Stage of colorectal cancer diagnosis for immigrants: a population-based retrospective cohort study in Ontario, Canada.

BACKGROUND: Colorectal cancer (CRC) is the second most common cause of cancer death in Canada. Immigrants in Ontario, Canada's most populous province, are known to have lower rates of CRC screening, but differences in stage of CRC diagnosis are not known. METHODS: We utilized linked administrative databases to compare early (stage I-II) versus late (stage III-IV) stage of CRC diagnosis for immigrants versus long-term residents among patients diagnosed in Ontario between 2012 and 2017 (n = 37,717) and examined the association of immigration-related, sociodemographic, and healthcare-related factors with stage. RESULTS: Almost 45% of those with CRC were diagnosed at a late stage. Immigrants were slightly more likely to be diagnosed at a late stage than their long-term resident counterparts [Adjusted relative risks (ARRs) 1.06 (95% CI 1.02-1.10)], but after adjusting for age and sex, this difference was no longer significant. In fully adjusted models, we observed a higher likelihood of late-stage diagnosis for people with the fewest co-morbidities (ARR 0.86 [95% CI 0.83-0.89]) and those with no visits to primary care (versus a high level of continuity of care) [ARR 1.07 (95% CI 1.03-1.12)]. CONCLUSION: Immigrants were not more likely to have a late-stage CRC diagnosis after adjusting for relevant factors, but access to primary care and healthcare contact was significantly associated with diagnostic stage. IMPACT: Attachment to a primary care provider who provides regular preventive care may play a role in more favorable stage at diagnosis for CRC and thus should be a healthcare system priority.

Risk of infertility in female adolescents and young adults with cancer: a population-based cohort study.

STUDY QUESTION: Do female adolescents and young adults (AYAs) with cancer have a higher risk of subsequent infertility diagnosis than AYAs without cancer? SUMMARY ANSWER: Female AYAs with breast, hematological, thyroid and melanoma cancer have a higher risk of subsequent infertility diagnosis. WHAT IS KNOWN ALREADY: Cancer therapies have improved substantially, leading to dramatic increases in survival. As survival improves, there is an increasing emphasis on optimizing the quality of life among cancer survivors. Many cancer therapies increase the risk of infertility, but we lack population-based studies that quantify the risk of subsequent infertility diagnosis in female AYAs with non-gynecological cancers. The literature is limited to population-based studies comparing pregnancy or birth rates after cancer against unexposed women, or smaller studies using markers of the ovarian reserve as a proxy of infertility among female survivors of cancer. STUDY DESIGN, SIZE, DURATION: We conducted a population-based cohort study using universal health care databases in the province of Ontario, Canada. Using data from the Ontario Cancer Registry, we identified all women 15-39 years of age diagnosed with the most common cancers in AYAs (brain, breast, colorectal, leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, thyroid and melanoma) from 1992 to 2011 who lived at least 5 years recurrence-free (Exposed, n = 14,316). Women with a tubal ligation, bilateral oophorectomy or hysterectomy previous to their cancer diagnosis were excluded. We matched each exposed woman by age, census subdivision, and parity to five randomly selected unexposed women (n = 60,975) and followed subjects until 31 December 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: Infertility diagnosis after 1 year of cancer was identified using information on physician billing codes through the Ontario Health Insurance Plan database (ICD-9 628). Modified Poisson regression models were used to assess the risk of infertility diagnosis (relative risk, RR) adjusted for income quintile and further stratified by parity at the time of cancer diagnosis (nulliparous and parous). MAIN RESULTS AND THE ROLE OF CHANCE: Mean age at cancer diagnosis was 31.4 years. Overall, the proportion of infertility diagnosis was higher in cancer survivors compared to unexposed women. Mean age of infertility diagnosis was similar among cancer survivors and unexposed women (34.8 years and 34.9 years, respectively). The overall risk of infertility diagnosis was higher in cancer survivors (RR 1.30; 95% CI 1.23-1.37). Differences in infertility risk varied by type of cancer. Survivors of breast cancer (RR 1.46; 95% CI 1.30-1.65), leukemia (RR 1.56; 95% CI 1.09-2.22), Hodgkin lymphoma (RR 1.49; 95% CI 1.28-1.74), non-Hodgkin lymphoma (RR 1.42; 95% CI 1.14, 1.76), thyroid cancer (RR 1.20; 95% CI 1.10-1.30) and melanoma (RR 1.17; 95% CI 1.01, 1.35) had a higher risk of infertility diagnosis compared to women without cancer. After stratification by parity, the association remained in nulliparous women survivors of breast cancer, leukemia, lymphoma and melanoma, whereas it was attenuated in parous women. In survivors of thyroid cancer, the association remained statistically significant in both nulliparous and parous women. In survivors of brain or colorectal cancer, the association was not significant, overall or after stratification by parity. LIMITATIONS, REASONS FOR CAUTION: Non-biological factors that may influence the likelihood of seeking a fertility assessment may not be captured in administrative databases. The effects of additional risk factors, including cancer treatment, which may modify the associations, need to be assessed in future studies. WIDER IMPLICATIONS OF THE FINDINGS: Reproductive health surveillance in female AYAs with cancer is a priority, especially those with breast cancer, leukemia and lymphoma. Our finding of a potential effects of thyroid cancer (subject to over-diagnosis) and, to a lesser extent, melanoma need to be further studied, and, if an effect is confirmed, possible mechanisms need to be elucidated. STUDY FUNDING/COMPETING INTEREST(S): Funding was provided by the Faculty of Health Sciences and Department of Obstetrics and Gynecology, Queen's University. There are no competing interests to declare. TRIAL REGISTRATION NUMBER: N/A.

