Disparities in breast cancer diagnosis for immigrant women in Ontario and BC: results from the CanIMPACT study.

BACKGROUND: In Canada, clinical practice guidelines recommend breast cancer screening, but there are gaps in adherence to recommendations for screening, particularly among certain hard-to-reach populations, that may differ by province. We compared stage of diagnosis, proportion of screen-detected breast cancers, and length of diagnostic interval for immigrant women versus long-term residents of BC and Ontario. METHODS: We conducted a retrospective cohort study using linked administrative databases in BC and Ontario. We identified all women residing in either province who were diagnosed with incident invasive breast cancer between 2007 and 2011, and determined who was foreign-born using the Immigration Refugee and Citizenship Canada database. We used descriptive statistics and bivariate analyses to describe the sample and study outcomes. We conducted multivariate analyses (modified Poisson regression and quantile regression) to control for potential confounders. RESULTS: There were 14,198 BC women and 46,952 Ontario women included in the study population, of which 11.8 and 11.7% were foreign-born respectively. In both provinces, immigrants and long-term residents had similar primary care access. In both provinces, immigrant women were significantly less likely to have a screen-detected breast cancer (adjusted relative risk 0.88 [0.79-0.96] in BC, 0.88 [0.84-0.93] in Ontario) and had a significantly longer median diagnostic interval (2 [0.2-3.8] days in BC, 5.5 [4.4-6.6] days in Ontario) than long-term residents. Women from East Asia and the Pacific were less likely to have a screen-detected cancer and had a longer diagnostic interval, but were diagnosed at an earlier stage than long-term residents. In Ontario, women from Latin America and the Caribbean and from South Asia were less likely to have a screen-detected cancer, had a longer median diagnostic interval, and were diagnosed at a later stage than long-term residents. These findings were not explained by access to primary care. CONCLUSIONS: There are inequalities in breast cancer diagnosis for Canadian immigrant women. We have identified particular immigrant groups (women from Latin America and the Caribbean and from South Asia) that appear to be subject to disparities in the diagnostic process that need to be addressed in order to effectively reduce gaps in care.

Symptom appraisal, help seeking, and lay consultancy for symptoms of head and neck cancer.

OBJECTIVE: Early diagnosis is important in head and neck cancer (HNC) patients to maximize the effectiveness of the treatments and minimize the debilitation associated with both the cancer and the invasive treatments of advanced disease. Many patients present with advanced disease, and there is little understanding as to why. This study investigated patients' symptom appraisal, help seeking, and lay consultancy up to the time they first went to see a health care professional (HCP). METHODS: We interviewed 83 patients diagnosed with HNC. The study design was cross sectional and consisted of structured telephone interviews and a medical chart review. We gathered information on the participant's personal reactions to their symptoms, characteristics of their social network, and the feedback they received. RESULTS: We found that 18% of the participants thought that their symptoms were urgent enough to warrant further investigation. Participants rarely (6%) attributed their symptoms to cancer. Eighty-nine percent reported that they were unaware of the early warning signs and symptoms of HNC. Fifty-seven percent of the participants disclosed their symptoms to at least one lay consultant before seeking help from an HCP. The lay consultants were usually their spouse (77%), and the most common advice they offered was to see a doctor (76%). Lastly, 81% of the participants report that their spouse influenced their decision to see an HCP. CONCLUSIONS: The results of this study suggest that patients frequently believe that their symptoms were nonurgent and that their lay consultants influence their decision to seek help from an HCP.

Use of physician services during the survivorship phase: a multi-province study of women diagnosed with breast cancer.

