Volume 21, Issue 3, August 2019

EditorialBy Dr. Edward Chow

In this issue of Hot Spot:Editorial

Oral mucositis in oncology patients

Specialized palliative care physicians’ practices and opinions regarding early palliative care for patients with advanced cancer

Continuing Medical Education

The Newsletter of the Rapid Response Radiotherapy Programof the Odette Cancer Centre

Insert:Latest update in 2019 Antiemetic Recommendations from Cancer Care Ontario

continued on page 2…

Welcome to the August 2019 issue. Sweta Bhimani, BPharm, MSc(c), RPh, and Mark Pasetka, BSc, BScPharm, PharmD, RPh, at Sunnybrook Odette Cancer Centre have written a comprehensive article on oral mucositis in oncology patients. Ellen Neal, BSc,

Emily Cheng, BSc, Nadia Swami, BSc, Anna Sorensen, MSc, and Camilla Zimmermann, MD, PhD, at Princess Margaret Cancer Centre, University of Toronto, highlight specialized palliative care physicians’ practices and opinions regarding early palliative care for patients with advanced cancer.

Toby Rodin and Bernadette Gregoris provide information on continuing medical education.

Our insert provides the key highlights on Latest update in 2019 Antiemetic Recommendations from Cancer Care Ontario. I hope you will find them useful.

Oral mucositis in oncology patientsBy Sweta Bhimani, BPharm, MSc (c), RPh, and Mark Pasetka, BSc, BScPharm, PharmD, RPh

IntroductionMucositis is a common and frequently

debilitating complication of cancer therapy. It refers to inflammatory and/or ulcerative lesions affecting the mucosa of the gastrointestinal tract.1

Oral mucositis (OM) affects 100 per cent of patients receiving high-dose radiation to the head and neck region, as well as about 20%-40% of patients receiving chemotherapy alone, to some degree.1-3 Approximately 85% of patients receiving head and neck radiation experience World Health Organization (WHO) grade 3-4 toxicities, as well as about 75% of patients undergoing hematopoietic stem cell transplantation (HSCT).1 Radiation-induced OM is typically more severe and lasts longer (3-12 weeks) than OM induced by chemotherapy, which is less severe and of a shorter duration (3-12 days).4 Concurrent chemoradiation results in OM of a more profound severity and duration, with a reduced time of onset.4

OM compromises a patient’s ability to tolerate treatment, as well as having a negative impact on their nutritional status.3

Signs and symptoms of OM can range from mild erythema and discomfort, to more severe symptoms such as pain and inability to tolerate oral intake.3

Risk factors for oral mucositis1,4,5

Patient-related factors include: age, female>male sex, genetic predisposition (e.g., dihydropyrimidine dehydrogenase [DPD] deficiency), oral health, normalcy of saliva, alcohol or tobacco use and comorbidities (e.g., malnutrition).

Treatment-related factors include: location of tumour (e.g., head and neck tumours), type of ionizing radiation, volume or irradiated tissue, daily radiation dose, cumulative radiation dose > 5000 cGy and concurrent chemotherapy.

Pathophysiology of oral mucositis6-8

The current five-phase pathophysiological model of OM consists of the following:

1. Initiation phase – Both radiation therapy and chemotherapy induce DNA damage either directly or indirectly via reactive oxygen species. These free radicals damage DNA, lipids and connective tissue and lead to cell death and release of inflammatory substances.

2. Primary damage response phase – Cell death and the release of inflammatory substances leads to a series of enzyme and transcription factor activity.

3. Signal amplification phase – Positive feedback loops are activated, resulting in an up-regulation of genes coding for inflammatory cytokines such as tumour necrosis factor alpha, interleukin 1β and interleukin 6. This results in erythema from increased vascularity and epithelial atrophy a few days after initiation of treatment.

4. Ulceration and inflammation phase – The cytokines target the submucosa and basal epithelium resulting in tissue damage. The resulting inflammation and tissue damage leads to ulceration and subsequent bacterial colonization, allowing the flow of endotoxins into mucosal tissue and precipitating a vicious cycle of inflammatory cytokine mediated damage. Pain and morbidity associated with mucositis are predominantly attributed to this phase, as a result of the elimination of the protective barrier, which leads to the exposure of nerve endings in the lamina propria.

