Use of chemotherapy in patients with oesophageal, stomach, colon, rectal, liver, pancreatic, lung, and ovarian cancer: an International Cancer Benchmarking Partnership (ICBP) population-based study.

BACKGROUND: There are few data on international variation in chemotherapy use, despite it being a key treatment type for some patients with cancer. Here, we aimed to examine the presence and size of such variation. METHODS: This population-based study used data from Norway, the four UK nations (England, Northern Ireland, Scotland, and Wales), eight Canadian provinces (Alberta, British Columbia, Manitoba, Newfoundland and Labrador, Nova Scotia, Ontario, Prince Edward Island, and Saskatchewan), and two Australian states (New South Wales and Victoria). Patients aged 15-99 years diagnosed with cancer in eight different sites (oesophageal, stomach, colon, rectal, liver, pancreatic, lung, or ovarian cancer), with no other primary cancer diagnosis occurring from within the 5 years before to 1 year after the index cancer diagnosis or during the study period were included in the study. We examined variation in chemotherapy use from 31 days before to 365 days after diagnosis and time to its initiation, alongside related variation in patient group differences. Information was obtained from cancer registry records linked to clinical or patient management system data or hospital administration data. Random-effects meta-analyses quantified interjurisdictional variation using 95% prediction intervals (95% PIs). FINDINGS: Between Jan 1, 2012, and Dec 31, 2017, of 893 461 patients with a new diagnosis of one of the studied cancers, 111 569 (12·5%) did not meet the inclusion criteria, and 781 892 were included in the analysis. There was large interjurisdictional variation in chemotherapy use for all studied cancers, with wide 95% PIs: 47·5 to 81·2 (pooled estimate 66·4%) for ovarian cancer, 34·9 to 59·8 (47·2%) for oesophageal cancer, 22·3 to 62·3 (40·8%) for rectal cancer, 25·7 to 55·5 (39·6%) for stomach cancer, 17·2 to 56·3 (34·1%) for pancreatic cancer, 17·9 to 49·0 (31·4%) for lung cancer, 18·6 to 43·8 (29·7%) for colon cancer, and 3·5 to 50·7 (16·1%) for liver cancer. For patients with stage 3 colon cancer, the interjurisdictional variation was greater than that for all patients with colon cancer (95% PI 38·5 to 78·4; 60·1%). Patients aged 85-99 years had 20-times lower odds of chemotherapy use than those aged 65-74 years, with very large interjurisdictional variation in this age difference (odds ratio 0·05; 95% PI 0·01 to 0·19). There was large variation in median time to first chemotherapy (from diagnosis date) by cancer site, with substantial interjurisdictional variation, particularly for rectal cancer (95% PI -15·5 to 193·9 days; pooled estimate 89·2 days). Patients aged 85-99 years had slightly shorter median time to first chemotherapy compared with those aged 65-74 years, consistently between jurisdictions (-3·7 days, 95% PI -7·6 to 0·1). INTERPRETATION: Large variation in use and time to chemotherapy initiation were observed between the participating jurisdictions, alongside large and variable age group differences in chemotherapy use. To guide efforts to improve patient outcomes, the underlying reasons for these patterns need to be established. FUNDING: International Cancer Benchmarking Partnership (funded by the Canadian Partnership Against Cancer, Cancer Council Victoria, Cancer Institute New South Wales, Cancer Research UK, Danish Cancer Society, National Cancer Registry Ireland, The Cancer Society of New Zealand, National Health Service England, Norwegian Cancer Society, Public Health Agency Northern Ireland on behalf of the Northern Ireland Cancer Registry, DG Health and Social Care Scottish Government, Western Australia Department of Health, and Public Health Wales NHS Trust).

Use of radiotherapy in patients with oesophageal, stomach, colon, rectal, liver, pancreatic, lung, and ovarian cancer: an International Cancer Benchmarking Partnership (ICBP) population-based study.

