Patient and disease characteristics, treatment practices and oncologic outcomes among patients with colorectal cancer: a population-based analysis.

BACKGROUND: The incidence of colorectal cancer (CRC) is increasing among young adults. We sought to report on patient and disease characteristics, treatment practice patterns and outcomes in this population. METHODS: We conducted a retrospective cohort study using administrative health data from the Alberta Cancer Registry (2004-2015), including demographic and tumour characteristics, and treatment received. Outcome measures included overall and cancer-specific deaths. We used Cox regression and Kaplan-Meier curves to assess for factors associated with survival. RESULTS: We included 18 070 patients with CRC (n = 1583 [8.8%] < 50 yr, n = 16 487 [91.2 %] ≥ 50 yr). Younger patients were more likely to present with locally advanced disease (21.0% v. 18.0%, p < 0.0001), stage III (16.4 % v. 14.6%, p < 0.0001) or metastatic (16.7% v. 13.8%, p < 0.0001) involvement. Younger patients were more likely to receive surgery (87.2% v. 80.9%, p < 0.0001), chemotherapy (59.6% v. 34.1%, p < 0.0001) or radiation therapy (49.5% v. 37.2%, p < 0.001). At 5 years, overall and cancer-specific survival was better among younger patients than older patients (30.6% v. 51.5% overall deaths, 27.5% v. 38.4% cancer-specific deaths, p < 0.0001). CONCLUSION: Despite higher stage and higher grade disease, young patients with CRC had more favourable oncologic outcomes than stage-matched older patients, which may be related to younger patients receiving more aggressive treatment. Further investigation should focus on optimal treatment patterns for young patients with CRC.

Efficacy of perioperative chemotherapy in resected colorectal liver metastasis: A systematic review and meta-analysis.

BACKGROUND: Nearly half of patients with colorectal cancer develop liver metastases. Radical resection of colorectal liver metastases (CRLM) offers the best chance of cure, significantly improving 5-year survival. Recurrence of metastatic disease is common, occurring in 60 % or more of patients. Clinical equipoise exists regarding the role of perioperative chemotherapy in patients with resected CRLM. This investigation sought to clarify the efficacy of perioperative chemotherapy in patients that have undergone curative-intent resection of CRLM. METHODS: A systematic review and meta-analysis was completed of randomized controlled trials (RCTs) comparing perioperative chemotherapy to surgery alone in patients with resected CRLM. MEDLINE (Ovid), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched, as well as abstracts from recent oncology conferences. A meta-analysis was performed pooling the hazard ratios for disease-free survival (DFS) and overall survival (OS), using a random-effects model. RESULTS: A total of five, phase 3, open-label, RCTs were included resulting in a pooled analysis of 1119 of the total 1146 enrolled patients. 559 patients were randomized to perioperative chemotherapy and 560 to surgery alone. Pooled estimates demonstrated a statistically significant improvement in DFS (HR 0.71, 95 % CI: 0.61-0.82; p < 0.001) but not OS (HR 0.87, 95 % CI: 0.73-1.04; p = 0.136). CONCLUSION: Perioperative chemotherapy in the setting of resected CRLM resulted in an improvement in DFS, however this did not translate into an OS benefit. Poor compliance to post-hepatectomy oxaliplatin-based chemotherapy regimens was identified. Further investigation into the optimal regimen and sequencing of perioperative chemotherapy is justified.

Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: A cross-sectional Investigation.

BACKGROUND: Women are underrepresented at higher levels of promotion or leadership despite the increasing number of women physicians. In surgery, this has been compounded by historical underrepresentation. With a nation-wide focus on the importance of diversity, our aim was to provide a current snapshot of gender representation in Canadian universities. METHODS: This cross-sectional online website review assessed the current faculty listings for 17 university-affiliated academic surgical training departments across Canada in the 2019/2020 academic year. Gender diversity of academic surgical faculty was assessed across surgical disciplines. Additionally, gender diversity in career advancement, as described by published leadership roles, promotion and faculty appointment, was analyzed. RESULTS: Women surgeons are underrepresented across Canadian surgical specialties (totals: 2,689 men versus 531 women). There are significant differences in the gender representation of surgeons between specialties and between universities, regardless of specialty. Women surgeons had a much lower likelihood of being at the highest levels of promotion (OR: 0.269, 95% CI: 0.179-0.405). Men surgeons were statistically more likely to hold academic leadership positions than women (p = 0.0002). Women surgeons had a much lower likelihood of being at the highest levels of leadership (OR: 0.372, 95% CI: 0.216-0.641). DISCUSSION: This study demonstrates that women surgeons are significantly underrepresented at the highest levels of academic promotion and leadership in Canada. Our findings allow for a direct comparison between Canadian surgical subspecialties and universities. Individual institutions can use these data to critically appraise diversity policies already in place, assess their workforce and apply a metric from which change can be measured.