Building on existing tools to improve chronic disease prevention and screening in public health: a cluster randomized trial.

BACKGROUND: The BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) intervention was designed to integrate the approach to chronic disease prevention and screening in primary care and demonstrated effective in a previous randomized trial. METHODS: We tested the effectiveness of the BETTER HEALTH intervention, a public health adaptation of BETTER, at improving participation in chronic disease prevention and screening actions for residents of low-income neighbourhoods in a cluster randomized trial, with ten low-income neighbourhoods in Durham Region Ontario randomized to immediate intervention vs. wait-list. The unit of analysis was the individual, and eligible participants were adults age 40-64 years residing in the neighbourhoods. Public health nurses trained as "prevention practitioners" held one prevention-focused visit with each participant. They provided participants with a tailored prevention prescription and supported them to set health-related goals. The primary outcome was a composite index: the number of evidence-based actions achieved at six months as a proportion of those for which participants were eligible at baseline. RESULTS: Of 126 participants (60 in immediate arm; 66 in wait-list arm), 125 were included in analyses (1 participant withdrew consent). In both arms, participants were eligible for a mean of 8.6 actions at baseline. At follow-up, participants in the immediate intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22-1.84]). CONCLUSION: Public health nurses using the BETTER HEALTH intervention led to a higher proportion of identified evidence-based prevention and screening actions achieved at six months for people living with socioeconomic disadvantage. TRIAL REGISTRATION: NCT03052959 , registered February 10, 2017.

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services.

BACKGROUND: The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery. METHODS: This was a scoping review of all available literature pertaining to COVID-19 and surgery, using electronic databases, society websites, webinars and preprint repositories. RESULTS: Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross-cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning. CONCLUSION: Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase.

