Michael Brundage

Purpose: The phase III CHALLENGE trial (CCTG CO.21) demonstrated that a 3-year structured exercise program (SEP) improved disease-free and overall survival versus health education materials (HEM) in patients with stage III or high-risk stage II colon cancer after surgery and adjuvant chemotherapy. We assessed the cost-effectiveness of the SEP versus HEM. Methods: This pre-specified economic evaluation used prospectively collected data from all trial participants (n = 889). The base case adopted the Canadian public payer perspective and included direct healthcare costs over a 5-year time horizon with a 1.5% discount rate. 36-Item Short Form (SF-36) outcomes were mapped to Short-Form 6-Dimension (SF-6D) utilities using a validated algorithm. Mean costs (2024 CAD) and effects (life-years (LYs) and quality-adjusted life-years (QALYs)) per participant in each intervention group were used to estimate the incremental costs, incremental LYs/QALYs, incremental cost-effectiveness ratio (ICER, $/life-year gain (LYG)), and incremental cost-utility ratio (ICUR, $/QALY) when applicable. Uncertainty was assessed via bootstrapping (1,000 samples). Notable scenario analyses included a 10-year time horizon and a societal perspective incorporating lost wages due to missed work, measured through the Work Productivity and Activity Impairment questionnaire. Results: In the base case, despite an up-front cost of $2,917 to provide the exercise sessions, the SEP ($31,957) was dominant over HEM ($33,546), being less costly (−$1,589) and more effective (+0.05 LYs; +0.10 QALYs). The SEP was dominant in 53% of bootstrap samples, and 80% fell below a $50,000 per QALY willingness-to-pay threshold. Major cost drivers were cancer recurrence or new malignancy and anticancer therapy. Scenario analyses were consistent with the base case. Conclusion: The SEP was less costly and more effective than HEM. This study can inform payers and health-systems with implementation of SEPs in routine care.

Background: Randomized controlled trials are the foundation of oncology drug development, yet increasing concern exists that some prioritize regulatory approval over outcomes that matter to patients. The Common Sense Oncology (CSO) initiative was founded to reorient research toward patient-valued endpoints. The CSO Patient Priorities Working Group sought to codevelop a pragmatic, patient-centered framework articulating values and actions to guide the design, conduct, and reporting of oncology randomized controlled trials. Methods: A multiphase, mixed-methods process included literature review, thematic analysis, and international stakeholder engagement. Eight focus groups were held between April 2024 and January 2025 with 131 participants across 7 countries, including people with lived cancer experience, advocates, clinicians, and trialists. Feedback from surveys and structured discussions—quantitative ratings and qualitative insights—informed iterative framework refinement. Results: The final framework defines 9 core values with associated actions: meaningful research question, patient partnerships, informed consent, meaningful benefit, generalizability, optimal comparator arm, minimal participant burden, timely feedback of results, and clear dissemination. All values received high endorsement (median 8-9 on a 9-point numeric rating scale [from 1 (least important) to 9 (most important)]). Qualitative analysis emphasized meaningful endpoints, transparent communication, equitable inclusion, fair compensation, and plain-language consent. Conclusions: The CSO Values to Action Framework provides a validated, internationally informed structure for trialists, ethics boards, funders, and advocates. It offers a practical tool to align oncology research with what matters most to patients, promoting more ethical, inclusive, and relevant clinical trials.

(1) Background: Comprehensive and timely lung cancer (LC) staging is essential for prognosis and management. The Lung Diagnostic Assessment Program (LDAP) in Southeastern (SE) Ontario aims to provide rapid, guideline-concordant care for suspected LC patients. We evaluated factors affecting the completeness and timeliness of staging for stage I–III LC patients in SE Ontario, including the impact of LDAP management. (2) Methods: This was a population-based retrospective cohort study using the LDAP database (January 2017–December 2019), linked with the Ontario Cancer Registry, to identify newly diagnosed LC patients. A Cox model approach identified variables associated with staging completeness and timeliness. (3) Results: Among 755 patients, 459 (60.8%) were managed through LDAP. Optimal staging was achieved in 596 patients (78.9%), 23 (3.0%) had alternative staging, and 136 (18.0%) had incomplete staging. In the adjusted analyses, LDAP management was associated with a higher likelihood of complete staging (OR 2.29, p < 0.0001) and faster staging completion (β = −18.53, p < 0.0001). Increased distance to PET centres was associated with a longer time to complete staging (β = 8.95 per 100 km, p = 0.0007), as was longer time to diagnosis (β = 21.63 per 30 days, p < 0.0001). (4) Conclusions: LDAP management in SE Ontario significantly improved staging completeness and shortened staging time for stage I–III LC patients.

