The diverse worlds of unemployed adults Havitz, Mark E; Morden, Peter A; Samdahl, Diane Marie
The diverse worlds of unemployed adults,
2004, 2006, 2006-01-01, 20040101
eBook
Multi-method research study shows why leisure activities are as important for the unemployed as they are for the employed. Can someone who is unemployed experience leisure, or does that seem like a ...contradiction in terms? If unemployed people can experience leisure, how might it mitigate the negative effects of unemployment? And what form, then, would that leisure take? The relationship between leisure and unemployment has not received the attention it merits, especially in North America. Because research on leisure and unemployment must cross over areas of study, as well as theoretical perspectives, it can often seem conflicting and inconclusive. Yet the need for an understanding of that relationship remains. This groundbreaking book addresses that need. Mark E. Havitz, Peter A. Morden, and Diane M. Samdahl describe the sometimes surprising results of their multi-method study of the effects of unemployment on leisure, lifestyle, and well-being within Canada, and integrate those results with literature collected worldwide into a comprehensive picture. Using in-depth interviews, quantitative experience sampling, and standardized questionnaire data, this fascinating book provides ample evidence that the lived experiences of the unemployed are incredibly diverse, and the need for leisure is as intense for them as for the employed. The authors also pinpoint changes in public policy and social service agency management at local, provincial, and federal levels that will better serve unemployed people and their dependents, and enable them to use leisure activities to improve their lives.
Summary Background Adjuvant chemotherapy for early breast cancer has improved outcomes but causes toxicity. The UK TACT2 trial used a 2×2 factorial design to test two hypotheses: whether use of ...accelerated epirubicin would improve time to tumour recurrence (TTR); and whether use of oral capecitabine instead of cyclophosphamide would be non-inferior in terms of patients' outcomes and would improve toxicity, quality of life, or both. Methods In this multicentre, phase 3, randomised, controlled trial, we enrolled patients aged 18 years or older from 129 UK centres who had histologically confirmed node-positive or high-risk node-negative operable breast cancer, had undergone complete excision, and were due to receive adjuvant chemotherapy. Patients were randomly assigned to receive four cycles of 100 mg/m2 epirubicin either every 3 weeks (standard epirubicin) or every 2 weeks with 6 mg pegfilgrastim on day 2 of each cycle (accelerated epirubicin), followed by four 4-week cycles of either classic cyclophosphamide, methotrexate, and fluorouracil (CMF; 600 mg/m2 cyclophosphamide intravenously on days 1 and 8 or 100 mg/m2 orally on days 1–14; 40 mg/m2 methotrexate intravenously on days 1 and 8; and 600 mg/m2 fluorouracil intravenously on days 1 and 8 of each cycle) or four 3-week cycles of 2500 mg/m2 capecitabine (1250 mg/m2 given twice daily on days 1–14 of each cycle). The randomisation schedule was computer generated in random permuted blocks, stratified by centre, number of nodes involved (none vs one to three vs four or more), age (≤50 years vs >50 years), and planned endocrine treatment (yes vs no). The primary endpoint was TTR, defined as time from randomisation to first invasive relapse or breast cancer death, with intention-to-treat analysis of standard versus accelerated epirubicin and per-protocol analysis of CMF versus capecitabine. This trial is registered with ISRCTN, number 68068041, and with ClinicalTrials.gov , number NCT00301925. Findings From Dec 16, 2005, to Dec 5, 2008, 4391 patients (4371 women and 20 men) were recruited. At a median follow-up of 85·6 months (IQR 80·6–95·9) no significant difference was seen in the proportions of patients free from TTR events between the accelerated and standard epirubicin groups (overall hazard ratio HR 0·94, 95% CI 0·81–1·09; stratified p=0·42). At 5 years, 85·9% (95% CI 84·3–87·3) of patients receiving standard epirubicin and 87·1% (85·6–88·4) of those receiving accelerated epirubicin were free from TTR events. 4358 patients were included in the per-protocol analysis, and no difference was seen in the proportions of patients free from TTR events between the CMF and capecitabine groups (HR 0·98, 95% CI 0·85–1.14; stratified p=0·00092 for non-inferiority). Compared with baseline, significantly more patients taking CMF than those taking capecitabine had clinically relevant worsening of quality of life at end of treatment (255 58% of 441 vs 235 50% of 475; p=0·011) and at 12 months (114 34% of 334 vs 89 22% of 401; p<0·001 at 12 months) and had worse quality of life over time (p<0·0001). Detailed toxicity and quality-of-life data were collected from 2115 (48%) of treated patients. The most common grade 3 or higher adverse events in cycles 1–4 were neutropenia (175 16%) and fatigue (56 5%) of the 1070 patients treated with standard epirubicin, and fatigue (63 6%) and infection (34 3%) of the 1045 patients treated with accelerated epirubicin. In cycles 5–8, the most common grade 3 or higher adverse events were neutropenia (321 31%) and fatigue (109 11%) in the patients treated with CMF, and hand-foot syndrome (129 12%) and diarrhoea (67 6%) in the 1044 patients treated with capcitabine. Interpretation We found no benefit from increasing the dose density of the anthracycline component of chemotherapy. However, capecitabine could be used in place of CMF without significant loss of efficacy and with improved quality of life. Funding Cancer Research UK, Amgen, Pfizer, and Roche.
