Published randomized controlled trials of surveillance in cancer patients - a systematic review

With solid tumor cancer survivorship increasing, the number of patients requiring post-treatment surveillance also continues to increase. This highlights the need for evidence-based cancer surveillance guidelines. Ideally, these guidelines would be based on combined high-quality data from randomized controlled trials (RCTs). We present a systematic review of published cancer surveillance RCTs in which we sought to determine the feasibility of data pooling for guideline development. We carried out a systematic search of medical databases for RCTs in which adult patients with solid tumors that had undergone surgical resection with curative intent and had no metastatic disease at presentation, were randomized to different surveillance regimens that assessed effectiveness on overall survival (OS). We extracted study characteristics and primary and secondary outcomes, and assessed risk of bias and validity of evidence with standardized checklist tools. Our search yielded 32,216 articles for review and 18 distinct RCTs were included in the systematic review. The 18 trials resulted in 23 comparisons of surveillance regimens. There was a highlevel of variation between RCTs, including the study populations evaluated, interventions assessed and follow-up periods for the primary outcome. Most studies evaluated colorectal cancer patients (11/18, [61%]). The risk of bias and validity of evidence were variable and inconsistent across studies. This review demonstrated that there is tremendous heterogeneity among RCTs that evaluate effectiveness of different postoperative surveillance regimens in cancer patients, rendering the consolidation of data to inform high-quality cancer surveillance guidelines unfeasible. Future RCTs in the field should focus on consistent methodology and primary outcome definition

The role of cannabis use in suicidal ideation among patients with opioid use disorder.

OBJECTIVES Cannabis use is associated with suicide risk in the general population; however, it is unknown if this association is also present in patients with opioid use disorder (OUD). The purpose of this study is to investigate the association between cannabis use and suicidal ideation in patients with OUD. METHODS We conducted a multivariable logistic regression analysis to assess the association between cannabis use and suicidal ideation, amongst a large cohort of patients with OUD. Current cannabis use and suicidal ideation over the past 30 days were obtained by self-report. RESULTS Cross-sectional data from 2335 participants with OUD were included in the analysis, of whom 51% report current cannabis use. We found a positive association between cannabis use and suicidal ideation (OR = 1.41, 95% CI 1.11, 1.80, P = 0.005). We found that men (OR = 1.84, 95% CI 1.44, 2.35, P < 0.001), younger individuals (OR = 1.02, 95% CI 1.01, 1.03), P = 0.004), and that those with more symptoms of anxiety or depression (OR = 1.16, 95% CI 1.15, 1.18, P < 0.001) were more likely to report suicidal ideation. CONCLUSIONS Cannabis use is associated with a heightened propensity for suicidal ideation amongst patients with OUD, who are already a high-risk population. Further research into the potential harms of cannabis use in this population is required given the prevalence of its use and potential benefits in mitigating opioid withdrawal

The association between cannabis use and suicidal behavior in patients with psychiatric disorders: an analysis of sex differences

Abstract Background Cannabis is the most commonly used illicit drug. In the general population, its use has been linked to a heightened propensity for suicidal behavior (SB). We hypothesize that this association varies in patients with psychiatric disorders. SB is known to vary by sex and therefore an investigation of cannabis’ association with SB must consider sex differences. The purpose of this study is to investigate the association between cannabis use and suicide attempts in men and women with psychiatric disorders. Methods We merged data collected for two studies based in Ontario, Canada (n = 985). We employed a multivariable logistic regression to assess the association between cannabis use and suicide attempts in men and women with psychiatric disorders. Results We analyzed data from 465 men and 444 women. Amongst these, 112 men and 158 women had attempted suicide. The average age of our participants was 40 years (standard deviation (SD) 12.4). We found no significant association between suicide attempts and cannabis use in men (odds ratio (OR) = 1.34, 95% confidence interval (CI) 0.81, 2.22, p = 0.260) or women (OR = 0.97, 95% CI 0.61, 1.54, p = 0.884). In a sensitivity analysis using a sample of patients with substance use disorder only, the heaviness of cannabis use was associated with small but significant association with SB in men (OR = 1.03, 95% CI 1.01, 1.05, p = 0.007). Conclusion Our findings indicate that there is no association between cannabis use and suicidal behavior in men or women with psychiatric disorders unlike what was reported for the general population, though the heaviness of cannabis use may have an effect in men. The impact of cannabis use in psychiatric disorders needs ongoing examination in light of its common use, impending legalization with expected increased access and the uncertainty about cannabis’ effects on prognosis of psychiatric disorders. In addition, research should continue to investigate modifiable risk factors of SB in this population of which cannabis is not a significant factor based on this study

Are patients' goals in treatment associated with expected treatment outcomes? Findings from a mixed-methods study on outpatient pharmacological treatment for opioid use disorder.