ANTECEDENTES: La pandemia en curso tiene un efecto colateral sobre la salud en la prestación de atención quirúrgica a millones de pacientes. Se sabe muy poco sobre el manejo de la pandemia y sus efectos colaterales en otros servicios, incluida la prestación de servicios quirúrgicos. MÉTODOS: Se ha realizado una revisión de alcance de toda la literatura disponible relacionada con COVID-19 y cirugía utilizando bases de datos electrónicas, páginas web de sociedades, seminarios online y repositorios de pre-publicaciones. RESULTADOS: Se han publicado varias guías perioperatorias en un corto período de tiempo. Muchas recomendaciones son contradictorias y, en el mejor de los casos, se basan en datos anecdóticos. A medida que las regiones con el mayor volumen de operaciones per cápita se ven afectadas, se cancela o difiere un número sin precedentes de operaciones. Ninguna de las principales partes interesadas parece haber considerado cómo una pandemia priva de recursos a los pacientes que necesitan una intervención quirúrgica, con pacientes afectados de manera desproporcionada debido a la naturaleza del tratamiento (uso de anestesia, quirófanos, equipo de protección, contacto físico y necesidad de atención perioperatoria). No existen recomendaciones sobre cómo reanudar la actividad quirúrgica. La evaluación tras la pandemia y la planificación futura deben incluir a los servicios quirúrgicos como una parte esencial para mantener la atención quirúrgica adecuada para la población también durante un brote epidémico. La prestación de servicios quirúrgicos, debido a su naturaleza transversal y a sus efectos sinérgicos en los sistemas de salud en general, debe incorporarse a la agenda de la OMS para la planificación nacional de la salud. CONCLUSIÓN: Los pacientes se ven privados de acceso a la cirugía con una pérdida de función incierta y riesgo de un pronóstico adverso como efecto colateral de la pandemia. Los servicios quirúrgicos necesitan un plan de contingencia para mantener la atención quirúrgica durante la pandemia y en la fase post-pandemia.

Perioperative outcomes of women with and without class III obesity undergoing hysterectomy for endometrioid endometrial cancer: A population-based study.

OBJECTIVE: Population-based data on perioperative complications among women with endometrial cancer and severe obesity are lacking. We evaluated 30-day complication rates among women with and without class III obesity (body mass index ≥ 40 kg/m2) undergoing primary surgical management for endometrioid endometrial cancer (EEC), and how outcomes differed according to surgical approach (open vs. minimally invasive). METHODS: We performed a retrospective population-based cohort study of women with EEC undergoing hysterectomy in Ontario, Canada, between 2006 and 2015. We evaluated perioperative complications in the whole cohort, and in a 1:1 matched analysis using hard and propensity score matching to ensure similar distributions of patient, tumour, provider and institution-level factors between women with and without class III obesity (identified using a surgical billing code). The primary outcome of interest was the 30-day perioperative complication rate. RESULTS: 12,112 women met inclusion criteria; 2697 (22.3%) had class III obesity. We matched 2320 (86%) women with class III obesity to those without. The composite complication rate was significantly higher among women with class III obesity (23.2% vs. 18.4%, standardized mean difference [SMD] = 0.12), primarily due to wound infection/disruption (12.1% vs. 6.2%). There was no difference in outcomes for women with and without class III obesity when a minimally invasive approach was used. CONCLUSIONS: Wound infection/disruption was increased for women with class III obesity compared to women without. Otherwise, perioperative complications were similar between the matched pairs. When minimally invasive approaches were used, women with class III obesity had a similar risk of complications as women without obesity.

Does the presence of an intact primary increase the risk of nonelective colorectal surgery in patients treated with bevacizumab?

AIM: In patients with incurable metastatic colorectal cancer (mCRC), resection of the primary tumour is debated; however, patients with intact primaries may be at a higher risk of complications requiring surgery when receiving treatment with bevacizumab. Our aim was to estimate the risk of nonelective colorectal surgery in patients undergoing bevacizumab therapy for mCRC and evaluate the association between intact primary tumours and risk of nonelective surgery. METHOD: We designed a population-based, retrospective cohort study using administrative and cancer registry data in Ontario, Canada. We included patients with mCRC who received bevacizumab from 1 January 2008 to 31 December 2014. The primary outcome was nonelective colorectal surgery after initiation of bevacizumab. We determined the cumulative incidence of nonelective colorectal surgery among patients with previously resected and unresected primaries, accounting for the competing risk of death. We explored the relationship between previous resection of the primary and need for nonelective surgery using a cause-specific hazards model, controlling for patient, tumour and treatment factors. RESULTS: We identified 1840 (32.7%) patients with intact primaries and 3784 (67.3%) patients with prior resection. The cumulative incidence of nonelective surgery 1 year after initiating bevacizumab for all patients was 3.9% (95% CI 3.4-4.5%). One-year cumulative incidence was higher in those with intact primaries than in those with resected primaries (6.1% vs 2.9%, P < 0.0001). After adjustment, an intact primary remained strongly associated with nonelective colorectal surgery (hazard ratio = 2.89, 95% CI 2.32-3.61; P < 0.0001). CONCLUSION: Bevacizumab is associated with a low but meaningful risk for serious gastrointestinal complications, necessitating vigilance, particularly among patients with an intact primary tumour.