This paper examines the treatment of race and ethnicity within the leisure literature and introduces an added layer of complexity to this literature through an examination of transracial adoptions. ...Of particular interest is the role that leisure may play in the development of ethnic identity among transracial adoptees. This paper illustrates that research related to ethnic identity development conducted within immigrant populations and biracial families has insights to share, but that much remains to be discovered that is potentially unique to transracial, adoptive families. Similarly, this paper highlights that studies conducted within the United States, due to the differing orientations toward immigration and visible minorities, may not accurately generalize to the Canadian context, which indicates a need for exclusively Canadian as well as comparative research. Recommendations are made regarding future research needs concerning the ethnic identity development of transracial adoptees and the role of leisure in such a process.
To assess the effects of adjuvant hormone therapy (AHT) on survival and disease outcome in women with epithelial ovarian cancer.
Participants were premenopausal and postmenopausal women who had been ...diagnosed with epithelial ovarian cancer (any International Federation of Gynecology and Obstetrics stage) 9 or fewer months previously. Ineligible patients included those with deliberately preserved ovarian function, with a history of a hormone-dependent malignancy, or with any contraindications to hormone-replacement therapy. Patients were centrally randomly assigned in a 1:1 ratio to either AHT for 5 years after random assignment or no AHT (control). Main outcome measures were overall survival (OS), defined as time from random assignment to death (any cause), and relapse-free survival, defined as time from random assignment to relapse or death (any cause). Patients who continued, alive and relapse free, were censored at their last known follow-up.
A total of 150 patients (n = 75, AHT; n = 75, control) were randomly assigned from 1990 to 1995 from 19 centers in the United Kingdom, Spain, and Hungary; all patients were included in intention-to-treat analyses. The median follow-up in alive patients is currently 19.1 years. Of the 75 patients with AHT, 53 (71%) have died compared with 68 (91%) of 75 patients in the control group. OS was significantly improved in patients who were receiving AHT (hazard ratio, 0.63; 95% CI, 0.44 to 0.90; P = .011). A similar effect was seen for relapse-free survival (hazard ratio, 0.67; 95% CI, 0.47 to 0.97; P = .032). Effects remained after adjustment for known prognostic factors.
These results show that women who have severe menopausal symptoms after ovarian cancer treatment can safely take hormone-replacement therapy, and this may, in fact, infer benefits in terms of OS in addition to known advantages in terms of quality of life.
The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, ...healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3‐year cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 67:674–694, 2019.
See related editorial by Steinman et al. in this issue.
Adjuvant chemotherapy for patients with early breast cancer improves outcomes but its toxicity affects patients' quality of life (QOL). The UK TACT2 trial investigated whether accelerated epirubicin ...improves time to recurrence and if oral capecitabine is non-inferior to cyclophosphamide, methotrexate, and fluorouracil (CMF) for efficacy with less toxicity. Results showed no benefit for accelerated epirubicin and capecitabine was non-inferior. As part of the QOL substudy, we aimed to assess the effect of chemotherapies on psychological distress, physical symptoms, and functional domains.
