completion, grade ≥ 3 adverse events (CTCAE v3.0), surgical outcomes, overall survival (OS) and progression-free survival (PFS) were compared between older and younger adults. RESULTS: Of the 574 patients enrolled, 135 (24%) were ≥ 70 years. Older adults more frequently required preoperative chemotherapy dose reductions, omissions, or delays (chemoradiotherapy: 55% vs 35%, p = 0.004; chemotherapy: 60% vs 48%, p = 0.087). Rates of grade ≥ 3 adverse events were comparable between older and younger patients (chemoradiotherapy: 66% vs 67%, p = 0.874; chemotherapy: 68% vs 59%, p = 0.220), but older adults more often had hematologic toxicity and grade ≥ 3 diarrhea in the chemotherapy group (56% vs 37%, p = 0.006; 21% vs 6%, p < 0.001). Resection rates, grade 3/4 surgical complications, number of removed lymph nodes, and 30-/90-day mortality were similar by age. OS and PFS were comparable across age groups, with numerically favorable outcomes for older adults (OS: HR 0.86, 95% CI 0.58-1.26 [chemoradiotherapy]; HR 0.75, 95% CI 0.51-1.11 [chemotherapy]; PFS: HR 0.78, 95% CI 0.53-1.15 [chemoradiotherapy]; HR 0.70, 95% CI 0.47-1.03 [chemotherapy]). CONCLUSIONS: Older adults with gastric cancer achieved comparable oncologic outcomes to younger patients, despite more frequent treatment modifications and higher hematologic toxicity.

Humans↗

PubMed2006

The treatment of depression in cancer patients: a systematic review.

GOALS OF THE WORK: To evaluate the efficacy of pharmacological and nonpharmacological treatments for depression in cancer populations. MATERIALS AND METHODS: The Supportive Care Guidelines Group conducted a systematic review of the published literature through June 2005. Search sources includes MEDLINE, EMBASE, CINAHL, PsycInfo, and the Cochrane Library. Comparative studies of treatments for depression in cancer patients were selected for review by two group members based on predefined criteria. MAIN RESULTS: Seven trials of pharmacological agents and four of nonpharmacological interventions were identified. Two trials detected a significant reduction in depressive symptoms for mianserin compared with placebo, and one trial found alprazolam to be superior to progressive muscle relaxation. Four drug trials found no significant difference between groups on depression measures although posttreatment reduction of symptoms was observed for all groups in two trials comparing active treatments (fluoxetine vs desipramine and paroxetine vs amitriptyline). Of the four trials involving nonpharmacological therapies for the management of depression, two detected a benefit for treatment (a multicomponent nurse delivered intervention and an orientation program) over usual care. CONCLUSION: There is limited evidence for the effectiveness of pharmacological and psychosocial interventions in the treatment of cancer patients with depressive disorders, and no evidence for the superiority of one treatment modality over another. Based on evidence from the general population and other medically ill populations, combined approaches to the treatment of depression may be the most effective. Further research is necessary in cancer patients to determine the relative effectiveness of psychosocial, pharmacological, and combined treatments.

Antidepressive Agents↗

PubMed2006

5-hydroxytryptamine-3 receptor antagonist with or without short-course dexamethasone in the prophylaxis of radiation induced emesis: a placebo-controlled randomized trial of the National Cancer Institute of Canada Clinical Trials Group (SC19).