Uptake of Cancer Screening Tests Among Recipients of Solid Organ Transplantation.

Population-based cancer screening recommendations are also suggested for solid organ transplant recipients (SOTR); however, recommendation adherence is unknown. In a population-based cohort of SOTR in Ontario between 1997 and 2010, we determined the uptake of breast, cervical, and colorectal cancer screening tests and identified factors associated with up-to-date screening using recurrent event analysis. We identified 4436 SOTR eligible for colorectal, 2252 for cervical, and 1551 for breast cancer screening. Of those, 3437 (77.5%), 1572 (69.8%), and 1417 (91.4%), respectively, were not up-to-date for cancer screening tests during the observation period. However, these rates are likely an overestimate due to the inability to differentiate between tests done for screening or for diagnosis. SOTR with fewer comorbidities had higher rates of becoming screen up-to-date. Assessment by a primary care provider (PCP) was associated with becoming up-to-date with cancer screening (breast relative risk [RR] = 1.40, 95% confidence interval [CI]: 1.12-1.76, cervical RR = 1.29, 95% CI: 1.06-1.57, colorectal RR = 1.30, 95% CI: 1.15-1.48). Similar results were observed for continuity of care by transplant specialist at a transplant center. In conclusion, cancer screening for most SOTR does not adhere to standard recommendations. Involvement of PCPs in posttransplant care and continuity of care at a transplant center may improve the uptake of screening.

Cancer Screening Recommendations for Solid Organ Transplant Recipients: A Systematic Review of Clinical Practice Guidelines.

Solid organ transplant recipients (SOTRs) are at increased risk of developing and dying from cancer. However, controversies exist around cancer screening in this population owing to reduced life expectancy and competing causes of death. This systematic review assesses the availability, quality and consistency of cancer screening recommendations in clinical practice guidelines (CPGs). We systematically searched bibliographic databases and gray literature to identify CPGs and assessed their quality using AGREE II. Recommendations were extracted along with their supporting evidence. Thirteen guidelines were included in the review. CPGs for kidney recipients were the most frequent source of screening recommendations, and recommendations for skin cancer screening were most frequently presented. Some screening recommendations differed from those for the general population, based on literature demonstrating higher cancer incidence among SOTRs versus direct evidence of screening effectiveness. Relevant stakeholders such as oncology specialists, primary care providers and public health experts were not involved in the formulation of the screening recommendations. In conclusion, although several guidelines make recommendations for cancer screening in SOTRs, the availability of cancer screening recommendations varied considerably by transplanted organ. More studies are required to inform cancer screening recommendations in SOTRs, and guideline development should involve transplant patients, oncologists and cancer screening specialists.

Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges.