TACT2 was a multicentre, phase 3, open-label, parallel-group, randomised, controlled trial done in 129 UK centres. Participants were aged 18 years or older with histologically confirmed node-positive or high-risk node-negative invasive primary breast cancer, who had undergone complete excision, and due to receive adjuvant chemotherapy. Patients were randomly assigned (1:1:1:1) to four cycles of 100 mg/m2 epirubicin either every 3 weeks (standard epirubicin) or every 2 weeks with 6 mg pegfilgrastim on day 2 of each cycle (accelerated epirubicin), followed by four 4-week cycles of either CMF (600 mg/m2 cyclophosphamide intravenously on days 1 and 8 or 100 mg/m2 orally on days 1–14; 40 mg/m2 methotrexate intravenously on days 1 and 8; and 600 mg/m2 fluorouracil intravenously on days 1 and 8 of each cycle) or four 3-week cycles of 2500 mg/m2 capecitabine (1250 mg/m2 given twice daily on days 1–14 of each cycle). The randomisation schedule was computer generated in random permuted blocks, stratified by centre, number of nodes involved (none vs 1–3 vs ≥4), age (≤50 years vs >50 years), and planned endocrine treatment (yes vs no). QOL was one of the secondary outcomes and is reported here. All patients from a subset of 44 centres were invited to complete QOL questionnaires (Hospital Anxiety and Depression Scale HADS and European Organisation for Research and Treatment of Cancer EORTC Quality of Life Questionnaire 30-item core module QLQ-C30 and Quality of Life Questionnaire breast module QLQ-BR23) at baseline, end of standard or accelerated epirubicin, end of CMF or capecitabine, and at 12 and 24 months after randomisation. The QOL substudy prespecified two coprimary QOL outcomes assessed in the intention-to-treat population: overall QOL (reported elsewhere) and HADS total score. Prespecified secondary QOL outcomes were EORTC QLQ-C30 subscales of physical function, role function, and fatigue and EORTC QLQ-BR23 subscales of sexual function and systemic therapy side-effects. This trial is registered with ISRCTN, ISRCTN68068041, and ClinicalTrials.gov, NCT00301925.
From Dec 16, 2005, to Dec 5, 2008, 4391 patients (20 0·5% of whom were male) were enrolled in TACT2; 1281 (85·8%) of 1493 eligible patients were included in the QOL substudy. Eight (0·6%) participants in the QOL substudy were male and 1273 (99·4%) were female. Median follow-up was 85·6 months (IQR 80·6–95·9). Analysis was performed on the complete QOL dataset (as of Sept 15, 2011) when all participants had passed the 24-month timepoint. Prerandomisation questionnaires were completed by 1172 (91·5%) patients and 1179 (92·0%) completed at least one postrandomisation questionnaire. End-of-treatment HADS depression score (p=0·0048) and HADS total change score (p=0·0093) were worse for CMF versus capecitabine. Accelerated epirubicin led to worse physical function (p=0·0065), role function (p<0·0001), fatigue (p=0·0002), and systemic side-effects (p=0·0001), but not sexual function (p=0·36), compared with standard epirubicin during treatment, but the effect did not persist. Worse physical function (p=0·0048), sexual function (p=0·0053), fatigue (p<0·0001), and systemic side-effects (p<0·0001), but not role functioning (p=0·013), were seen for CMF versus capecitabine at end of treatment; these differences persisted at 12 months and 24 months.
Accelerated epirubicin was associated with worse QOL than was standard epirubicin but only during treatment. These findings will help patients and clinicians make an informed choice about accelerated chemotherapy. CMF had worse QOL effects than did capecitabine, which were persistent for 24 months. The favourable capecitabine QOL compared with CMF supports its use as an adjuvant option after neoadjuvant chemotherapy in patients with triple-negative breast cancer.
Cancer Research UK, Amgen, Pfizer, and Roche.
Abstract Background and purpose Randomised trials testing 15- or 16-fraction regimens of adjuvant radiotherapy in women with early breast cancer have reported favourable outcomes compared with ...standard fractionation. To evaluate hypofractionation further, two 5-fraction schedules delivering 1 fraction per week have been tested against a 25-fraction regimen. Materials and methods Women aged ⩾50 years with node negative early breast cancer were randomly assigned after microscopic complete tumour resection to 50 Gy in 25 fractions versus 28.5 or 30 Gy in 5 once-weekly fractions of 5.7 or 6.0 Gy, respectively, to the whole breast. The primary endpoint was 2-year change in photographic breast appearance. Results Nine hundred and fifteen women were recruited from 2004 to 2007. Seven hundred and twenty-nine patients had 2-year photographic assessments. Risk ratios for mild/marked change were 1.70 (95% CI 1.26–2.29, p < 0.001) for 30 Gy and 1.15 (0.82–1.60, p = 0.489) for 28.5 Gy versus 50 Gy. Three-year rates of physician-assessed moderate/marked adverse effects in the breast were 17.3% (13.3–22.3%, p < 0.001) for 30 Gy and 11.1% (7.9–15.6%, p = 0.18) for 28.5 Gy compared with 9.5% (6.5–13.7%) after 50 Gy. With a median follow-up in survivors of 37.3 months, 2 local tumour relapses and 23 deaths have occurred. Conclusions At 3 years median follow-up, 28.5 Gy in 5 fractions is comparable to 50 Gy in 25 fractions, and significantly milder than 30 Gy in 5 fractions, in terms of adverse effects in the breast.