INTRODUCTION: Oncologists have traditionally been responsible for providing routine follow-up care for cancer survivors; in recent years, however, primary care providers (pcps) are taking a greater role in care during the follow-up period. In the present study, we used a longitudinal multi-province retrospective cohort study to examine how primary care and specialist care intersect in the delivery of breast cancer follow-up care. METHODS: Various databases (registry, clinical, and administrative) were linked in each of four provinces: British Columbia, Manitoba, Ontario, and Nova Scotia. Population-based cohorts of breast cancer survivors were identified in each province. Physician visits were identified using billings or claims data and were classified as visits to primary care (total, breast cancer-specific, and other), oncology (medical oncology, radiation oncology, and surgery), and other specialties. The mean numbers of visits by physician type and specialty, or by combinations thereof, were examined. The mean numbers of visits for each follow-up year were also examined by physician type. RESULTS: The results showed that many women (>64%) in each province received care from both primary care and oncology providers during the follow-up period. The mean number of breast cancer-specific visits to primary care and visits to oncology declined with each follow-up year. Interprovincial variations were observed, with greater surgeon follow-up in Nova Scotia and greater primary care follow-up in British Columbia. Provincial differences could reflect variations in policies and recommendations, relevant initiatives, and resources or infrastructure to support pcp-led follow-up care. CONCLUSIONS: Optimizing the role of pcps in breast cancer follow-up care might require strategies to change attitudes about pcp-led follow-up and to better support pcps in providing survivorship care.

Multigene expression profile testing in breast cancer: is there a role for family physicians?

BACKGROUND: Family physicians (fps) play a role in aspects of personalized medicine in cancer, including assessment of increased risk because of family history. Little is known about the potential role of fps in supporting cancer patients who undergo tumour gene expression profile (gep) testing. METHODS: We conducted a mixed-methods study with qualitative and quantitative components. Qualitative data from focus groups and interviews with fps and cancer specialists about the role of fps in breast cancer gep testing were obtained during studies conducted within the pan-Canadian canimpact research program. We determined the number of visits by breast cancer patients to a fp between the first medical oncology visit and the start of chemotherapy, a period when patients might be considering results of gep testing. RESULTS: The fps and cancer specialists felt that ordering gep tests and explaining the results was the role of the oncologist. A new fp role was identified relating to the fp-patient relationship: supporting patients in making adjuvant therapy decisions informed by gep tests by considering the patient's comorbid conditions, social situation, and preferences. Lack of fp knowledge and resources, and challenges in fp-oncologist communication were seen as significant barriers to that role. Between 28% and 38% of patients visited a fp between the first oncology visit and the start of chemotherapy. CONCLUSIONS: Our findings suggest an emerging role for fps in supporting patients who are making adjuvant treatment decisions after receiving the results of gep testing. For success in this new role, education and point-of-care tools, together with more effective communication strategies between fps and oncologists, are needed.

Effect of specialized diagnostic assessment units on the time to diagnosis in screen-detected breast cancer patients.

BACKGROUND: The duration of the cancer diagnostic process has considerable influence on patients' psychosocial well-being. Breast diagnostic assessment units (DAUs) in Ontario, Canada are designed to improve the quality and timeliness of care during a breast cancer diagnosis. We compared the diagnostic duration of patients diagnosed through a DAU vs usual care (UC). METHODS: Retrospective population-based cohort study of 2499 screen-detected breast cancers (2011) using administrative health-care databases linked to the Ontario Cancer Registry. The diagnostic interval was measured from the initial screen to cancer diagnosis. Diagnostic assessment unit use was based on the biopsy and/or surgery hospital. We compared the length of the diagnostic interval between the DAU groups using multivariable quantile regression. RESULTS: Diagnostic assessment units had a higher proportion of patients diagnosed within the 7-week target compared with UC (79.1% vs 70.2%, P<0.001). The median time to diagnosis at DAUs was 26 days, which was 9 days shorter compared with UC (95% CI: 6.4-11.6). This effect was reduced to 8.3 days after adjusting for all study covariates. Adjusted DAU differences were similar at the 75th and 90th percentiles of the diagnostic interval distribution. CONCLUSIONS: Diagnosis through an Ontario DAU was associated with a reduced time to diagnosis for screen-detected breast cancer patients, which likely reduces the anxiety and distress associated with waiting for a diagnosis.

