rapid response radiotherapy program · rrrp-bmc first decade, we reviewed the following components...

Rapid Response Radiotherapy Program (RRRP) And Bone Metastases Site Group Clinic (BMC)

Annual Report

January–December 2006

Dr. Edward Chow Dr. Cyril Danjoux Chair Chair Bone Metastases Site Group Rapid Response Radiotherapy Program

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Executive Summary

On behalf of the Rapid Response Radiotherapy Program and the Bone Metastases Site Group (RRRP-BMC), we are pleased to send you our 2006 annual report. As part of our evaluation of the RRRP-BMC first decade, we reviewed the following components of the program. 1. Clinics

a) RRRP clinics: The results indicated that we are meeting the initial goals of the RRPP to provide timely palliative radiotherapy to patients in the terminal phase of their illness. The number of patients seen annually in the five weekly half-day clinics has reached a plateau of 500-600, eighty percent of which are new to TSRCC. The median time for consultation and treatment was eight days.

b) We reviewed and published our experience with the multidisciplinary Bone Metastases Clinic.

c) We initiated a new multidisciplinary prostate bone metastases clinic with a research fellow, supported by an educational grant from Novartis.

d) We successfully evaluated the role of an advanced practice radiation therapist with the support of the Ministry of Health (MOH).

2. Education

a) Newsletter - Our readers indicated they found our quarterly newsletter HOT SPOT informative and educational. To meet their needs we increased the content from 4 to 6 pages and added new topics and contributors.

b) Drs. Barnes and Chow organized another successful Ontario Provincial Conference on palliative and end-of-life care held in April and the 13th Annual Science & Art of Pain and Symptom Management Conference held in November 2006.

c) Our monthly videoconferencing research rounds which initially included the Palliative Radiation Oncology Group of Ontario (PROG-O) has expanded to include Centres beyond Ontario and currently includes Alberta, Manitoba, British Columbia and the Maritimes. It has been renamed the Canadian Palliative Radiation Oncology Group (CPROG).

d) We continue to offer electives to palliative health care professionals to visit our Centre and learn about our programs.

e) We participated in a needs assessment study to improve access to radiotherapy services in the Simcoe-Muskoka region of Ontario.

3. Research

a) We held a half-day research retreat to identify themes we would like to study over the coming years.

b) We were successful in obtaining grant support to continue our research projects. c) A research fellow from Edmonton completed a three month elective with Dr. Barnes. d) Research students from Waterloo’s co-op program under the mentorship of Dr. Chow

have been extremely productive and have also won numerous awards.

4. Our Quality Assurance rounds resulted in several published case reports.

This report summarizes our very successful year and the academic activities of the RRRP-BMC as we start our second decade.

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Toronto Sunnybrook Regional Cancer Centre Rapid Response Radiotherapy Program and

Bone Metastases Site Group December 2006

The membership of the RRRP and BMC currently includes: Radiation Oncologists: Medical Physicist:

Lisa Barbera (left in Dec 2006) Parminder Basran Toni Barnes Edward Chow (Bone Mets Site Chair) Cyril Danjoux (RRRP Chair) Palliative Care Physicians:Andrew Loblaw (Spinal cord compression) Hyon Kim May Tsao Jeff Myers Debbie Selby

Orthopedic Surgeons: Leisa Wynnchuk Terry Axelrod Joel Finkelstein Medical Oncologists:Michael Ford Scott Berry Hans Kreder Yooj Ko David Stephen Maureen Trudeau Albert Yee

Radiologists: Pharmacists:Ganesan Annamalai Carlo DeAngelis Richard Aviv Monique Christakis Elizabeth David Linda Probyn Psycho-Social Service:Robyn Pugash Margaret Fitch Joel Rubenstein Magdeline Winterhoff Sean Symons Nurses: Laboratory Medicine:

Grace Chan David Cole Michelle Davis Reinhold Veith Ernest Dixon Cathy Doyle Macey Farhadian Rosemary Irish Basic Science: Gurmit Singh - Director of Research,

Radiation Therapist: (Hamilton Research Cancer Centre) Emily Sinclair Shun Wong

Clinical Trials: Bioengineers:Mary O’Brien (left in Feb 2007) Tomas Skrinskas Adam Lam Cari Whyne

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TSRCC Rapid Response Radiotherapy Program (RRRP) and Bone Metastases Site Group Clinic (BMC)

The RRRP was initiated in 1996 and consists of the palliative radiotherapy & bone metastases clinic.

Palliative Radiotherapy Clinics From the initial two clinics per week, the palliative radiotherapy clinics have increased to five half-day clinics per week. In January 1999, radiation oncologists involved with the program decided that the RRRP should not only provide service but also be academically productive. We have reached a plateau of approximately 500-600 patients seen annually in the RRRP clinics; eighty percent of which are new to TSRCC. Over the past decade the median time to consultation and treatment was 8 days, suggesting that we are meeting our objective of providing timely palliative radiotherapy to patients in the terminal phase of their illness. In December 2006, Dr. Lisa Barbera left the RRRP to be more involved with the Lung Site Group. We plan to maintain our five half-day clinics per week and look forward to add a replacement for Dr Barbera later this year.

[Appendix A – RRRP Clinics] [Appendix B – Decision Tree for Patients Referred to RRRP-BMC]

Bone Metastases Clinics A multidisciplinary Bone Metastases Clinic was initiated in January 1999 and is held on alternate Fridays. It is the first of its kind in Canada to provide multidisciplinary care to patients with complicated bony metastases. The Bone Metastases group (BMSG) is a separate site group at TSRCC under the leadership of Dr. E. Chow.

[Appendix C – Bone Metastases Clinic]

New Initiatives

1. We started a multidisciplinary prostate bone metastases clinic under the leadership of Drs. E. Chow and Y. Ko. A research fellow, supported by an educational grant from Novartis is involved in the clinic research projects.

[Appendix D – Hot Spot Insert November 2005]

2. The RRRP-BMC team was involved in a project led by Dr. Ewa Szumacher entitled "Improving access to Radiotherapy services in the Simcoe-Muskoka region of Ontario: Needs assessment study." The results of this study will be presented at the Humber Regional Palliative Care Conference London, Ontario in April 2007; as well as the 4th Radiation Medicine Conference in Kingsbridge, Ontario, held in April 2007. A manuscript is being prepared for publication.

[Appendix E – Improving Access to Radiotherapy Services in the Simcoe-Muskoka Region of Ontario – Needs Assessment Study]

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3. At the end of each RRRP-BMC clinic, our research students and Radiation therapist review the cases seen and keep a record of unusual problems for later discussion at our monthly rounds. We started a program to monitor unusual and difficult cases seen in the RRRP-BMC. At the quarterly quality assurance rounds, selected cases are presented with a review of the literature for discussion. This has been useful for quality assurance, served as an educational opportunity and resulted in the publication of several case reports. 4. We are in the process of initiating projects based on the research themes identified in our half-day research retreat in 2006.

[Appendix F – Report of research retreat] 5. Dr. Barnes is exploring the feasibility of research collaboration with Edmonton, London and Ottawa to investigate the possible role of Tomotherapy for palliative treatment of complex cases or re-treatment of recurrence close to radiosensitive organs.

EDUCATION

The RRRP organizes monthly Palliative Rounds, publishes a quarterly newsletter “HOT SPOT” and provides educational electives for students and health care professionals interested in palliative radiotherapy.

CME Monthly Rounds The rounds are organized by Dr. E. Barnes and held on the last Tuesday of the Month from 12-1 p.m. in the R.D.T. Jenkin Auditorium. They are accredited for MOCERT credits.

The subjects discussed during 2006 were: 2006 Title Presenter January 31

Piece of a puzzle (The PMH palliative radiation Oncology program perspective)

Dr. Rebecca Wong

February 28 Communication skills near the end of life: Lessons from the ISU

Dr. Laura Hawryluck

March 28 Rounds cancelled April 25 Rounds cancelled May 30 Truth–telling: Challenges and Strategies Dr. Monica Branigan June 27 When good clots go bad: A practical approach to

thrombosis in cancer. Dr. William Geerts

July 25 Rounds cancelled August 29 Rounds cancelled September 26 The meaning of meaningful: The PCU perspective Dr. Debbie Selby October 31 Rounds cancelled November 28 Psycho-oncology update: Focus on depression & anxiety

management Dr. Eileen LaCroix

December 26

Rounds cancelled

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Hot Spot Newsletter

In response to a satisfaction survey from our referring physicians who wanted better communication, we initiated a quarterly newsletter in 1999 called “HOT SPOT”. HOT SPOT is the educational newsletter of the RRRP at TSRCC. It is published quarterly and distributed to oncologists, palliative care specialists, family doctors and professional health care workers in palliative medicine. Our readership has expanded to over 2,000 per issue and we continue to expand our circulation to new readers. Survey results from our readers rated the educational value of HOT SPOT as high and suggested that we add other topics of interest. We increased the content of our newsletter from four to six pages with additional sections and contributors. The newsletter has regular articles on the following topics:

ETHICS RESEARCH PSYCHOSOCIAL TLCPC UPDATE PEDIATRIC EDUCATIONAL ACTIVITIES EDUCATIONAL INSERT

Each issue also has a double-sided educational insert.

