Determinants of delays in treatment initiation in children and adolescents diagnosed with leukemia or lymphoma in Canada.

Minimizing delays that may occur along the cancer care pathway requires an understanding of their determinants. Few studies on childhood cancers have been published on the factors that influence the time it takes for patients to get a first medical consultation (patient delay) and treatment (health care system [HCS] delay) once cancer symptoms have been recognized. Our objective was to assess factors related to disease, patient and HCS on patient and HCS delay for children and adolescents with leukemias and lymphomas in Canada. A prospective cohort study was conducted on subjects enrolled in the Treatment and Outcomes Surveillance program of the Canadian Childhood Cancer Surveillance and Control Program, a national surveillance program. We studied 963 leukemia and 397 lymphoma patients who were less than 19-years old at diagnosis in 1995-2000. Logistic regression models were used to measure the associations between candidate predictive factors and delays. Age was positively associated with patient delay for both leukemia and lymphoma patients, but not with HCS delay. Patients first seen in a hospital emergency room had a lower risk of HCS delay than patients first seen by a general practitioner. Cancer subtype was associated with patient delay for leukemia patients, and HCS delay for lymphoma patients. Longer patient delay was associated with a lower risk of long HCS delay for both cancers. Factors related to the patients, their disease and the HCS may exert different influences on varying segments of the care pathway of leukemia and lymphoma patients.

Delays in diagnosis and treatment among children and adolescents with cancer in Canada.

BACKGROUND: Few studies have investigated delays in diagnosis and treatment among children and adolescents with cancer, especially from the perspective of an entire country. Detailed understanding of delays along the continuum of cancer patient care is important in order to establish appropriate benchmarks for timely oncological care. Our objective was to characterise the different components of delay in 2,896 Canadian children and adolescents (aged 0-19 years) with cancer that were enrolled in the Treatment and Outcome Surveillance component of the Canadian Childhood Cancer Surveillance and Control Program from 1995 to 2000. PROCEDURE: We examined median and standardised means concerning the distribution of delay times across categories of pertinent variables and over time. The word "delay" was used simply to represent a time interval, measured in days, without implying whether this interval exceeded a particular threshold of clinical acceptability. RESULTS: The median times (and inter-quartile ranges) for patient, diagnosis and healthcare system delays for all cancers were 9 (1-31), 30 (13-69) and 12 (4-35) days, respectively. The median total delay was 34 (16-76) days. CONCLUSIONS: Patient and referral delays were the longest time segments influencing timely diagnosis. Differences in delays were observed across age groups, cancer types and geographical regions. There was a significant trend for decreasing delays to diagnosis and treatment.

Childhood and adolescent cancer survival: a period analysis of data from the Canadian Cancer Registry.

This study provides up-to-date estimates of childhood and adolescent (ages 0-19) cancer survival in Canada using data from the Canadian Cancer Registry (CCR). Cases were classified according to the third edition of the International Classification of Childhood Cancer classification scheme. Follow-up for vital status was determined through record linkage to the Canadian Mortality Data Base, and from information reported by provincial/territorial cancer registries. Observed survival proportions (OSPs) were based on period analysis (1999-2003). The 1-, 3- and 5-year OSPs for all cancers combined were 92%, 85% and 82%, respectively. Among diagnostic groups, five-year survival estimates were highest for retinoblastoma (99%), carcinomas and other malignant epithelial neoplasms and malignant melanomas (91%) and for renal tumours (91%); they were poorest for hepatic tumours (68%) and for malignant bone tumours (68%). Survival for childhood and adolescent cancer in Canada has improved substantially since last reported.

Impact of age and diagnosis on waiting times between important healthcare events among children 0 to 19 years cared for in pediatric units: the Canadian Childhood Cancer Surveillance and Control Program.

BACKGROUND: The objectives were to describe and compare waiting times to diagnosis and treatment of children and adolescents who accessed pediatric oncology centers in Canada for healthcare, and to assess the effects and relative contributions of age, sex, and diagnosis to waiting times. METHODS: Waiting times were assessed for 2,365 children (0 to 14 y) and 375 adolescents (15 to 19 y) diagnosed with cancer between 1995 and 2000 inclusive and followed by the Treatment and Outcome Surveillance system of the Canadian Children's Cancer Surveillance and Control Program. Differences were assessed using the chi2 test, Fisher exact test, and Wilcoxon test statistic. RESULTS: Median waiting times between first assessment by treating oncologist or surgeon and definitive diagnostic procedure, and the subsequent interval to first therapeutic event, were 2 days each. Significant variation existed in both periods when stratified by age and diagnosis but not sex. The most significant differences between age groups were eliminated when stratified by diagnosis. INTERPRETATION: This analysis suggests that once they enter the healthcare system, children and adolescents treated in pediatric centers in Canada experience short waiting times to key diagnostic and treatment events. Differences in wait times between the 2 age groups are not clinically significant and can be attributed to the differences in the types of cancer experienced by adolescents compared with children.

Use of health care services by survivors of childhood and adolescent cancer in Canada.

