Risk-based lung cancer screening performance in a universal healthcare setting.

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Spread of Makoyoh'sokoi (Wolf Trail): a community led, physical activity-based, holistic wellness program for Indigenous women in Canada.

Globally, Indigenous populations have been impacted by colonization. Populations who have endured colonization are at higher risk of developing chronic diseases. Canada's Truth and Reconciliation Commission emphasizes reducing barriers to participation in physical activity and recommends the creation of culturally relevant and supportive policies and programing. Physical activity is a cornerstone in health promotion and public health to combat chronic diseases; however, in Canada, Indigenous developed physical activity programing is sparse, and those targeting women are non-existent in some regions. Makoyoh'sokoi (The Wolf Trail Program) is an 18-week long, holistic wellness program that was created by and for Indigenous women. Makoyoh'sokoi was developed by communities following extensive consultation and cultural oversight. Makoyoh'sokoi's core program consists of 12 weeks of weekly physical activity programing and health education, followed by another 6 weeks of weekly health education. Notably, communities have control over the program to modify based on individual needs and challenges. Programs commence and conclude with a ceremony with Elders giving a blessing and opening each other to connection. The goals of Makoyoh'sokoi are to empower women, improve health outcomes, and to implement a sustainable program by training a network of community members in their respective communities to facilitate delivery.

Integrating Smoking Cessation Into Low-Dose Computed Tomography Lung Cancer Screening: Results of the Ontario, Canada Pilot.

INTRODUCTION: Low-dose computed tomography screening in high-risk individuals reduces lung cancer mortality. To inform the implementation of a provincial lung cancer screening program, Ontario Health undertook a Pilot study, which integrated smoking cessation (SC). METHODS: The impact of integrating SC into the Pilot was assessed by the following: rate of acceptance of a SC referral; proportion of individuals who were currently smoking cigarettes and attended a SC session; the quit rate at 1 year; change in the number of quit attempts; change in Heaviness of Smoking Index; and relapse rate in those who previously smoked. RESULTS: A total of 7768 individuals were recruited predominantly through primary care physician referral. Of these, 4463 were currently smoking and were risk assessed and referred to SC services, irrespective of screening eligibility: 3114 (69.8%) accepted referral to an in-hospital SC program, 431 (9.7%) to telephone quit lines, and 50 (1.1%) to other programs. In addition, 4.4% reported no intention to quit and 8.5% were not interested in participating in a SC program. Of the 3063 screen-eligible individuals who were smoking at baseline low-dose computed tomography scan, 2736 (89.3%) attended in-hospital SC counseling. The quit rate at 1 year was 15.5% (95% confidence interval: 13.4%-17.7%; range: 10.5%-20.0%). Improvements were also observed in Heaviness of Smoking Index (p < 0.0001), number of cigarettes smoked per day (p < 0.0001), time to first cigarette (p < 0.0001), and number of quit attempts (p < 0.001). Of those who reported having quit within the previous 6 months, 6.3% had resumed smoking at 1 year. Furthermore, 92.7% of the respondents reported satisfaction with the hospital-based SC program. CONCLUSIONS: On the basis of these observations, the Ontario Lung Screening Program continues to recruit through primary care providers, to assess risk for eligibility using trained navigators, and to use an opt-out approach to referral for cessation services. In addition, initial in-hospital SC support and intensive follow-on cessation interventions will be provided to the extent possible.

The economic impact of rural healthcare on rural economies: A rapid review.

Introduction: One critical component of any rural community is its healthcare system. Rural healthcare systems are essential as rural communities have worse health outcomes when compared to urban areas. Rural healthcare systems might also have a positive impact on rural economies. In some rural areas, these health services are threatened with a reduction or closure. This rapid review was carried out to examine the impact of rural healthcare systems' declines on rural economies. Methods: We conducted a rapid review of peer-reviewed and grey literature sources on studies that examined the economic impact of rural healthcare on rural economies in Canada, Australia, Scandinavia and the United States of America (USA). We used a data extraction template adapted from the Centre for Reviews and Dissemination. Results: We found 17 research papers between two databases and nine websites. Articles examined various health professions (dentist, physician assistant and pharmacist), the inclusion of family physicians, a physician with an increased scope of practice (obstetrics and surgery), the impact of a rural primary care hospital, telemedicine, a distributed medical education programme and the health care sector. Conclusion: Rural healthcare seems to have a positive impact on jobs and labour-based wages in rural communities. There is a considerable need for research outside the USA.