The Editorial Board of Hot Spot

Editor Dr. E. Chow Associate Editors Dr. C. Danjoux and Ms. D. Adams Consultant Dr. S. Wong Advisers Dr. L. Barbera, Dr. E. Barnes, Dr. R. Goldman, Dr. A. Husain,

Dr. L. Librach, Dr. C. Newman, Ms. E. Sinclair, Dr. E. Szumacher, Dr. M. Tsao.

Editorial & Financial Managers Mrs. M. Frost and Ms. K. Phokeo The publication of the newsletter is made possible by the financial support of pharmaceutical & radiotherapy equipment companies. The newsletter is also available electronically on the TSRCC web site: http://www.sunnybrook.ca/programs/tsrcc/treatmentprevention/rapidresponse.

[Appendix G provides the content of previous issues and inserts of HOT SPOT from 1999-2006.]

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http://www.sunnybrook.ca/programs/tsrcc/treatmentprevention/rapidresponse

Educational Electives As part of our undergraduate teaching, students from the co-op program at the University of Waterloo have their electives working with the RRRP-BMC. This co-operative educational elective was initiated by Dr. E Chow and has been extremely successful. Several of our students have won numerous awards. Awards Meagan Doyle (2004-2005), Third year undergraduate student. Decadron prophylaxis in the pain flare from radiation treatment of bone metastases.

2006 Marion J. Todd Memorial Award, Faculty of Applied Health Sciences, U of Waterloo. Kristin Harris (2005-2006), Second year undergraduate student. Gender difference in brain metastases and bone metastases module development.

New Investigator Scholarship, 13th Annual Conference of the International Society for Quality of Life Research; Lisbon, Portugal, October 2006.

2006 Marion J. Todd Memorial Award, Faculty of Applied Health Sciences, U of Waterloo.

2006 Co-op Student of the Year, Faculty of Applied Health Sciences, U of Waterloo.

50th Anniversary Co-op Student Award, University of Waterloo.

2006 University Canadian Association for Co-op Education, Co-op Student of the Year.

2006 Emery-Dufault Award

2006 Education at Work for Ontario Award.

2006 RRRP student of the Year Award, Toronto Sunnybrook Regional Cancer Centre. Julie Napolskikh (2006), Third year undergraduate student. Length of stay in hospice care

2006 Laura Talbot-Allan Award, Faculty of Applied Health Sciences, U of Waterloo

Sukirtha Tharmalingam (2006), Fourth year undergraduate student. Bone metastases module.

Young Investigator Award, MASCC/ISOO 18th International Symposium Supportive Care in Cancer, Toronto, Canada, June 2006. Patients’ and health care professionals’ perspectives on the most important quality of life issues in bone metastases.

[Appendix H – Undergraduate Teaching–Co-op Program]

Dr. Alysa Fairchild (2006), Fellow under the supervision of Dr. Barnes.

Young Investigator Award, MASCC/ISOO 18th International Symposium Supportive Care in Cancer, Toronto, Canada, June 2006. Has the pattern of practice in the prescription of palliative thoracic radiotherapy for lung cancer changed between 1999 and 2006 at the RRRP?

First Place, Outstanding Poster Award, Cleveland Clinic 11th Annual International Symposium on Palliative Care, Florida, USA, 2006. Bone Metastases Survey project.

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Health Care Professionals electives The RRRP provides a half-day elective for health care professionals to experience the activities of the RRRP clinics. Drs. B. Hinder from Australia and T. Ago from Halifax, Nova Scotia spent a week with us as they plan to start a similar project in their Centre. They found the experience valuable and recommend it for others planning to start a similar program. Dr. Alysa Fairchild completed a three month Fellowship under the supervision of Dr. T. Barnes. She won the Young Investigators Award for her presentation “Has the pattern of practice in the prescription of palliative thoracic radiotherapy for lung cancer changed between 1999 and 2006 at the RRRP?” Her poster, Bone Metastases Survey presented at the Cleveland Clinic’s 11th Annual International Symposium on Palliative Care in Florida, 2006; won First Place in the Outstanding Poster Award.

RESEARCH

The RRRP-BMC team objective is to provide palliative radiotherapy in an academic environment. We participate in local, national and international clinical trials, have regular research rounds and have been successful in securing grants to fund our research projects.

Clinical Trials We participate in several clinical trials. The research students under the supervision of Dr Chow have been an essential resource in helping us to enroll, follow-up, analyze and publish our studies. Without the dedication of our research students, it would have been difficult to successfully complete our research studies.

[Appendix I - A list of ongoing research studies in the RRRP and BMC]

PROG-O (Palliative Radiation Oncology Group Ontario) Our collaboration with Princess Margaret Hospital (PMH) and the Hamilton Regional Cancer Centre Palliation Radiation Oncology Group, led to the formation of the Palliative Radiotherapy Oncology Group Ontario (PROG-O) in 2000. Since then PROG-O has expanded to include Cancer Centres from the Maritimes, Manitoba, Calgary and British Columbia. Currently, this group meets monthly through videoconference. This has improved communication between the staff involved in the palliative radiotherapy program in those Centres and offered the opportunity for collaboration in research. At the last CARO meeting, more Cancer Centres expressed enthusiasm in participating in PROG-O rounds. PROG-O offers a national forum for monthly research discussion in palliative radiotherapy. Over the past years the coordinators for the PROG-O rounds have been Drs. C. Danjoux, A. Bezyak, R. Wong and T. Barnes. For the academic year 2005-2006, Dr. J. Wu is the coordinator. The rounds are scheduled for the first Tuesday of every month held from 4:00–5:30 p.m.

To represent the change in participation from Ontario to Cancer Centres across Canada we renamed the group as Canadian Palliative Radiation Oncology Group (CPROG) We published our experience with the PROG-O Videoconferencing rounds in the Hot Spot Insert of August 2006.

[Appendix J – Hot Spot insert August 2006]

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Videoconference Rounds (PROG-O)

The subjects discussed during 2006 were: 2006 Title Presenter(s) Feb 7 Update on Radiation Hypersensitivity Tissue Bank:

Review of Accrual & Patient Characteristics. Results of a Phase III Randomized Trial of Biologically Active Aloe Cream vs. Plain Cream vs. Powder: In Breast Cancer Patients & Lessons I have learned

Dr. Diane Severin, The Alberta Cancer Board, Edmonton, Alberta

March 7 Predicting Successful Dexamethasone taper in Patients with Brain Metastases treated with Whole Brain Radiotherapy – A Research Study

Drs. Richard Aviv & May Tsao, TSRCC

April 4 Pain Flare in Patients with Bone Metastases after Palliative Radiotherapy

Drs. Andrew Loblaw & Edward Chow

May 2 The Utilization of Radiation Therapy in the Management of Melanoma in British Columbia. B.C. Cancer Agency

Drs. Graeme Duncan, & John French.

June 6 Lessons learned from a Family Physician Survey Ottawa Regional Cancer Centre

Dr. Rajiv Samant, Radiation Oncologist

July 4 Rounds cancelled for Summer Holiday August 1 Rounds cancelled for Summer Holiday October 3 Neuropathic Pain in Patients With Bone Metastases

Referred for Palliative Radiotherapy: A Study ProposalDr. Jackson Wu

November 14 Palliative Radiotherapy: Is more really better? Dr. Alysa Fairchild, Fellow, Radiation Oncologist

December 5 Bone Mets QoL Module & Meta-analysis update new studies

Dr. Edward Chow

RRRP and BMC Monthly Meetings Our research rounds are scheduled on the second Tuesday of every month. 2006 Title Chair(s)

Jan 17 Quality Assurance Rounds: Discussion of interesting, controversial and complicated cases.

Dr. Cyril Danjoux

Feb 21 Business Meeting Drs. C. Danjoux, E. Chow

April 18 Quality Assurance Rounds: CCO Tumour Guidelines – Dr. Francis Wright Validation of FACT-BP, Early integration of Zometa and radiation in prostate cancer bone metastases –Dr. E. Chow

Dr. Cyril Danjoux

May 23 Management of Brain Metastases. Speakers: Drs. P. Davey, M. Schwartz & M.Tsao.

Dr. Toni Barnes June 20 Research with Dr. Chow & RRRP Research Students. Dr. Edward Chow

Sept 19 Annual General Meeting Drs. Cyril Danjoux & Edward Chow

Oct 17 Quality Assurance Rounds Dr. Cyril Danjoux

Nov 21 Research/Educational Rounds Dr. Toni Barnes

*Rounds cancelled: March 21, July 18, August 15 and December 19th.

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Grants

1. A Prospective Study of Bio-mechanically Based Guidelines in Metastatic Burst Fracture Risk

Prediction-$330,000. Canadian Breast Cancer Research Initiative. 2003–2006. Whyne C (PI), Yee A, Kreder H, Finkelstein J, Chow E (Co-investigator), Weller I, Barnes E, Clemons M and Trudeau M.

2. The efficacy of risedronate in protecting bone mineral density for men with locally advanced

prostate cancer receiving radiotherapy and neoadjuvant/adjuvant hormone therapy for 2 or 3 years. Phase III, Double-Blinded, Placebo-Controlled Study ($250,000) Aventis-Sanofi Pharma Ltd. (2004- ). C Danjoux, R Choo, S Malone, J Bowen, H Lukka, R Briones-Urbina, L Ehrlich, R Vieth.