BACKGROUND: There is little evidence on variation in radiotherapy use in different countries, although it is a key treatment modality for some patients with cancer. Here we aimed to examine such variation. METHODS: This population-based study used data from Norway, the four UK nations (England, Northern Ireland, Scotland, and Wales), nine Canadian provinces (Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Ontario, Prince Edward Island, and Saskatchewan), and two Australian states (New South Wales and Victoria). Patients aged 15-99 years diagnosed with cancer in eight different sites (oesophageal, stomach, colon, rectal, liver, pancreatic, lung, or ovarian cancer), with no other primary cancer diagnosis occurring within the 5 years before to 1 year after the index cancer diagnosis or during the study period were included in the study. We examined variation in radiotherapy use from 31 days before to 365 days after diagnosis and time to its initiation, alongside related variation in patient group differences. Information was obtained from cancer registry records linked to clinical or patient management system data, or hospital administration data. Random-effects meta-analyses quantified interjurisdictional variation using 95% prediction intervals (95% PIs). FINDINGS: Between Jan 1, 2012, and Dec 31, 2017, of 902 312 patients with a new diagnosis of one of the studied cancers, 115 357 (12·8%) did not meet inclusion criteria, and 786,955 were included in the analysis. There was large interjurisdictional variation in radiotherapy use, with wide 95% PIs: 17·8 to 82·4 (pooled estimate 50·2%) for oesophageal cancer, 35·5 to 55·2 (45·2%) for rectal cancer, 28·6 to 54·0 (40·6%) for lung cancer, and 4·6 to 53·6 (19·0%) for stomach cancer. For patients with stage 2-3 rectal cancer, interjurisdictional variation was greater than that for all patients with rectal cancer (95% PI 37·0 to 84·6; pooled estimate 64·2%). Radiotherapy use was infrequent but variable in patients with pancreatic (95% PI 1·7 to 16·5%), liver (1·8 to 11·2%), colon (1·6 to 5·0%), and ovarian (0·8 to 7·6%) cancer. Patients aged 85-99 years had three-times lower odds of radiotherapy use than those aged 65-74 years, with substantial interjurisdictional variation in this age difference (odds ratio [OR] 0·38; 95% PI 0·20-0·73). Women had slightly lower odds of radiotherapy use than men (OR 0·88, 95% PI 0·77-1·01). There was large variation in median time to first radiotherapy (from diagnosis date) by cancer site, with substantial interjurisdictional variation (eg, oesophageal 95% PI 11·3 days to 112·8 days; pooled estimate 62·0 days; rectal 95% PI 34·7 days to 77·3 days; pooled estimate 56·0 days). Older patients had shorter median time to radiotherapy with appreciable interjurisdictional variation (-9·5 days in patients aged 85-99 years vs 65-74 years, 95% PI -26·4 to 7·4). INTERPRETATION: Large interjurisdictional variation in both use and time to radiotherapy initiation were observed, alongside large and variable age differences. To guide efforts to improve patient outcomes, underlying reasons for these differences need to be established. FUNDING: International Cancer Benchmarking Partnership (funded by the Canadian Partnership Against Cancer, Cancer Council Victoria, Cancer Institute New South Wales, Cancer Research UK, Danish Cancer Society, National Cancer Registry Ireland, The Cancer Society of New Zealand, National Health Service England, Norwegian Cancer Society, Public Health Agency Northern Ireland on behalf of the Northern Ireland Cancer Registry, DG Health and Social Care Scottish Government, Western Australia Department of Health, and Public Health Wales NHS Trust).

Increase in the Life Expectancy of Patients with Cancer in the United States.

BACKGROUND: Cancer is becoming more of a chronic disease due to improvements in treatment and early detection for multiple cancer sites. To gain insight on increased life expectancy due to these improvements, we quantified trends in the loss in expectation of life (LEL) due to a cancer diagnosis for six cancer sites from 1975 through 2018. METHODS: We focused on patients diagnosed with female breast cancer, chronic myeloid leukemia (CML), colon and rectum cancer, diffuse large B-cell lymphoma (DLBCL), lung cancer, or melanoma between 1975 and 2018 from nine Surveillance, Epidemiology, and End Results cancer registries. Life expectancies for patients with cancer ages 50+ were modeled using flexible parametric survival models. LEL was calculated as the difference between general population life expectancy and life expectancy for patients with cancer. RESULTS: Over 2 million patients were diagnosed with one of the six cancers between 1975 and 2018. Large increases in life expectancy were observed between 1990 and 2010 for female breast, DLBCL, and CML. Patients with colon and rectum cancer and melanoma had more gradual improvements in life expectancy. Lung cancer LEL only began decreasing after 2005. Increases in life expectancy corresponded with decreases in LEL for patients with cancer. CONCLUSIONS: The reported gains in life expectancy largely correspond to progress in the screening, management, and treatment of these six cancers since 1975. IMPACT: LEL provides an important public health perspective on how improvements in treatment and early detection and their impacts on survival translate into changes in cancer patients' life expectancy.

