The aim of this study is to identify and evaluate the quality of videos for patients available on YouTube for learning to self-administer subcutaneous methotrexate. Using the search term "Methotrexate injection," two clinical reviewers analyzed the first 60 videos on YouTube. Source and search rank of video, audience interaction, video duration, and time since video was uploaded on YouTube were recorded. Videos were classified as useful, misleading, or a personal patient view. Videos were rated for reliability, comprehensiveness, and global quality scale (GQS). Reasons for misleading videos were documented, and patient videos were documented as being either positive or negative towards methotrexate (MTX) injection. Fifty-one English videos overlapped between the two geographic locations; 10 videos were classified as useful (19.6 %), 14 misleading (27.5 %), and 27 personal patient view (52.9 %). Total views of videos were 161,028: 19.2 % useful, 72.8 % patient, and 8.0 % misleading. Mean GQS: 4.2 (±1.0) useful, 1.6 (±1.1) misleading, and 2.0 (±0.9) for patient videos (p < 0.0001). Mean reliability: 3.3 (±0.6) useful, 0.9 (±1.2) misleading, and 1.0 (±0.7) for patient videos (p < 0.0001). Comprehensiveness: 2.2 (±1.9) useful, 0.1 (±0.3) misleading, and 1.5 (±1.5) for patient view videos (p = 0.0027). This study demonstrates a minority of videos are useful for teaching MTX injection. Further, video quality does not correlate with video views. While web video may be an additional educational tool available, clinicians need to be familiar with specific resources to help guide and educate their patients to ensure best outcomes.

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Background: COVID-19 has spread rapidly, requiring health delivery systems to undertake dramatic transformations. To evaluate these system changes, we undertook one of the first Canadian health delivery system reviews and the first Canadian cancer centre evaluation of pandemic system modifications. Methods: Questionnaires were distributed to the Canadian Association of Provincial Cancer Agencies (CAPCA) members in order to assess changes to cancer centre services and patient management. Documentation relating to COVID-19 from the CAPCA electronic space was accessed, and all publicly available cancer centre documentation related to COVID-19 was reviewed. Results: Seven provinces completed the questionnaire and had documentation available from the CAPCA electronic space. All screening programs across Canada were suspended. In most provinces surveyed, ≥50% of outpatient appointments were occurring virtually, with <25% using video platforms. Generally, the impact on diagnostic imaging and new patient referrals correlated with the impact of COVID-19. Most provinces had a reduction in operating room availability, with chemotherapy and radiation treatments continuing. Public health modification, including personal protective equipment and screening staff, varied across the country. Conclusion: Canadian cancer centres underwent a rapid and aggressive transformation of services in response to COVID-19, with many similarities and differences across provinces. In part, this response was facilitated by communication under a national association, which in Canada remains unique to cancer. This response may serve to inform changes in other jurisdictions or disease states now and in future waves of the pandemic, as well as a record of changes for future health services and patient outcome research.

Central nervous system (CNS) metastasis will develop in 50% of small cell lung cancer (SCLC) patients throughout disease course. Development of CNS metastasis poses a particular treatment dilemma due to the accompanied cognitive changes, poor permeability of the blood-brain barrier to systemic therapy and relatively advanced state of disease. Survival of patients with untreated SCLC brain metastases is generally < 3 months with whole brain radiotherapy used as first-line management in most SCLC patients. To prevent development of CNS metastasis prophylactic cranial irradiation (PCI) is recommended in limited stage disease, after response to chemotherapy and radiation, while PCI may be considered in extensive stage disease after favorable response to upfront treatment. Neurocognitive toxicity with whole brain radiotherapy and PCI is a concern and remains difficult to predict. The mechanism of toxicity is likely multifactorial, but a potential mechanism of injury to the hippocampus has led to hippocampal sparing radiation techniques. Treatment of established nonsmall cell lung cancer CNS metastases has increasingly focused on using stereotactic radiotherapy (SRS) and it is tempting to extrapolate these results to SCLC. In this review, we explore the evidence surrounding the prediction, prevention, detection, and treatment of CNS metastases in SCLC. We further review whether existing evidence supports extrapolating less toxic treatments to SCLC patients with CNS metastases and discuss trials that may shed more light on this question.

Constitutional mismatch repair deficiency (CMMRD) is a rare autosomal recessive hereditary cancer syndrome due to biallelic germline mutation involving one of the four DNA mismatch repair genes. Here we present a case of a young female with CMMRD, homozygous for the c.2002A>G mutation in the PMS2 gene. She developed an early stage adenocarcinoma of the colon at the age of 14. Surveillance MRI of the brain at age 18 resulted in the detection of an asymptomatic brain cancer. On resection, this was diagnosed as an anaplastic astrocytoma. Due to emerging literature suggesting benefit of immunotherapy in this patient population, she was treated with adjuvant dual immune checkpoint inhibition, avoiding radiation. The patient remains stable with no evidence of progression 20 months after resection. The patient’s clinical course, as well as the rational for considering adjuvant immunotherapy in patients with CMMRD are discussed in this report.

Immunotherapy is less effective in non-small cell lung cancer (NSCLC) with driver mutations in epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) and some may extrapolate this trend to other driver mutations. Up to 4% of NSCLC cases contain a BRAF mutation. Most BRAF mutations are V600E, and little is known about the impact of treatment in rare BRAF G469A mutations. We present a case of a patient found to have BRAF G469A mutated NSCLC. She was diagnosed with Stage IIIB NSCLC and treated with concurrent chemotherapy and radiation. Post-treatment imaging demonstrated disease progression and she was started on nivolumab, resulting in a dramatic and prolonged response which is ongoing after 76 cycles. Her substantial response and prolonged benefit suggest that BRAF -mutated NSCLC may respond better than EGFR - or ALK -driven disease to immunotherapy. Due to the rarity of specific mutations, this case adds to the limited current published literature on NSCLC harbouring a BRAF G469A mutation and suggests that immunotherapy is a reasonable treatment option.

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Background The United States (US) Food and Drug Administration (FDA) introduced an Accelerated Approval (AA) pathway to expedite patient access to new drugs. AA accepts less rigorous trial designs, including single arm studies (SAS), owing to perceived lack of feasibility of timely RCTs. Methods We designed hypothetical RCTs with endpoints of objective response rate (ORR), progression free survival (PFS), and overall survival (OS) for FDA approvals based on SAS for solid tumors during 2010–2019. Existing standards of care served as controls. RCTs were designed to detect a difference with power of 0.80, α-error of 5% (two-sided), and 1:1 randomization. Accrual duration was estimated based on participation by &lt; 5% of eligible patients derived from cancer-specific incidence and mortality rates in the US. Results Thirty-one of 172 (18.0%) approvals during the study period were based on SAS. Median sample size was 104 (range = 23–411), and 77.4% were AA. All studies reported ORR, 55% reported duration of response, 19.4% reported PFS, and 22.5% reported OS. Median sample size needed to conduct RCTs with endpoints of ORR, PFS and OS were 206, 130, and 396 respectively. It would have been theoretically possible to conduct RCTs within duration comparable to that required by SAS for 84.6%, 94.1%, and 80.0% of approvals with endpoints of ORR, PFS and OS respectively. Conclusion An overwhelming majority of FDA approvals based on SAS should be feasible as RCTs within a reasonable time-frame. Given the collateral harms to patients and to scientific rigor, drug approval based on SAS should only be permitted under exceptional circumstances.