3. Validation of a predictive model for survival in metastatic cancer patients attending an

outpatient palliative radiotherapy clinic-$180,192. Canadian Institute of Health Research. 2004–2007. Chow E (PI), Panzarella T, Bezjak A and Wu J.

4. Development of a Canadian-led international bone metastases module to accompany

European Organization for Research and Treatment of Cancer Quality of Life Group core questionnaire (the EORTC QLQ-C30) for future clinical trials in patients with bone metastases.-$271,483. National Cancer Institute of Canada. 2005-2008. Chow E (PI),

Clemons M, Wu J Bezjak A, Brundage M, Yee A, Bottomley A, Velikova G, and Hoskin P.

5. Effect of radiation for bone metastases in patients with prostate cancer on urinary markers of osteoclast activity.-$20,605. Abbott-CARO Uro-Oncologic Radiation Award. 2006. Chow E (PI), Veith R, Danjoux C, Barnes E, Tsao M, Barbera L, Ko Y, Sinclair E.

6. Improving the Delivery of Palliative Care in Ontario. -$152,400 Cancer Care Ontario

Research Network Grants 2006. Principal investigator: Barbera, L. Co-Investigators: Adams, D., Dudgeon, D., Grunfeld, E., Howell, D., Husain, A., Librach, L., Paszat, L., Stukel, T., Sussman, J., Tourangeau, A., Viola, R., Walker, H.

7. Improving Access to Quality Palliative Care for Cancer Patients. -$1,485,448 Canadian

Institute of Health Research (Submitted in 2006) Principal Investigator: Brazil, K. Co-Investigators: Barbera, L., Howell, D., Husain, A., Sussman, J., Williams, A., Goldwasser, M., Krueger, P., Heyland, D., Thebane, L.

8. Waiting Times for Radiation Therapy in Ontario and Associated Cancer Outcomes. -

$392,373. National Cancer Institute of Canada (Submitted in 2006). Principal Investigator: Singh, S. Co-Investigators: Paszat, L., Goldwasser, M., Barbera, L.

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Publications

1. Danjoux C, Chow E, Hayter C, Tsao M, Barnes E, Holden L, Sinclair E, Drossos A,

Farhadian M. An innovative Rapid Response Radiotherapy Program to reduce waiting time or palliative radiotherapy. Supportive Care in Cancer 14(1); 38-43, 2006

2. Cheung G, Chow E, Holden L, Vidmar M, Danjoux C, Yee A, Connolly R, Finkelstein J. Percutaneous Vertebroplasty in Patients with Intractable Pain from Osteoporotic or Metastatic fractures: a Prospective Study using Quality of Life Assessment. Canadian Association of Radiologists Journal 57(1); 13-21, 2006

3. Bradley N, Chow E, Tsao M, Danjoux C, Barnes E, Hayter C, Holden L, Yau V, Li K, Doyle M, Sinclair E. Reasons for poor accrual in palliative radiotherapy research studies. Supportive Cancer Therapy 3(2); 110-119, 2006

4. Tsao M, Chow E, Laperriere N, Wong R, Lloyd N, Rakovitch E. Whole brain radiotherapy for the treatment of multiple brain metastases. Cochrane Database of Systematic Reviews Cochrane Review CD003869 Issue 3, 2006 July

5. Chow E, Doyle M, Li K, Bradley N, Harris K, Hruby G, Sinclair E, Barnes T, Danjoux C. Mild, moderate or severe pain categorized by cancer patients with bone metastases. Journal of Palliative Medicine 9(4): 850-854, 2006

6. Chow E, Harris K, Fung K. Successful validation of a survival prediction model in patients with metastases in the spinal column. International Journal of Radiation Oncology, Biology and Physics 65(5): 1522-1527, 2006

7. Bradley N, Sinclair E, Danjoux C, Barnes E, Tsao M, Farhadian M, Yee A, Chow E. The Do-Not-Resuscitate Order: Incidence of documentation in the medical records of cancer patients referred for palliative radiotherapy. Current Oncology 13 (2): 1-8, 2006

8. Fan G, Sinclair E, Christakis M, Erhlich L, Zubovits J, Chow E. Solitary bone metastasis beneath the shoulder shield: Coincidence or cause. Current Oncology 13 (4): 1-4, 2006

9. Harris K, Chow E, Davis L, Chiu H, Bradley N, Doyle M, Li K, Sinclair E, Barnes E, Danjoux C. Gender differences in patient-rated symptoms following whole brain radiotherapy for brain metastases. Journal of Cancer Pain & Symptom Palliation 2 (1): 11-15, 2006

10. Harris K, Doyle M, Barnes E, Sinclair E, Danjoux C, Barbera L, Chow E. Diarrhea as a radiation side effect “welcomed” by patients taking opioids. (Letter to the editor) Journal of Pain and Symptom Management 31(2): 97-98, 2006

11. Vieth R, Choo R, Deboer L, Danjoux C, Morton GC, and Klotz, G. Rise in prostate-specific antigen in men with untreated low grade prostate cancer in slower during spring-summer. American Journal of Therapeutics Volume 13(5), September/October 2006, pp 394-399

12. Bradley N, Chow E, Husted J, Sey M, Husain A, Sinclair E, Harris K. Review of patterns of practice and patients’ preferences in the treatment of bone metastases with palliative radiotherapy. Supportive Care in Cancer (published on line Nov 9, 2006)

13. Szumacher E, Perry P, Hayter C, Adams L, Danjoux C. Are we addressing patient’s needs in the radiation practice? The determinants of a Health Care Pilot Project. Canadian Journal of Medical Radiation Technology; Fall 2006, Vol 37, No 3.

14. Cheung G, Chow E, Holden L, Vidmar M, Danjoux C, Yee A, Connolly R, Finkelstein J. Percutaneous Vertebroplasty in Patients with Intractable Pain from Osteoporotic or Metastatic fractures: a Prospective Study using Quality of Life Assessment.

Canadian Association of Radiologists Journal 57(1), 13-21, 2006. 15. Andrade-Souza YM, Ramani M, Scora D, Tsao MN (C), TerBrugge K, Schwartz ML.

Embolization prior to radiosurgery reduces the obliteration rate of arteriovenous malformations (accepted Neurosurg, 2006).

16. Barbera, L., Paszat, L., Chartier, C. Indicators of Poor Quality Care in End of Life Cancer Care in Ontario. Journal of Palliative Care (2006); 22 (1):12-17.

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In Press

1. Harris K, Zhang L, Chow E. Reliability of brief pain inventory in patients with bone

metastases. Journal of Cancer Pain & Symptom Palliation. 2. Chiu H, Bradley N, Wu J, Li K, Doyle M, Fan G, Goh P, Harris K, Tharmalingam S, Ling A,

Yau V, Sinclair E, Danjoux C, Barnes E, Tsao M, Barbera L, Chow E. Smiles and Tears: Undergraduate students’ experience in an outpatient palliative radiotherapy clinic. Journal of Cancer Pain & Symptom Palliation.

3. Wang Y, Chow E, Piliotis E, Tsao M. Initial presentation as sclerotic bone metastases in a patient with acute myelogenous leukemia. Journal of Palliative Medicine.

4. Goh P, Harris K, Napolskikh J, Chow E, Sinclair S, Emmenegger U, Lemon S, Yee A,Wynnychuk L, Myers J, Danjoux C, Ko Y. New multidisciplinary prostate bone metastases--clinic-first of its kind in Canada. Current Oncology.

5. Harris K, Pugash R, David E, Yee A, Sinclair E, Myers J, Chow E. Percutaneous cementoplasty of the lytic metastasis in left acetabulum. Current Oncology. 6. Li K, Sinclair E, Pope J, Farhadian M, Harris K, Napolskikh J, Yee A, Librach S,

Wynnychuk L, Danjoux C, Chow E. A multidisciplinary bone metastases clinic at Toronto Sunnybrook Regional Cancer Centre-A review of the experience from 1999 to 2005. Journal of Cancer Pain & Symptom Palliation.

7. Kirou-Mauro A, Harris K, Sinclair E, Selby D, Chow E. Are family proxies a valid source of information about cancer patients’ quality of life at the end of life? A literature review. Journal of Cancer Pain & Symptom Palliation.

8. Li K, Chow E, Chiu H, Bradley N, Doyle M, Barnes E, Tsao M, Sinclair E, Danjoux C. Effectiveness of palliative radiotherapy in the treatment of bone metastases employing the

Brief Pain Inventory. Journal of Cancer Pain & Symptom Palliation. 9. Chow E, Harris K, Fan G, Tsao M, Sze WM. Palliative radiotherapy trials for bone

metastases: a systematic review. Journal of Clinical Oncology. 10. Lutz S, Konski A, Chow E, Hartsell W. A review of hypofractionated palliative radiotherapy.

Cancer (published on line March 1, 2007) 11. Chow E, Chiu H, Doyle M, Hruby G, Holden L, Barnes E, Tsao M, Mallia G, Harris K, Danjoux

C. Patient expectation of the partial response and response shift in pain score. Supportive Cancer Therapy.

12. Chow E, Loblaw A, Harris K, Doyle M, Goh P, Chiu H, Panzarella T, Tsao M, Barnes E, Sinclair E, Farhadian M, Danjoux C. Dexamethasone for the prophylaxis of radiation-induced pain flare following palliative radiotherapy for bone metastases: A pilot study. Supportive Care in Cancer (published on line Jan 23, 2007)

13. Fan G, Filipczak L, Chow E. Symptom cluster in cancer patients: a review of the literature. Current Oncology.

14. Doyle M, Bradley N, Li K, Sinclair E, Lam K, Chan G, Chow E, Barnes E, Danjoux C, Tsao M. Quality of life in patients with brain metastases treated with a palliative course of whole brain radiotherapy Journal of Palliative Medicine.

