Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study.

OBJECTIVE: Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting. METHODS: A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework and Consolidated Framework for Implementation Research informed content analysis for clinician and manager perspectives, respectively. RESULTS: Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources. CONCLUSION: Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills, the provision of clinical decision-making tools, access to expert consultation, the roles and social influence of the interprofessional team and formal and informal leaders, and supportive processes adapted to the local context. IMPACT: Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.

Impact of variation in cancer registration practice on observed international cancer survival differences between International Cancer Benchmarking Partnership (ICBP) jurisdictions.

BACKGROUND: International cancer survival comparisons use cancer registration data to report cancer survival, which informs the development of cancer policy and practice. Studies like the International Cancer Benchmarking Partnership (ICBP) have a duty to understand how registration differences impact on survival prior to drawing conclusions. METHODS: Key informants reported differences in registration practice for capturing incidence date, death certificate case handling and registration of multiple primary tumours. Sensitivity analyses estimated their impact on one-year survival using baseline and supplementary cancer registration data from England and Sweden. RESULTS: Variations in registration practice accounted for up to a 7.3 percentage point difference between unadjusted (estimates from previous ICBP survival data) and adjusted (estimates recalculated accounting for registration differences) one-year survival, depending on tumour site and jurisdiction. One-year survival estimates for four jurisdictions were affected by adjustment: New South Wales, Norway, Ontario, Sweden. Sweden and Ontario's survival reduced after adjustment, yet they remained the jurisdictions with the highest survival for breast and ovarian cancer respectively. Sweden had the highest unadjusted lung cancer survival of 43.6% which was adjusted to 39.0% leaving Victoria and Manitoba with the highest estimate at 42.7%. For colorectal cancer, Victoria's highest survival of 85.1% remained unchanged after adjustment. CONCLUSION: Population-based cancer survival comparisons can be subject to registration biases that may impact the reported 'survival gap' between populations. Efforts should be made to apply consistent registration practices internationally. In the meantime, survival comparison studies should provide acknowledgement of or adjustment for the registration biases that may affect their conclusions.

Is there an association between trends in alcohol consumption and cancer mortality? Findings from a multicountry analysis.

The aim of this analysis is to examine long-term trends in alcohol consumption and associations with lagged data on specific types of cancer mortality, and indicate policy implications. Data on per capita annual sales of pure alcohol; mortality for three alcohol-related cancers - larynx, esophageal, and lip, oral cavity, and pharynx; and per capita consumption of tobacco products were extracted at the country level. The Unobservable Components Model was used for this time-series analysis to examine the temporal association between alcohol consumption and cancer mortality, using lagged data, from 17 countries. Statistically significant associations were observed between alcohol sales and cancer mortality, in the majority of countries examined, which remained after controlling for tobacco use (P<0.05). Significant associations were observed in countries with increasing, decreasing, or stable trends in alcohol consumption and corresponding lagged trends in alcohol-related cancer mortality. Curtailing overall consumption has potential benefits in reducing a number of harms from alcohol, including cancer mortality. Future research and surveillance are needed to investigate, monitor, and quantify the impact of alcohol control policies on trends in cancer mortality.

Investigation of the international comparability of population-based routine hospital data set derived comorbidity scores for patients with lung cancer.

INTRODUCTION: The International Cancer Benchmarking Partnership (ICBP) identified significant international differences in lung cancer survival. Differing levels of comorbid disease across ICBP countries has been suggested as a potential explanation of this variation but, to date, no studies have quantified its impact. This study investigated whether comparable, robust comorbidity scores can be derived from the different routine population-based cancer data sets available in the ICBP jurisdictions and, if so, use them to quantify international variation in comorbidity and determine its influence on outcome. METHODS: Linked population-based lung cancer registry and hospital discharge data sets were acquired from nine ICBP jurisdictions in Australia, Canada, Norway and the UK providing a study population of 233 981 individuals. For each person in this cohort Charlson, Elixhauser and inpatient bed day Comorbidity Scores were derived relating to the 4-36 months prior to their lung cancer diagnosis. The scores were then compared to assess their validity and feasibility of use in international survival comparisons. RESULTS: It was feasible to generate the three comorbidity scores for each jurisdiction, which were found to have good content, face and concurrent validity. Predictive validity was limited and there was evidence that the reliability was questionable. CONCLUSION: The results presented here indicate that interjurisdictional comparability of recorded comorbidity was limited due to probable differences in coding and hospital admission practices in each area. Before the contribution of comorbidity on international differences in cancer survival can be investigated an internationally harmonised comorbidity index is required.

Construction of a North American Cancer Survival Index to Measure Progress of Cancer Control Efforts.