PURPOSE: To evaluate the effectiveness of prophylactic dexamethasone for the control of radiation induced emesis (RIE) when added to ondansetron during days 1 to 5 of fractionated radiotherapy. The study had two hypotheses: ondansetron and dexamethasone could provide superior control of RIE over ondansetron alone during the prophylactic period and; the combination could provide sustained control of RIE during subsequent fractions of radiotherapy. PATIENTS AND METHODS: Between May 2001 to Jan 2004, 211 patients receiving radiotherapy (> or = 15 fractions) to the upper abdomen were randomly assigned to receive ondansetron 8 mg bid with either dexamethasone 4 mg daily or placebo during fractions 1 to 5. Rescue antiemetics were provided. RESULTS: During the prophylactic period there was a trend for improved complete control of nausea in the dexamethasone arm (50% v 38%; P = .06) while complete and partial control of emesis, average nausea score, and use of rescue medications were similar in the two groups. During the overall study period patients receiving dexamethasone had better complete control of emesis (23% v 12%; P = .02) and a lower average nausea score (0.28 v 0.39; P = .03); there was a trend towards less use of rescue medications with dexamethasone (70% v 80%; P = .09); other outcomes were similar on the two arms. Quality of life analysis showed a significant difference in appetite. CONCLUSION: The addition of dexamethasone to ondansetron as prophylaxis provides a modest improvement in protection against RIE during moderately emetogenic fractionated radiotherapy. It is a potentially useful addition to 5-hydroxytryptamine-3 receptor antagonists in this setting.

Antiemetics↗

PubMed2006

The prevention and management of acute skin reactions related to radiation therapy: a systematic review and practice guideline.

GOALS OF WORK: To develop a practice guideline report on the questions: What are the optimal methods to prevent acute skin reactions (occurring within the first 6 months of irradiation) related to radiation therapy? What are the optimal methods to manage acute skin reactions related to radiation therapy? MATERIALS AND METHODS: Cancer Care Ontario's Supportive Care Guidelines Group (SCGG) conducted a systematic review of literature on this topic. Evidence-based recommendations were formulated to guide clinical decision making, and a formal external review process was conducted to validate the relevance of these opinions for Ontario practitioners. MAIN RESULTS: Twenty-eight trials meeting the inclusion criteria were identified. Of the twenty-three trials that evaluated preventative methods, washing was the only practice which significantly prevented skin reaction. Some evidence suggested topical steroid creams and calendula ointment might be effective. None of the five trials evaluating skin reaction management detected a positive effect using steroid cream, sucralfate cream, or dressings. CONCLUSIONS: Skin washing, including gentle washing with water alone with or without mild soap, should be permitted in patients receiving radiation therapy to prevent acute skin reaction. There is insufficient evidence to support or refute specific topical or oral agents for the prevention or management of acute skin reaction. In the expert opinion from the SCGG, the use of a plain, non-scented, lanolin-free hydrophilic cream may be helpful in preventing radiation skin reactions. In addition, a low dose (i.e., 1%) corticosteroid cream may be beneficial in the reduction of itching and irritation.

Acute Disease↗

PubMed2006

Decision making in palliative radiation therapy: reframing hope in caregivers and patients with brain metastases.

GOALS OF WORK: To explore the major factors important in decision making for whole-brain radiotherapy (WBRT) for patients with brain metastases and their caregivers. PATIENTS AND METHODS: Two parallel qualitative studies, one for patients and one for caregivers of patients with newly diagnosed brain metastases, were conducted. Semistructured interviews were conducted and audiotaped with each participant. Content analysis and theme extraction of the transcripts were undertaken to identify recurring themes and relational patterns. RESULTS: Twenty patients and 19 caregivers (including eight patient and caregiver pairs) were recruited into the study. Four major factors were identified to influence decision making of whole-brain radiation: hope, knowledge, expectations of radiation therapy, and current symptoms. Analysis reveals that patients generally focus on current informational needs, while caregivers want more information about the future (e.g., life expectancy and anticipated symptoms). Caregivers expressed frustration when unable to explore future needs because patients were unprepared to discuss prognostic issues. Participants expressed substantial relief when offered WBRT after the diagnosis, but WBRT is often considered the only available plan rather than an informed choice. CONCLUSIONS: Given the importance of caregivers in the care of patients with brain metastases, fulfilling their unique informational needs appears to require more attention. The blurred boundary between hopes and expectations for WBRT creates unique challenges in joint treatment decision making for patients with brain metastases and their caregivers.

Adaptation, Psychological↗

PubMed2005

Clinical practice guideline on the optimal radiotherapeutic management of brain metastases.

