Oral drug treatment helps protect cancer patients from potentially deadly DVT and pulmonary embolism

University of Warwick| May 2018 |Oral drug treatment helps protect cancer patients from potentially deadly DVT and pulmonary embolism

Patients with a diagnosis of cancer are at high risk of developing blood clots. 20 per cent of cancer patients will develop venous thromboembolism (VTE) – either deep vein thrombosis (DVT) or pulmonary embolism (PE). This is due to a number of factors including immobility (if in bed poorly), pancreatic and gastric tumours, and chemotherapy. Because VTE can be life-threatening, blood thinners are used to shrink existing clots and prevent others from forming.

Currently, international guidelines recommend cancer patients are injected with an anticoagulant (a low molecular weight heparin) to treat and prevent recurrence of VTE. Now scientists from the University of Warwick suggest that taking a tablet a day can help treat cancer patients for a potentially deadly condition.  The results of a large trial run at the University’s  Medical School called ‘select-d’ indicate that a daily tablet could be a beneficial alternative for treating VTE in selected patients, and  that prescribing the oral drug rivaroxaban (Xarelto) significantly reduced venous thromboembolism recurrence among patients with cancer and VTE

 

Lead researcher Professor Annie Young said,

“Clinicians were already adopting the oral drug into practice for non-cancer patients and now they have data from this study to indicate that this form of treatment is an alternative option for many cancer patients who have a clot.” ( Source: University of Warwick).

The full, unedited press release is available from University of Warwick 

Mothers with advanced cancer experience psychological distress

A research paper published in the journal Cancer publishes the findings of research that examined the mental health and well-being of over 200 mothers with advanced cancer. The women all had at least one child under the age of 18,  had metastatic cancer  via Science Daily 

The researchers found that for mothers with stage IV cancer, parenting concerns contributed to their psychological distress. Associated with lower quality of life; the women scored higher in both depression and anxiety than the general population in the United States. The scientists also found a mother’s emotional well-being (these participants’ scores were lower than in other people with cancer in the United States) was linked with whether she had talked with her children about her illness and concerns about how her illness will financially impact her children.

The news item is available from Science Daily 

Abstract

BACKGROUND

Cancer is a leading cause of death among women of parenting age in the United States. Women living with advanced or incurable cancer who have dependent children experience high rates of depression and anxiety as well as unique parenting challenges. To the authors’ knowledge, few studies to date have examined the parenting factors associated with health‐related quality of life (HRQOL) in women with advanced cancer.

METHODS

The authors conducted a cross‐sectional, Web‐based survey of the psychosocial concerns of 224 women with a tumor‐node‐metastasis staging system of the AJCC stage IV solid tumor malignancy who had at least 1 child aged  less than 18 years. Participants completed validated measures of HRQOL (Functional Assessment of Cancer Therapy–General [FACT‐G]); depression and anxiety symptom severity; functional status; parenting concerns; and investigator‐designed questions to assess demographic, communication, and parenting characteristics. Multiple linear regression models were estimated to identify factors associated with FACT‐G total and subscale scores.

RESULTS

The mean FACT‐G score was 66 (standard deviation, 16). The mean Emotional Well‐Being subscale scores were particularly low (13; standard deviation, 5). In multivariable linear regression models, parenting variables explained nearly 40% of the HRQOL model variance. In the fully adjusted model, parenting concerns and the absence of parental prognostic communication with children both were found to be significantly associated with HRQOL scores. For each 1‐point increase in parenting concern severity, FACT‐G scores decreased by 4 points (P equal to .003).

CONCLUSIONS

Women with metastatic cancer who are parents of dependent children are at risk of high psychological distress and low HRQOL. Parenting factors may have a negative influence on HRQOL in this patient population. Cancer 2018. © 2018 American Cancer Society.

Full reference:

Park, E. M, et al |  Understanding health‐related quality of life in adult women with metastatic cancer who have dependent children |Cancer |ePub  https://doi.org/10.1002/cncr.31330

6 in 7 women offered Tamoxifen choose not to take it

University of Leeds | April 2018 |Women at increased cancer risk shun preventative tamoxifen therapy

A study published in Breast Cancer Research and Treatment  shows that only 1 in 7 women who were offered Tamoxifen due to a familial history of cancer decided to take it. This new research sought to highlight that women eligible to take the drug were electing not to, it also aimed to explore the reasons behind such decisions. Researchers also found that patients consulted informal networks such as friends and family before making a decision about whether to take Tamoxifen (via University of Leeds) .

