At the Canadian GCT meeting held in Toronto in 2018, Canadian GCT providers prioritized updating the Canadian consensus document, which was last updated in 2010. 7 MethodsA multidisciplinary group of Canadian testicular cancer experts (nine medical oncologists, five uro-oncologists, two radiation oncologists, one genitourinary pathologist, and one genitourinary radiologist) participated in updating this guideline. Participants were assigned stage-specific topics to update and the project leads (RH, CC, LW) participated in updating all topics. Five individual stage-specific meetings with each subgroup of experts were conducted in April 2021 to discuss and develop key recommendations. Once recommendations were compiled, all participants voted via SurveyMonkey to determine their level of agreement. Modifying methods used by the European Association of Urology and European Society for Medical Oncology Guidelines Committees, each recommendation was followed by a five-point Likert scale: completely disagree, somewhat disagree, undecided, somewhat agree, completely agree, abstain (out of scope of my practice and/or I don't feel comfortable answering). 8 A priori, agreement was defined as ≥75% of experts voting somewhat agree or completely agree. Results from this initial vote are shown in Supplementary Figure 1 (available at cuaj.ca).In June 2021, a full group virtual meeting was held to discuss one recommendation that did not reach agreement, along with 22 other recommendations that, despite ≥75% agreement, some experts had indicated disagreement or undecided opinions. Proposed changes were made accordingly, including the creation of one new recommendation. In July 2021, a second and final vote was conducted including all of the recommendations where any changes had been proposed. Agreement was achieved in all recommendations. Throughout the guideline, after each recommendation, the percent of experts who voted "completely agree" or "somewhat agree" with each statement is shown in parentheses.* Bone.scan.and.brain.imaging.in.patients.with.symptoms.or.poor.prognosis.metastatic. disease..CT:..computed.tomography.

Background Optimal use of bone-modifying agent (BMA) therapy in patients with bone metastases from breast and castrateresistant prostate cancer (CRPC) is evolving. Methods Patients receiving BMA for bone metastases from breast or CRPC were surveyed. Information was collected on patient and disease characteristics, BMA treatments and perceptions regarding BMA benefits and side effects. Interest in participation in trials of de-escalated BMA therapy was also gauged. Results Of 220 patients contacted, 172 eligible patients responded (response rate 78%). Median age was 67 (range: 21-91); 137 (80%) had breast cancer and 35 (20%) CRPC. Symptomatic skeletal events (SSEs) occurred prior to starting BMAs in 61% (84/137) of breast and 48% (17/35) of CRPC patients. Among breast cancer patients, 47, 33 and 13% received zoledronate, pamidronate and denosumab, respectively. Eighty-five percent (30/35) of CRPC patients received denosumab. De-escalation of therapy was more common among breast cancer patients. Although most patients correctly reported the goals of BMA therapy were to "help stop fractures" (62%) and "[improve] quality of life" (63%), 46.5% felt it prolonged survival and 54% felt it reduced bone progression. Most respondents (102/129, 79%) were comfortable with de-escalating to 6-monthly treatment after 2 years of BMA therapy. Patients considered the most important endpoints of de-escalation studies to be "stability of bone metastases" (45%), "quality of life" (22%) and "SSE rates" (14%). Conclusion Twelve weekly BMA was more common in breast than in prostate cancer. There remain misconceptions about the benefits of BMAs, highlighting potential gaps in patient education. Patients were interested in further BMA de-escalation after 2 years of prior BMA and provided study endpoints that were most important to them.

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