Adherence to and uptake of clinical practice guidelines: lessons learned from a clinical practice guideline on chemotherapy concomitant with radiotherapy in head-and-neck cancer.

BACKGROUND: Clinical practice guidelines (cpgs) are systematically developed statements designed to assist practitioners and patients in making decisions about appropriate heath care interventions. Clinical practice guidelines are expensive and time-consuming to create. A cpg on concurrent chemotherapy with radiation therapy (ccrt) was developed in Ontario at a time when treatment approaches for head-and-neck cancer were changing significantly. METHODS: An assessment of treatments and outcomes based on electronic and chart data obtained from a population-based study of 571 patients with oropharynx cancer treated in Ontario (2003-2004) was combined with a review of relevant knowledge transfer (publications and presentations at major meetings) to understand variation in adherence to a cpg. RESULTS: In 9 Ontario cancer treatment centres, ccrt was used for 55% of all patients with oropharyngeal cancer; however, at the centres individually, that proportion ranged from 82% to 39%. Furthermore, there was no agreement on the chemotherapy regimen: 2-4 years later (a period during which newer regimens were emerging), only 4 of 9 centres were following the guideline for most patients. When outcomes of treated patients were compared for centres with "higher" and "lower" use of ccrt, no difference in survival was observed (p = 0.64). CONCLUSIONS: At a time of treatment evolution, the new guideline was controversial, and there are many reasons for the mixed adherence. An estimation of adherence should be included during both development and review of guidelines.

Social support and quality of life of prostate cancer patients after radiotherapy treatment.

Research suggests that social support can have an impact on health-related quality of life (HRQOL). Social support can be structural support (SSS) or functional support (FSS). Our study was designed to clarify the relationships between HRQOL, FSS and SSS. We conducted a cross-sectional survey and a detailed chart review. The study population was men attending a follow-up clinic after receiving radiotherapy for prostate cancer. Functional social support was measured by using the MOS Social Support Survey. Structural social support was measured by using questions adapted from the 1994-1995 National Population Health Survey conducted by Statistics Canada. Health-related quality of life was measured by using the European Organization for Research and Treatment of Cancer's QLQ-C30. We found a statistically significant positive correlation between FSS and HRQOL but no association between overall SSS and HRQOL. Worsening urinary symptoms were significantly associated with lower levels of FSS and with lower HRQOL. This study underscores that the perception of support (functional) is more important than the amount or size of support (structural). We also identified a subgroup of men who have lower FSS and lower HRQOL that suffer from urinary side effects of their treatment. Further research to clarify the relationship between FSS and urinary symptoms will also clarify how an intervention could improve the HRQOL of these men.

Breast cancer diagnosis and treatment wait times in specialized diagnostic units compared with usual care: a population-based study.

Background: Breast assessment sites (bass) were developed to provide expedited and coordinated care for patients being evaluated for breast cancer (bca) in Ontario. We compared the diagnostic and treatment intervals for patients diagnosed at a bas and for those diagnosed through a usual care (uc) route. Methods: This population-based, cross-sectional study of patients diagnosed with bca in Ontario during 2007-2015 used linked administrative data. "Diagnostic interval" was the time from the earliest cancer-related health care encounter before diagnosis to diagnosis; "treatment interval" was the time from diagnosis to treatment. Diagnosis at a bas was determined from the patient's biopsy and mammography institutions. Interval lengths for the bas and uc groups were compared using multivariable quantile regression, stratified by detection method. Results: The diagnostic interval was shorter for patients who were bas-diagnosed than for those who were uc-diagnosed, with adjusted median differences of -4.0 days [95% confidence interval (ci): -3.2 days to -4.9 days] for symptomatic patients and -5.4 days (95% ci: -4.7 days to -6.1 days) for screen-detected patients. That association was modified by stage at diagnosis, with larger differences in patients with early-stage cancers. In contrast, the treatment interval was longer in patients who were bas-diagnosed than in those who were uc-diagnosed, with adjusted median differences of 4.2 days (95% ci: 3.8 days to 4.7 days) for symptomatic patients and 4.2 days (95% ci: 3.7 days to 4.8 days) for screen-detected patients. Conclusions: Diagnosis of bca through a bas was associated with a shorter diagnostic interval, but a longer treatment interval. Although efficiencies in the diagnostic interval might help to reduce distress experienced by patients, the longer treatment intervals for patients who are bas-diagnosed remain a cause for concern.