Association of hospitalization for suicide attempts in adolescent girls with subsequent hospitalization for eating disorders.

OBJECTIVE: To determine the association between adolescent hospitalization for suicide attempts and the subsequent risk of eating disorder hospitalization. METHOD: This was a cohort study of 162,398 adolescent girls in Quebec, Canada, including 7741 with suicide attempts before 20 years of age, matched to 154,657 adolescents with no attempt between 1989 and 2019. The main exposure measure was suicide attempt hospitalization. The main outcome measure was hospitalization for an eating disorder up to 31 years later, including anorexia nervosa, bulimia nervosa, and other eating disorders. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between adolescent suicide attempts and eating disorder hospitalization. RESULTS: Adolescent girls admitted for a suicide attempt had 5.55 times the risk of eating disorder hospitalization over time (95% CI 3.74-8.23), compared with matched controls. Suicide attempt was associated with anorexia nervosa (HR 3.57, 95% CI 1.78-7.17) and bulimia nervosa and other eating disorders (HR 8.55, 95% CI 5.48-13.32). Associations were pronounced in girls with repeated suicide attempts. Girls who attempted suicide through self-poisoning had an elevated risk of anorexia nervosa, whereas girls who used violent methods such as cutting or piercing had a greater risk of bulimia nervosa and other eating disorders. Suicide attempt was strongly associated with eating disorder hospitalization in the year following the attempt, but associations persisted throughout follow-up. DISCUSSION: Suicide attempt admission is associated with the long-term risk of eating disorder hospitalization in adolescent girls. PUBLIC SIGNIFICANCE: This study of adolescent girls suggests that suicide attempt admission is associated with the long-term risk of hospitalization for eating disorders. The risk is greatest in the year after the attempt, but persists over time. Adolescents who present with a suicide attempt may benefit from screening for eating disorders and long-term follow-up to help prevent the exacerbation or development of eating disorders.

Extended Risk of Mortality in Children with Inborn Errors of Metabolism: A Longitudinal Cohort Study.

OBJECTIVES: To determine the long-term risk of mortality among children with inborn errors of metabolism. STUDY DESIGN: We conducted a retrospective cohort study of 1750 children with inborn errors of metabolism (excluding mitochondrial disorders) and 1 036 668 children without errors of metabolism who were born in Quebec, Canada, between 2006 and 2019. Main outcome measures included all-cause and cause-specific mortality between birth and 14 years of age. We used adjusted survival regression models to estimate HRs and 95% CIs for the association between inborn errors of metabolism and mortality over time. RESULTS: Mortality rates were greater for children with errors of metabolism than for unaffected children (69.1 vs 3.2 deaths per 10 000 person-years). During 7 702 179 person-years of follow-up, inborn errors of metabolism were associated with 21.2 times the risk of mortality compared with no error of metabolism (95% CI 17.23-26.11). Disorders of mineral metabolism were associated with greater mortality the first 28 days of life (HR 60.62, 95% CI 10.04-365.98), and disorders of sphingolipid metabolism were associated with greater mortality by 1 year (HR 284.73, 95% CI 139.20-582.44) and 14 years (HR 1066.00, 95% CI 298.91-3801.63). Errors of metabolism were disproportionately associated with death from hepatic/digestive (HR 208.21, 95% CI 90.28-480.22), respiratory (HR 116.57, 95% CI 71.06-191.23), and infectious causes (HR 119.83, 95% CI 40.56-354.04). CONCLUSIONS: Children with errors of metabolism have a considerably elevated risk of mortality before 14 years, including death from hepatic/digestive, respiratory, and infectious causes. Targeting these causes of death may help improve long-term survival.

Validation of Canproj for projecting Canadian cancer incidence data. / Validation de Canproj pour les projections de données sur l'incidence du cancer au Canada.

INTRODUCTION: Cancer projections can provide key information to help prioritize cancer control strategies, allocate resources and evaluate current treatments and interventions. Canproj is a cancer-projection tool that builds on the Nordpred R-package by adding a selection of projection models. The objective of this project was to validate the Canproj R-package for the short-term projection of cancer rates. METHODS: We used national cancer incidence data from 1986 to 2014 from the National Cancer Incidence Reporting System and Canadian Cancer Registry. Cross-validation was used to estimate the accuracy of the projections generated by Canproj and relative bias (RB) was used as validation measure. The Canproj automatic model selection decision tree was also assessed. RESULTS: Five of the six models had mean RB between 5% and 10% and median RB around 5%. For some of the cancer sites that were more difficult to project, a shorter time period improved reliability. The Nordpred model was selected 79% of the time by Canproj automatic model selection although it had the smallest RB only 24% of the time. CONCLUSIONS: The Canproj package was able to provide projections that closely matched the real data for most cancer sites.