BACKGROUND: Data on the social determinants of health can help primary care practices target improvement efforts, yet relevant data are rarely available. Our family practice located in Toronto, Ontario routinely collects patient-level sociodemographic data via a pilot-tested survey developed by a multi-organizational steering committee. We sought to use these data to assess the relationship between the social determinants and colorectal, cervical and breast cancer screening, and to describe the opportunities and challenges of using data on social determinants from a self-administered patient survey. METHODS: Patients of the family practice eligible for at least one of the three cancer screening types, based on age and screening guidelines as of June 30, 2015 and who had answered at least one question on a socio-demographic survey were included in the study. We linked self-reported data from the sociodemographic survey conducted in the waiting room with patients' electronic medical record data and cancer screening records. We created an individual-level income variable (low-income cut-off) that defined a poverty threshold and took household size into account. The sociodemographic characteristics of patients who were overdue for screening were compared to those who were up-to-date for screening for each cancer type using chi-squared tests. RESULTS: We analysed data for 5766 patients for whom we had survey data. Survey participants had significantly higher screening rates (72.9, 78.7, 74.4% for colorectal, cervical and breast cancer screening respectively) than the 13, 036 patients for whom we did not have survey data (59.2, 65.3, 58.9% respectively). Foreign-born patients were significantly more likely to be up-to-date on colorectal screening than their Canadian-born peers but showed no significant differences in breast or cervical cancer screening. We found a significant association between the low-income cut-off variable and cancer screening; neighbourhood income quintile was not significantly associated with cancer screening. Housing status was also significantly associated with colorectal, cervical and breast cancer screening. There was a large amount of missing data for the low-income cut-off variable, approximately 25% across the three cohorts. CONCLUSION: While we were able to show that neighbourhood income might under-estimate income-related disparities in screening, individual-level income was also the most challenging variable to collect. Future work in this area should target the income disparity in cancer screening and simultaneously explore how best to collect measures of poverty.

A centrally generated primary care physician audit report does not improve colonoscopy uptake after a positive result on a fecal occult blood test in Ontario's ColonCancerCheck program.

BACKGROUND: Timely follow-up of fecal occult blood screening with colonoscopy is essential for achieving colorectal cancer mortality reduction. In the present study, we evaluated the effectiveness of centrally generated, physician-targeted audit and feedback to improve colonoscopy uptake after a positive fecal occult blood test (fobt) result within Ontario's population-wide ColonCancerCheck Program. METHODS: This prospective cohort study used data sets from Ontario's ColonCancerCheck Program (2008-2011) that were linked to provincial administrative health databases. Cox proportional hazards regression was used to estimate the effect of centralized, physician-targeted audit and feedback on colonoscopy uptake in an Ontario-wide fobt-positive cohort. RESULTS: A mailed physician audit and feedback report identifying individuals outstanding for colonoscopy for 3 or more months after a positive fobt result did not increase the likelihood of colonoscopy uptake (hazard ratio: 0.95; 95% confidence interval: 0.79 to 1.13). Duration of positive fobt status was strongly inversely associated with the hazard of follow-up colonoscopy (p for linear trend: <0.001). CONCLUSIONS: In a large population-wide setting, centralized tracking in the form of physician-targeted mailed audit and feedback reports does not improve colonoscopy uptake for screening participants with a positive fobt result outstanding for 3 or more months. Mailed physician-targeted screening audit and feedback reports alone are unlikely to improve compliance with follow-up colonoscopy in Ontario. Other interventions such as physician audits or automatic referrals, demonstrated to be effective in other jurisdictions, might be warranted.

Systematic review of internet patient information on colorectal cancer surgery.

BACKGROUND: Patients diagnosed with colorectal cancer often seek information on the Internet to help them make treatment decisions. OBJECTIVE: The aim of this study is to evaluate the quality of Web-based patient information regarding surgery for colorectal cancer. DESIGN: This study is a cross-sectional survey of patient-directed Web sites. SETTINGS: The search engine Google (Mountain View, CA) and the search terms "colorectal cancer surgery," "colon cancer surgery," and "rectal cancer surgery" were used to identify Web sites. MAIN OUTCOME MEASURES: To assess quality, we used the DISCERN instrument, a validated questionnaire developed to analyze written consumer health information on treatment options to aid consumers in evaluating the quality of health-related information on treatment choices for a specific health problem. An additional colorectal cancer-specific questionnaire was used to evaluate Web site content for colorectal cancer surgical treatment. Two independent assessors reviewed each Web site. RESULTS: Searches revealed a total of 91 distinct Web sites, of which 37 met inclusion criteria. Web site affiliation was as follows: 32% open-access general information, 24% hospital/health care organization, and 19% professional medical society. Twelve (32.4%) Web sites had clear aims, 10 (27.0%) had identifiable references to their sources of information, and 9 (24.3%) noted the date of published information. Ten sites (27.0%) provided some description of the surgical procedure, 8 (21.6%) discussed either the risks or the benefits of surgery, and 4 (10.8%) addressed quality-of-life issues. Nineteen (51.4%) Web sites discussed postoperative complications, and 7 (18.9%) discussed stoma-related maintenance/care. LIMITATIONS: The small sample size and interrater reliability bias are limitations of this study. CONCLUSIONS: The quality of online patient information regarding colorectal cancer treatment is highly variable, often incomplete, and does not adequately convey the information necessary for patients to make well-informed medical decisions regarding treatment for colorectal cancer. An opportunity exists for professional medical societies to create more comprehensive online patient information materials that may serve as a resource to physicians and their patients (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A122).