Improving Wait Times and Patient Experience Through Implementation of a Provincial Expedited Diagnostic Pathway for BI-RADS 5 Breast Lesions.

BACKGROUND: Long diagnostic intervals following abnormal breast imaging (DI) cause patient anxiety and possibly poorer prognosis. This study evaluates the effect of a provincial diagnostic pathway for BI-RADS 5 lesions on wait times and the patient-reported experience (PRE). METHODS: With multidisciplinary input, we developed a pathway for BI-RADS 5 lesions featuring expedited biopsy, early surgical referral, and nurse (RN) navigator support. Key diagnostic intervals were captured prospectively and compared with a prepathway control cohort. PRE data were obtained from a voluntary survey. RESULTS: 1205 patients were managed on the BI-RADS 5 pathway with 797 primary care physicians, 57 imaging centers, and 2 regional breast programs participating. Median duration from DI to biopsy was 6 days, from biopsy to pathology report was 5 days, DI to surgical referral was 6 days, and DI to surgical consult was 21 days. Compared with 128 prepathway controls, median intervals from DI to surgical referral and consult were significantly improved (15 vs. 6 days, 26 vs. 21 days, p < 0.001). Amongst 294 women who completed the survey, 92% experienced ≥ 1 anxiety complaint during assessment; prompt surgical consultation and multiple features of RN support reduced anxiety, and wait time satisfaction was high (70%). Patient preferences varied for receiving biopsy results from a surgeon (57%) vs. another provider (43%). CONCLUSIONS: A diagnostic pathway for BI-RADS 5 lesions reduced wait times and improved the patient experience through prompt surgical referral and RN navigator support. Differing preferences for receiving biopsy results emerged, and future iterations should incorporate individualized patient wishes.

Same-Day Surgery for Mastectomy Patients in Alberta: A Perioperative Care Pathway and Quality Improvement Initiative.

BACKGROUND: Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived. METHODS: The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected. RESULTS: SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise. CONCLUSIONS: Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.

Epidemiology of interruptions to nutrition support in critically ill children in the pediatric intensive care unit.

BACKGROUND: Nutrition support is often delayed or interrupted. The aim of this study is to identify reasons for and quantify time spent without nutrition in a mixed medical-surgical-cardiac pediatric intensive care unit (PICU). METHODS: Data were prospectively collected to describe the patient cohort (anthropometrics and diagnostic category) and nutrition practices (time to nutrition initiation; frequency, duration, and causes of interruptions; and overall caloric intake). Descriptive statistics were used; comparisons of groups were performed using an independent t test and P < .05 as significance. RESULTS: The mean (standard deviation) time to nutrition initiation was 22.8 (16.6) hours following admission; 35% of patients were initiated after >24 hours. Nutrition was interrupted 1.2 (2.0) times per patient. Time spent without nutrition due to interruptions was 11.6 (23.0) hours, up to 102 hours. Patients spent 42.4% (28.2%) of their median (range) PICU admission of 2.9 days (0.25-39 days) without any form of nutrition. Patients aged 0-6 months had a significantly higher mean number and duration of interruptions (P = .001 and P < .001, respectively) compared with children >6 months. Interruptions due to surgery and planned extubation lasted significantly longer than all other interruptions (P < .001 and P = .001, respectively). Pediatric Risk of Mortality (PRISM) III scores were not correlated with percentage of length of stay spent without nutrition (r = 0.137). CONCLUSIONS: Prolonged time to nutrition initiation and interruptions in delivery caused pediatric patients to spend a high proportion of admission without nutrition support, preventing most from meeting energy requirements. Further research addressing specific patient outcomes is required to define optimal initiation times and appropriate procedural-specific fasting times.