Résumé Introduction: Un élément essentiel de toute communauté rurale est son système de soins de santé. Les systèmes de soins de santé ruraux sont essentiels car les communautés rurales présentent des résultats sanitaires moins bons que les zones urbaines. Ces systèmes pourraient également avoir un impact positif sur les économies rurales. Dans certaines zones rurales, ces services de santé sont menacés de réduction ou de fermeture. Cette revue rapide a été réalisée pour examiner l'impact du déclin des systèmes de soins de santé ruraux sur les économies rurales. Méthodes: Nous avons procédé à un examen rapide de documentation évaluée par les pairs et de documentation parallèle sur les études qui ont examiné l'impact économique des soins de santé ruraux sur les économies rurales au Canada, en Australie, en Scandinavie et aux États-Unis. Nous avons utilisé un modèle d'extraction de données adapté du Centre for Reviews and Dissemination. Résultats: Nous avons trouvé 17 articles de recherche entre deux bases de données et neuf sites Web. Les articles portaient sur diverses professions de santé (dentiste, assistant(e) médical(e), pharmacien(ne)), l'inclusion des médecins de famille, un médecin ayant un champ d'exercice élargi (obstétrique et chirurgie), l'impact d'un hôpital rural de soins primaires, la télémédecine, un programme d'enseignement médical distribué et le secteur des soins de santé. Conclusion: Les soins de santé en milieu rural semblent avoir un impact positif sur les emplois et les salaires basés sur le travail dans les communautés rurales. Il existe un besoin considérable de recherche en dehors des États-Unis. Mots-clés: rural, soins de santé, économie, revue.

Evolution of a Systematic Approach to Smoking Cessation in Ontario's Regional Cancer Centres.

Smoking cessation after a cancer diagnosis can significantly improve a person's prognosis, treatment efficacy and safety, and quality of life. In 2012, Cancer Care Ontario (now part of Ontario Health) introduced a Framework for Smoking Cessation, to be implemented for new ambulatory cancer patients at the province's 14 Regional Cancer Centres (RCCs). Over time, the program has evolved to become more efficient, use data for robust performance management, and broaden its focus to include new patient populations and additional data collection. In 2017, the framework was revised from a 5As to a 3As brief intervention model, along with an opt-out approach to referrals. The revised model was based on emerging evidence, feedback from stakeholders, and an interim program evaluation. Results showed an initial increase in referrals to cessation services. Two indicators (tobacco use screening and acceptance of a referral) are routinely monitored as part of Ontario Health's system-wide performance management approach, which has been identified as a key driver of change among RCCs. Due to the COVID-19 pandemic, many RCCs reported a decrease in these indicators. RCCs that were able to maintain a high level of smoking cessation activities during the pandemic offer valuable lessons, including the opportunity to swiftly leverage virtual care. Future directions for the program include capturing data on cessation outcomes and expanding the intervention to new populations. A focus on system recovery from COVID-19 will be paramount. Smoking cessation must remain a core element of high-quality cancer care, so that patients achieve the best possible health benefits from their treatments.

Identifying Best Implementation Practices for Smoking Cessation in Complex Cancer Settings.

BACKGROUND: In response to evidence about the health benefits of smoking cessation at time of cancer diagnosis, Ontario Health (Cancer Care Ontario) (OH-CCO) instructed Regional Cancer Centres (RCC) to implement smoking cessation interventions (SCI). RCCs were given flexibility to implement SCIs according to their context but were required to screen new patients for tobacco status, advise patients about the importance of quitting, and refer patients to cessation supports. The purpose of this evaluation was to identify practices that influenced successful implementation across RCCs. METHODS: A realist evaluation approach was employed. Realist evaluations examine how underlying processes of an intervention (mechanisms) in specific settings (contexts) interact to produce results (outcomes). A realist evaluation may thus help to generate an understanding of what may or may not work across contexts. RESULTS: The RCCs with the highest Tobacco Screening Rates used a centralized system. Regarding the process for advising and referring, three RCCs offered robust smoking cessation training, resulting in advice and referral rates between 80% and 100%. Five RCCs surpassed the target for Accepted Referral Rates; acceptance rates for internal referral were highest overall. CONCLUSION: Findings highlight factors that may influence successful SCI implementation.

Understanding Men's Experiences With Prostate Cancer Stigma: A Qualitative Study.