15. Tharmalingam S, Chow E, Harris K, Sinclair E. Quality of Life Measurement in Bone Metastases: A Literature Review. Journal of Cancer Pain & Symptom Palliation.

16. Danjoux C, Gardner S, Fitch M. "Prospective evaluation of fatigue during a course of curative radiotherapy for localized prostate cancer" Supportive Care in Cancer; 2007 in press manuscript number JSCC-06-0334

17. Li K, Lee D, Sinclair E, Danjoux C. Correlation of pain scorings with functional interference in brief pain inventory. Submitted to Supportive Care in Cancer.

18. Barbera, L., Paszat, L., Qiu, F. End of life care in lung cancer patients: A population based description of aggressiveness of care and description of hospital admissions. Journal of Pain and Symptom Management.

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19. Barnes, EA. Librach, L., Chow, E., Harris, K., Fan, G., Tsao, M., Barbera, L., Danjoux, C. Involvement of Family Physicians in the Care of Patients seen in the Rapid Response Program. Journal of Clinical Oncology.

20. Szumacher, E., Barbera, L., Barnes, T., Keighley-Clarke, T., Pressnail, B., Matyas, Y., Danjoux, C., Liying, Z., Nyhof-Young, J. Improving access to radiotherapy services in the Simcoe-Muskoka region of Ontario – needs assessment study.

21. Desa V, Danjoux C, Matyas Y, Fitch M, Husain A, Horvath N, Myers J, Clemons M, Hux J, Barnes EA. An Interdisciplinary and Collaborative Initiative in Palliative Care Research. Journal of Cancer Pain & Symptom Palliation.

Books, Book Chapters 1. Barnes E, Chow E. Cancer: radiotherapy. Palliative Medicine. Chapter 91 pages 871-879.

Editors: Eduardo Bruera, Irene Higginson, Carla Ripamonti and Charles von Gunten. Arnold Health Sciences 2006.

2. Chow E, Yee A. Bone secondaries. Prognosis in advanced cancer. Editors: Paul Glare and Nicholas Christakis. Oxford University Press (In press)

5. Braybrooke J, Yee A, Chow E. Palliative orthopaedic surgery. Palliative Medicine. Editor-in-Chief: Declan Walsh. Elsevier (In press)

6. Chow E. Update on radiation treatment for cancer pain. Current Opinion in Supportive & Palliative Care. Pain: Cancer section. Section Editors: Sam Ahmedzai and Anthony Dickenson (In press)

7. Barnes E, Chow E. Cancer-radiotherapy. Palliative Medicine. Chapter 15 (91) pages 871-880. Editors: Eduardo Bruera, Irene Higginson, Carla Ripamonti and Charles von Gunten. Hodder Arnold Health Sciences 2006

8. Chow E, Finkelstein J, Coleman R. Metastatic Cancer to the Bone. Cancer: Principles and Practice of Oncology. Eighth Edition. Editors: DeVita V, Lawrence T, Rosenberg S. Lippincott Williams & Wilkins. (In press)

Posters, Presentations and Published Abstracts

Bone and the Oncologist New Updates. Toronto, Ontario, March 2006.

E. Chow. Radiation therapy and metastatic bone disease. E. Chow. Radiation Oncology research.

16th Annual Ontario Provincial Conference on Palliative and End-of-Life Care. Toronto, Ontario, April 2006

C. Danjoux, E. Chow, A. Drossos, L. Holden. Review of Eight Years Experience with the Rapid Response Radiotherapy Program at Toronto Sunnybrook Regional Cancer Centre. Poster Presentation.

E. Chow. Management of oncological emergencies and skeletal fractures. E. Chow. Management of lymphedema and locally advanced/recurrent breast cancer. E. Chow. Bone metastases module. EORTC Quality of Life Group Spring meeting. Paris,

France, May 2006.

MASCC/ISOO 18th International Symposium Supportive Care in Cancer, Toronto, Ontario, Canada, June 2006.

E. Chow. Determining patient expectation of a clinically relevant partial response and investigating response shift in the treatment of bone metastases with palliative radiotherapy.

Danjoux C, Gardner S, Fitch M. Evaluation of fatigue in patients receiving curative radiation for localized prostate cancer

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Tsao MN, Doyle M, Bradley N, Chan G, Barnes E. Lam K, Chow E. Prospective study of quality of life following whole brain radiotherapy in patients with brain metastases. Multinational Association for Supportive Care in Cancer, Toronto, Ontario, June 2006.

Barnes EA, Librach L, Chow E, Harris K, Fan G, Tsao M, Barbera L, Danjoux C. Involvement of Family Physicians in the Care of Patients Receiving Palliative Radiotherapy.

Medical Oncology Group of Australia/Faculty of Radiation Oncology Annual Scientific Meeting; Queensland, Australia, August 2006.

E. Chow. Modern management of bone metastases, Breakfast session. E. Chow. Survival prediction in geriatric cancer patients. Plenary speaker. Cancer Care in

an ageing population. E. Chow. Bone metastases research, Department of Radiation Oncology, Sydney Cancer Centre/Royal Prince Alfred Hospital, University of Sydney; Sydney, Australia, August 2006.

E. Chow. Bone metastases research, Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong, China. August 2006.

E. Chow. Bone metastases research, Department of Clinical Oncology, Queen Mary Hospital, The University of Hong Kong; Hong Kong, China. August 2006. Canadian Association of Radiation Oncologists (CARO); Calgary, Alberta, September 2006

E. Chow. Patient expectation of the partial response and response shift in bone

metastases. Tsao MN, Doyle M, Bradley N, Chan G, Barnes E. Lam K, Chow E. Prospective study of

quality of life following whole brain radiotherapy in patients with brain metastases. Wang Y, Makhani N, Tsao M. How good is clinical mark-up in whole brain radiation

therapy? Barnes EA, Librach L, Chow E, Harris K, Fan G, Tsao M, Barbera L, Danjoux C.

Involvement of Family Physicians in the Care of Patients Receiving Palliative Radiotherapy.

American Society for Therapeutic Radiotherapy and Oncology (ASTRO); Philadelphia, Pennsylvania, November 2006

E. Chow. ASTRO Educational Session 201: Symptom cluster management. Tsao MN, Doyle M, Bradley N, Chan G, Barnes E. Lam K, Chow E. Prospective study of

quality of life following whole brain radiotherapy in patients with brain metastases. E. Barnes. Palliative Radiotherapy, Palliative Care Rounds, Mount Sinai Hospital, Toronto, ON

October 12, 2006

The Science & Art of Pain and Symptom Management, 13th Annual Conference; Toronto, Ontario, November 2006.

E. Chow. Palliative Radiotherapy. E. Barnes. Palliative Radiotherapy

15

[Back]APPENDIX A

Rapid Response Radiotherapy Palliative Clinics

http://www.sunnybrook.ca/programs/tsrcc/treatmentprevention/rapidresponse.

Staff: Dr. E. Chow (Rad Onc), Dr. C. Danjoux (Rad Onc), Dr. M. Tsao (Rad Onc), Dr. T. Barnes (Rad Onc), E. Sinclair (RT). Objective: Provide expedited access for symptom relief from incurable cancers in patients with limited life expectancies. Eligible Patients:

Symptomatic cancer (any disease site) where palliative radiotherapy may be indicated.

Patients with life expectancies of <6 months.

A “most responsible physician” available to provide follow-up and ongoing oncological care upon completion of the RRRP consultations.

Ineligible Patients: 1. Candidates for potentially curative treatments. 2. Patients requiring further investigations before radiotherapy opinion can be rendered. 3. Patients who are currently actively being followed by a radiation oncologist at

TSRCC (unless otherwise specifically arranged). 4. Patients whose disease status is better served by a radiation oncologist who could provide

longitudinal follow-up. 5. Off-service in-patients who require transfer of care to radiation oncology for ongoing oncological

care.

Monday Dr. T. Barnes Sim 4 Tuesday Dr. M. Tsao Sim 4 Wednesday Dr. C. Danjoux Sim 4 Thursday Dr. E. Chow Sim 4 Friday Dr. M. Tsao Sim 4

To make a referral:

1. Contact the new patient booking office and request a referral to the RRRP clinic. 2. Contact the RRRP nurse. 3. Contact one of the RRRP physicians directly.

http://www.sunnybrook.ca/programs/tsrcc/treatmentprevention/rapidresponse

APPENDIX B

16

[Back]

Decision Tree for Patients Referred to RRRP / BMC (January 2001)

Yes No No

Did patient see a TSRCC Rad Onc?

Is patient new to TSRCC?

Yes No

Yes Refer to his / her Rad Onc

Is patient estimated survival greater than 6 months?

To site group based on diagnosis

- lung - breast - GU etc.

Emergency Urgent Elective < 24 h <1 week Book next available RRRP slot (Cord Compression (Bleeding, Do not book beyond 2 weeks SVCO) SOB)

No Yes YES YES

What is the urgency of appointment?

Is RRRP slot available?