OBJECTIVES: Existing methods of measuring effectiveness of pharmacological treatment for opioid use disorder (OUD) are highly variable. Therefore, understanding patients' treatment goals is an integral part of patient-centred care. Our objective is to explore whether patients' treatment goals align with a frequently used clinical outcome, opioid abstinence. DESIGN: Triangulation mixed-methods design. SETTING AND PARTICIPANTS: We collected prospective data from 2030 participants who were receiving methadone or buprenorphine-naloxone treatment for a diagnosis of OUD in order to meet study inclusion criteria. Participants were recruited from 45 centrally-managed outpatient opioid agonist therapy clinics in Ontario, Canada. At study entry, we asked, 'What are your goals in treatment?' and used NVivo software to identify common themes. PRIMARY OUTCOME MEASURE: Urine drug screens (UDS) were collected for 3 months post-study enrolment in order to identify abstinence versus ongoing opioid use (mean number of UDS over 3 months=12.6, SD=5.3). We used logistic regression to examine the association between treatment goals and opioid abstinence. RESULTS: Participants had a mean age of 39.2 years (SD=10.7), 44% were women and median duration in treatment was 2.6 years (IQR 5.2). Six overarching goals were identified from patient responses, including 'stop or taper off of treatment' (68%), 'stay or get clean' (37%) and 'live a normal life' (14%). Participants reporting the goal 'stay or get clean' had lower odds of abstinence at 3 months than those who did not report this goal (OR=0.73, 95% CI 0.59 to 0.91, p=0.005). Although the majority of patients wanted to taper off or stop medication, this goal was not associated with opioid abstinence, nor were any of their other goals. CONCLUSIONS: Patient goals in OUD treatment do not appear to be associated with programme measures of outcome (ie, abstinence from opioids). Future studies are needed to examine outcomes related to patient-reported treatment goals found in our study; pain management, employment, and stopping/tapering treatment should all be explored

A Prospective Study to Investigate Predictors of Relapse among Patients with Opioid Use Disorder Treated with Methadone

Introduction Concomitant opioid abuse is a serious problem among patients receiving methadone maintenance treatment (MMT) for opioid use disorder. This is an exploratory study that aims to identify predictors of the length of time a patient receiving MMT for opioid use disorder remains abstinent (relapse-free). Methods Data were collected from 250 MMT patients enrolled in addiction treatment clinics across Southern Ontario. The impact of certain clinical and socio-demographic factors on the outcome (time until opioid relapse) was determined using a Cox proportional hazard model. Results History of injecting drug use behavior (hazard ratio (HR): 2.26, P = 0.042), illicit benzodiazepine consumption (HR: 1.07, P = 0.002), and the age of onset of opioid abuse (HR: 1.10, P < 0.0001) are important indicators of accelerated relapse among MMT patients. Conversely, current age is positively associated with duration of abstinence from illicit opioid use, serving as a protective factor against relapse (HR: 0.93, P = 0.003). Conclusion This study helps to identify patients at increased risk of relapse during MMT, allowing health care providers to target more aggressive adjunct therapies toward high-risk patients

The association between age of onset of opioid use and comorbidity among opioid dependent patients receiving methadone maintenance therapy

Abstract Background Opioid use disorder (OUD) affects approximately 21.9 million people worldwide. This study aims to determine the association between age of onset of opioid use and comorbid disorders, both physical and psychiatric, in patients receiving methadone maintenance treatment (MMT) for OUD. Understanding this association may inform clinical practice about important prognostic factors of patients on MMT, enabling clinicians to identify high-risk patients. Methods This study includes data collected between June 2011 and August 2016 for the Genetics of Opioid Addiction research collaborative between McMaster University and the Canadian Addiction Treatment Centers. All patients were interviewed by trained health professionals using the Mini-International Neuropsychiatric Interview and case report forms. Physical comorbidities were verified using patients’ electronic medical records. A multi-variable logistic regression model was constructed to determine the strength of the association between age of onset of opioid use and the presence of physical or psychiatric comorbidity while adjusting for current age, sex, body mass index, methadone dose and smoking status. Results Data from 627 MMT patients with a mean age of 38.8 years (SD = 11.07) were analyzed. Individuals with an age of onset of opioid use younger than 18 years were found to be at higher odds for having a physical or psychiatric comorbid disorder compared to individuals with an age of onset of opioid use of 31 years or older (odds ratio 2.94, 95% confidence interval 1.20, 7.19, p = 0.02). A significant association was not found between the risk of having a comorbidity and an age of onset of opioid use between 18 and 25 years or 26 and 30 years, compared to an age of onset of opioid use of 31 years or older. Conclusion Our study demonstrates that the younger one begins to use opioids, the greater their chance of having a physical or psychiatric co-morbidity. Understanding the risk posed by an earlier onset of opioid use for the later development of comorbid disorders informs clinical practice about important prognostic predictors and aids in the identification of high-risk patients