Premature mortality due to social and material deprivation in Nova Scotia, Canada.

INTRODUCTION: Inequalities in health attributable to inequalities in society have long been recognized. Typically, those most privileged experience better health, regardless of universal access to health care. Associations between social and material deprivation and mortality from all causes of death--a measure of population health, have been described for some regions of Canada. This study further examines the link between deprivation and health, focusing on major causes of mortality for both rural and urban populations. In addition, it quantifies the burden of premature mortality attributable to social and material deprivation in a Canadian setting where health care is accessible to all. METHODS: The study included 35,266 premature deaths (1995-2005), grouped into five causes and aggregated over census dissemination areas. Two indices of deprivation (social and material) were derived from six socioeconomic census variables. Premature mortality was modeled as a function of these deprivation indices using Poisson regression. RESULTS: Premature mortality increased significantly with increasing levels of social and material deprivation. The impact of material deprivation on premature mortality was similar in urban and rural populations, whereas the impact of social deprivation was generally greater in rural populations. There were a doubling in premature mortality for those experiencing a combination of the most extreme levels of material and social deprivation. CONCLUSIONS: Socioeconomic deprivation is an important determinant of health equity and affects every segment of the population. Deprivation accounted for 40% of premature deaths. The 4.3% of the study population living in extreme levels of socioeconomic deprivation experienced a twofold increased risk of dying prematurely. Nationally, this inequitable risk could translate into a significant public health burden.

Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia.

PURPOSE: The purpose of this study was to examine colorectal cancer (CRC) follow-up care in Nova Scotia, Canada. More specifically, the objectives were to describe adherence to two elements of follow-up guidelines (colonoscopies and physician visits) and to identify factors associated with receiving at least guideline-recommended care. METHODS: All patients with stage II or III CRC undergoing curative-intent surgery in Nova Scotia, Canada, were identified through the provincial cancer registry and anonymously linked to additional administrative health databases. For a 3-year follow-up period, beginning 1 year after the diagnosis date, descriptive statistics were calculated for physician visits and colonoscopies. Factors associated with receiving at least guideline-recommended care were identified using logistic regression. RESULTS: Most patients received follow-up care from multiple physician specialties. In year 3, 58.1% of patients received oncologist follow-up care. Guideline adherence for colonoscopies was 52.4%, whereas guideline adherence for physician visits decreased from 41.9% to 25.4%. Receipt of at least guideline-recommended care was inversely associated with age and comorbidity for colonoscopy and inversely associated with age for physician visits. CONCLUSION: Receipt of follow-up care from oncologists and primary care physicians, prolonged oncologist care, and receipt of care inconsistent with guideline recommendations suggest there may be potential issues with inefficient use of cancer system resources and integration of guidelines into follow-up care practices in Nova Scotia. Transitioning routine follow-up to primary care could potentially increase guideline adherence by improving access to and continuity of care. CRC may be well suited to targeted knowledge translation strategies to improve guideline adherence.

Examining stage IIB survival in a population-based cohort of patients with colorectal cancer.

BACKGROUND: In Nova Scotia, Canada, a previous study of colorectal cancer (CRC) cases diagnosed between January 1, 2001, and December 31, 2005, found that patients with stage IIB CRC had similar 5-year overall survival (OS) to those with stage IIIC cancer. This study sought to examine factors contributing to the observed stage IIB outcome, specifically nodal harvest, receipt of chemotherapy, and use of a new coding system to derive stage. METHODS: The provincial cancer registry identified all CRC cases diagnosed during the study period and staged this cohort using the Collaborative Stage (CS) Data Collection System. All patients with stage II and III cancer in the cohort were examined. Kaplan-Meier (KM) survival curves compared 5-year OS for patients with stage IIB cancer based on the factors of interest, and compared patients with stage IIB cancer to those with stage IIA and III cancer. RESULTS: OS for patients with stage IIB cancer (n = 187) was 44.7%, and differed depending on adequacy of nodal harvest (P = .005) and whether pathological or clinical/mixed evidence was used to derive stage (P = .013). Pathologically-staged patients with stage IIB cancer who had adequate nodal harvest had marginally improved OS compared to pathologically-staged patients who had inadequate nodal harvest (P = .07), and improved survival compared to patients with clinical/mixed stage (P = .004). Pathologically-staged patients with stage IIB cancer with adequate nodal harvest demonstrated similar 5-year OS to those with stage IIA and III cancer (P = .52 and P = .25, respectively). Cox proportional hazards models supported these findings. CONCLUSIONS: The inclusion of clinical/mixed evidence into staging classification and, perhaps to a lesser extent, the adequacy of nodal harvest appear to contribute to the observed worse survival for patients with stage IIB versus stage III cancer.