Demographic differences between cancer survivors and those who die quickly of their disease.

AIMS: Some people diagnosed with cancer die extremely quickly of their disease. We investigated whether certain demographic and geographical characteristics were associated with these early deaths. MATERIALS AND METHODS: The Ontario Cancer Registry enhanced with census data was used to study early death in patients aged 40-69 years, diagnosed between 1990 and 1997 with colorectal, female breast, head and neck, lung, prostate, stomach, or primary cancer of unknown origin. For each site, cases were either those who constituted the quickest 10% of deaths, or those who died within 30 days, whichever was the larger number (n = 5022). Controls were those still alive at 1 year (n = 59 406). Analyses were stratified by disease site and logistic regression identified independent effects. Characteristics included: age, gender, area-level socioeconomic status, county of residence, urban/rural residence, diagnosis year, and distance to a cancer centre. RESULTS: Lower socioeconomic status (all sites) and increasing age (all sites except prostate and primary of unknown origin) were most strongly and consistently associated with early death. Male gender was a risk factor for early death from lung cancer. Living in urban areas was a risk factor for breast, lung, and unknown primary cancers. CONCLUSIONS: People living in poorer and/or urban areas and the young-elderly are more susceptible to a very late cancer diagnosis. Unequal access to cancer care can lead to devastating consequences for vulnerable sectors of society.

Measuring the Quality of Personal Care in Patients Undergoing Radiotherapy for Prostate Cancer.

AIMS: To describe the quality of the non-technical component of the care (personal care) of patients receiving radical radiotherapy for prostate cancer and to identify elements of personal care that should be priorities for quality improvement. MATERIALS AND METHODS: One hundred and eight patients undergoing radiotherapy for localised prostate cancer completed a self-administered questionnaire that asked them to rate the importance of 143 non-technical elements of care and to rate the quality of their own care with respect to each element. The elements that a patient rated as both 'very important' and less than 'very good' were deemed to be his priorities for improvement. The priorities of the population were established by ranking the elements based on the percentage of patients who identified them as a priority (importance/quality analysis). RESULTS: The response rate was 65%. The percentage of elements rated 'very good' varied from patient to patient: median 79% (interquartile range 69-92%). The percentage of elements rated either 'very good' or 'good' was higher: median 96% (interquartile range 86-98%). Nonetheless, almost every patient rated at least some elements of his care as less than optimal, regardless of the cut-off point used to define optimal quality. Patients assigned their lowest quality ratings to elements relating to the quality of the treatment environment and comprehensiveness of additional services available to them. However, patients rated most of these elements as relatively unimportant, and importance/quality analysis identified elements of care relating to communication of information about the disease and its treatment as the highest priorities for quality improvement. CONCLUSIONS: Most patients rated most elements of their personal care as very good, but almost all were able to identify some elements that were less than optimal. When ratings of quality were integrated with ratings of importance, elements relating to communication emerged as the patients' highest priorities for quality improvement.

Explaining socioeconomic status effects in laryngeal cancer.