BACKGROUND: An evidence-based clinical practice guideline on the optimal radiotherapeutic management of single and multiple brain metastases was developed. METHODS: A systematic review and meta-analysis was performed. The Supportive Care Guidelines Group formulated clinical recommendations based on their interpretation of the evidence. External review of the report by Ontario practitioners was obtained through a mailed survey, and final approval was obtained from Cancer Care Ontario's Practice Guidelines Coordinating Committee (PGCC). RESULTS: One hundred and nine Ontario practitioners responded to the survey (return rate 44%). Ninety-six percent of respondents agreed with the interpretation of the evidence, and 92% agreed that the report should be approved. Minor revisions were made based on feedback from external reviewers and the PGCC. The PGCC approved the final practice guideline report. CONCLUSIONS: For adult patients with a clinical and radiographic diagnosis of brain metastases (single or multiple) we conclude that: surgical excision should be considered for patients with good performance status, minimal or no evidence of extracranial disease, and a surgically accessible single brain metastasis. Postoperative whole brain radiotherapy (WBRT) should be considered to reduce the risk of tumour recurrence for patients who have undergone resection of a single brain metastasis. Radiosurgery boost with WBRT may improve survival in select patients with unresectable single brain metastases. The whole brain should be irradiated for multiple brain metastases. Standard dose-fractionation schedules are 3000 cGy in 10 fractions or 2000 cGy in 5 fractions. Radiosensitizers are not recommended outside research studies. In select patients, radiosurgery may be considered as boost therapy with WBRT to improve local tumour control. Radiosurgery boost may improve survival in select patients. Chemotherapy as primary therapy or chemotherapy with WBRT remains experimental. Supportive care is an option but there is a lack of Level 1 evidence as to which subsets of patients should be managed with supportive care alone. Qualifying statements addressing factors to consider when applying these recommendations are provided in the full report. The rigorous development, external review and approval process has resulted in a practice guideline that is strongly endorsed by Ontario practitioners.

Humans↗

PubMed2005

Radiotherapeutic management of brain metastases: a systematic review and meta-analysis.

BACKGROUND: The management of brain metastases is a significant health care problem. An estimated 20-40% of cancer patients will develop metastatic cancer to the brain during the course of their illness. METHODS: A systematic review of randomized trials on adult cancer patients with single or multiple brain metastases from cancer of any histology was conducted. Eligible studies investigated external beam radiotherapy or radiosurgery in one of the study arms. Outcomes of interest included survival, intracranial progression-free duration, response of brain metastases to therapy, quality of life, symptom control, neurological function, and toxicity. RESULTS: Twenty-seven trials were included in this systematic review of the evidence. Pooled results from three randomized trials of surgical excision combined with whole brain radiotherapy (WBRT) showed no improvement in overall survival as compared to WBRT alone in patients with single brain metastasis. One randomized study of postoperative WBRT following excision of a single brain metastasis versus surgery alone detected a significant reduction in intracranial tumour recurrence rates but no corresponding difference in overall survival. Nine trials of altered dose-fractionation schedules compared to a standard control fractionation schedule (3000 cGy in 10 fractions) of WBRT showed no difference in probability of survival at 6 months. The addition of radiosensitizers, as assessed in five trials, did not confer additional benefit to WBRT in terms of overall survival or the frequency of brain metastases response. Three trials examined the use of WBRT and radiosurgery boost versus WBRT alone in selected patients with brain metastases. Overall survival did not improve for patients with multiple brain metastases. However, one trial reported an improvement in survival for patients with single brain metastasis treated with WBRT and radiosurgery boost. One older randomized trial examined the use of WBRT versus supportive care alone (using oral prednisone). Results were not conclusive. CONCLUSION: For patients with a single brain metastasis, good performance status, and minimal or no evidence of extracranial disease, surgical excision and postoperative WBRT improves survival (as compared to WBRT alone). There may be a small survival advantage associated with the use of radiosurgery boost and WBRT as compared to WBRT alone in selected patients with a single brain metastasis. There is no difference in overall survival or in neurologic function improvement with the use of altered whole brain dose-fractionation schedules as compared to standard fractionation schedules (3000 cGy in 10 fractions or 2000 cGy in 5 fractions). There is no survival benefit associated with the use of radiosurgery boost and WBRT versus WBRT alone in patients with multiple brain metastases. Currently, neither chemotherapy nor radiosensitizers show a clear benefit in the objective parameters of survival and progression-free survival. For patients with poor performance status and active extracranial disease, steroids and supportive care are an option.