INTRODUCTION: Population-based cancer survival data provide insight into the effectiveness of health care delivery. Comparing survival for all cancer sites combined is challenging, because the primary cancer site and age distribution of patients may differ among areas or change over time. Cancer survival indices (CSIs) are summary measures of survival for cancers of all sites combined and are used in England and Europe to monitor temporal trends and examine geographic differences in survival. We describe the construction of the North American Cancer Survival Index and demonstrate how it can be used to compare survival by geographic area and by race. METHODS: We used data from 36 US cancer registries to estimate relative survival ratios for people diagnosed with cancer from 2006 through 2012 to create the CSI: the weighted sum of age-standardized, site-specific, relative survival ratios, with weights derived from the distribution of incident cases by sex and primary site from 2006 through 2008. The CSI was calculated for 32 registries for all races, 31 registries for whites, and 12 registries for blacks. RESULTS: The survival estimates standardized by age only versus age-, sex-, and site-standardized (CSI) were 64.1% (95% confidence interval [CI], 64.1%-64.2%) and 63.9% (95% CI, 63.8%-63.9%), respectively, for the United States for all races combined. The inter-registry ranges in unstandardized and CSI estimates decreased from 12.3% to 5.0% for whites, and from 5.4% to 3.9% for blacks. We found less inter-registry variation in CSI estimates than in unstandardized all-sites survival estimates, but disparities by race persisted. CONCLUSIONS: CSIs calculated for different jurisdictions or periods are directly comparable, because they are standardized by age, sex, and primary site. A national CSI could be used to measure temporal progress in meeting public health objectives, such as Healthy People 2030.

Nevus count associations with pigmentary phenotype, histopathological melanoma characteristics and survival from melanoma.

Although nevus count is an established risk factor for melanoma, relationships between nevus number and patient and tumor characteristics have not been well studied and the influence of nevus count on melanoma-specific survival is equivocal. Using data from the Genes, Environment and Melanoma (GEM) study, a large population-based study of primary cutaneous melanoma, we evaluated associations between number of nevi and patient features, including sun-sensitivity summarized in a phenotypic index, and tumor characteristics. We also assessed the association of nevus count with melanoma-specific survival. Higher nevus counts were independently and positively associated with male gender and younger age at diagnosis, and they were inversely associated with lentigo maligna histology. We observed a borderline significant trend of poorer melanoma-specific survival with increasing quartile of nevus count, but little or no association between number of nevi and pigmentary phenotypic characteristics or prognostic tumor features.

Evaluation of North American Association of Central Cancer Registries' (NAACCR) data for use in population-based cancer survival studies.

Follow-up procedures vary among cancer registries in North America. US registries are funded by the Surveillance, Epidemiology, and End Results (SEER) Program and/or the National Program of Cancer Registries (NPCR). SEER registries ascertain vital status and date of last contact to meet follow-up standards. NPCR and Canadian registries primarily conduct linkages with local and national death records to ascertain deaths. Data on patients diagnosed between 2002 through 2006 and followed through 2007 were obtained from 51 registries. Registries that met follow-up standards or, at a minimum, conducted linkages with local and national death records had comparable age-standardized five-year survival estimates (all sites and races combined): 63.9% SEER, 63.1% NPCR, and 62.6% Canada. Estimates varied by cancer site. Survival data from registries using different follow-up procedures are comparable if death ascertainment is complete and all nondeceased patients are presumed to be alive to the end of the study period.

Cervical cancer incidence in ontario women: differing sociodemographic gradients by morphologic type (adenocarcinoma versus squamous cell).

OBJECTIVE: Identify patterns in cervical cancer incidence in Ontario according to neighborhood sociodemographic characteristics over time and by morphologic type. METHODS: Incident cases of cervical cancer diagnosed from 1991 to 2009 were obtained from the Ontario Cancer Registry. Population data and data on neighborhood sociodemographic characteristics were obtained from the Canadian Census. Age-standardized incidence rates (ASIR) and rate ratios (RRs) with 95% confidence intervals (CIs) were calculated for each sociodemographic characteristic, stratified by morphologic type (squamous cell carcinoma and adenocarcinoma) and time period of diagnosis. RESULTS: Incidence was 51% higher in the poorest neighborhoods compared with the richest (RR, 1.51; 95% CI, 1.42-1.61) and 7% higher in rural areas compared with urban (RR, 1.07; 95% CI, 1.01-1.13). Incidence of squamous cell carcinoma was significantly higher in the poorest neighborhoods compared with the richest (RR, 1.74; 95% CI, 1.61-1.88), a trend observed for all time periods, and in rural areas compared with urban (RR, 1.10; 95% CI, 1.02-1.18). For adenocarcinoma, ASIRs in the earlier time period (1991-1998) were higher in the poorest neighborhoods compared with richest (RR, 1.26; 95% CI, 1.01-1.57), whereas for the more recent time period (1999-2009), ASIRs were lower for women living in the poorest neighborhoods compared with the richest (RR, 0.82; 95% CI, 0.68-0.99). CONCLUSIONS: This study identified significantly higher incidence of cervical cancer in low-income neighborhoods in Ontario. The association was especially pronounced for squamous cell carcinoma and varied by time period for adenocarcinoma. Improvements to screening and prevention efforts against oncogenic human papillomavirus strains would increase the detection of cervical cancer, adenocarcinoma especially, and may further reduce cervical cancer incidence.