5. Healing phase – The final healing phase occurs approximately 2-3 weeks after the cessation of radiation therapy and/or chemotherapy and involves signaling via the extracellular matrix, which induces cell proliferation and epithelialization, reestablishing the mucosal barrier.

Assessment of oral mucositis

There are numerous scales that are used to assess the severity of OM; the WHO and National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) are the most widely used.

Management of oral mucositisCurrent OM management strategies are based on guidelines published by MAS-CC/ISOO, NCCN and ESMO.MASCC/ISOO = Multinational Association

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Oral mucositis in oncology patients…continued from page 1

continued on page 3…

Table 1: The WHO and NCI CTCAE scales for assessment of oral mucositis

WHO scale9 NCI CTCAE v 5.010 - Functional

Grade 1 Erythema and soreness Asymptomatic or mild symptoms; intervention not indicated

Grade 2 Ulcers, able to eat solids Moderate pain; not interfering with oral intake; modified diet indicated

Grade 3 Ulcers, required liquid diet

Severe pain; interfering with oral intake

Grade 4 Ulcers, alimentation not possible

Life-threatening consequences; urgent intervention indicated

Table 2: Summary of recommendations for the prevention and management of oral mucositis

1. Prevention strategies• Basic oral hygiene, which includes brushing teeth at least twice daily, using alcohol-free mouth

rinses, flossing as tolerated, and proper denture care should be maintained by all patients.1, 2

• Sodium bicarbonate containing mouth rinse is recommended 4-6 times daily as preventative therapy for patients on targeted therapies. Inadequate/conflicting evidence for use in patients receiving chemotherapy/hematopoietic stem cell transplant or calcium phosphate.1

• 30 minutes of oral cryotherapy may be effective as preventative therapy in patients receiving bolus 5-fluourouracil and high-dose melphalan ± total body irradiation before HSCT.2

• Palifermin is recommended as a preventive therapy in patients with hematological malignancy treated with chemotherapy and/or targeted agents, and/or HSCT ± total body irradiation and who are anticipated to develop grade 3 or 4 OM.1

• Low-level laser therapy may be effective as a preventative therapy in HSCT patients conditioned with high-dose chemotherapy ± total body irradiation and patients undergoing radiation therapy without concurrent chemotherapy, for head and neck cancers.2

• Benzydamine mouthwash is recommended as preventative therapy in patients with head and neck cancer receiving moderate dose radiation therapy.2

• Oral systemic zinc supplements may be effective as prevention therapy in oral cancer patients receiving radiation therapy or chemoradiation.2

2. Treatment strategies• Patient-controlled analgesia with morphine is recommended as treatment for pain in patients

undergoing HSCT.2

• Transdermal fentanyl may be effective as treatment for pain in patients receiving conventional or high-dose chemotherapy ± total body irradiation.2

• 0.2% morphine mouthwash may be effective as treatment for pain in patients receiving chemoradiation for head and neck cancers.2

• 0.5% doxepin mouthwash may be effective as treatment for pain.2

• Frequency of sodium bicarbonate containing mouth rinse to be increased up to each hour as treatment for OM for patients on targeted therapies.1

• Chewing sugar free gum or candy, saliva substitutes or sialagogues may be effective as treatment for oral dryness.1

• Anesthetic mouthwashes (e.g., 2% viscous lidocaine), coating agents or systemic analgesics following the WHO pain management ladder may be effective as treatment for pain.1

• High potency topical steroids (e.g., dexamethasone 0.1mg/mL) maybe effective as treatment for ulcers. Intralesional steroid injections may be considered if there is no ulcer resolution. Systemic steroids may be considered for highly symptomatic or recurrent ulcers.1

3. General guidelines• Sources of injury and painful stimuli (e.g., hot food and drinks, hard, sharp and spicy foods) to the

oral mucosa should be avoided.1

• Regular dental examinations are recommended for all patients to identify and treat potential sources of infection and areas at risk for exacerbating OM.1