BACKGROUND: The number of survivors of childhood cancer in Canada is growing. The large majority of survivors experience at least 1 adverse late effect of their cancer therapy, which often becomes more severe and clinically apparent with time. The extent of survivors' use of health services in Canada is unknown, although coordinated, continuous, long-term follow-up care has been recommended by numerous investigators. METHODS: Information on reported consultations with healthcare practitioners in the past year was obtained from 2152 survivors of child and adolescent cancer (mean age at diagnosis, 7.3; range, 0-19) and 2432 age- and sex-matched population-based controls through a mailed questionnaire. RESULTS: Similar proportions of survivors (71%) and controls (73%) reported consulting a general practitioner in the past year. Survivors were more likely than controls to consult with any specialist (68% vs. 46%), including an oncologist (29% vs. 0.3%). Survivors' consultations with oncologists increased with concurrent physical health problems (adjusted odds ratio [OR(adj)], 1.7, 95% confidence interval [CI], 1.4-2.1), history of high risk therapy (OR(adj), 2.4, 95% CI, 1.9-2.9), and multiple treatment series (OR(adj), 2.2, 95% CI, 1.7- 3.0), but decreased with time since diagnosis (OR(adj), 0.3, 95% CI, 0.2-0.4). CONCLUSION: Although most survivors reported consulting with at least 1 healthcare practitioner in the past year, the large majority did not report consulting an oncologist and thus may not be receiving optimal follow-up care. Moreover, consultations decreased with time since diagnosis, exactly when risk of late effects increases. This limited preventive care could have major implications on survivors' long-term health.

The relationship between childhood adverse experiences and disability due to physical health problems in a community sample of women.

The goal of this study was to examine the association of physical and sexual abuse in childhood, poverty, parental substance abuse problems and parental psychiatric problems with disability due to physical health problems in a community sample of women. We included 4,243 women aged 15-64 years from the Ontario Mental Health Supplement in the analysis. The associations were tested by multiple logistic regression. Ten percent of women had a disability due to physical health problems. Among women with a disability, approximately 40% had been abused while growing up. After controlling for income and age, disability showed the strongest association with childhood physical abuse, parental education less than high school and parental psychiatric disorder. The association with child sexual abuse was not significant. Given the high correlation between abuse and disability due to physical health problems, it is important to investigate approaches to identify women who are at increased risk of subsequent impairment.

Waiting times for cancer care in Canadian children: impact of distance, clinical, and demographic factors.

BACKGROUND: The objective of this study was to evaluate the impact of distance from residence to pediatric oncology centers on waiting times to diagnostic assessment and treatment in Canadian children with cancer. PROCEDURE: Two thousand three hundred sixteen children (< 15 years of age) captured by the Canadian Childhood Cancer Surveillance and Control Program's (CCCSCP) Treatment and Outcome Surveillance (TOS) system were included in the analysis. The number of days between onset of symptoms and first anti-cancer therapy was compared for those living less than 25, 25-99, and more than 100 kilometers from their treating center. For each time period, the adjusted odds of falling into the longest time quartiles were estimated using logistic regression analysis. RESULTS: Thirty-four percent (n = 786) of children lived more than 100 kilometers from their treating center. There were no significant differences in age at diagnosis (P = 0.33), sex (P = 0.68), or ICCC diagnosis (P = 0.02) by distance from center, though there was a significant difference in region of residence (P < 0.01) and the first health care professional contacted (P < 0.01). Except for waiting time from first health care contact to first assessment by treating oncologist which increased with increasing distance (P < 0.01), there were no significant differences in waiting times by distance. When adjusted for important demographic and clinical characteristics, distance to center did not affect the odds of waiting longer for any event. CONCLUSIONS: Distance to treating center had no significant impact on waiting times for important diagnostic and treatment events, when adjusted for age at diagnosis, diagnosis, region, and first health care professional seen.

The relation between childhood adverse experiences and disability due to mental health problems in a community sample of women.

OBJECTIVE: The objective of this study was to examine the association between selected childhood adverse experiences and disability due to mental health problems in a community sample of women. Variables of interest included childhood physical and sexual abuse, parental psychiatric and substance abuse history, and sociodemographic factors. METHOD: Girls and women (aged 15 to 64 years) from a province-wide community sample (n = 4239) were asked about disability and most childhood adverse experiences through interview; a self-administered questionnaire inquired about child abuse. Logistic regression (crude and adjusted odds ratios) was used to test the associations between childhood adversity and disability due to mental health problems. RESULTS: Approximately 3% of the women had a disability due to mental health problems. Among women with a disability, about 50% had been abused while growing up. After controlling for income and age, we found that disability showed the strongest association with childhood sexual abuse, physical abuse, and parental psychiatric disorder. CONCLUSION: Disability due to mental health problems was experienced by women with and without exposure to abuse in childhood. However, childhood sexual abuse and physical abuse were important correlates of disability. Disability creates suffering and loss for the individual and society; this issue merits more research in relation to child abuse.