A systematic review of the anal fistula plug for patients with Crohn's and non-Crohn's related fistula-in-ano.

BACKGROUND: The management of fistula-in-ano is a balance between fistula cure and preservation of continence. OBJECTIVE: The aim of this study is to summarize the anal fistula plug literature for Crohn's and non-Crohn's fistula-in-ano in a homogenous patient population. DATA SOURCES: PubMed, MEDLINE, Embase, and Cochrane medical databases were searched from 1995 to 2011. Abstracts from The American Society of Colon and Rectal Surgeons, The Society for Surgery of the Alimentary Tract, The European Society of Coloproctology, and the Association of Coloproctology of Great Britain and Ireland meetings between 2007 and 2010 were also evaluated. STUDY SELECTION: Studies were included if results for patients with and without Crohn's disease could be differentiated. Patients with rectovaginal, anovaginal, rectourethral, or ileal-pouch vaginal fistulas were excluded as were studies where the mean or median follow-up was less than 3 months. Two researchers independently selected studies matching the inclusion criteria. INTERVENTION: Anal fistula plug insertion was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were the overall fistula closure rates and length of follow-up. RESULTS: Seventy-six articles or abstracts were identified from the title as being of relevance. Twenty studies (2 abstracts, 18 articles) were finally included. Study sample size ranged from 4 to 60 patients; 530 patients were included in all studies (488 non-Crohn's and 42 Crohn's patients). The plug extrusion rate was 8.7% (46 patients). The proportion of patients achieving fistula closure varied widely between studies for non-Crohn's, ranging from 0.2 (95% CI 0.04-0.48) to 0.86 (95% CI 0.64-0.97). The pooled proportion of patients achieving fistula closure in patients with non-Crohn's fistula-in-ano was 0.54 (95% CI 0.50-0.59). The proportion achieving closure in patients with Crohn's disease was similar (0.55, 95% CI 0.39-0.70). LIMITATIONS: This study was limited by the variability of operative technique and perioperative care between studies. CONCLUSIONS: Fistula closure is achieved by using the anal fistula plug in approximately 54% of patients without Crohn's disease. The anal fistula plug has not been adequately evaluated in the Crohn's population.

Early urinary catheter removal after rectal surgery: systematic review and meta-analysis.

BACKGROUND: Urinary catheters are placed after rectal surgery to prevent urinary retention, but prolonged use may increase the risk of urinary tract infection (UTI). This review evaluated the non-inferiority of early urinary catheter removal compared with late removal for acute urinary retention risk after rectal surgery. METHODS: MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched from January 1980 to February 2019. RCTs comparing early versus late catheter removal after rectal surgery were eligible. Primary outcomes were acute urinary retention and UTI; the secondary outcome was length of hospital stay. Early catheter removal was defined as removal up to 2 days after surgery, with late removal after postoperative day 2. The non-inferiority margin from an included trial was used for analysis of change in urinary retention (ΔNI = 15 per cent). Pooled estimates of risk differences (RDs) were derived from random-effects models. Risk of bias was assessed using a modified Cochrane risk-of-bias tool. RESULTS: Four trials were included, consisting of 409 patients. There was insufficient evidence to conclude non-inferiority of early versus late catheter removal for acute urinary retention (RD 9 (90 per cent c.i. -1 to 19) per cent; PNI = 0·31). Early catheter removal was superior for UTI (RD -11 (95 per cent c.i. -17 to -4) per cent; P = 0·001). Results for length of stay were mixed. There were insufficient data to conduct subgroup analyses. CONCLUSION: The existing literature is inconclusive for non-inferiority of early versus late urinary catheter removal for acute urinary retention. Early catheter removal is superior in terms of reducing the risk of UTI.

