Longitudinal adherence to surveillance for late effects of cancer treatment: a population-based study of adult survivors of childhood cancer.

BACKGROUND: Adult survivors of childhood cancer are at elevated risk of morbidity and mortality compared to the general population, but their adherence to lifelong periodic surveillance is suboptimal. We aimed to examine adherence to surveillance guidelines for high-yield tests and identify risk factors for nonadherence in adult survivors of childhood cancer. METHODS: In this retrospective, population-based cohort study, we used health care administrative data from Ontario, Canada, to identify adult survivors of childhood cancer diagnosed between 1986 and 2014 who were at elevated risk of therapy-related colorectal cancer, breast cancer, or cardiomyopathy. Using a Poisson regression framework, we assessed longitudinal adherence and predictors of adherence to the Children's Oncology Group surveillance guideline. RESULTS: Among 3241 survivors, 327 (10%), 234 (7%), and 3205 (99%) were at elevated risk for colorectal cancer, breast cancer, and cardiomyopathy, respectively. Within these cohorts, only 13%, 6%, and 53% were adherent to recommended surveillance as of February 2020. During a median follow-up of 7.8 years, the proportion of time spent adherent was 14% among survivors at elevated risk for colorectal cancer, 10% for breast cancer, and 43% for cardiomyopathy. Significant predictors of adherence varied across the risk groups, but higher comorbidity was associated with adherence to recommended surveillance. INTERPRETATION: Survivors of childhood cancer in Ontario are rarely up to date for recommended surveillance tests. Tailored interventions beyond specialized clinics are needed to improve surveillance adherence.

Protocol for the ONLOOP trial: pragmatic randomized trial evaluating a province-wide system of personalized reminders for evidence-based surveillance tests in adult survivors of childhood cancer in Ontario.

BACKGROUND: Childhood cancer treatment while often curative, leads to elevated risks of morbidity and mortality. Survivors require lifelong periodic surveillance for late effects of treatment, yet adherence to guideline-recommended tests is suboptimal. We created ONLOOP to provide adult survivors of childhood cancer with detailed health information, including summaries of their childhood cancer treatment and recommended surveillance tests for early detection of cardiomyopathy, breast cancer, and/or colorectal cancer, with personalized reminders over time. METHODS: This is an individually randomized, registry-based pragmatic trial with an embedded process and economic evaluation to understand ONLOOP's impact and whether it can be readily implemented at scale. All adult survivors of childhood cancer in Ontario overdue for guideline-recommended tests will be randomly assigned to one of two arms: (1) intervention or (2) delayed intervention. A letter of information and invitation will detail the ONLOOP program. Those who sign up will receive a personalized toolkit and a screening reminder 6 months later. With the participants' consent, ONLOOP will also send their primary care clinician a letter detailing the recommended tests and a reminder 6 months later. The primary outcome will be the proportion of survivors who complete one or more of the guideline-recommended cardiac, breast, or colon surveillance tests during the 12 months after randomization. Data will be obtained from administrative databases. The intent-to-treat principle will be followed. Based on our analyses of administrative data, we anticipate allocating at least 862 individuals to each trial arm, providing 90% power to detect an absolute increase of 6% in targeted surveillance tests completed. We will interview childhood cancer survivors and family physicians in an embedded process evaluation to examine why and how ONLOOP achieved success or failed. A cost-effectiveness evaluation will be performed. DISCUSSION: The results of this study will determine if ONLOOP is effective at helping adult survivors of childhood cancer complete their recommended surveillance tests. This study will also inform ongoing provincial programs for this high-risk population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05832138.

Up-to-date on cancer screening among Ontario patients seen by walk-in clinic physicians: A retrospective cohort study.