INTRODUCTION: People with lower socioeconomic status (SES) experience shorter survival times after a cancer diagnosis for many disease sites. We determined whether area-level SES was associated with the outcomes: cause-specific survival and local-regional failure in laryngeal cancer in Ontario, Canada. When we found an association we sought explanations that might be related to access to care including age, sex, rural residence, tumor stage, lymph node status, use of diagnostic imaging, treatment type, percentage of prescribed radiotherapy delivered, number of radiotherapy interruption days, treatment waiting time, and treating cancer center. MATERIALS AND METHODS: The study population consisted of 661 glottic and 495 supraglottic stage-stratified randomly-sampled patients identified using the Ontario Cancer Registry. Area-level SES quintiles were assigned using adjusted median household income from the Canadian Census. Other data were collected from patient charts. Explanations for SES effects were determined by measuring whether the effect moved toward the null value by at least 10% when an access indicator was added to a the model. RESULTS: Socioeconomic status was not related to either outcome for those with supraglottic cancer, but an association was present in glottic cancer. With the highest socioeconomic status quintile as the referent group, the relative risks for patients in the lowest socioeconomic quintile were 2.75 (95% CI 1.48, 5.12) for cause-specific survival and 1.90 (95% CI 1.24, 2.93) for local-regional failure. Disease stage as measured by T-category explained between 3% and 23% of these socioeconomic effects. None of the other access indicators met our 10% change criterion. CONCLUSION: We question why people in lower socioeconomic quintiles were not diagnosed earlier in the disease progression. Having ruled out several variables that may be related to access to care, additional biologic and social variables should be examined to further understand socioeconomic status effects.

Associations between community income and cancer survival in Ontario, Canada, and the United States.

PURPOSE: The objectives of this study were as follows: (1) to compare the magnitude of the association between socioeconomic status (SES) and cancer survival in the Canadian province of Ontario with that in the United States (U.S.), and (2) to compare cancer survival in communities with similar SES in Ontario and in the U.S. METHODS: The Ontario Cancer Registry provided information about all cases of invasive cancer diagnosed in Ontario from 1987 to 1992, and the Surveillance, Epidemiology and End Results Registry (SEER) provided information about all cases diagnosed in the SEER regions of the U.S. during the same time period. Census data provided information about SES at the community level. The product-limit method was used to describe cause-specific survival. Cox proportional hazards models were used to describe the association between SES and the risk of death from cancer. RESULTS: There were significant associations between SES and survival for most cancer sites in both the U.S. and Ontario, but the magnitude of the association was usually larger in the U.S. In the poorest communities, there were significant survival advantages in favor of cancer patients in Ontario for many disease groups, including cancers of the lung, head and neck region, cervix, and uterus. However, in upper- and middle-income communities, there were significant survival advantages in favor of the U.S. for all cases combined and for several individual diseases, including cancers of the breast, colon and rectum, prostate, and bladder. CONCLUSION: The association between SES and cancer survival is weaker in Ontario than it is in the U.S. This is due to a combination of better survival among patients in the poorest communities and worse survival among patients in the wealthier communities of Ontario relative to those in the U.S.

Decision analysis in locally advanced non-small-cell lung cancer: is it useful?

PURPOSE: The optimal management of locally advanced non-small-cell lung cancer (NSCLC) has not been established. While combined-modality treatments have been shown to increase the survival of patients with this illness, the appropriate balance between the benefit of increased quantity of life and the quality-of-life costs of the more toxic treatment combinations remains unresolved. Decision analysis has been promoted as useful when medical decisions must be made under conditions of uncertainty. We consider the potential of this method to guide therapy in locally advanced NSCLC. METHODS: We developed two types of decision models that addressed the choice between radiation alone and combined chemotherapy-radiation therapy in locally advanced NSCLC. The models were constructed using the principles of decision analysis. RESULTS: The models successfully replicated results of relevant clinical trials published in the literature. The analyses of both models showed that the treatment decision was sensitive to patients' values, despite significant increases in survival rates. The models clarified a need for further validation of the three fundamental components: structuring the decision, determining the probabilities of events, and assigning utilities to treatment outcomes. CONCLUSION: In the setting of NSCLC, the models suggest that quality-of-life considerations are important in the treatment choice. Further research is required to identify the health states critical to the decision, the probabilities for occurrence of these health states, and valid measures of their utility.