A team approach to improving colorectal cancer services using administrative health data.

BACKGROUND: Colorectal cancer (CRC) is the third most commonly diagnosed cancer in Canada and accounts for 11.9% of all cancer-related mortality. Fortunately, previous studies have provided evidence of improved outcomes from access to timely and appropriate health services along the disease trajectory in CRC. As a result, the CIHR/CCNS Team in Access to Colorectal Cancer Services in Nova Scotia (Team ACCESS) was created to build colorectal cancer (CRC) research capacity in Nova Scotia (NS) and to study access to and quality of CRC services along the entire continuum of cancer care. OBJECTIVES: The objectives of this paper are to: 1) provide a detailed description of the methodologies employed across the various studies being conducted by Team ACCESS; 2) demonstrate how administrative health data can be used to evaluate access and quality in CRC services; and 3) provide an example of an interdisciplinary team approach to addressing health service delivery issues. METHODS: All patients diagnosed with CRC in NS between 2001 and 2005 were identified through the Nova Scotia Cancer Registry (NSCR) and staged using the Collaborative Stage Data Collection System. Using administrative databases that were linked at the patient level, Team ACCESS created a retrospective longitudinal cohort with comprehensive demographic, clinical, and healthcare utilization data. These data were used to examine access to and quality of CRC services in NS, as well as factors affecting access to and quality of care, at various transition points along the continuum of care. Team ACCESS has also implemented integrated knowledge translation strategies targeting policy- and decision- makers. DISCUSSION: The development of Team ACCESS represents a unique approach to CRC research. We anticipate that the skills, tools, and knowledge generated from our work will also advance the study of other cancer disease sites in NS. Given the increasing prevalence of cancer, and with national and provincial funding agencies promoting collaborative research through increased funding for research team development, the work carried out by Team ACCESS is important in the Canadian context and exemplifies how a team approach is essential to comprehensively addressing issues surrounding not only cancer, but other chronic diseases in Canada.

A population-based case-control study of occupational exposure to acids and the risk of lung cancer: evidence for specificity of association.

Occupational exposure to strong inorganic acid mists containing sulfuric acid has been recognized as a carcinogen (Group 1) since 1992. An augmented, secondary data analysis of a population-based case-control study of lung cancer was conducted to assess lung cancer-specific risks using 772 lung cancer cases diagnosed between 1981 and 1985. Individually matched controls--on age, gender, and borough of residence--were identified. Lifetime exposure to 10 acidic agents, including strong inorganic acids and some gases, was assessed from complete lifetime occupational histories in terms of concentration, frequency, and reliability of the various exposure assessments. Smoking-adjusted odds ratios and 95% confidence intervals were determined for overall and histology-categorized lung cancers using conditional logistic regression. No excess risk for overall lung cancer was associated with any of the acids, and effect modification by gender could not be identified. The absence of an acid lung cancer effect reinforces more recent toxicological data that suggest specificity to the larynx.

Survivin and COX-2 expression in male breast carcinoma.

Male breast carcinoma (Male BC) is a distinct biological subtype of breast cancer. We previously reported an association between 5-year overall survival and strong intratumoral aromatase (ITA) expression in Male BC. In this study, we investigate survivin and COX-2 expression and their relationship to ITA. Clinical data were abstracted for all Male BC patients diagnosed between 1985 and 2005 in Nova Scotia, Canada. Archival tissues were retrieved for tissue microarray (TMA) and immunohistochemistry (IHC). Of 54 Male BCs identified, 39 cases had tissue available for IHC. Survivin expression was noted in 27 cases (69%); 12 nuclear and 26 cytoplasmic while strong COX-2 expression was observed in 14 cases (36%). Cytoplasmic survivin and COX-2 expressions were positively associated with ITA expression. However, survivin and COX-2 expression were not predictive of survival. Additional studies are needed to further elucidate the correlation between cytoplasmic survivin, COX-2 and ITA expression in Male BC considering their potential therapeutic implications.