Cancer patients’ attitudes toward progression-free survival (PFS) gains offered by treatment are not well understood, particularly in the absence of overall survival (OS) gains. The objectives were to describe patients’ willingness to accept treatment that offers PFS gains without OS gains, to compare these findings with treatments offering OS gains, and to qualitatively summarize patients’ reasons for their preferences. A multicenter, cross-sectional, convergent mixed-methods study design recruited patients who had received at least 3 months of systemic therapy for incurable solid tumors. A treatment trade-off exercise determined the gains in imaging PFS that patients require to prefer additional systemic treatment for a scenario of a newly diagnosed, asymptomatic, incurable abdominal tumor. A qualitative, descriptive, thematic analysis explored factors influencing patients’ decisions, and a narrative method integrated the quantitative and qualitative findings. In total, 100 patients participated (63% were older than 60 years of age). If additional treatment with added toxicity offered no OS advantage, 17% would prefer it for no PFS benefit; 26% for some PFS benefit (range, 3-9 months), whereas 51% would decline it regardless of PFS benefit. Similarly, 71% preferred additional treatment offering a 6-month OS advantage dependent on described toxicity levels (P = .03). A spectrum of reasons for these preferences reflected the complexity of participants’ attitudes and values. Prolongation of time to progression was not universally valued. Most patients did not prefer treatments that negatively affect quality of life for PFS gains alone. Implications for individual decision making, policy, and trials research are discussed.

Introduction: Regional variability in lung cancer (LC) outcomes exists across Canada, including in the province of Ontario. The Lung Diagnostic Assessment Program (LDAP) in southeastern (SE) Ontario is a rapid-assessment clinic that expedites the management of patients with suspected LC. We evaluated the association of LDAP management with LC outcomes, including survival, and characterized the variability in LC outcomes across SE Ontario. Methods: We conducted a population-based retrospective cohort study by identifying patients with newly diagnosed LC through the Ontario Cancer Registry (January 2017–December 2019) and linked to the LDAP database to identify LDAP-managed patients. Descriptive data were collected. Using a Cox model approach, we compared 2-year survival for patients managed through LDAP vs. non-LDAP. Results: We identified 1832 patients, 1742 of whom met the inclusion criteria (47% LDAP-managed and 53% non-LDAP). LDAP management was associated with a lower probability of dying at 2 years (HR 0.76 vs. non-LDAP, p < 0.0001). Increasing distance from the LDAP was associated with a lower likelihood of LDAP management (OR 0.78 for every 20 km increase, p < 0.0001). LDAP-managed patients were more likely to receive specialist assessment and undergo treatments. Conclusions: In SE Ontario, initial diagnostic care provided via LDAP was independently associated with improved survival in patients with LC.

Background: Lung cancer (LC) is the leading cause of cancer-related mortality. In Ontario, Canada, there are significant survival differences for patients with newly diagnosed LC across the 14 provincial regions. Methods: A population-based retrospective cohort study using ICES databases from 01/2007–12/2017 identified patients with newly diagnosed LC through the Ontario Cancer Registry and those with LC as the cause of death. Descriptive data included patient, disease, and system characteristics. The primary outcome was 5-year survival by region. Results: 178,202 patient records were identified; 101,263 met inclusion criteria. LC incidence varied by region (5.6–14.6/10,000), as did histologic subtype (adenocarcinoma: 27.3–46.1%). Five-year cancer-specific survival was impacted by age, rurality, pathologic subtype, stage at diagnosis, and income quintile. Timely care was inversely related to survival (fastest quintile: HR 3.22, p < 0.0001). Adjusted 5-year cancer-specific survival varied across regions (24.1%, HR 1.12; 34.0%, HR 0.89, p < 0.001). Conclusions: When adjusting for confounders, differences in survival by health region persisted, suggesting a complex interplay between patient, disease, and system factors. A single approach to improving patient care is likely to be ineffective across different systems. Quality improvement initiatives to improve patient outcomes require different approaches amongst health regions to address local disparities in care.

Randomized clinical trials are critical for evaluating the safety and efficacy of interventions in oncology and informing regulatory decisions, practice guidelines, and health policy. Patient-reported outcomes (PROs) are increasingly used in randomized trials to reflect the impact of receiving cancer therapies from the patient perspective and can inform evaluations of interventions by providing evidence that cannot be obtained or deduced from clinicians’ reports or from other biomedical measures. This commentary focuses on how PROs add value to clinical trials by representing the patient voice. We employed 2 previously published descriptive frameworks (addressing how PROs are used in clinical trials and how PROs have an impact, respectively) and selected 9 clinical trial publications that illustrate the value of PROs according to the framework categories. These include 3 trials where PROs were a primary trial endpoint, 3 trials where PROs as secondary endpoints supported the primary endpoint, and 3 trials where PROs as secondary endpoints contrast the primary endpoint findings in clinically important ways. The 9 examples illustrate that PROs add valuable data to the care and treatment context by informing future patients about how they may feel and function on different treatments and by providing clinicians with evidence to support changes to clinical practice and shared decision making. Beyond the patient and clinician, PROs can enable administrators to consider the cost-effectiveness of implementing new interventions and contribute vital information to policy makers, health technology assessors, and regulators. These examples provide a strong case for the wider implementation of PROs in cancer trials.

Despite the known importance and necessity of the standardized collection and use of patient-reported outcomes (PROs), there remain challenges to successful clinical implementation. Facilitated through a quality improvement initiative spearheaded by the Canadian Partnership for Quality Radiotherapy (CPQR), and now guided by the Canadian Association of Radiation Oncology (CARO)’s Quality and Standards Committee, patient representatives and early-adopter radiation treatment programs continue to champion the expansion of PROs initiatives across the country. The current review discusses the evolution of a pan-Canadian approach to PROs use, striving to fill in gaps between clinical practice and guideline recommendations through multi-centre and multidisciplinary collaboration.