• A stepwise approach to OM management is recommended, starting with bland rinses, then topical anesthetics, then systemic analgesics of increasing strength, as needed.11

• Placement of a prophylactic gastrostomy tube may be considered in patients at high risk for OM and esophagitis, typically patients with a large volume of tumour who are receiving radiation therapy and platinum-based chemotherapy, or patients presenting with significant dysphagia or weight loss.2,11

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Vol. 21, Issue 3, August 2019Founders: Dr. L. Andersson, Dr. C. DanjouxEditor: Dr. E. ChowAssociate Editor: Dr. C. DanjouxConsultant: Dr. S. WongAdvisers: Dr. E. Barnes, Dr. R. Goldman, Ms. L. Holden, Dr. A. Husain, Dr. A. Sahgal, Dr. E. Szumacher, Dr. M. TsaoEditorial Manager: Ms. T. RodinOdette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Tel: 416-480-4974, Fax: 416-480-6002 E-mail: toby.rodin@sunnybrook.ca Hot Spot can be accessed on the RRRP website: http://sunnybrook.ca/content/?page=OCC_rrrp_aboutProduced by Pappin Communications, Pembroke, Ontario www.pappin.comThe opinions expressed here are those of the authors and do not necessarily reflect the views of Hot Spot or the RRRP/BMC. The contents of the newsletter and inserts cannot be reproduced or used for other purposes without the written permission of both the editor and the author.

The newsletter of the Rapid Response Radiotherapy Program of the Odette Cancer Centre is published through the support of:

Apobiologix

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Celgene

Janssen Inc.

Novartis

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Purdue Pharma

Roche

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Shire

Takeda

Scan the QR code with your smartphone to read past issues of Hot Spot

of Supportive Care in Cancer/International Society of Oral Oncology; NCCN = Nation-al Comprehensive Cancer Network; ESMO = European Society for Medical Oncology

Future directionsRecently published studies have

shown promising results for the use of propolis,12 honey,13,14 glutamine14 and topical vitamin E14 for the prevention and/or treatment of OM. However, further research is warranted to confirm these findings. Several phase II trials using new agents have also shown promise in the management of OM.15

REFERENCES1. Peterson DE, Boers-Doets

CB, Bensadoun RJ, Herrstedt J. Management of oral and gastrointestinal mucosal injury: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up. Ann Oncol. 2015;26(suppl 5):139-151.

2. Lalla RV, Bowen J, Barasch A, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014;120(10):1453-1461.

3. Naidu MU, Ramana GV, Rani PU, Suman A, Roy P. Chemotherapy-induced and/or radiation therapy-induced oral mucositis-complicating the treatment of cancer. Neoplasia. 2004;6(5):423-431.

4. Rosenthal DI, Trotti A. Strategies for managing radiation-induced mucositis in head and neck cancer. Semin Radiat Oncol.I 2009;19(1):29-34.

5. Satheesh Kumar PS, Balan A, Sankar A, Bose T. Radiation induced oral Mucositis. Indian J Palliat Care. 2009;15(2):95-102.

6. Sonis ST. The pathobiology of mucositis. Nat Rev Cancer. 2004;4(4):277-284.

7. Sonis ST. Pathobiology of oral mucositis: novel insights and opportunities. J Support Oncol. 2007;5(9 suppl 4):3-11.

8. Sonis ST. Mucositis: the impact, biology and therapeutic opportunities of oral Mucositis. Oral Oncol. 2009;45(12):1015-1020.

9. World Health Organization. WHO handbook for reporting results of cancer treatment. World Health Organization. 1979.

10. National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE). Version 5.0. U.S. Department of Health and Human Services. 2017.

11. Bensinger W, Schubert M, Ang, KK, et al. NCCN Task Force Report. Prevention and management of mucositis in cancer care. J Natl Compr Canc Netw. 2008;6(suppl 1):S1-S21

12. Kuo CC, Wang RH, Wang HH, Li CH. Meta-analysis of randomized controlled trials of the efficacy of propolis mouthwash in cancer therapy-induced oral mucositis. Support Care Cancer. 2018;26(12):4001-4009.