ANTECEDENTES: Las sondas urinarias se colocan después de la cirugía rectal para prevenir la retención urinaria, pero su uso prolongado puede aumentar el riesgo de infección del tracto urinario. Esta revisión evaluó si la retirada precoz de la sonda urinaria no fue inferior a la retirada tardía del catéter en cuanto al riesgo de retención urinaria aguda tras cirugía rectal. MÉTODOS: Se realizaron búsquedas en las bases de datos MEDLINE, Embase y en el Registro Central Cochrane de Ensayos Controlados desde enero de 1980 hasta febrero de 2019. Se consideraron elegibles los ensayos controlados aleatorizados que comparaban la retirada precoz y tardía de la sonda tras cirugía rectal. Las variables principales fueron la retención urinaria aguda y la infección del tracto urinario. La variable secundaria fue la duración de la estancia hospitalaria. Se consideró retirada precoz cuando ésta ocurrió hasta el segundo día postoperatorio mientras que más allá de ese tiempo se consideró retirada tardía. El margen de no inferioridad de uno de los ensayos incluidos se utilizó para el análisis de la retención urinaria (ΔNI = 15%). Las estimaciones agrupadas de las diferencias de riesgo se derivaron de los modelos de efectos aleatorios. El riesgo de sesgo se evaluó utilizando una herramienta de riesgo de sesgo Cochrane modificada. RESULTADOS: Se incluyeron cuatro ensayos que incluyeron un total de 409 pacientes. No se encontraron evidencias suficientes para concluir la no inferioridad de la retirada precoz del catéter versus la retirada tardía para la retención urinaria aguda (diferencia de riesgo, risk difference, RD 9%, i.c. del 90% -1% a 19%, valor de la P para no inferioridad, P value for non-inferiority, PNI = 0,31). La retirada precoz del catéter fue superior con relación a la infección del tracto urinario (RD -11%, IC del 95%: -17% a -4%, P = 0,001). Los resultados de la duración de la estancia hospitalaria fueron mixtos. No hubo datos suficientes para realizar análisis de subgrupos. CONCLUSIÓN: La literatura existente no es concluyente para determinar la no inferioridad de la retirada precoz de la sonda urinaria versus la retirada tardía con relación a la retención urinaria aguda. La retirada precoz de la sonda es superior y reduce el riesgo de infección del tracto urinario.

A pan-Canadian prospective study of young women with breast cancer: the rationale and protocol design for the RUBY study.

Introduction: The understanding of the biology and epidemiology of, and the optimal therapeutic strategies for, breast cancer (bca) in younger women is limited. We present the rationale, design, and initial recruitment of Reducing the Burden of Breast Cancer in Young Women (ruby), a unique national prospective cohort study designed to examine the diagnosis, treatment, quality of life, and outcomes from the time of diagnosis for young women with bca. Methods: Over a 4-year period at 33 sites across Canada, the ruby study will use a local and virtual recruitment model to enrol 1200 women with bca who are 40 years of age or younger at the time of diagnosis, before initiation of any treatment. At a minimum, comprehensive patient, tumour, and treatment data will be collected to evaluate recurrence and survival. Patients may opt to complete patient-reported questionnaires, to provide blood and tumour samples, and to be contacted for future research, forming the core dataset from which 4 subprojects evaluating genetics, lifestyle factors, fertility, and local management or delivery of care will be performed. Summary: The ruby study will be the most comprehensive repository of data, biospecimens, and patient-reported outcomes ever collected with respect to young women with bca from the time of diagnosis, enabling research unique to that population now and into the future. This research model could be used for other oncology settings in Canada.