Brain Neoplasms↗

PubMed2004

Radiotherapy fractionation for the palliation of uncomplicated painful bone metastases - an evidence-based practice guideline.

BACKGROUND: This practice guideline was developed to provide recommendations to clinicians in Ontario on the preferred standard radiotherapy fractionation schedule for the treatment of painful bone metastases. METHODS: A systematic review and meta-analysis was performed and published elsewhere. The Supportive Care Guidelines Group, a multidisciplinary guideline development panel, formulated clinical recommendations based on their interpretation of the evidence. In addition to evidence from clinical trials, the panel also considered patient convenience and ease of administration of palliative radiotherapy. External review of the draft report by Ontario practitioners was obtained through a mailed survey, and final approval was obtained from the Practice Guidelines Coordinating Committee. RESULTS: Meta-analysis did not detect a significant difference in complete or overall pain relief between single treatment and multifraction palliative radiotherapy for bone metastases. Fifty-nine Ontario practitioners responded to the mailed survey (return rate 62%). Forty-two percent also returned written comments. Eighty-three percent of respondents agreed with the interpretation of the evidence and 75% agreed that the report should be approved as a practice guideline. Minor revisions were made based on feedback from the external reviewers and the Practice Guidelines Coordinating Committee. The Practice Guidelines Coordinating Committee approved the final practice guideline report. CONCLUSION: For adult patients with single or multiple radiographically confirmed bone metastases of any histology corresponding to painful areas in previously non-irradiated areas without pathologic fractures or spinal cord/cauda equine compression, we conclude that: Where the treatment objective is pain relief, a single 8 Gy treatment, prescribed to the appropriate target volume, is recommended as the standard dose-fractionation schedule for the treatment of symptomatic and uncomplicated bone metastases. Several factors frequently considered in clinical practice when applying this evidence such as the effect of primary histology, anatomical site of treatment, risk of pathological fracture, soft tissue disease and cord compression, use of antiemetics, and the role of retreatment are discussed as qualifying statements.Our systematic review and meta-analysis provided high quality evidence for the key recommendation in this clinical practice guideline. Qualifying statements addressing factors that should be considered when applying this recommendation in clinical practice facilitate its clinical application. The rigorous development and approval process result in a final document that is strongly endorsed by practitioners as a practice guideline.

Adult↗

PubMed2004

Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a clinical practice guideline.

BACKGROUND: Carcinoma of the esophagus is an aggressive malignancy with an increasing incidence. Its virulence, in terms of symptoms and mortality, justifies a continued search for optimal therapy. A clinical practice guideline was developed based on a systematic review investigating neoadjuvant or adjuvant therapy on resectable thoracic esophageal cancer. METHODS: A systematic review with meta-analysis was developed and clinical recommendations were drafted. External review of the practice guideline report by practitioners in Ontario, Canada was obtained through a mailed survey, and incorporated. Final approval of the practice guideline was obtained from the Practice Guidelines Coordinating Committee. RESULTS: The systematic review was developed and recommendations were drafted, and the report was mailed to Ontario practitioners for external review. Ninety percent of respondents agreed with both the evidence summary and the draft recommendations, while only 69% approved of the draft recommendations as a practice guideline. Based on the external review, a revised document was created. The revised practice guideline was submitted to the Practice Guidelines Coordinating Committee for review. All 11 members of the PGCC returned ballots. Eight PGCC members approved the practice guideline report as written and three members approved the guideline conditional on specific concerns being addressed. After these recommended changes were made, the final practice guideline report was approved. CONCLUSION: In consideration of the systematic review, external review, and subsequent Practice Guidelines Coordinating Committee revision suggestions, and final approval, the Gastrointestinal Cancer Disease Site Group recommends the following:For adult patients with resectable thoracic esophageal cancer for whom surgery is considered appropriate, surgery alone (i.e., without neoadjuvant or adjuvant therapy) is recommended as the standard practice.