13. Howlader D, Singh V, Mohammad S, Gupta S, Pal US, Pal M. Effect of Topical Application of Pure Honey in Chemo-radiation-Induced Mucositis and Its Clinical Benefits in Improving Quality of Life in Patients of Oral Squamous Cell Carcinoma. J Maxillofac Oral Surg.2019;18(1):73-79.

14. Thomsen M, Vitetta L. Adjunctive treatments for the prevention of chemotherapy-and radiotherapy-induced Mucositis. Integr Cancer Ther. 2018;17(4):1027-1047.

15. Sonis ST, Villa A. Phase II investigational oral drugs for the treatment of radio/chemotherapy induced oral mucositis. Expert Opin Investig Drugs. 2018;27(2):147-154.

…continued from page 2

Oral mucositis in oncology patients

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Specialized palliative care physicians’ practices and opinions regarding early palliative care for patients with advanced cancerBy Ellen Neal, BSc, Emily Cheng, BSc, Nadia Swami, BSc, Anna Sorensen, MSc, and Camilla Zimmermann, MD, PhD, Princess Margaret Cancer Centre, University of Toronto

In the last decade, several large randomized controlled trials have demonstrated the benefits of early palliative care for patients with advanced cancer, including improved quality of life, symptom control, mood, and satisfaction with care.1-5 As a result, international agencies now recommend referral of patients with advanced cancer to palliative care services early in their disease trajectory6,7 at a time when they may still be receiving curative treatments.8 However, there remains a gap between the recommendation for early palliative care and the continued late referral to specialized palliative care (SPC) in clinical practice.9-11 This pattern of late referral could be due to an individualistic approach to care,12,13 the perception that oncologists’ palliative care skills are equivalent to those of palliative care specialists,11 and concerns regarding patient perception of a service named “palliative care.”9,10,12-15

In contrast to the large literature available regarding oncologists’ opinions and practices related to early palliative care, the literature regarding SPC physicians’ attitudes in this regard is sparse, consisting of only one qualitative study.16 Further, there has been no formal assessment of SPC physicians’ opinions regarding renaming the speciality of palliative care. Here we report on the findings of a recent study that provides unique insight into the practices and opinions of SPC physicians regarding early palliative care for patients with cancer.17

Before launching the survey, the Canadian Society of Palliative Care Physicians (CSPCP) was contacted to assist in the identification of palliative care physicians in Canada. From a previous survey administered by the CSPCP, a cohort of 823 physicians was identified who reported that they practised palliative care and agreed to be approached for future surveys.18 The survey was distributed by both mail and e-mail, and assessed physicians’ demographics, characteristics of their palliative care practice, their views about their available resources to provide early palliative care, and their opinion regarding changing the name of the specialty

of palliative care to supportive care. Physicians were excluded if they reported that they were “completely retired” or “do not practise any palliative care.” The response rate for eligible participants was 71% (531/746) and, of the 531 respondents, 257 (48.4%) practised SPC.

The results showed that more than 90% of SPC physicians who worked in home, clinic or inpatient settings reported that their service accepted patients with full resuscitation status, those with a prognosis of six to 12 months, or those who were receiving oral cancer treatment or blood transfusions. However, only 62% of physicians’ palliative care units accepted patients with a prognosis between 6 to 12 months and only 46% accepted patients without a do-not-resuscitate status. Moreover, for patients with a prognosis more than one year, 88% of physicians reported they were accepted in clinic/inpatient settings, 63% in home palliative care settings, and 43% in palliative care units.

SPC physicians believed that, in ideal circumstances, patients with cancer should be referred to SPC early in their illness, with more than 90% agreeing that the referral should take place at diagnosis of cancer or of incurable cancer, or at a prognosis of greater than six months. As well, 96% agreed that referral at a prognosis of 6-24 months increased quality of life. However, only 66% were comfortable providing care to patients with full resuscitation status. Although 73% of SPC physicians were satisfied with their relationship with the referring physician, 48% agreed that physicians make palliative care referrals late in the disease trajectory.