Socioeconomic status and cancer survival in Ontario.

BACKGROUND AND PURPOSE: It is known that the socioeconomic status (SES) of the patient is associated with cancer survival in the United States. The purpose of this study was to determine whether the association between SES and survival is also present in Canada, a society with a comprehensive, universal, health insurance program. METHODS: A population-based cancer registry was used to identify the 357,530 cases of invasive cancer diagnosed in the Canadian province of Ontario between 1982 and 1991. Information from the 1986 Canadian census was linked to the registry and used to describe the SES of the area in which each patient resided. Cox regression was used to describe the association between median household income and survival while controlling for age, sex, and the region in which the patient resided. The Cox model was fitted in a competing risk framework to assess the association between income and the probability of specific causes of death. RESULTS: Lung cancer and cancers of the head and neck region were relatively more common in poor-income communities, and cancers of the breast, CNS, and testis were relatively more common in richer communities. A strong and statistically significant association between community income and survival was observed in cancers of the head and neck region, cervix, uterus, breast, prostate, bladder, and esophagus. Smaller, but significant associations were seen in cancers of the lung and rectum. No significant association between community income and survival was observed in cancers of the stomach, colon, pancreas, or ovary. Analysis of the cause of death showed that community income is associated both with the probability of death from cancer and with the probability of death from other causes. CONCLUSION: Although Canada's health care system was designed to provide equitable access to equivalent standards of care, it does not prevent a difference in cancer survival between rich and poor communities.

Time spent in hospital in the last six months of life in patients who died of cancer in Ontario.

PURPOSE: To describe hospital bed utilization in the final 6 months of life in patients dying of cancer in Ontario, Canada. PATIENTS AND METHODS: Hospital separation records were linked to a population-based cancer registry to identify factors associated with hospitalization in the 203,713 patients who died of cancer in Ontario between 1986 and 1998. RESULTS: Between 1986 and 1998, 5.3% of all acute care beds in Ontario were devoted to the care of cancer patients in the last 6 months of life. The mean time spent in hospital in the last 6 months of life decreased from 34.3 days in 1986 to 22.7 days in 1998. Hospitalization rates increased exponentially during the last month of life. Patients younger than 50 years of age, women, and residents of poorer communities spent significantly longer in hospital than others. Hospitalization rates differed very little among the common solid tumors, but patients with CNS malignancies, the lymphomas, and the leukemias spent significantly longer in hospital than the other groups. There was significant interregional variations in hospitalization that were not explained by differences in case mix. There was a statistically significant inverse correlation between the rate of use of palliative radiotherapy and the hospital bed use in the county in which the patient resided. CONCLUSION: The total time spent in hospital in the last 6 months of life has decreased over the last decade, but acute care hospitals continue to play a large role in the care of patients who are dying of cancer.

Mortality from myocardial infarction after adjuvant radiotherapy for breast cancer in the surveillance, epidemiology, and end-results cancer registries.