Discuss with RRRP Rad Onc who has a clinic for that day or next few days. Is RRRP Rad Onc able to see patient?

• overbook patient to Rad Onc in RRRP • inform ref MD and patient

No

Refer to Rad Onc on call

** RRRP Policy circulated as addendum to Minutes of Radiation Oncology staff meeting of March 2nd 2000.

17

[Back]APPENDIX C

Jan 1999: Initiated Bone Metastases Clinic (BMC)

A bi-weekly Bone Metastasis Clinic (BMC) was initiated at the T-SRCC on January 8, 1999. The clinic is staffed by Orthopaedic Surgical Oncologists: Drs. T. Axelrod, J. Finkelstein, D. Stephen, M. Ford and A. Yee; Radiation Oncologists: Drs. E. Chow, C. Danjoux, M. Tsao, T. Barnes. The BMC is held on the 2nd and 4th Friday morning of each month in clinic C at the TSRCC.

The goals of the BMC are to:

Provide an elective orthopaedic consultation service for patients with bone metastasis referred by TSRCC oncologists; provide elective radiation oncology consultations to patients with bone metastasis referred by SWHSC physicians.

Provide elective orthopaedic and radiation oncology consultations to patients with bone

metastasis referred by community physicians.

Provide follow-up to oncology patients after orthopaedic interventions.

Bone Metastases Clinic – 2nd and 4th Friday (Clinic C)

To make a referral:

1. Contact the new patient booking office and request referral to the Bone metastases clinic.

2. Contact the RRRP nurse.

3. Contact one of the RRRP physicians directly.

APPENDIX D

ck] [Ba

18

APPENDIX D

19

APPENDIX E

20

[Back]

APPENDIX F [Back]

An Interdisciplinary and Collaborative Initiative in Palliative Care Research

Veena Desa B.Sc.(Hons)1, Cyril Danjoux M.D., F.R.C.P.(C)2, Yvette Matyas M.Sc.1, Margaret Fitch R.N., Ph.D.3, Amna Husain M.D., C.C.F.P., M.P.H.4, Nina Horvath M.D., C.C.F.P.5, Jeff Myers M.D., C.C.F.P., MS.Ed.5, Mark Clemons M.B. B.S., M.D., M.R.C.P.6, Janet E. Hux M.D., S.M., F.R.C.P.(C)5,7,8, Elizabeth A. Barnes M.D., F.R.C.P.(C)2 1 Department of Administration, Toronto Sunnybrook Regional Cancer Centre, Toronto, Ontario,

Canada 2 Department of Radiation Oncology, Toronto Sunnybrook Regional Cancer Centre, Toronto,

Ontario, Canada 3 Psychosocial and Behavioral Research Unit, Toronto Sunnybrook Regional Cancer Centre,

Toronto, Ontario, Canada 4 The Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada 5 Department of Family Medicine, Sunnybrook Hospital, Toronto, Ontario, Canada 6 Department of Medical Oncology, Toronto Sunnybrook Regional Cancer Centre, Toronto, Ontario,

Canada 7 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 8 Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto,

Ontario, Canada Address of corresponding author: Elizabeth A. Barnes, Department of Radiation Oncology, Toronto Sunnybrook Regional Cancer Centre, 2075 Bayview Ave, Toronto, Ontario, Canada, M4N 3M5 (416) 480 - 4951(p), (416) 480 - 6002 (f), email: [email protected] Acknowledgments: We would like to thank all those who attended the palliative research retreat.

21

mailto:[email protected]

APPENDIX F ABSTRACT The scale and complexity of palliative care increasingly demands that researchers move beyond

their own discipline and explore interdisciplinary collaboration. At a Palliative Care Research retreat

held January 2006 at the Toronto Sunnybrook Regional Cancer Centre, researchers from multiple

care settings with the center and from other Toronto hospitals came together with the vision of

becoming Canadian leaders in palliative care research. As a result of this retreat, five

interdisciplinary groups were formed to pursue research in the areas of pain and symptom

management, access to services, translational research, education, and communication. An

overview of the retreat and direction of research for each group is provided.

KEY WORDS Palliative care, research retreat, pain and symptom management, access to care, translational

research, palliative care education, communication.

22

APPENDIX F 1. INTRODUCTION The number of deaths in Canada is expected to increase 33% by the year 2020 and the current

number of Canadians having access to hospice palliative care is only estimated at 15%1. Each

death potentially affects the immediate well being of an average of five other people, or more than

one million Canadians each year 2.

The most promising approach to improving the quality of palliative care is the generation of new

knowledge through research. Rigorous scientific research can provide the evidence for informed

decision-making by clinical practitioners and policy makers 3. To be useful in providing new

insights, such research should involve collaboration across disciplines and encourage researchers to

develop innovative approaches. In order for such collaboration to occur, there must be

infrastructure in place to support this. On January 13, 2006, the Rapid Response Radiotherapy

Program (RRRP) in collaboration with the Toronto Sunnybrook Palliative Care Initiative, the

Psychosocial and Behavioral Research Unit, Bone Metastases Clinic, and the Temmy Latner Centre

for Palliative Care at Mount Sinai Hospital sponsored a Palliative Care research retreat. The vision

of this retreat was to become a Canadian leader in interdisciplinary palliative care research.

Objectives of this retreat included:

• To have a shared overview of palliative care research

• To learn about each other’s research and research interests

• To identify clinical synergies that might foster research questions

• To identify common research areas and questions

• To identify strategies to increase research collaboration

In order to facilitate the widest possible overview of palliative care research, the retreat brought

together 32 participants representing the following professions: physicians (oncologists, palliative

care physicians, and surgeons), nurses, pharmacists, social workers, psychologists, basic scientists,

radiation therapists, and administrators.

Prior to the retreat, attendees were asked to submit their research publications for the past two

years, as well as their current research interests. An extraction of themes from the submitted

publications showed that there were ten areas of research concentration: symptom assessment,

patients’ perspective and experience, communication, workforce issues, program evaluation,

technology, health services, knowledge transfer-exchange, intervention, and research expertise.

23

APPENDIX F

2. EMERGING AREAS OF INTERDISCIPLINARY RESEARCH

From the ten research themes identified, participants were asked to select three themes that were

of interest to them. The five most popular choices for interdisciplinary research were pain and

symptom management, access to palliative care services, translational research, education, and

communication. Each group was charged with formulating a research question, brainstorming

strategies, and discussing next steps to investigate their research question. The following sections

will discuss the overview and direction of research for each group.

2.1 Pain and Symptom Management

Research in the area of symptom clusters is likely to make a significant contribution to the state of

scientific knowledge in this nascent area and is likely to have a broad impact on patients through

the progression of their condition. Although a definition of a symptom cluster has been proposed by

Dodd et al., the definition has yet to be tested and conceptual understanding of symptom

clustering has to be developed 4.

Some early work has identified fatigue, sleep disturbance, and pain as a cluster in cancer patients 5. The evidence for the prevalence and significance of this cluster and the identification of other

clusters remains in large part to be studied.

Understanding symptom clusters will allow the design of interventions and outcome measures in

trials that more closely reflect patients’ experiences. Improving the conceptual understanding of

symptom clustering will provide the evidence-based knowledge to the experiential knowledge of

the interaction and impact of multiple symptoms in patients. The evidence based knowledge will

improve the efficiency and efficacy of dissemination of this clinical experience to new generations

of health care providers. The direct clinical utility of symptom cluster work is that it will inform the

timing and choice of therapeutic strategies when faced with patients with multiple symptoms.

Symptom cluster work will make it possible to explore the complex set of clinical questions that

clinicians face when caring for patients.

24

APPENDIX F

2.2 Access to Palliative Care Services

Access is a complex construct, and may be influenced by health system factors (provider training,

provider reimbursement, integration of care), provider factors (knowledge and attitude toward end

of life care, knowledge regarding local services) and patient factors (knowledge and attitudes

toward palliative care, language and culture barriers).

Utilization is more easily measured but may reflect an even more complex interplay of service

availability and accessibility. A clinical concern is that palliative services are under-utilized by

patients with identified end-stage illness (both cancer and other diseases) and that the proportion

of patients not receiving appropriate care may be greater outside of an oncology context.

Two approaches will be used to assess access to palliative care services in Ontario. The first is to

use health care administrative data to examine the extent of the problem of under-use of palliative

care services among cancer patients. The second is to locally examine some of the patient and

physician level barriers to accessing Palliative Care at Sunnybrook. A study will aim to determine

whether implementation of an End of Life Care Pathway can improve the rate of referral to

palliative care by general internal medicine and improve the end of life care provided on a medicine

unit.

2.3 Translational Research

One of the fundamental problems of performing true translational research in palliative care

revolves around the actual meaning of “translation”. Many millions of dollars are spent in more

traditional aspects of translational research. Indeed, many clinical trials in metastatic cancer (a

situation in which most patients are palliative) have translational components. For example, there

has been a rapid expansion in studies of novel targeted therapies looking at tumor characteristics

that might predict for clinical benefit. Pivotal research took the observation that women with HER2

amplified breast cancer had a poorer prognosis through to the development of the recombinant

humanized monoclonal antibody, trastuzumab (herceptin), directed against HER2 for the treatment

of HER2 positive breast cancer. This agent has shown remarkable results in the metastatic setting

and is now a standard of care for women with early breast cancer that over expresses HER26.