SPC-related factors found to be associated with receiving early referrals included having a post-graduate degree and being female. Conversely, SPC physicians who provided care mainly for patients with cancer and those who believed that patients should stop all chemotherapy before palliative care referral were less likely to receive early referrals.

A majority of SPC physicians (60%) agreed that patients have a negative perception of the term “palliative care”, and more than one third agreed that

changing the name from “palliative care” to “supportive care” would increase comfort with early referral among both referring physicians and patients. However, only 21% agreed that “the speciality of palliative care should be renamed supportive care.”

In summary, SPC physicians were overall in favour of an early palliative care model. However, this was not consistently reflected in their practice. To improve integration of palliative care early in a patient’s disease course, actions must be taken not only by referring physicians, but also within the field of SPC. These include further expanding referral criteria, improving education of palliative care physicians in oncology, expanding outpatient provision of palliative care, and developing models for collaborative care among oncologists, SPC physicians and primary care providers.

References 1. (2014) Lancet 383:1721-302. (2009) JAMA 302:741-7493. (2010) N Engl J Med 363:733-7424. (2018) Lancet Oncol 19:394-4045. (2016) Eur J Cancer 65:61-686. World Health Organization 2014.

WHO definition of palliative care. Available at: http://www.who.int/cancer/palliative/definition/en

7. (2010) Ann Oncol 21:362-3698. (2017) J Clin Oncol 35:96-1129. (2012) J Clin Oncol 30:4380-438610. (2014) BMC Palliat Care 13:5911. (2008) Palliat med 22:51-5712. (2014) J Oncol Pract 10:e37-e4413. (2013) Palliat Support Care

11:397-40414. (2009) Palliat Med 23:698-70715. (2012) Ann Oncol 23:382-38716. (2011) Support Care Cancer

19:343-35117. (2019) Support Care Cancer doi:

10.1007/s00520-019-04876-0 [Epub ahead of print]

18. Canadian Society of Palliative Care Physicians Human Resources Committee: Highlights from the national palliative medicine survey. Available at: http://www.cspcpca/information/reports-publications

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Continuing Medical EducationBy Toby Rodin and Bernadette Gregoris, Director of Operations, Oncology Education

Continuing Medical Education (CME) updates healthcare professionals about recent advances for modifying their clinical practice. CME organizers for Hot Spot will list national and international activities in oncology and palliative medicine that are of interest to our readers. Please forward details of CME activities to: toby.rodin@sunnybrook.ca

• September 15–18, 2019 ASTRO Annual Meeting, Chicago, IL. https://www.astro.org/

• October 2–5, 2019 Canadian Association of Radiation Oncology. Annual Scientific Meeting. Halifax, Nova Scotia. http://www.caro-acro.ca/

• October 23–24, 2019 7th Global Congress on Prostate Cancer. International Society for the Study and Exchange of evidence from Clinical research And Medical experience. International University City of Paris, Paris, France. https://www.emedevents.com/c/medical-conferences-2019/global-congress-on-prostate-cancer-2019

• November 1–2, 2019 American Brachytherapy Society. HDR LDR Prostate Scholarship Workshop. Denver, Colorado, US. https://www.americanbrachytherapy.org/index.cfm

• November 3–5, 2019 5th Canadian Cancer Research Conference. Ottawa, Ontario, Canada. http://conference.ccra-acrc.ca/

• November 3–6, 2019 European Society for Therapeutic Radiology and Oncology. Research Course in Radiation Oncology: How to Develop Research – Validation Programmes when Implementing New Technology? Edition 1: MRI Linac. Madrid, Spain. https://www.estro.org/courses

• November 26–28, 2019 European Society for Therapeutic Radiology and Oncology. Palliative Care and Radiotherapy - A Course on Prognosis, Symptom Control, Re-Irradiation and Oligometastases. Brussels, Belgium. https://www.estro.org/courses

• December 1–6, 2019 Radiological Society of North America. 105th Scientific Assembly and Annual Meeting. Chicago, US. https://meeting.rsna.org/

• February 2–6, 2020 Canadian Radiation Oncology Winter School. Mont-Tremblant, Quebec. https://www.conferenceindex.org