PURPOSE: The purpose of this study was to explore the experiences and perspectives of men who have had prostate cancer to better understand the effect of prostate cancer and associated stigmas on men in the Canadian province Newfoundland and Labrador (NL). PARTICIPANTS & SETTING: Eleven men from NL who have had prostate cancer participated in semistructured interviews exploring their perspectives and experiences of prostate cancer and stigma. METHODOLOGIC APPROACH: A social-ecological framework was used to understand experiences from different domains. Interviews were analyzed using Lichtman's three Cs approach. Analysis focused on establishing themes of the participants' lived experience of prostate cancer and related stigma. FINDINGS: Participants described how emasculating a prostate cancer diagnosis can feel. They identified ways prostate cancer negatively affected their behaviors and sense of self, described coping with the diagnosis and different strategies, and talked about broader system change required to address prostate cancer stigma. Participants expressed a need for additional support from healthcare providers (HCPs). IMPLICATIONS FOR NURSING: HCPs, such as oncology nurses, may be able to reduce stigmatization by providing patient navigation, improving information delivery, or providing psychosocial counseling to individuals experiencing feelings of internal or external stigmatization related to prostate cancer.

Implementing smoking cessation within cancer treatment centres and potential economic impacts.

BACKGROUND: Although the health benefits of smoking cessation in newly diagnosed cancer patients are well established, systematic efforts to help cancer patients stop smoking have rarely been implemented in cancer centres. METHODS: Starting in 2012, the 14 regional cancer centres overseen by Cancer Care Ontario in the province of Ontario, Canada began to screen ambulatory cancer patients for their smoking status, to provide smokers with advice on the health benefits of quitting and to offer referral to smoking cessation services. Multiple initiatives were undertaken to educate healthcare providers and patients on the health benefits of cessation. Critical to the success of the initiative was strong leadership from Cancer Care Ontario executives and regional vice presidents, advice from an advisory committee of smoking cessation experts, engagement of regional champions and support from a provincial secretariat. The quarterly review of performance metrics was an important driver of change. RESULTS: Most cancer centres now screen in excess of 75% of ambulatory patients but rates for the acceptance of a referral to smoking cessation services remain low (less than 25%). Introduction of an opt-out referral process appears to increase referral acceptance. Economic analyses suggest that smoking cessation is cost-effective in a cancer centre environment. CONCLUSIONS: Although there are barriers to the implementation of smoking cessation in cancer centres, it is possible to change the culture to one in which smoking cessation is considered part of high-quality treatment.

Economic evaluation of smoking cessation in Ontario's regional cancer programs.

Quitting smoking after a diagnosis of cancer results in greater response to treatment and decreased risk of disease recurrence and second primary cancers. The objective of this study was to evaluate the potential cost-effectiveness of two smoking cessation approaches: the current basic smoking cessation program consisting of screening for tobacco use, advice, and referral; and a best practice smoking cessation program that includes the current basic program with the addition of pharmacological therapy, counseling, and follow-up. A Markov model was constructed that followed 65-year-old smokers with cancer over a lifetime horizon. Transition probabilities and mortality estimates were obtained from the published literature. Costs were obtained from standard costing sources in Ontario and reports. Probabilistic and deterministic sensitivity analyses were conducted to address parameter uncertainties. For smokers with cancer, the best practice smoking cessation program was more effective and more costly than the basic smoking cessation program. The incremental cost-effectiveness ratio of the best practice smoking cessation program compared to the basic smoking cessation program was $3367 per QALY gained and $5050 per LY gained for males, and $2050 per QALY gained and $4100 per LY gained for females. Results were most sensitive to the hazard ratio of mortality for former and current smokers, the probability of quitting smoking through participation in the program and smoking-attributable costs. The study results suggested that a best practice smoking cessation program could be a cost-effective option. These findings can support and guide implementation of smoking cessation programs.

Root foraging influences plant growth responses to earthworm foraging.

Interactions among the foraging behaviours of co-occurring animal species can impact population and community dynamics; the consequences of interactions between plant and animal foraging behaviours have received less attention. In North American forests, invasions by European earthworms have led to substantial changes in plant community composition. Changes in leaf litter have been identified as a critical indirect mechanism driving earthworm impacts on plants. However, there has been limited examination of the direct effects of earthworm burrowing on plant growth. Here we show a novel second pathway exists, whereby earthworms (Lumbricus terrestris L.) impact plant root foraging. In a mini-rhizotron experiment, roots occurred more frequently in burrows and soil cracks than in the soil matrix. The roots of Achillea millefolium L. preferentially occupied earthworm burrows, where nutrient availability was presumably higher than in cracks due to earthworm excreta. In contrast, the roots of Campanula rotundifolia L. were less likely to occur in burrows. This shift in root behaviour was associated with a 30% decline in the overall biomass of C. rotundifolia when earthworms were present. Our results indicate earthworm impacts on plant foraging can occur indirectly via physical and chemical changes to the soil and directly via root consumption or abrasion and thus may be one factor influencing plant growth and community change following earthworm invasion. More generally, this work demonstrates the potential for interactions to occur between the foraging behaviours of plants and soil animals and emphasizes the importance of integrating behavioural understanding in foraging studies involving plants.