Relationship of time since childbirth and other pregnancy factors to premenopausal breast cancer prognosis.

OBJECTIVE: To investigate the influence of time since childbirth and other pregnancy factors on the prognosis of premenopausal breast cancer. METHODS: Women who delivered an infant in Nova Scotia, Canada, between 1980 and 2001 were identified from a provincial perinatal database and linked to the Nova Scotia Cancer Registry to determine primary breast cancer diagnoses among women aged younger than 50 years. Relative risks and Cox proportional hazards ratios were calculated to quantify the relationship of time from childbirth to diagnosis and other pregnancy factors to the extent of disease at diagnosis and on survival after breast cancer diagnosis. RESULTS: Of the 123,323 women who delivered an infant during the study period, 716 women were diagnosed with invasive breast cancer. Women with less than 5 years between their last delivery and diagnosis were more likely to be diagnosed with later-stage disease and had poorer survival even after adjusting for stage of disease (less than 2 years, adjusted hazards ratio 2.1, 95% confidence interval 1.2-3.9; 2-4 years, hazards ratio 1.6, 95% confidence interval 0.9-2.8) compared with women with 5 years or more. For every 13 women with less than 2 years between delivery and diagnosis, one excess death will occur, compared with women with 5 or more years between delivery and diagnosis. CONCLUSION: A time interval of less than 2 years (and 2-4 years) between childbirth and breast cancer diagnosis worsens the prognosis in a dose-response fashion. Clinicians should be aware of these findings when examining women in the first 5 years after a delivery. LEVEL OF EVIDENCE: II.

End-of-life care for nursing home residents dying from cancer in Nova Scotia, Canada, 2000-2003.

INTRODUCTION: With our population aging, an increasing proportion of cancer deaths will occur in nursing homes, yet little is known about their end-of-life care. This paper identifies associations between residing in a nursing home and end-of-life palliative cancer care, controlling for demographic factors. METHODS: For this population-based study, a data file was created by linking individual-level data from the Nova Scotia Cancer Centre Oncology Patient Information System, Vital Statistics, and the Halifax and Cape Breton Palliative Care Programs for all persons 65 years and over dying of cancer from 2000 to 2003. Multivariate logistic regression was used to compare nursing home residents to nonresidents. RESULTS: Among the 7,587 subjects, 1,008 (13.3%) were nursing home residents. Nursing home residents were more likely to be female [adjusted odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.7], older (for > or = 90 vs 65-69 years OR 5.4, CI 4.1-7.0), rural (OR 1.5, CI 1.2-1.8), have only a death certificate cancer diagnosis (OR 4.2, CI 2.8-6.3), and die out of hospital (OR 8.5, CI 7.2-10.0). Nursing home residents were less likely to receive palliative radiation (OR 0.6, CI 0.4-0.7), medical oncology consultation (OR 0.2, CI 0.1-0.4), and palliative care program enrollment (Halifax OR 0.2, CI 0.2-0.3; Cape Breton OR 0.4, CI 0.3-0.7). CONCLUSION: Demographic characteristics and end-of-life services differ between those residing and those not residing in nursing homes. These inequalities may or may not reflect inequities in access to quality end-of-life care.

Clinical and pathological correlations in male breast cancer: intratumoral aromatase expression via tissue microarray.