• May 18–22, 2020 International Conference on Radiation Oncology, Radiobiology and Medical Physics. https://waset.org/conference/2020/05/vancouver/ICRORMP

• May 29–30, 2020 RTi3 Conference 2020. University of Toronto, Toronto, ON. https://www.eventbrite.ca/e/rti3-conference-2020-may-29th-30th-2020-tickets-62718136635

Oncology Education – CME Events • November 7, 2019

Canadian Immuno-Oncology Summit 2019, Toronto, ON. https://www.oncologyeducation.com/events/upcoming-events/canadian-immuno-oncology-summit-2019/

• November 8, 2019 Best of Lung Cancer Summit 2019, Toronto, ON. https://www.oncologyeducation.com/events/upcoming-events/best-of-lung-cancer-summit-2019/

• November 22, 2019 Best of Oncology East 2019, Toronto, ON. https://www.oncologyeducation.com/events/upcoming-events/best-of-oncology-east-2019/

• January 17, 2020 Best of the SABCS™ Toronto 2019 Annual Meeting, Toronto, ON. https://www.oncologyeducation.com/events/upcoming-events/best-of-sabcs-2020/

• January 24, 2020 Best of Oncology West 2020, Vancouver, BC. https://www.oncologyeducation.com/events/upcoming-events/best-of-oncology-west-2020/

• February 20-22, 2020 14th Canadian Melanoma Conference, Banff, AB. https://www.oncologyeducation.com/events/upcoming-events/14th-canadian-melanoma-conference-2020/

Video LinkOncologyEducation is pleased

to share a special presentation from Dr. Rosalyn Juergens on Real World Data in Lung Cancer – Implementing Immunotherapy into Practice. Please begin by answering a few multiple choice questions accessed by clicking this link (which will also lead to the video): http://bit.ly/RealWorldDataLungCancer. Note that in order to view the links, you will need to log in or sign up as an OncologyEducation member; it is free to do so. This program was made possible through unrestricted sponsorship support from Bristol-Myers Squibb Canada Co. https://www.oncologyeducation.com/events/oncologyeducation-event-videos/real-world-data-in-lung-cancer-implementing-immunotherapy-into-practice/

Supplement to Hot Spot, the newsletter of the Rapid Response Radiotherapy Program of the Odette Cancer Centre – August 2019

Latest update in 2019 Antiemetic Recommendations from Cancer Care Ontario

This education grant provided by Purdue Pharma is

gratefully acknowledged

Footnotes: 1) An anthracycline plus cyclophosphamide for a breast 4) Adults given HEC should be offered a four-drug regimen adding cancer indication should receive a four-drug regimen as part of HEC olanzapine. For patients at increased risk of sedation, clinical judge-prophylaxis. ment should be used and dose recommendation: 5 mg PO prior to

chemotherapy, and 5mg PO daily (or 2.5 mg PO bid) continued on 2) Chemotherapy regimens with carboplatin AUC≥5 should days two to four.be offered primary prophylaxis with an NK1RA in addition to 5-HT3RA and dexamethasone. 5) In adults given HEC, the combination agent, NEPA (NK1 RA,

netupitant/ 5-HT3 RA, palonosetron) is a reasonable alternative to 3) Five-day cisplatin regimens should be offered a four-drug anti- an NK1 RA plus a 5-HT3 RA.emetic regimen consisting of aprepitant, a 5-HT3RA, dexametha-sone, and olanzapine. 6) No recommendation can be made to incorporate synthetic or

non-synthetic cannabinoids as part of standard antiemetic therapy.

Supplement to Hot Spot, the newsletter of the Rapid Response Radiotherapy Program of the Odette Cancer Centre – August 2019

Refer to the 2019 Antiemetic Recommendations for Chemotherapy-Induced Nausea and Vomiting: A Clinical Practice Guideline, for the full guideline. Permission for use from Cancer Care Ontario 2019 Antiemetic Recommendations Expert Working Group.

Volume 6

SCORS Sunnybrook’s Multidisciplinary Brain & Spine

Radiosurgery Clinic

Welcome to this edition of the SCORS newsletter!