25

APPENDIX F

Can such gains be obtained in other translational settings in palliative care? It is clear that despite

the stunning advances in the management of bone metastases in recent years that most patients

continue to suffer the morbidity and mortality consequences of these metastases. This clinical

observation can be truly translated back to the bench. By analyzing tumor specimens from bone

metastases, the in vivo mechanisms of bone destruction can be studied despite modern anticancer

therapy. If the mechanism of bone breakdown is elucidated then it will allow the development of

rational new strategies to improve patient management. In addition, as bisphosphonate therapy

works through their osteoclast inhibiting effects, the occurrence of bone destruction in breast

cancer patients occurs in the near absence of osteoclasts. This phenomenon has been reported in

previous studies of biopsies from bone metastases and it raises important questions about the

continued use of bisphosphonates until death that is often seen in metastatic breast cancer

patients.

2.4 Education

The knowledge base in palliative and end of life care is continuing to rapidly expand. There is a

need for those with an interest in education and palliative medicine to have effective means and

opportunities to transfer their knowledge to undergraduate and postgraduate students. Currently

there exists a dearth of information as to how to best provide an adequate educational experience

at all levels of training.

Models of innovative educational experiences will be developed with the intent to evaluate the

success of their implementation. For example, the College of Family Physicians of Canada is poised

to adopt a set of competencies in Palliative Medicine, and it is expected that by 2007 each program

will need to demonstrate adequate curricular integration in order to achieve accreditation. It is

currently unclear how best to integrate information into an already saturated program. By working

collaboratively with the Family Medicine Program, unique models of curricular integration will be

developed and evaluated.

2.5 Communication

Communication is an important element in palliative and supportive care. The quality of

communication with patients, family, and team members has been found to be fundamental to the

26

APPENIDX F

quality of care for the patients at the end of life 7. The need to provide opportunities for health care

providers to improve their communication skills has been recognized 8. Poor communication can

leave clinicians and family members stressed and dissatisfied, as well as patients' wishes

neglected.

Many issues need to be addressed in communication research. For example, when providing

palliative and supportive care services, questions arise as to how information should be given,

especially in the electronic age. Other issues include determining the optimal process and content,

communicating with marginalized groups, and recognizing diversity in cultural and ethnic

backgrounds, with the latter being especially relevant in Toronto.

3.0 CONCLUSION

The January 2006 Palliative Care Research Retreat was successful in bringing together people from

different disciplines and with different areas of expertise, all with a common interest in palliative

care research. By integrating different viewpoints and fostering communication, such collaboration

can help to build an environment that facilitates palliative care research. Following the positive

response to the first palliative care research retreat, we are now planning to hold this retreat on an

annual basis. Our goal of promoting collaborative palliative care research will be measured in part

by the generation of projects, success in grant applications, and publications in peer reviewed

journals. Ultimately, the aim is to improve the access and quality of palliative care for patients at

the end of life and their families.

27

APPENDIX F

4. REFERENCES

1. Quality End of Life Care Coalition of Canada. Retrieved March 5, 2006 from

http://www.caot.ca/pdfs/National%20Strategy%20Final%20Draft.pdf. The Quality End

of Life Care Coalition of Canada.

2. Hospice and Palliative Care Manitoba. Retrieved February 10, 2006 from

http://www.manitobahospice.mb.ca/Factsheet_HospicePalliativeCareinCanada_Feb200

4_EN.pdf.

3. Singer P, Bowman KW. Quality end-of-life care: A global perspective. BMC Palliative

Care 2002; 1:4.

4. Miaskowski C, Dodd M, Lee K. Symptom clusters: the new frontier in symptom

management research. J Natl Cancer Inst Monogr 2004;17-21.

5. Dodd MJ, Miaskowski C, Paul SM. Symptom clusters and their effect on the functional

status of patients with cancer. Oncol Nurs Forum 2001;28:465-70.

6. Tokunaga E, Oki E, Nishida K, et al. Trastuzumab and breast cancer: developments

and current status. Int J Clin Oncol 2006;11:199-208.

7. DelVecchio Good MJ, Gadmer NM, et al. Narrative nuances on good and bad deaths:

internists' tales from high-technology work places. Soc Sci Med 2004; 58:939-953.

8. Gysels M, Richardson A, Higginson IJ. Communication training for health professionals

who care for patients with cancer: a systematic review of training methods. Support

Care Cancer 2005;13:356-66.

28

http://www.manitobahospice.mb.ca/Factsheet_HospicePalliativeCareinCanada_Feb2004_EN.pdf

http://www.manitobahospice.mb.ca/Factsheet_HospicePalliativeCareinCanada_Feb2004_EN.pdf

APPENDIX G [Back]

Content of HOT SPOT Newsletter

1999-2006

29

CONTENT AND INSERTS OF HOT SPOT 1999-2006

Editor’s Corner Dr. Gillian Thomas From the Chief Executive Officer Dr. Ken Shumak The first RRRP newsletter Dr. Gillian Thomas Palliative radiotherapy rounds Dr. Ewa Szumacher New combined bone metastases clinic Drs. Joel Finkelstein,

Edward Chow A phase II trial of palliative radiotherapy for metastatic renal cell carcinoma

Drs. Edward Chow, Padraig Warde

Prospective assessment of symptom palliation for patients attending a rapid response radiotherapy program

Drs. Edward Chow, Cyril Danjoux, Rebecca Wong

The challenge of speedy delivery of pain relief met by the rapid response clinic at T-SRCC

Dr. Ewa Szumacher, Ms. Lou Andersson

The cancer pain and palliative care clinic at T-SRCC Dr. Larry Librach Research Corner Dr. Rebecca Wong

Vol 1, Issue 1 February 1999

Message from the Chief Executive Officer Dr. Carol Sawka

A note of thanks Ms. Ruth Connolly, Dr. Edward Chow

Editor’s Corner Differentiating normal grief from clinical depression Dr. Mary Vachon Ontario Drug Benefit (ODB) Formulary Changes Ms. Trudi Schueller Surgical management of metastatic spine disease Dr. Joel Finkelstein Radiosurgery for brain metastases Dr. Phillip Davey Surgical management of metastatic extremity lesions Dr. David Stephen

Vol 1, Issue 2 May 1999

Highlights in the Multinational Association of Supportive Care Cancer Dr. Rebecca Wong Insert May 1999 Cancer Related Pain Management (Sponsored by Janssen-Ortho Inc.) Dr. David Warr

Referring physicians’ satisfaction with the RRRP Ms. Ruth Connolly, Dr. Edward Chow

Preparing the community and health care professionals for new challenges in palliative care – a new endeavour of the rapid response radiotherapy program

Ms. Lou Andersson, Dr. Ewa Szumacher

Editor’s Corner

Management of bone metastases with external beam radiotherapy Drs. Ewa Szumacher and Rebecca Wong

Single dose wide field radiotherapy Dr. Cyril Danjoux Bisphosphonates in palliative care Dr. Sandeep Sehdev Mitoxantrone and prednisone for hormone refractory prostate cancer Dr. Scott Berry

Vol 1, Issue 3 August 1999

Research Corner Dr. Rebecca Wong Insert August 1999 Malignant wound management (Sponsored by Convatec) Dr. Valerie Schultz

Bayview Support Network: Ontario’s first on-site cancer support network Ms. Mridula Sood Dope and cope: it is no longer enough Dr. Michele Chaban Editor’s comment Psychosocial issues with a cancer diagnosis Dr. Margaret Fitch

Vol 1, Issue 4 Nov 1999

Cancer care at York Central Hospital Ms. Jane Anderson

30

Yee Hong palliative care services: A culturally sensitive approach Dr. Stanley Zheng Hill House – A Richmond Hill hospice Ms. Ann Gold Charles R.R. Hayter, MD, BA, MA, FRCPC joins T-SRCC Interview with Russell Goldman, MD, CCFP, palliative care physician with the Temmy Latner Centre for Palliative Care, Mount Sinai Hospital

Research Corner Dr. Rebecca Wong

Bowel Obstruction Dr. Larry Librach Management of Radiotherapy-Induced Acute Gastrointestinal Toxicities Dr. Rebecca Wong

Insert Nov 1999

(Sponsored by Novartis Pharmaceuticals Canada, Inc.)