PURPOSE: To compare the risk for fatal myocardial infarction (MI) after adjuvant radiotherapy (RT) for left-sided breast cancer with the risk for MI after adjuvant RT for right-sided breast cancer. METHODS: We studied women with local- and regional-stage breast cancer diagnosed from 1973 to 1992 from the Surveillance, Epidemiology, and End-Results (SEER) cancer registries. We performed life-table analysis, the log-rank test, and Cox proportional hazards regression to compare the time to fatal MI from diagnosis between left-sided and right-sided cases, censoring deaths from other causes. RESULTS: Among irradiated patients, the relative risk (RR) for fatal MI in women with left-sided breast cancer was 1.17 (95% confidence interval [CI], 1.01 to 1.36), controlling for age, compared with those with right-sided breast cancer. The RR for fatal MI among left-sided cases was increased for those under the age of 60 years (RR = 1.98; 95% CI, 1.31 to 2.97) compared with right-sided cases, but not at age 60 years or older. Among women with irradiated regional-stage cancer who were younger than 60 years of age, the risk was significantly increased (RR = 2.24; 95% CI, 1.38 to 3.64) for those with left-sided compared with right-sided breast cancer, but not among patients aged 60 years or older. Among irradiated local-stage cases, the risk for those with left-sided breast cancer was not significantly elevated in either age category. Analysis of 5-year conditional survival cohorts showed an increased risk for irradiated left-sided cases among women younger than 60 years of age in the 10- to 15-year conditional survival cohort (RR = 5.28; 95% CI, 1.82 to 15.3). CONCLUSION: Adjuvant RT for left-sided breast cancer diagnosed in women younger than 60 years of age is associated with a higher risk for fatal MI 10 to 15 years later compared with adjuvant RT for right-sided cases.

Does a centralized radiotherapy system provide adequate access to care?

PURPOSE: In the Canadian province of Ontario, all radiotherapy is provided by a centrally managed provincial network of nine cancer centers. The primary goal of this study was to determine whether this highly centralized radiotherapy system provides adequate and equitable access to care for the province's dispersed population. METHODS: The Ontario Cancer Registry (OCR) was used to identify 295,386 cases of invasive cancer, excluding nonmelanoma skin cancer, which were diagnosed in Ontario between 1984 and 1991. Electronic radiotherapy records from each of the province's radiotherapy centers were linked to the registry at the level of the individual case. RESULTS: The proportion of incident cases treated with radiotherapy was 18.8% at 4 months after diagnosis, 23.7% at 1 year, 25.8% at 2 years, 28.2% at 5 years, and 29.1% at 8 years. These rates of radiotherapy use are much lower than the accepted national and international targets, and lower than rates reported from other jurisdictions. The rate of radiotherapy use at 1 year varied significantly from county to county across Ontario (range, 18.6% to 32.4%; P < 10(-6)), and the highest rates were recorded in communities close to radiotherapy centers. There was a common geographic pattern of rate variations among several disease groups, including breast cancer, lung cancer, the genitourinary malignancies, and the gastrointestinal malignancies. CONCLUSION: The low and uneven rates of radiotherapy use across the province indicate that Ontario's centralized radiotherapy system does not, at present, provide adequate or equitable access to care.

Necrosis following radiotherapy for carcinoma of the pinna.

PURPOSE: Radiation therapy is often the preferred modality of treatment for carcinoma of the pinna because it avoids the cosmetic defect of surgery. However, radiation oncologists are sometimes reluctant to irradiate the ear because of the risk of subsequent necrosis. The goal of this study was to establish the long-term disease control and necrosis rates following irradiation of the external ear. METHODS AND MATERIALS: A retrospective analysis was undertaken of 138 courses of curative radiotherapy given to 128 patients for biopsy-proven basal (70 courses), squamous (62 courses), or mixed (6 courses) tumors of the pinna between January 1, 1982, and December 31, 1991, at the Kingston Regional Cancer Center. RESULTS: The median age of the patients was 73 (range 43-94) and the median size of the tumors was 12 mm (range 3-50 mm). Treatment was given using orthovoltage X rays (79) or electrons (59). The most common dose prescription was 35 Gy/5 fractions; total doses ranged from 17.50 to 64 Gy. The median follow-up is 58 months (range 6-149). The actuarial 5-year local control rate is 93%; the actuarial necrosis rate at 5 years is 13%. Most necroses healed with conservative management; only two patients required surgery for necrosis. We analyzed the following factors as possible predictors of radiation necrosis: patient age, size of lesion, histology, fraction size, total dose, overall time, and beam energy. Only daily fraction sizes > 6 Gy (p = 0.0093) and treatment times < 5 days (p = 0.0053) were significantly associated with an increased risk of necrosis. CONCLUSION: To reduce the risk of necrosis, radiation therapy for external ear cancer should be given using protracted fractionation.