Adenocarcinoma↗

PubMed2004

The treatment of lymphedema related to breast cancer: a systematic review and evidence summary.

GOALS OF WORK: To provide an evidence summary report on the question: What are the treatment options for women with lymphedema following treatment for breast cancer? METHODS: Cancer Care Ontario's Supportive Care Guidelines Group (SCGG) employed systematic review methodology to produce an evidence summary on this topic. Evidence-based opinions were formulated to guide clinical decision making, and a formal external review process was conducted to validate the relevance of these opinions for Ontario practitioners. RESULTS: The systematic review search strategy identified ten randomized controlled trials which form the basis of this evidence summary report. Four key opinions offered by the SCGG are outlined below. Responses from the practitioner feedback process supported the validity of these opinions in Ontario. (1) There is some evidence to suggest that compression therapy and manual lymphatic drainage may improve established lymphedema, but further studies are needed. Compression garments should be worn from morning to night and be removed at bedtime. Patients should be advised that lymphedema is a lifelong condition and that compression garments must be worn on a daily basis. Patients can expect stabilization and/or modest improvement of edema with the use of the garment in the prescribed fashion. (2) There is no current evidence to support the use of medical therapies, including diuretics. (3) Additional efforts to define relevant clinical outcomes for the assessment of patients with lymphedema would be valuable. (4) These opinions are appropriate for patients with more than mild lymphedema, where the signs and symptoms are considered significant from the patients' perspective.

Breast Neoplasms↗

PubMed2004

Outcome and toxicity of postoperative short course adjuvant radiation and chemotherapy following resection of adenocarcinoma of the rectum.

A retrospective review has been performed to assess the outcome and toxicity of post-operative adjuvant therapy of 25 Gy/5 fractions/1 week following resection of stage II and III rectal cancer. Forty patients were treated between August 1992 and May 1995. The ages ranged from 42 to 79 (median 63); 32 were male (80%). At last follow up 32 were alive with 0.9 to 11.3 years of follow-up (median 6.6 years). The 5-year actuarial survival was 76% (95% CI: 62-91%). The local relapse free rate was 73% (95% CI: 58-88). Seven patients experienced grade 3 or 4 early toxicity. Three patients had grade 2 or 3 late toxicity. Although treatment was well tolerated, the local relapse rate observed was high. In view of the changes in surgical and pathological techniques in the last decade, further studies are required to determine the merits or otherwise of postoperative Short Course Adjuvant Radiation.

Adenocarcinoma↗

PubMed2003

The use of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer: a practice guideline.

BACKGROUND: This systematic review with meta-analysis was designed to evaluate the literature and to develop recommendations regarding the use of preoperative radiotherapy in the management of patients with resectable rectal cancer. METHODS: The MEDLINE, CANCERLIT and Cochrane Library databases, and abstracts published in the annual proceedings of the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were systematically searched for evidence. Relevant reports were reviewed by four members of the Gastrointestinal Cancer Disease Site Group and the references from these reports were searched for additional trials. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee. RESULTS: Two meta-analyses of preoperative radiotherapy versus surgery alone, nineteen trials that compared preoperative radiotherapy plus surgery to surgery alone, and five trials that compared preoperative radiotherapy to alternative treatments were obtained. Randomized trials demonstrate that preoperative radiotherapy followed by surgery is significantly more effective than surgery alone in preventing local recurrence in patients with resectable rectal cancer and it may also improve survival. A single trial, using surgery with total mesorectal excision, has shown similar benefits in local recurrence. CONCLUSION: For adult patients with clinically resectable rectal cancer we conclude that: Preoperative radiotherapy is an acceptable alternative to the previous practice of postoperative radiotherapy for patients with stage II and III resectable rectal cancer. Both preoperative and postoperative radiotherapy decrease local recurrence but neither improves survival as much as postoperative radiotherapy combined with chemotherapy. Therefore, if preoperative radiotherapy is used, chemotherapy should be added postoperatively to at least patients with stage III disease.