Editor’s comments Dr. Cyril Danjoux Advance care planning for people with cancer Dr. Scott Berry The emotional needs of the person with advanced cancer Dr. Mary Vachon Historical Vignette: The beginnings of palliative radiotherapy in Canada Dr. Charles Hayter When does palliative care begin? Dr. Larry Librach Palliative radiation oncology program at the Princess Margaret Hospital Dr. Andrea Bezjak Ask the Experts Dr. Rebecca Wong



Prevention and treatment of radiation-induced emesis Dr. Rebecca Wong Insert February 2000 Prevention and treatment of chemotherapy-induced nausea and vomiting

(N&V) - (Sponsored by Glaxo-Wellcome) Mr. Carlo De Angelis

From the associate editor’s desk Dr. Edward Chow Enhancing culturally sensitive practice when caring for seriously ill patients and their families Dr. Elizabeth Latimer Quality end-of-life care: What do patients think? Dr. Scott Berry Family dealing with advanced cancer Dr. Mary Vachon Percutaneous vertebroplasty / cementoplasty at bone metastases clinic, TSRCC Dr. Edward Chow Historical Vignette: Dr. Joseph-Ernest Gendreau and the early use of radium Dr. Charles Hayter


Research Corner Dr. Rebecca Wong Insert May 2000 Accessing palliative care in your community

Ms. Joan Pope, Ms. Lou Andersson

From the editorial board Dr. Ewa Szumacher, Ms. Ruth Connolly

When the patient of a young child is seriously ill Dr. Mary Vachon Disclosure Dr. Philip Hebert Utilization of complementary therapies in palliative care Ms. Ruth Connolly Historical Vignette: Private radiotherapy in Canada Dr. Charles Hayter Research Corner - Summer research for the Rapid Response Radiotherapy Program Dr. Rebecca Wong


Andrew Loblaw, MD, FRCPC, joins T-SRCC Insert August 2000

-Nutrition and cancer -The ABCs of vitamins and minerals (Supported by Novartis Pharmaceuticals Canada, Inc.) Ms. Elaine Posluns

Editor’s Corner Dr. Rebecca Wong Report from the “tri-centre” meeting with Dr. William E. Powers Dr. Jackson Wu


Adolescents living with a parent with advanced illness Dr. Mary Vachon

31

Resources on the Internet for improving end-of-life care – How to get started Dr. Scott Berry Historical Vignette: Vera Peters: Canadian pioneer in psychosocial oncology Dr. Charles Hayter Research Corner – Informational needs assessment on patients receiving palliative radiotherapy Dr. Rebecca Wong Seventh Annual Conference – The Science and Art of Pain and Symptom Management

Insert November 2000

Cancer-related fatigue -Supported by an educational grant from Janssen-Ortho Inc. Dr. Rebecca Wong

From the associate editor’s desk Dr. Edward Chow Dr. Maureen Trudeau Dr. Kathleen Pritchard Staff stress and suffering Dr. Mary Vachon Historical Vignette: Cancer care before medicare Dr. Charles Hayter Pain and symptom management conference Follow-up for breast cancer Dr. Eva Grunfeld Research Corner – Shared treatment decision-making Dr. Rebecca Wong


Thank you…

-Hormones in Breast Cancer,Metastatic Breast Cancer (Supported by Astra-Zeneca Canada Inc.)

Dr. Maureen Trudeau

-Chemotherapy in Metastatic Breast Cancer Treatment, Treatment of Systemic Recurrence with Chemotherapy (Supported by Aventis)

Dr. Maureen Trudeau

Insert February 2001

-Herceptin (Supported by Hoffman LaRoche) Dr. Maureen Trudeau

From the guest editor's desk Dr. Charles Hayter Addressing spiritual needs Dr. Sharon Grant When the shrink gets cancer and gets spiritually transformed Dr. Mary Vachon Historical Vignette: The history of hospices Dr. Charles Hayter Ethics: Caring for patients with different faiths Dr. Scott Berry Research Corner - Patient expectations Dr. Rebecca Wong


Notice regarding treatment delays... Insert May 2001

A guide to spiritual care of the caregiver, A guide to spiritual assessment of cancer patients. (Supported by AstraZeneca Canada Inc. and Purdue Pharma)

Dr. Michele Chaban

From the editor's desk Dr. Cyril Danjoux Comfort and stress among cancer caregivers Dr. Eva Grunfeld On suffering in terminal illness Dr. Mary Vachon Historical Vignette: The history of morphine Dr. Charles Hayter


Research Corner Dr. Rebecca Wong Insert August 2001 Palliation in lung cancer

(Supported by AstraZeneca Inc. and Purdue Pharma)

Drs. Andrea Bezjak, Dr. Catherine Heath, Ms. Jane Lea

From the guest editor's desk Dr. Andrew Loblaw, Ms. Lori Holden

Survey shows 40% of RRRP patients arrive with missing info: A plea for help

Dr. Charles Hayter, Ms. Ruth Connolly


Finding meaning in life in the face of advancing cancer Dr. Mary Vachon

32

Historical Vignette: The 50th anniversary of cobalt treatment Dr. Charles Hayter Tough decisions about funding for new palliative therapies: How do we decide? Dr. Scott Berry Research Corner Dr. Rebecca Wong

Insert Nov 2001

Malignant Spinal Cord Compression (Partially supported by Purdue Pharma)

Dr. Andrew Loblaw, Ms. Lori Holden

From the editor's desk Dr. Ewa Szumacher, Ms. Joan Pope

Advance notice of the ninth annual conference on the science and art of pain and symptom management Denial and minimization in advanced cancer Dr. Mary Vachon Global health ethics and palliative care Dr. Scott Berry Historical Vignette: The story of Essiac Dr. Charles Hayter



Oral health care in the patient with cancer Dr. Trey Petty Mouth care for radiation patients Dr. Alex Hammond


(Supported by Biotene Canada, Division of Bolton Dental Mfg. Inc.)

From the associate editor’s desk Dr. Edward Chow

New chiefs at TSRCC and University of Toronto Dr. Edward Chow, Dr. Cyril Danjoux

Depression in advanced cancer Dr. Mary Vachon Historical Vignette: Blood and medicine Dr. Charles Hayter Hope for a good death Dr. Monica Branigan


Research Corner Dr. Rebecca Wong Insert May 2002

Anemia in hematology and medical/radiation oncology (Supported by Ortho Biotech)

Dr. Gerard Morton, Dr. Rena Buckstein

From the associate editor’s desk Ms. Lou Andersson, Dr. Cyril Danjoux

TSRCC pharmacy services Ms. Kim Stefaniuk The transformation from tragedy into grace in terminal illness – part one Dr. Mary Vachon Historical Vignette: Plants, poisons and potions: Drug treatments for cancer Dr. Charles Hayter TSRCC pharmacy assists Third World countries Ms. Kim Stefaniuk Informed decision-making in palliative care Dr. Scott Berry


Research Corner Dr. May Tsao, Dr. Rebecca Wong

Insert August 2002

Accessing medication (Supported by Amgen Canada and Abbott Laboratories) Ms. Kim Stefaniuk

From the associate editor’s desk Dr. Edward Chow Palliative care is not euthanasia Dr. Monica Branigan The transformation from tragedy into grace in terminal illness – part two Dr. Mary Vachon Palliative care at the University of Texas M.D. Anderson Cancer Center Dr. Toni Barnes Historical Vignette: Charles Huggins: The Canadian who discovered hormone therapy for prostate cancer Dr. Charles Hayter

Vol4, Issue 4 Nov 2002


33

Award of Excellence Dr. Cyril Danjoux Insert Nov 2002

Expanded role of hormone therapy as neoadjuvant or adjuvant therapy in prostate cancer patients undergoing definitive treatment. (Supported by Aventis)

Dr. Richard Choo

From the editor’s desk Drs. Cyril Danjoux, Edward Chow

Congratulations on fifth year Dr. Carol Sawka Congratulations on fifth year Dr. Peeter Poldre Suffering, healing and the wounded healer Dr. Mary Vachon More fifth year congratulations Dr. Shun Wong Advance care planning – update and practical tips Dr. Scott Berry Historical Vignette – A century of radiation therapy in Canada Dr. Charles Hayter


Research Corner Dr. Rebecca Wong Insert February 2003 Pain in cancer: The CARE approach Dr. Larry Librach

From the guest editor’s desk Dr. Charles Hayter, Ms. Lou Andersson

The role of the social worker in palliative oncology Ms. Magdalene Winterhoff

Reflections on anxiety in confronting advanced cancer Dr. Mary Vachon Historical Vignette – Spring fever Dr. Charles Hayter


Research Corner Dr. Rebecca Wong Insert May 2003

Advances and challenges in the management of febrile neutropenia. (Supported by Amgen Canada Inc.)

Dr. Elizabeth J. Phillips

From the guest editor’s desk Dr. Toni Barnes Lymphoma in the elderly Dr. Tom Kouroukis Demorarlization in persons with advanced cancer Dr. Mary Vachon Ethical issues in dealing with demands for “futile” treatment Dr. Scott Berry Historical Vignette – The history of oxygen therapy Dr. Charles Hayter


Research Corner Dr. Rebecca Wong Insert August 2003 Advances for end-of-life respiratory care (Supported by Vital Aire) Dr. Chin K. Chung

From the guest editor’s desk Dr. Cyril Danjoux Referral of patients to the rapid response radiotherapy clinic Boredom in terminal illness Dr. Mary Vachon Hot Spot Survey 2003 “No CPR” – Talking it over Dr. Scott Berry Historical Vignette – The Radium Institute of Toronto Dr. Charles Hayter


Research Corner Dr. Andrea Bezjak Insert Nov 2003 Androgen ablation for metastatic prostate cancer (Supported by Aventis)

Dr. Richard Choo

From the guest editor’s desk Dr. May Tsao Vol 6, Issue 1 February 2004 Brain metastases:

The magnitude of the problem and the struggle to improve outcomes Dr. May Tsao

34

Dignity-conserving care in palliative care Dr. Mary Vachon When capacity fluctuates, what happens to consent? Ms. Karen Faith Historical Vignette: The Montreal Neurological Institute Dr. Charles Hayter

Research Corner Dr. Alina Sturdza, Dr. Andrea Bezjak


Palliation in patients with metastatic cancer to the brain Management of brain metastases (Supported by Aventis)