A population-based study of the effectiveness of breast conservation for newly diagnosed breast cancer.

PURPOSE: Our objective was to evaluate the effectiveness of breast conservation for newly diagnosed breast cancer. Effectiveness was operationalized as two outcomes within 5 years of the diagnosis of breast cancer: the probability of mastectomy-free survival (either death or mastectomy count as event, whichever comes first), and the probability of mastectomy conditional on survival (mastectomy counts as event, observations censored at death). METHODS AND MATERIALS: We linked records of 46,687 new cases of breast cancer from 1982 to 1991 in the Ontario Cancer Registry to records of surgery from 1982 to 1995, radiotherapy (RT) from 1982 to 1992, and median household income from the 1986 census. We labeled breast surgery within 4 months and postoperative RT within 12 months of diagnosis as treatment for newly diagnosed breast cancer. Surgery was categorized as mastectomy, lumpectomy plus RT, lumpectomy alone, or no surgical procedure. Among cases that did not undergo mastectomy within 4 months of diagnosis, we labeled mastectomy subsequent to 4 months after diagnosis as treatment failure. We performed life-table analysis and Cox proportional hazards regression, to describe the probability of mastectomy conditional on survival and the probability of mastectomy-free survival. RESULTS: A total of 16,279 cases underwent lumpectomy as the maximum procedure on the breast within 4 months of diagnosis, and 49.7% of these received postoperative RT. Compared to the provincial mean, regions with higher rates of lumpectomy plus RT have higher probability of mastectomy-free survival and lower probability of mastectomy conditional upon survival 5 years after diagnosis of breast cancer. CONCLUSIONS: These findings are consistent with a hypothesis that breast conservation is effective in the overall breast cancer population of Ontario within the first 5 years after diagnosis.

A population-based study of rectal cancer: permanent colostomy as an outcome.

PURPOSE: The objectives of this study are to describe the utilization of surgery and of radiotherapy in the treatment of newly diagnosed rectal cancer in Ontario between 1982 and 1994, and to describe the probability of permanent colostomy at any time after the diagnosis of rectal cancer, as an outcome of the treatment of newly diagnosed rectal cancer. METHODS AND MATERIALS: Electronic records of rectal cancer (International Classification of Diseases code 154) from the Ontario Cancer Registry (n = 18,695, excluding squamous, basaloid, cloacogenic, and carcinoid histology) were linked to surgical records from all Ontario hospitals, and radiotherapy (RT) records from Ontario cancer centers. Procedures occurring within 4 months of diagnosis, or within 4 months of another procedure for rectal cancer, were considered part of initial treatment. Multivariate analyses controlled for age, sex, and year of diagnosis. RESULTS: Resection plus permanent colostomy was performed in 33.1% of cases, whereas local excision or resection without permanent colostomy was performed in 38.2%. Multivariate logistic regression demonstrated higher odds ratios (OR) for resection plus permanent colostomy in all regions of Ontario relative to Toronto. The OR for postoperative RT following local excision or resection without permanent colostomy varied among the regions relative to Toronto (e.g., OR Ottawa = 0.59, OR Hamilton = 0.76, OR London = 1.25). The relative risk (RR) of colostomy conditional upon survival within 5 years from diagnosis varied among regions relative to Toronto (e.g., RR Ottawa = 1.21, RR Hamilton = 1.20). CONCLUSIONS: There is regional variation in the utilization of resection with permanent colostomy, and in the utilization of postoperative RT among cases not undergoing permanent colostomy. Regions with higher initial rates of resection plus permanent colostomy continue to experience higher probability of permanent colostomy 5 years after diagnosis of rectal cancer. Higher initial rates of permanent colostomy may be malleable to interventions aimed at improving overall outcomes.