Adult↗

PubMed2003

Combined modality radiotherapy and chemotherapy in nonsurgical management of localized carcinoma of the esophagus: a practice guideline.

PURPOSE: To make recommendations regarding combined radiotherapy (RT) and chemotherapy (RTCT), compared with RT alone, when a nonsurgical approach is used for patients with localized esophageal carcinoma. MATERIALS AND METHODS: The Medline, Cancerlit, Cochrane Library databases, and abstracts published in the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology proceedings were searched for evidence. Evidence was evaluated by two members of the Gastrointestinal Cancer Disease Site Group and methodologists. RESULTS: Pooling seven randomized trials detected a statistically significant survival benefit at 1 year for concomitant RTCT compared with RT alone (1-year mortality odds ratio 0.61; 95% confidence interval 0.44-0.84; p <0.00001). Local control also significantly improved with concomitant RTCT compared with RT alone for the available data (odds ratio 0.52; 95% confidence interval 0.31-0.89; p = 0.004), but a significant increase in adverse effects, including life-threatening toxicities, was shown. CONCLUSIONS: Concomitant RT and cisplatin-based CT is recommended over RT alone. Patients should be aware of the increased acute toxicity associated with this approach, and this recommendation should only be made after consideration of the potential risks and benefits and the patient's general condition. Sequential RTCT is not recommended as standard practice.

Adenocarcinoma↗

PubMed2002

Defining patient-based minimal clinically important effect sizes: a study in palliative radiotherapy for painful unresectable pelvic recurrences from rectal cancer.

PURPOSE: To measure patient-based minimal clinically important effect sizes (minimal incremental benefit that an individual would require to accept one treatment option over another) for pain relief between two contrasting palliative radiotherapy regimens for painful pelvic recurrences from rectal cancer. METHODS AND MATERIALS: Forty-three patients with a history of cancer pain without prior pelvic radiotherapy participated in decision aid-facilitated trade-off exercises. The clinical scenario and treatment options of a 5-day vs. a 20-day course of radiotherapy were described. The duration of pain relief for the 20-day regimen was increased until the respondents' preferences switched to the 20-day regimen. The exercises were repeated for different probabilities of benefit and pain intensity at the time of decision making. RESULTS: When the probability of pain relief was unchanged, the median switch point for the duration of pain relief was 6.7 and 7.2 months for severe and mild pain, respectively. The cumulative percentage frequency curve for the switch points approximated a sigmoid distribution. CONCLUSION: Determining the minimal clinically important effect sizes for symptom relief for palliative therapies is feasible. This type of information can be used to incorporate patient values into clinical trial designs. Modification of this method can be used to improve our understanding of shared (physician and patient) decision making.

Decision Making↗

PubMed2002

What do patients living with advanced cancer and their carers want to know? - a needs assessment.

Our primary objective was to determine the content and format that is most suitable for educational events targeting patients and carers who are living with advanced cancer. Secondary objectives included examining the differences in information needs between patients and their carers, and providing an estimate of the rate of participation in educational events targeting such patients and carers. Out-patients receiving palliative radiotherapy at Toronto Sunnybrook Regional Cancer Center and their carers were invited to complete the Advanced Cancer Information Needs Survey. One hundred forty-four respondents participated in the survey. The participants identified the management of pain, fatigue, and home palliative care resources as the areas in which information was most needed. Carers displayed greater interest, and the range of topics in which they continue to seek additional information is wider. Thirty-one percent of respondents said they would participate in an educational event. A 'one-on-one' interview approach and short written materials were the preferred sources of information. Our study examined potential content areas and preferred format for proposed educational events targeting patients and carers living with advanced cancer. We also highlighted the reasons for, and potential limitations of this approach. The investment of future effort in evaluating the impact of 1 on 1 interviews and 'short written materials' on the informational needs of patients and carers living with advanced cancer is warranted.

Caregivers↗