BACKGROUND: Male breast cancer (MBC) commonly expresses hormone receptors and there is anecdotal evidence of disease responsivity to aromatase inhibitors in the metastatic setting. Our objectives were to: (i) assess clinical-pathologic characteristics in a consecutive cohort of MBC (ii) evaluate intratumoral aromatase (ITA) expression via tissue microarray (TMA) and (iii) assess the prognostic impact of ITA METHODS: A retrospective review was conducted to identify all cases of MBC seen at the Nova Scotia Cancer Center between 1985 and 2005. Specimens were reviewed for standard pathologic characteristics and tumor blocks were incorporated into three TMA's (four 1 mm cores per tumor). Immunohistochemistry (IHC) for ER, PR, Her2-neu and ITA was performed blinded to clinical outcomes. ITA staining intensity was compared to control, benign hepatic tissue and if greater than or equal to liver was scored positive and if less than liver was scored negative. The log-rank test was used for survival comparisons and Kaplan-Meyer curves were used to estimate 3- and 5-year progression-free and overall survival probabilities. RESULTS: Fifty-four cases were identified with a median age of 64 (31-85 years). Median tumor size was 2.6 cm (0.3-8.0 cm) and 22(41%) had nodal metastases. Forty-five cases had tissue available for IHC. Of these, 40 (89%) were ER and 33 (73%) were PR positive. Her2-neu was overexpressed in four cases (10%) and 12 (27%) were positive for ITA expression. ITA positive tumors were less likely to be grade 3, have lymphovascular invasion or nodal metastases and were more likely to be of favorable histology compared to ITA negative tumors. In univariate analysis strong (versus weak) ITA expression was associated with improved 5 year overall (92% vs. 49%, P = 0.038) but not progression-free (82% vs. 76% P = 0.44) survival rates. CONCLUSIONS: Tumors with strong ITA expression may have a less aggressive phenotype compared to those with negative/weak ITA expression. Further investigation of ITA as a relevant prognostic factor as well as a potential therapeutic target in MBC is warranted.

Comparison of elapsed times from breast cancer detection to first adjuvant therapy in Nova Scotia in 1999/2000 and 2003/04.

BACKGROUND: Waiting times for cancer care continue to be an important issue for Canadians. We evaluated 2 cohorts of breast cancer patients to compare changes in elapsed times to care, to determine the proportion of patients who received their postoperative oncology consultation within the recommended time and to examine elapsed times between date of surgery and start of first adjuvant therapy. METHODS: We conducted a retrospective chart review of all women with surgically treated breast cancer who were referred to a provincial cancer centre for adjuvant therapy. The first cohort comprised women referred between Sept. 1, 1999, and Sept. 1, 2000 (n = 342), and the second cohort comprised women referred between Sept. 1, 2003, and Sept. 1, 2004 (n = 295). A general linear model with a stepwise selection was used to identify dominant factors that influenced elapsed times; covariates included cohort period, age at diagnosis, place of residence, disease stage, type of surgery, type of adjuvant therapy, distance to cancer centre, median household income and mean education level. RESULTS: The overall median time from disease detection to the start of first adjuvant therapy for the combined cohorts was 96 days (quartiles 76, 122); this interval was longer for patients in the second cohort (90 v. 102 days, p < 0.001). For the combined cohorts, significantly more patients saw a radiation oncologist within the recommended time from date of surgery than did patients referred to a medical oncologist (82.7% v. 51.7%; p < 0.001). Patients who received adjuvant radiation therapy as their first adjuvant treatment waited longer from the date of definitive surgery to the start of treatment than did patients who received chemotherapy or hormonal treatment (77 v. 48 or 42 days; p < 0.001). INTERPRETATION: The median elapsed time from the detection of breast cancer to the start of first adjuvant therapy was longer in the second cohort (referred in 2003/04) than in the first cohort (referred in 1999/2000). The proportion of patients whose first oncology consultation was within the recommended timeframe varied significantly according to type of oncology specialist, favouring radiation oncology. Despite this difference in access, patients whose first adjuvant therapy was systemic therapy experienced significantly shorter elapsed times from surgery to the start of adjuvant therapy than did patients whose first adjuvant therapy was radiation therapy.

Towards using administrative databases to measure population-based indicators of quality of end-of-life care: testing the methodology.

This study is concerned with methods to measure population-based indicators of quality end-of-life care. Using a retrospective cohort approach, we assessed the feasibility, validity and reliability of using administrative databases to measure quality indicators of end-of-life care in two Canadian provinces. The study sample consisted of all females who died of breast cancer between 1 January 1998 and 31 December 2002, in Nova Scotia or Ontario, Canada. From an initial list of 19 quality indicators selected from the literature, seven were determined to be fully measurable in both provinces. An additional seven indicators in one province and three in the other province were partially measurable. Tests comparing administrative and chart data show a high level of agreement with inter-rater reliability, confirming consistency in the chart abstraction process. Using administrative data is an efficient, population-based method to monitor quality of care which can compliment other methods, such as qualitative and purposefully collected clinical data.

The epidemiology of cutaneous malignant melanoma in Nova Scotia.