Walk-in clinics are typically viewed as high-volume locations for managing acute issues but also may serve as a location for primary care, including cancer screening, for patients without a family physician. In this population-based cohort study, we compared breast, cervical and colorectal cancer screening up-to-date status for people living in the Canadian province of Ontario who were formally enrolled to a family physician versus those not enrolled but who had at least one encounter with a walk-in clinic physician in the previous year. Using provincial administrative databases, we created two mutually exclusive groups: i) those who were formally enrolled to a family physician, ii) those who were not enrolled but had at least one visit with a walk-in clinic physician from April 1, 2019 to March 31, 2020. We compared up to date status for three cancer screenings as of April 1, 2020 among screen-eligible people. We found that people who were not enrolled and had seen a walk-in clinic physician in the previous year consistently were less likely to be up to date on cancer screening than Ontarians who were formally enrolled with a family physician (46.1% vs. 67.4% for breast, 45.8% vs. 67.4% for cervical, 49.5% vs. 73.1% for colorectal). They were also more likely to be foreign-born and to live in structurally marginalized neighbourhoods. New methods are needed to enable screening for people who are reliant on walk-in clinics and to address the urgent need in Ontario for more primary care providers who deliver comprehensive, longitudinal care.

Developing a Provincial Surveillance and Support System for Childhood Cancer Survivors: Multiphase User-Centered Design Study.

BACKGROUND: Survivors of childhood cancer are at lifelong risk of morbidity (such as new cancers or heart failure) and premature mortality due to their cancer treatment. These are termed late effects. Therefore, they require lifelong, risk-tailored surveillance. However, most adult survivors of childhood cancer do not complete recommended surveillance tests such as mammograms or echocardiograms. OBJECTIVE: In partnership with survivors, family physicians, and health system partners, we are designing a provincial support system for high-priority tests informed by principles of implementation science, behavioral science, and design thinking. METHODS: Our multiphase process was structured as follows. Step 1 consisted of a qualitative study to explore intervention components essential to accessing surveillance tests. Step 2 comprised a workshop with childhood cancer survivors, family physicians, and health system stakeholders that used the Step 1 findings and "personas" (a series of fictional but data-informed characters) to develop and tailor the intervention for different survivor groups. Step 3 consisted of intervention prototype development, and Step 4 involved iterative user testing. RESULTS: The qualitative study of 30 survivors and 7 family physicians found a high desire for information on surveillance for late effects. Respondents indicated that the intervention should help patients book appointments when they are due in addition to providing personalized information. Insights from the workshop included the importance of partnering with both family physicians and survivorship clinics and providing emotional support for survivors who may experience distress upon learning of their risk for late effects. In our user-testing process, prototypes went through iterations that incorporated feedback from users regarding acceptability, usability, and functionality. We sought to address the needs of survivors and physicians while balancing the capacity and infrastructure available for a lifelong intervention via our health system partners. CONCLUSIONS: In partnership with childhood cancer survivors, family physicians, and health system partners, we elucidated the barriers and enablers to accessing guideline-recommended surveillance tests and designed a multifaceted solution that will support survivors and their family physicians. The next step is to evaluate the intervention in a pragmatic randomized controlled trial.

Determinants of surveillance for late effects in childhood cancer survivors: a qualitative study using the Theoretical Domains Framework.

PURPOSE: Most adult survivors of childhood cancer do not complete the recommended surveillance tests for late effects of their treatment. We used a theory-informed method to elucidate the barriers and enablers among childhood cancer survivors to accessing such tests. METHODS: Semi-structured interviews were completed with adult survivors of childhood cancer. Participants were eligible for the surveillance tests of interest (echocardiogram, mammogram/breast MRI and/or colonoscopy) but had not attended a specialised aftercare clinic in over five years. The Theoretical Domains Framework (TDF), a tool specifically developed for implementation research to identify influences on desired behaviour(s), informed the interview guide and analysis; interview transcripts were coded line-by-line and mapped to domains in accordance with the framework. RESULTS: Thirty childhood cancer survivors were interviewed (ages 25-60). The TDF domains described by survivors included: intention to complete the tests, which was facilitated by the fear of another cancer (emotion), confidence in the benefits of early detection (beliefs about consequences), and supportive reminders (memory, attention, and decision-making). In contrast, a lack of knowledge of late effects and relevant guidelines and the burden of arranging tests (social identity) were key barriers. CONCLUSION: Interventions seeking to increase surveillance testing for late effects may be more effective if they feature components that explicitly address all the theory-informed determinants identified. IMPLICATIONS FOR CANCER SURVIVORS: Awareness about the recommendations among survivors and their physicians is a necessary (but likely not sufficient) step towards implementation of guidelines regarding surveillance for late effects.