Dr. May Tsao

From the guest editor’s desk Dr. Charles Hayter Bisphosphonates in cancer Dr. Rebecca Wong Anger in the person with advanced disease Dr. Mary Vachon Ethics and SARS: Collateral damage and relationships in health care Ms. Karen Faith Historical Vignette: Dr. Herbert Bruce: Ontario cancer visionary Dr. Charles Hayter

Vol 6, Issue2 May 2004

Research Corner Dr. Jackson Wu, Dr. Edward Chow

Insert May 2004

Use of bisphosphonates in men with hormone refractory prostate cancer Use of bisphosphonates in women with breast cancer

Dr. Scott Berry Dr. Mark Clemons

From the guest editor’s desk Dr. Cyril Danjoux Supportive Care in Cancer Symposium Dr. Cyril Danjoux Forgiveness in palliative care Dr. Mary Vachon Making decisions for others Ms. Karen Faith Survey shows 40% of RRRP patients arrive with missing info: A plea for help

Dr. Charles Hayter, Ruth Connolly

Vol6, Issue3 August 2004

Research Corner Dr. Laura Dawson Insert August 2004

Rapid Response Radiotherapy Program (RRRP) Review 1996-2003 RRRP Referral Form

Dr. C. Danjoux

From the guest editor’s desk Dr. Edward Chow

The effect of SARS on access to palliative radiotherapy in the RRRP

Dr. Justin Lee, L. Holden, K. Fung, C. Danjoux, E. Chow, C. Gillies

Reflections on the life and death of Mary Peacock Dr. Mary Vachon Quality end-of-life care: Role of economics and the moral climate Ms. Karen Faith Historical Vignette: The Canadian Society for the History of Medicine Dr. Charles Hayter

Vol 6, Issue4 Nov 2004

Research Corner Dr. Jackson Wu, Dr. Edward Chow

Insert Nov 2004 Cannabinoids in medical practice Dr. Vincent Maida

From the guest editor’s desk Dr. Toni Barnes Treatment of bone metastases with palliative radiotherapy: Patients’ treatment preferences

Dr. Ewa Szumacher

Parenting teens during a cancer experience Dr. Mary Vachon Hospital CPR policy: Solution, prevention or band-aid? Ms. Karen Faith Historical Vignette: Alfred Hardisty: Ontario’s pioneer in cancer statistics Dr. Charles Hayter

Vol 7, Issue1 February 2005

Research Corner Dr. Rebecca Wong Insert February 2005 Methadone for cancer pain: An analgesic with a difference Dr. Larry Librach

35

From the guest editor’s desk Dr. Edward Chow The do-not-resuscitate (DNR) order – incidence of documentation in patient charts of patients referred for palliative radiotherapy

Ms. Lou Andersson, Ms. Nicole Bradley

Caught in the middle – mid-life adults with cancer Dr. Mary Vachon

Does culture influence patients’ and famlies’ DNR decision-making? Ms. L. Andersson, S. Mary Williams,N. Bradley

Lessons from my dad Ms. Karen Faith Temmy Latner Centre Update on Palliative Care – Palliative care and children

Mr. Stephen Jenkinson

PROG Rounds Dr. Tanya Berrang

Vol 7, Issue2 May 2005

Farewell to Dr. Charles Hayter Dr. Cyril Danjoux Insert May 2005

Latest advances in antiemetics for radiation therapy and chemotherapy (Supported by an educational grant from Solvay)

Dr. David Warr

Insert #2 May 2005

Novel therapeutics for management for multiple myeloma (Supported by an educational grant from Ortho Biotech)

Dr. Keith Stewart

From the guest editor’s desk Dr. Cyril Danjoux A survey to asses cancer patients’ awareness and interest in hypnosis for pain and distressing procedures – A synopsis

Mrs. Lori Holden, Dr. Charles Hayter

Are we making any progress? Reflections on stressors in the Ontario oncology system over the past 30 years Dr. Mary Vachon Organizational ethics in the eye of the storm: Woodside Hospice and Terri Schiavo Ms. Karen Faith Temmy Latner Centre Update on Palliative Care – End-of-life care distance education: An innovative approach to helping physicians to care for palliative patients

Dr. Anita Singh, Ms. Deborah Adams

Vol 7, Issue3 August 2005

TSRCC investigates advanced practice radiation therapy roles! Ms. S. Robson, R. Barker, L. Holden

Insert August 2005

A more minimally invasive approach to the treatment of metastatic spine lesions. (Supported by an educational grant from Kyphon)

Dr. Michael Ford

From the guest editor’s desk Dr. May Tsao What keeps us going in our work? Dr. Mary Vachon Research ethics and the importance of determining risk Ms. Karen Faith Temmy Latner Centre Update on Palliative Care – Is terminal sedation ethical?

Dr. Victor Cellarius

Vol 7, Issue4 Nov 2005

Research Corner – Results of three important randomized studies and their clinical implications. Dr. Jackson Wu

Insert Nov 2005

Management of hormone refractory prostate cancer / Prostate bone mestastsis multidisciplinary clinic. (Supported by an educational grant from Novartis)

Dr. Yoo-Joung Ko

From the guest editor’s desk Dr. Edward Chow

Greetings from Cancer Care Ontario Dr. Linda Rabeneck, Dr. Deb Dudgeon

Hope in advanced disease Dr. Mary Vachon Temmy Latner Centre Update on Palliative Care – Palliative care grand rounds Deborah Adams Private clinics providing palliative IV therapies – What are the ethical issues? Dr. Scott Berry Helping children and caregivers in fighting cancer – Truth telling in paediatric palliative care. Dr. Christine Newman


Research Corner Dr. Toni Barnes

36


Venous thromboembolism in cancer patients (Supported by an educational grant from Pfizer Canada) Dr. Agnes Y.Y. Lee

From the guest editor’s desk Dr. Cyril Danjoux Truth-telling at the end of life Dr. Monica Branigan What students think: Undergraduate students in palliative health care setting Hannah H. Chiu Temmy Latner Centre Update on Palliative Care – The educating future physicians for palliative and end-of-life care project (EFPPEC): Developing competencies in medical undergraduates and postgraduates Dr. Larry Librach Help no wanted? Dr. Margaret Fitch If symptom clusters exist, how are they relevant to patient care? Dr. Amna Husain


Forgoing nutrition and hydration in children at the end of life: Is it ever justified? Dr. Adam Rapoport

Insert May 2006

Radioimmunotherapies (Supported by an educational grant from GlaxoSmithKline) Dr. Rena Buckstein

From the guest editor’s desk Emily Sinclair Hope, denial and ethics of care Karen Faith The role of a child life specialist at the MBWC-CGPC Ceilidh Eaton Russell Quality indicators of end-of-life care in Ontario cancer patients Dr. Lisa Barbera Palliative care consult team: Moving forward Dr. Jeff Myers 16th Annual provincial conference on palliative and end-of-life care Emily Sinclair Patients’ and health care professionals’ perspectives on the most important quality of life issues in bone metastases

S.Tharmalingam and Kristin Harris


Interprofessionalism: A culture of caring Dr. Michele Chaban Insert August 2006

Video/teleconference as a tool to facilitate research and development in palliative radiotherapy – the Canadian model

Kathryn Burrows, Rebecca Wong, Andrea Bezjak, Jackson Wu, Graeme Duncan, Rajiv Samant, Jim Wright, Frances Wong, and Cyril Danjoux

From the guest editor’s desk Dr. Toni Barnes Ethics and preparing for pandemic influenza Karen Faith Research Column – Symptom control abstracts presented at the annual Canadian Association of Radiation Oncologist (CARO) meeting

Dr. Toni Barnes

Demanding to live Stephen Jenkinson Temmy Latner Centre Update on Palliative Care –Tariro (hope) Dr. Sandy Buchman

Communicating with children about dying Jennifer B. Pond, Ceilidh E. Russell


Exploring occupational therapy’s role – Working with palliative clients and their families

Amy Tymchuk

Insert Nov 2006

New developments in the treatment of advanced renal cell carcinoma (RCC) (Supported by an educational grant from Pfizer) Dr. Yoo-Joung Ko

37

APPENDIX H [Back]

Undergraduate Teaching – Co-op Program

Programme Student Period Final year student

University of Waterloo Has the pattern of practice in the

prescription of palliative radiotherapy for the treatment of uncomplicated bone metastases changed between 1999 and 2005 at the Rapid Response Radiotherapy Program?

Nicole Bradley 2005-2006

First year student University of Waterloo

Gender difference in bone metastases Hannah Chiu 2005-2006

Second year student University of Waterloo

Gender difference in brain metastases and bone metastases module development

Kristin Harris* 2005-2006


Symptom cluster Grace Fan 2006

Fourth year student University of Waterloo

Prostate bone metastases Philiz Goh 2006

Fourth year student University of Waterloo

Bone metastases module

Sukirtha Tharmalingam*

2006

Third year student University of Waterloo

QOL in brain metastases Gabriella Mallia 2006


Length of stay in hospice care Julie Napolskikh* 2006

First year student McMaster University

Patient/Proxy correlation of ESAS Andrea Kirou-Mauro 2006

Fourth year student York University

Eric De Sa 2006

Graduate student University of Waterloo

Palliative care projects Meera Patel 2006

* Award Recipients

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39

APPENDIX I

44

APPENDIX J

rapid response radiotherapy program · rrrp-bmc first decade, we reviewed the following components...

Documents