Whether the participants had children also had an impact on the decision, the scientists found those with children were more likely to take the drug. One participant explained that taking the drug might affect her ability to care for her children and parents, so decided not to take it.

The study was conducted in collaboration with scientists at the University Hospitals Southampton, University College London, Queen Mary University, University of Leeds and Northwestern University. The research was funded by Cancer Research UK and Yorkshire Cancer Research.

 

Abstract

Purpose Uptake of preventive therapy for women at increased breast cancer risk in England is unknown following the introduction of UK clinical guidelines in 2013. Preventive therapy could create socioeconomic inequalities in cancer incidence if it is more readily accepted by particular socio-demographic groups. In this multicentre study, we investigated uptake of tamoxifen and evaluated socio-demographic and clinical factors associated with initiation. We explored women’s experiences of treatment decision-making using qualitative interview data.
Methods Between September 2015 and December 2016, women (n=732) attending an appointment at one of 20 centres in England to discuss breast cancer risk were approached to complete a survey containing socio-demographic details and nul-
liparity. Of the baseline survey respondents (n equal to 408/732, 55.7% response rate), self-reported uptake of tamoxifen at 3-month follow-up was reported in 258 (63.2%). Sixteen women participated in semi-structured interviews.
Results One in seven (38/258=14.7%) women initiated tamoxifen. Women who had children were more likely to report use of tamoxifen than those without children (OR=5.26; 95%CI: 1.13–24.49, p=0.035). Interview data suggested that women weigh up risks and benefits of tamoxifen within the context of familial commitments, with exposure to significant other’s beliefs and experiences of cancer and medication a basis for their decision.

Conclusions Uptake of tamoxifen is low in clinical practice. There were no socio-demographic differences in uptake, suggesting that the introduction of breast cancer preventive therapy is unlikely to create socioeconomic inequalities in cancer incidence. Women’s decision-making was influenced by familial priorities, particularly having children.

The full article can be downloaded here 

Rapid cancer diagnostic and assessment pathways

NHS England has published three rapid cancer diagnostic and assessment pathways.  These documents set out how diagnosis within 14 days and diagnosis within 28 days can be achieved for the colorectal, lung, and prostate cancer pathways:

Implementing a timed colorectal cancer diagnostic pathway:

This handbook sets out how the 28 day standard can be achieved in colorectal cancer patients, in preparation for full monitoring against the standard from April 2020.

Implementing a timed lung cancer diagnostic pathway:

This handbook sets out how the 28 day standard can be achieved for lung cancer patients, in preparation for full monitoring against the standard from April 2020.

Implementing a timed prostate cancer diagnostic pathway:

This handbook sets out how the 28 day standard can be achieved for prostate cancer patients, in preparation for full monitoring against the standard from April 2020.

 

Study identifies ‘three evolutionarily distinct types of kidney cancer’

The Francis Crick Institute |  April 2018  | ‘Killer’ kidney cancers identified by studying their evolution

Three new studies funded by Cancer Research UK have led scientists to better understand that kidney cancer follows a specific evolutionary path. The first two studies involved the analysis of more than 1,000 tumour samples from kidney cancer patients (n equal to 100)  to reconstruct the sequence of genetic events that led to the cancer in each patient. Their analysis gave rise to the three evolutionarily distinct types of kidney cancer and each has its own path:

• The first type never acquires the ability to become aggressive
• The second tumour type forms the most aggressive tumours, evolving through a rapid burst of genomic damage early on.  This enables the tumour all it needs to spread to other regions of the body.
• The third tumour spreads over a longer period of time and are made of different populations of cancer cells, some of which are aggressive

Dr Samra Turajlic lead author of the study said: “The outcomes of patients diagnosed with kidney cancer vary a great deal – we show for the first time that these differences are rooted in the distinct way that their cancers evolve.

“Knowing the next step in cancer’s evolutionary trajectory could tailor the treatment choice for individual patients in the next decade. For instance, patients with the least aggressive tumours could be spared surgery and monitored instead, and those with gradually evolving tumours could have the primary tumour surgically removed even after it has spread.”

 

The Francis Crick Institute have created a video to accompany this press release

The third study found that events that trigger kidney cancer can take place in childhood or adolescence years before the primary tumour is diagnosed.

Dr Peter Campbell, corresponding author of this study said: “We can now say what the initiating genetic changes are in kidney cancer, and when they happen.” (The Francis Crick Institute).