Our goal is to keep you up-to-date on the latest clinical and research developments in cancers of the brain and spine,

at the Odette Cancer Centre, and address any questions/ topics you may have for us. Please feel free to share this

newsletter with your colleagues, or drop us a corresponding email, and we will be sure to include them onto our

distribution list!

In this edition, we introduce you to the newest member of our team Dr. Jay Detsky, as well as remind you of a

research study that will be opening soon and accruing patients at the Sunnybrook Odette Cancer Centre.

We hope you enjoy this edition!

Welcome to the Team!

By: Lori Holden as part of the SCORS team: Drs. Sahgal, Soliman, Myrehaug, Tseng, Husain, Detsky, Perry and Mainprize.

It’s been over two years since we treated our first patient on the Gamma Knife Icon unit. We continue to expand our indications and have treated a variety of benign conditions, including functional and mental health disorders. We are treating patients with larger intact brain metastases and after surgical resection to the cavity with hypofractionated SRS on the Gamma Knife Icon. We have recently published our experience on 5 fraction Stereotactic radiotherapy to the surgical cavity. Details of this can be found in this reference (Soliman et al, Neurosurgery, 2019 Jun 7)

The GK ICON Update!

Dr. Detsky is a new clinician investigator and staff radiation oncologist at the Odette Cancer Centre and an associate professor at the University of Toronto. He completed medical school and residency in radiation oncology at the University of Toronto followed a fellowship in CNS and GU oncology at the Odette Cancer Centre under Drs. Sahgal and Vesprini. Prior to medicine he completed a PhD in Medical Biophysics focusing on magnetic resonance imaging. His research focus is on imaging to improve radiation delivery and to evaluate outcomes for patients with brain and spine tumors as well as prostate cancer. Dr. Detsky is part of the GU team treating prostate and bladder cancer as well as the CNS team treating brain and spine tumors with radiosurgery.

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SRS vs WBRT + SRS trial A Randomized Trial Evaluating Stereotactic Radiosurgery Alone (SRS) to Whole Brain Radiotherapy (WBRT) plus SRS for patients with 5 to 20 Brain metastases The current management of brain metastases has evolved in patients with 1 to 4 metastases to incorporate stereotactic radiosurgery (SRS). As a result of multiple trials showing that survival is not compromised by withholding whole brain radiotherapy (WBRT), and furthermore, the harmful consequences in terms of neurocognition with WBRT, SRS alone now dominates the treatment of patients with limited brain metastases. Randomized evidence is lacking in patients with 5 or more brain metastases (multiple) with respect to more definitive treatment with the intent to optimize local control while potentially minimizing neurocognitive impact. This upcoming randomized trial will provide the much needed high level evidence to determine the role of SRS and WBRT in patients presenting with 5 to 20 metastases. The experience from prior randomized studies in the setting of limited brain metastases have guided the design of current trials and greater emphasis is placed on the evaluation of cognitive function, therefore, the primary endpoint is to determine the impact on neurocognitive function and secondary endpoints include local control, distant brain control, overall survival, and health-related quality of life (HRQoL). Inclusion criteria:

Age ≥ 18

Karnofsky Performance Status (KPS) ≥ 70

Histologic or cytologic diagnosis of non-hematopoietic malignancy

Patients with ≥ 5 but ≤ 20 measurable brain metastases on diagnostic MRI (patients who are found to have 21-30 metastatic lesions at the time of treatment planning may still participate)

Baseline Hopkins Verbal Learning Test-Revised (HVLT-R) above ≥ 6

Patients must be able to tolerate WBRT, and all brain lesions must be eligible for treatment with SRS as determined by the radiation oncologist

Immunotherapy and chemotherapy must be held at least 1 week before and after completion of radiotherapy; other targeted agents/therapy must be held at least 1 day before and after SRS

Exclusion criteria:

Any prior radiation therapy or surgical resection for brain metastases or evidence of leptomeningeal disease

Referring your patients to this clinic is easy. You can either:

Call New Patient Bookings at 416-480-5000 xt. 4205

OR Call our Advanced Practice RT Lori Holden at xt 7044

OR Fill out our standard referral form, and indicate “SCORS Clinic” on it.