Evaluating a Real World Ban on Menthol Cigarettes: An Interrupted Time-Series Analysis of Sales.

BACKGROUND: Menthol in cigarettes has been shown to increase regular cigarette smoking and nicotine dependence, and decrease success in smoking cessation. Owing to these reasons, in May 2015, the province of Ontario introduced a menthol ban on tobacco products that came into effect in January 2017 prior to a Federal Canadian Ban in October 2017. The objective of this article was to assess the effect of a provincial menthol ban on cigarette wholesale sales in Ontario. METHODS: Wholesale data submitted by tobacco manufacturers to Health Canada pursuant to the federal Tobacco Reporting Regulations from October 2012 to September 2017 were analyzed using interrupted time-series analysis. Changes in sales of cigarettes with and without menthol were estimated, using the province of British Columbia as a comparison. Analyses were seasonally adjusted. RESULTS: Sales of menthol and nonmenthol cigarettes increased from 2013 until the implementation of the 2017 provincial ban. Subsequently, a sharp decline of 55 million menthol cigarettes and 128 million total cigarettes was observed in Ontario. As a comparison, no significant changes were observed in British Columbia. CONCLUSION: This study supports the conclusion that implementation of a menthol ban in Ontario was associated with significant reduction of menthol cigarette sales and total cigarettes sales, compared to British Columbia where there was no provincial menthol ban. This suggests that menthol regulations in jurisdictions with a larger percentage of menthol smokers are likely to be highly effective. IMPLICATIONS: The 2017 menthol ban was associated with significant reduction of menthol cigarette sales and total cigarette sales suggesting that menthol regulations will have important effects on cigarette consumption.

Sociodemographic inequality in joint-pain medication use among community-dwelling older adults in Israel.

Joint pain is a common experience among adults aged 65 and over. Although pain management is multifaceted, medication is essential in it. The paper examines the use of medication among older adults with joint pain in Israel and asks whether socioeconomic factors are associated with this usage. The data, harvested, from the Survey of Health, Aging and Retirement in Europe (SHARE), include 1,294 randomly selected community-dwelling individuals aged 65 and over in Israel. Bivariate analysis and logistic regression are used to identify factors associated with the presence of joint pain medication use. About 38% of respondents report experiencing joint pain and 45% of those who so report are not taking prescription medication. Back pain is the most common location, reported by 64% of individuals who report joint pain. Taking medication is independently associated with younger age (OR = 0.965, 95% CI = 0.939-0.991), more education (OR = 1.044, 95% CI = 0.998-1.091), and better ability to cope economically (OR = 1.964, 95% CI = 1.314-2.936). However, older age and ability to cope economically are independently associated with women (OR = 0.964, 95% CI = 0.932-0.998 and OR = 2.438, 95% CI = 1.474-4.032, respectively) but not with men. It is suggested that socioeconomic inequality exists in healthcare access among adults aged 65 and over. Since income and gender are strongly associated with taking pain medication, physicians should follow-up on women and less affluent people to ensure that medication prescribed has been obtained. Policymakers should consider programs that would facilitate better access to pain medication among vulnerable older individuals.

Modified panel-based genetic counseling for ovarian cancer susceptibility: A randomized non-inferiority study.

OBJECTIVE: Genetic testing identifies cancer patients who may benefit from targeted treatment and allows for enhanced cancer screening and risk-reduction in their at-risk relatives. Traditional models of genetic counseling (GC) cannot meet the increasing demand and urgency for genetic testing. The objective of this study was to evaluate a new model of service delivery to improve the efficiency of pre-test GC for panel-based genetic testing. METHODS: A parallel, two-armed, randomized non-inferiority study compared traditional and modified pre-test GC models (1:2) prior to panel-based genetic testing. Participants were adult females, whose first-degree relative died of serous ovarian cancer. In the modified group, participants were emailed a 20-minute presentation prior to a scheduled pre-test GC telephone call. Psychosocial and knowledge questionnaires were provided at baseline (P1) and one week after pre-test GC (P2). RESULTS: 382 women completed pre-test GC (256 modified, 126 traditional). There were no differences in marital status, education level or household income. Pre-test GC time was shorter in the modified group (average 19 vs. 46 min, p < 0.001), with no difference in post-test GC time (average 16 min each, p = 0.78). The modified pre-test GC model was found to be non-inferior to traditional GC on measures of cancer-specific distress, depression, anxiety, decisional conflict, ovarian cancer knowledge and satisfaction. Perceived lifetime risk for ovarian cancer decreased to a lesser extent from baseline in women who received modified pre-test GC. CONCLUSIONS: A 20-minute presentation prior to pre-test telephone GC is non-inferior to traditional in-person GC on all variables tested, except for perceived ovarian cancer risk. This modified model improved GC efficiency without negatively affecting psychosocial outcomes, providing an alternative strategy to meet the growing demand for genetic testing.