Multi-method research study shows why leisure activities are as important for the unemployed as they are for the employed. Can someone who is unemployed experience leisure, or does that seem like a ...contradiction in terms? If unemployed people can experience leisure, how might it mitigate the negative effects of unemployment? And what form, then, would that leisure take? The relationship between leisure and unemployment has not received the attention it merits, especially in North America. Because research on leisure and unemployment must cross over areas of study, as well as theoretical perspectives, it can often seem conflicting and inconclusive. Yet the need for an understanding of that relationship remains. This groundbreaking book addresses that need. Mark E. Havitz, Peter A. Morden, and Diane M. Samdahl describe the sometimes surprising results of their multi-method study of the effects of unemployment on leisure, lifestyle, and well-being within Canada, and integrate those results with literature collected worldwide into a comprehensive picture. Using in-depth interviews, quantitative experience sampling, and standardized questionnaire data, this fascinating book provides ample evidence that the lived experiences of the unemployed are incredibly diverse, and the need for leisure is as intense for them as for the employed. The authors also pinpoint changes in public policy and social service agency management at local, provincial, and federal levels that will better serve unemployed people and their dependents, and enable them to use leisure activities to improve their lives.
Purpose
Tumour-infiltrating lymphocytes (TILs) have been shown to be prognostic for disease-free survival and predictive for the benefit of chemotherapy in patients with early breast cancer, but have ...not been studied for endocrine therapy.
Experimental design
The number of CD8-positive TILs was assessed in a subcohort of 236 patients in the Intergroup Exemestane Study. AQ After 2–3 years of adjuvant tamoxifen, AQpatients were randomized between the schemes of continuation for 5 years on tamoxifen and switching to exemestane. The numbers of CD8-positive TILs were analysed for correlations with disease-free survival (DFS) and overall survival (OS). A similar analysis was performed on 2596 patients in the TEAM trial who were randomized between the sequential scheme and the exemestane monotherapy.
Results
In the first cohort, patients with low (below median) numbers of CD8-positive TILs had a univariate hazard ratio (HR) for DFS of 0.27 (95% CI 0.13–0.55) in favour of treatment with exemestane, whereas this benefit was not observed in patients with high numbers of CD8-positive TILs (HR 1.34, 95% CI 0.71–2.50, HR for interaction 5.02,
p
= 0.001). In the second cohort, patients with low numbers of CD8-positive TILs showed a benefit of exemestane treatment on recurrence-free survival (RFS HR 0.67, 95% CI 0.45–0.99), and not with above-median numbers of CD8-positive TILs (HR 0.86, 95% CI 0.59–1.26, HR for interaction 1.29,
p
= 0.36).
Conclusions
This study is the first to propose the number of CD8-positive TILs as potential predictive markers for endocrine therapy, with the low presence of CD8-positive TILs associated to benefit for exemestane-inclusive therapy. However, treatment-by-marker interactions were only significant in one cohort, indicating the need for further validation.
Pre-surgical studies allow study of the relationship between mutations and response of oestrogen receptor-positive (ER+) breast cancer to aromatase inhibitors (AIs) but have been limited to small ...biopsies. Here in phase I of this study, we perform exome sequencing on baseline, surgical core-cuts and blood from 60 patients (40 AI treated, 20 controls). In poor responders (based on Ki67 change), we find significantly more somatic mutations than good responders. Subclones exclusive to baseline or surgical cores occur in ∼30% of tumours. In phase II, we combine targeted sequencing on another 28 treated patients with phase I. We find six genes frequently mutated: PIK3CA, TP53, CDH1, MLL3, ABCA13 and FLG with 71% concordance between paired cores. TP53 mutations are associated with poor response. We conclude that multiple biopsies are essential for confident mutational profiling of ER+ breast cancer and TP53 mutations are associated with resistance to oestrogen deprivation therapy.
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