Changing incidence of AIDS-related Kaposi sarcoma and non-Hodgkin lymphoma in Ontario, Canada.

OBJECTIVE: To examine the influence of the AIDS epidemic on the incidence of Kaposi sarcoma (KS) and non-Hodgkin lymphoma (NHL) in Ontario. METHODS: Age-standardized incidence rates for KS and NHL from 1981 to 2000 were calculated from the population-based Ontario Cancer Registry. AIDS cases were extracted from Ontario Ministry of Health and Long-Term Care reports. HIV death data were obtained from the Ontario Cancer Registry. RESULTS: KS was a rare cancer before the 1980s; however, incidence increased sharply between 1985 and 1995 by 13.8% per year. Thereafter, incidence rates fell close to those in the early 1980s. NHL incidence in males increased steadily during the 1980s at 3.2% per year and then slowed beyond 1990. In males aged 30-44, NHL incidence rose from 1981 to 1990 (8.8% per year) and then fell (-2.5%) thereafter. NHL and KS cases represented one-third of HIV deaths. CONCLUSIONS: The AIDS epidemic, the introduction of antiretroviral therapies, and the decrease in HIV infection rates explain the rise and decline of KS incidence in Ontario. NHL incidence trends are more complex, although the AIDS epidemic explains the trends observed in younger men (in whom AIDS is more common), and for the AIDS-related subtypes.

Predictors of self-reported confidence ratings for adult recall of early life sun exposure.

Use of self-reported confidence ratings may be an efficient method for assessing recall bias. In this exploratory application of the method, the authors examined the relation between case-control status and self-reported confidence ratings. In 2002 and 2003, melanoma cases (n = 141) and controls (n = 143) aged 20-44 years residing in Ontario, Canada, estimated the amounts of time they had spent outdoors in summer activities when they were 6-18 years of age and indicated their confidence in the accuracy of each estimate. The generalized estimating equations extension of logistic regression was used to examine dichotomized confidence ratings (more confident vs. less confident) for activities reported for ages 6-11 years and 12-18 years. Types of activity were associated with more confident reporting for both age strata; as the number of stable outdoor activity periods (total number of similar outdoor periods within each activity) reported by respondents increased, confidence decreased. Cumulative time spent outdoors was also associated with more confidence but reached statistical significance only for the age stratum 12-18 years. There was no statistically significant association between case-control status and self-reported confidence for either age stratum (6-11 years: odds ratio = 0.91; 12-18 years: odds ratio = 1.32), which suggests an absence of recall bias for reported time spent outdoors.

Cancer incidence in young adults in Canada: preliminary results of a cancer surveillance project.

Surveillance of cancer in young adults has been neglected, despite Sir Richard Doll's having emphasized its importance a decade ago. This report describes the patterns, time trends and regional variation in cancer incidence in Canada's young adults. In 1987 96, 97,469 cancers were diagnosed in Canadians aged 20 44, with almost two-thirds in females. Ten types of cancer accounted for 83% of diagnoses in women and 74% in men. The most common cancers in young women were breast, cervix, melanoma, thyroid and ovary, and in young men were testis, non- Hodgkin's lymphoma, melanoma, colorectal and lung. Although incidence rose only slightly for total cancer between 1969 and 1996, it increased dramatically for several specific types of cancer: lung (women), melanoma, testis, thyroid and non-Hodgkin's lymphoma. Incidence declined for a few cancers (colorectal, lung (men), cervix and ovary). Lung cancer incidence was significantly lower than the Canadian average in Prairie women and non-significantly high in Quebec (both sexes), while the rate of melanoma was significantly low in Quebec (both sexes) and high in women in the Pacific region.

Evaluation of a risk factor survey with three assessment methods.

This paper describes the evaluation of questions on a cancer risk factor survey using three different methods: dataset response patterns, qualitative feedback, and questionnaire appraisal. These methods addressed the survey data, procedures and questions. The three methods identified similar issues but also made unique contributions. Dataset response patterns showed missing and out-of-range data, an order effect, and mixed coding. Qualitative feedback revealed lack of clarity, sensitive topics, technical or undefined terms, failure to hear all response options, overlapping response options (as perceived by respondents), coding problems and recall difficulties. Questionnaire appraisal showed technical or undefined terms, complex syntax, hidden definitions, and ambiguous wording. The survey assessment methods described here can improve data quality, especially when limited time and resources preclude in-depth questionnaire development.