Incidence of breast and colorectal cancer among immigrants in Ontario, Canada: a retrospective cohort study from 2004-2014.

BACKGROUND: Studies have shown that morbidity and mortality rates due to cancer among recent immigrants are lower than those among the native-born population. The objectives of this study were to describe the incidence of colorectal and breast cancer among immigrants from major regions of the world compared to Canadian-born residents of the province of Ontario and to examine the role of length of stay and neighborhood income. METHODS: Retrospective cohort study including all individuals 18 years and over residing in Ontario from 2004 to 2014. Age-standardized incidence rates (ASIR) were calculated for immigrants from each world region versus Canadian-born residents and stratified by neighborhood income quintile and length of stay. Binomial regression analysis was used to determine the association of neighbourhood income, length of stay, and location of birth with colorectal and breast cancer incidence. RESULTS: Canadian immigrants born in South Asia had the lowest colorectal and breast cancer incidence (colorectal: women: ASIR = 0.14; men: ASIR = 0.18; breast: ASIR = 1.00) compared to long-term residents during the study period (colorectal: women: ASIR = .57; men: ASIR = .72; breast cancer ASIR = 1.61). In multivariate analyses, neighboorhood income did not consistently play a significant role in colorectal cancer incidence; however higher neighbourhood income was a risk factor for breast cancer among immigrant women (adjusted relative risk for highest neighboorhood income quintile versus lowest income quintile =1.21, 95% CI = 1.18-1.24). Increased length of stay was associated with higher risk of cancer. After adjusting for age, neighborhood income, and length of stay, those born in Europe and Central Asia had the highest risk of colorectal cancer compared to those born in East Asia and Pacific and those born in the Middle East had the greatest additional risk of breast cancer. CONCLUSIONS: After correcting for age, breast and colorectal cancer incidence rates among immigrants differ according to their region of birth and recent immigrants to Ontario have lower colorectal and breast cancer incidence rates than their native-born peers. However, those advantages diminish over time. These findings call for Ontario to generate tools and interventions to maintain the health of the immigrant population, particularly for those groups with a higher incidence of cancer.

Association of primary care physician sex with cervical cancer and mammography screening.

OBJECTIVE: To assess whether the sex of primary care physicians is associated with differing rates of cervical cancer and mammography screening in a contemporary multicultural context. DESIGN: Structured medical record review of a retrospectively defined cohort. SETTING: Academic urban primary care clinic in Montreal, Que. PARTICIPANTS: Seven male physicians and 9 female physicians, and all female patients aged 14 to 69 years registered to one of the physicians (N = 1948). MAIN OUTCOME MEASURES: Screening compliance rates as measured by the elapsed time between the last visit and cervical cancer screening for all women in the study. In addition, in women aged 50 to 69 years, elapsed time between the last visit and mammography screening. RESULTS: Crude rates of Papanicolaou tests for patients of female primary care physicians were higher than for patients of male primary care physicians in all patient age groups. The lowest rates of Pap testing were among the youngest and oldest patients. After adjustment for patient age, first language, and region of birth, as well as physician age, the odds ratio of having a Pap test was 2.24 (95% CI 1.18 to 4.28) for the patients of female physicians, relative to those of male physicians. The adjusted odds ratio for mammography screening was 1.25 (95% CI 0.97 to 1.61) for patients of female physicians. CONCLUSION: Male primary care physician sex is associated with lower rates of cervical cancer screening in an urban multicultural context. The study did not detect a physician sex effect in the mammography cohort.