BACKGROUND: Since 1993, the annual increase in cutaneous malignant melanoma (MM) incidence has been one of the highest for all cancers registered in Canada, with the leading rate in Nova Scotia (NS). The purpose of the present study was to document the pathological and epidemiological data on MM cases found in NS. PATIENTS AND METHODS: All MM cases identified by the Nova Scotia Cancer Registry from January 1998 to December 2002 were evaluated. The five-year survival outlook, by major prognostic factors, was also determined. In addition, the annual incidence and mortality rates from 1972 to 2002 were computed. RESULTS: Between 1998 and 2002, 925 MM cases were recorded. The age-standardized incidence rate for males and females in this period was 19.2 and 16.1 per 100,000 respectively. Men 65 years of age or older had the highest age-specific rate. The most common MM had a Breslow's depth of less than 1.0 mm (61.9%) and was Clark's level II (34.9%). There was no significant seasonal variation noted in the time of diagnosis. Survival analyses indicated that sex, age, tumour location and thickness were significant independent predictors. Despite the increase in incidence, there have only been modest changes in the annual mortality rate. CONCLUSION: The incidence of MM in NS increases with age, and is nearly double for men 65 years of age or older, compared with women in the same age group. Thin melanomas on the extremities of young females have the best prognosis in NS, which is similar to other parts of the world. Incidence appears to be unrelated to season. Public health interventions are necessary to reduce the burden of this disease.

Family physician visits and early recognition of melanoma.

BACKGROUND: Malignant melanoma is a deadly skin cancer with a rapidly-increasing incidence, mortality and public health burden. Thin melanomas are easily treated with good prognosis, while the thicker lesions have relatively poor survival. To broaden strategies for early recognition of melanoma, we investigated the relationship between primary care service and melanoma thickness at diagnosis. METHODS: All 714 patients diagnosed with a primary malignant melanoma between January 1995 and December 1999 in Nova Scotia were included in the present study and linked to provincial physician billing databases to reveal the patients' use of family physician services prior to the diagnosis of melanoma. We examined the importance of physician use of services for tumour thickness using logistic regression while adjusting for potential confounders. Tumour thickness was dichotomized to thin and thick using 0.75 mm as a cutoff. RESULTS: Patients who regularly visited their family physician (2 to 5 times during a two-year interval prior to diagnosis) were 66% (95% CI, 31-84) less likely to be diagnosed with thick melanoma as compared to patients who consulted their family physician less or not at all. Progression to thick tumours could have been reduced by 11.70% (95% CI, -1.33-25.77) if all patients had consulted their family physician at least once a year. DISCUSSION: Increased awareness of the need for regular medical check-ups could reduce the public health burden of melanoma.

Radiotherapy wait times for patients with a diagnosis of invasive cancer, 1992-2000.

PURPOSE: To study the wait times for cancer patients from the time of diagnosis to consultation with a radiation oncologist (T1), from consultation to radiotherapy (T2) and from diagnosis to radiotherapy (T3) in the context of treatment practices and measurement issues. METHODS: From 1992 to 2000, we studied 6585 Nova Scotian patients over the age of 24 years with a diagnosis of breast, lung, colorectal or prostate cancer who received radiotherapy within 1 year of diagnosis. Multivariate analyses examined associations between wait time and diagnosis year, age, sex, median household income (MHI), distance to the cancer centre and extent of disease. Univariate findings reported are median times and interquartile ranges. RESULTS: The T3 was 16 weeks for breast and colorectal cancer, 6 weeks for lung cancer and 18 weeks for prostate cancer. The greatest T1 decrease over time was for prostate cancer: 13-8 weeks (hazards ratio [HR] = 1.07, 95% confidence interval [CI] = 1.05-1.10). The T2 increased for all cancers, and the T3 increased from 5 to 7 weeks for lung cancer, from 17 to 22 weeks for prostate cancer and from 10 to 18 weeks for breast cancer, with no change for colorectal cancer. The T3 decreased by age for breast cancer (HR = 1.12, CI = 1.10-1.14) and prostate cancer (HR = 1.07, CI = 1.02-1.11), showed no consistent association with distance to a cancer centre and varied by extent of disease. Patients with localized lung disease had a longer T3 than those with distant disease, but the opposite results were noted for patients with breast cancer. The T3 was greater for regional than distant disease in lung and breast cancers. Sex and MHI had no effect. CONCLUSION: Wait times reflected clinical practice, and there were no adverse patterns related to age, sex, income or distance from a cancer centre.