The full news story can be read at The Francis Crick Institute website

All of the articles are published in Cell and can be read by following the links

 Turajlic, S. et al  |Deterministic Evolutionary Trajectories Influence Primary Tumor Growth: TRACERx Renal

 Turajlic, S. et al |Tracking Cancer Evolution Reveals Constrained Routes to Metastases: TRACERx Renal

 Turajlic, S. et al | Timing the Landmark Events in the Evolution of Clear Cell Renal Cell Cancer: TRACERx Renal

 

In the media

BBC News Why some cancers are born to be bad 

Cancer taskforce recommendations: progress report

An update on Public Health England’s progress towards their objectives in the Independent Cancer Taskforce strategy paper | Public Health England

This document outlines Public Health England’s progress on strategic priorities identified in the Independent Cancer Taskforce report, Achieving world-class cancer outcomes: a strategy for England 2015 to 2020.

Full document: PHE progress report on the Independent Cancer Taskforce recommendations

Supporting the emotional and mental health needs of people with cancer

The Mental Health Foundation | April 2018 | Supporting the emotional and mental health needs of people with cancer

The psychological impact of having cancer has been little researched. In response to this The Mental Health Foundation has conducted qualitative research with patients diagnosed with cancer in Scotland. Their research focused on the negative mental health impacts of cancer, how effective support can be delivered, the barriers to support and the unmet mental health support needs.

The interviews identified the post-treatment phase a an especially volatile time for mental wellbeing.  To address the unmet need in terms of service provision for mental health during cancer and to strengthen existing programmes, they  make the following recommendations:

1. There needs to be greater awareness by all service providers of the mental health impacts of cancer and the need to support emotional wellbeing and mental health
2. The right support needs to be given at the right time
3. Tailored, person-centred support needs to be offered at all stages of the cancer journey
4. There must be more collaboration and communication between service providers
5. Improve signposting for mental wellbeing services
6. Provide clearer and more co-ordinated support pathways after treatment
7. Improve the provision of support across Scotland
8. More research is needed into how best to tackle social deprivation and co-morbed health inequalities
9. More research and awareness is needed to design cancer and wellbeing support services that engage BME communities
10. Ensure all people with cancer have access to some level of tumour support (The Mental Health Foundation)

    You can download the full document from The Mental Health Foundation 

PM announces funding for research into prostate cancer

NIHR | April 2018 | Prime minister announces £75 million to support new prostate cancer research

Prostate cancer is the most common cancer in men. It has recently overtaken breast cancer as the third most common cause of cancer deaths in the UK. Now, £75 million funding has been announced by the Prime Minister to support new research into early diagnosis and treatment of prostate cancer.  This will be used to complement and extend research undertaken over the past 15 years by the NIHR, Cancer Research UK, Prostate Cancer UK and the Medical Research Council.

New studies will  test treatments such as more precise radiotherapy, high-intensity focused ultrasound, and cryotherapy, alongside supportive  interventions including exercise and dietary advice.

They will also particularly target groups at higher risk of prostate cancer, such as black men – one in four of whom will develop the disease – men aged 50 or over, and men with a family history of prostate cancer.

Dr Jonathan Sheffield, Chief Executive at the NIHR Clinical Research Network, said:

“Clinical research brings us closer to the development of new treatments for prostate cancer patients.

“The NIHR will work closely with the NHS, life sciences industry, charities and research funders to support the recruitment of 40,000 men into research studies over the next five years. This will provide more opportunities for earlier access to new drugs and therapies, which will ultimately lead to improved diagnoses and care in the future.”

Full story at NIHR 

In the media:

ITV News PM announces £75m for prostate cancer research

The Guardian Theresa May launches £75m drive against prostate cancer

 

Integrating systematic pain assessment and management into routine care using a simple tool improves pain outcomes for patients with cancer-related pain

 The findings of a cluster randomized (1:1) trial have been published in the Journal of Clinical Oncology’s website. The researchers leading the trial sought to compare the effect of a policy adding a clinician- delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes.

Employing a two-arm, parallel group, cluster randomized (1:1) trial, the scientists observed pain outcomes in 19 cancer centres in the UK, these centres were randomly assigned to implement EPAT or to continue UC. As part of the trial they enrolled 1,921 patients, with a mean age of 60; 49% of whom were female with a variety of cancer types.

The findings of this multicentre, cluster randomized trial indicate that a policy of integrating systematic pain assessment and management into routine cancer centre care using a simple tool (EPAT) improves pain outcomes for patients with moderate or severe cancer-related pain.
The scientists conclude that the centres employing EPAT had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC.

Abstract

Purpose

 Pain is suboptimally managed in patients with cancer. We aimed to compare the effect of a policy of adding a clinician-delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes.

Patients and Methods

 In a two-arm, parallel group, cluster randomized (1:1) trial, we observed pain outcomes in 19 cancer centers in the United Kingdom and then randomly assigned the centers to either implement EPAT or to continue UC. The primary outcome was change in the percentage of study participants in each center with a clinically significant (equal to 2 point) improvement in worst pain (using the Brief Pain Inventory Short Form) from admission to 3 to 5 days after admission. Secondary outcomes included quality of analgesic prescribing and opioid-related adverse effects.

Results

 Ten centers were randomly assigned to EPAT, and nine were assigned to UC. We enrolled 1,921 patients and obtained outcome data from 93% (n = 1,795). Participants (mean age, 60 years; 49% women) had a variety of cancer types. For centers randomly assigned to EPAT, the percentage of participants with a clinically significant improvement in worst pain increased from 47.7% to 54.1%, and for those randomly assigned to continue UC, this percentage decreased from 50.6% to 46.4%. The absolute difference was 10.7% (95% CI, 0.2% to 21.1%; P = .046) and it increased to 15.4% (95% CI, 5.8% to 25.0%; P = .004) when two centers that failed to implement EPAT were excluded. EPAT centers had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC.

 

Conclusion

 A systematic integrated approach improves pain outcomes for inpatients in cancer centers without increasing opioid adverse effects.

The full article can be read at Journal of Clinical Oncology, where it has been published online

Reference: DOI: 10.1200/JCO.2017.76.1825 Journal of Clinical Oncology – published online before print March 15, 2018

 

Unexpected weight loss associated with cancer in 10 cancer sites, finds new study

Oxford University | April 2018 | Weight loss is an important predictor of cancer

A team of scientists from  Oxford and Essex Universities conducted a systematic review and meta- analysis to examine all the literature on the association between weight loss and cancer in primary care. This robust study, the first of its kind in this area, demonstrates that unintentional weight loss is the second highest risk factor for colorectal, lung, pancreatic and renal cancers (via Oxford University).

Their analysis of 25 studies,  over 11.5 million patients  -predominantly in primary care 22 of the studies or 92% – used data coded by clinicians in primary care. Four-fifths of these data defined weight loss as a physician’s coding of the symptom; the remainder collected data directly.  An association was  identified with weight loss linked with 10 cancer sites: prostate, colorectal, lung, gastro-oesophageal, pancreatic, non-Hodgkin’s lymphoma, ovarian, myeloma, renal tract, and biliary tree.
This also showed that people aged over 60 with unexpected weight loss have more than 3% chance of having cancer in one of the 10 cancer sites. In females in this age group, the average risk across all sites involved was estimated to be up to 6.7%, and in males up to 14.2%.

The authors of the study conclude that a a primary care clinician’s decision to code for weight loss is highly predictive of cancer.
The article has been published in the British Journal of General Practice online ahead of print.

Abstract

Background Weight loss is a non-specific cancer symptom for which there are no clinical guidelines about investigation in primary care.

Aim To summarise the available evidence on weight loss as a clinical feature of cancer in patients presenting to primary care.

Design and setting A diagnostic test accuracy review and meta-analysis.
Method Studies reporting 2 × 2 diagnostic accuracy data for weight loss (index test) in adults presenting to primary care and a subsequent diagnosis of cancer (reference standard) were included. QUADAS-2 was used to assess study quality. Sensitivity, specificity, positive likelihood ratios, and positive predictive values were calculated, and a bivariate meta-analysis performed.

Results A total of 25 studies were included, with 23 (92%) using primary care records. Of these, 20 (80%) defined weight loss as a physician’s coding of the symptom; the remainder collected data directly. One defined unexplained weight loss using objective measurements. Positive associations between weight loss and cancer were found for 10 cancer sites: prostate, colorectal, lung, gastro-oesophageal, pancreatic, non-Hodgkin’s lymphoma, ovarian, myeloma, renal tract, and biliary tree. Sensitivity ranged from 2% to 47%, and specificity from 92% to 99%, across cancer sites. The positive predictive value for cancer in male and female patients with weight loss for all age groups greater than 60 years exceeded the 3% risk threshold that current UK guidance proposes for further investigation.

Conclusion A primary care clinician’s decision to code for weight loss is highly predictive of cancer. For such patients, urgent referral pathways are justified to investigate for cancer across multiple sites

Full reference:  Nicholson,  B. D.,  Hamilton, W.,  O’Sullivan, J.  Aveyard, P,  Hobbs, FD R. 9 April 2018| Weight loss as a predictor of cancer in primary care: a systematic review and meta-analysis | Br J Gen Pract | DOI: 10.3399/bjgp18X695801

The article can be read in the British Journal of General Practice