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1.
Lung Cancer ; 142: 80-89, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32120228

RESUMO

OBJECTIVES: Lung cancer is associated with significant disease- and treatment-related morbidity. The Edmonton Symptom Assessment System (ESAS) is a tool developed to elicit patients' own assessment of the severity of common cancer-associated symptoms. The objective of this study was to examine symptom severity in the 12 months following diagnosis of lung cancer, and to identify predictors of high symptom burden. MATERIALS AND METHODS: This was a retrospective population-based cohort study, including patients with stage I-III lung cancer diagnosed between 2007-2016, and who had symptom screening in the 12 months following diagnosis. The proportion of patients reporting severe symptoms (ESAS ≥ 7) in the year following diagnosis was plotted over time. Multivariable regression models were constructed to identify factors associated with severe symptoms. RESULTS: 69,440 unique symptom assessments were reported by 11,075 lung cancer patients. Tiredness was the most prevalent severe symptom (47.3 %), followed by shortness of breath (39.4 %) and poor wellbeing (36.5 %) among all disease stages. Patients diagnosed with higher stage disease reported more severe symptoms, but symptom trajectories were similar for all stages in the year following diagnosis. Disease stage (RR 1.10-2.01), comorbidity burden (RR 1.17-1.51), degree of socioeconomic marginalization (RR1.15-1.45), and female sex (RR 1.15-1.50) were associated with reporting severe symptoms in the year following diagnosis. CONCLUSION: Severe physical and psychological symptoms persist throughout the first year following lung cancer diagnosis, regardless of disease stage. Those at risk of experiencing high symptom burden may benefit from targeted supportive care interventions, including psychosocial support aimed at improving health-related quality of life.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32088358

RESUMO

CONTEXT: Prior work using symptom burden to predict emergency department (ED) visits among patients with cancer has used traditional statistical methods such as logistic regression (LR). Machine learning approaches for prediction, such as artificial neural networks (ANNs), are gaining attention but are yet to be commonly applied in practice. OBJECTIVES: We will compare an artificial neural network with logistic regression for predicting ED visit risk among patients with cancer. METHODS: This was a population-based study of patients diagnosed with cancer between 2007 and 2015 in Ontario, Canada. After splitting the cohort into training and test sets, an ANN model and a LR model were developed on the training cohort to predict the risk of an ED visit within seven days after an assessment of symptom burden. The predictive performance of each risk model was assessed on the test cohort and compared with respect to area under the curve and calibration. RESULTS: The training cohort consisted of 170,092 patients undergoing 1,015,125 symptom assessments, and the remaining 42,523 patients undergoing 252,169 symptom assessments were set aside as the test cohort. Both models performed similarly with respect to specificity (ANN 67.0%; LR 67.3%) and accuracy (ANN 67.1%; LR 67.2%), and only minor improvement was found with respect to sensitivity (ANN 68.9%; LR 67.1%), discrimination (ANN 74.3%; LR 73.7%), and calibration under the ANN model compared with the LR model. The most notable improvement in calibration was found among patients in the highest ED visit risk percentile. CONCLUSION: Although both models were similar in predictive performance using our data, ANNs have an important role in prediction because of their flexible structure and data-driven distribution-free benefits and should thus be considered as a potential modeling approach when developing a prediction tool.

3.
Eur J Cancer Prev ; 2020 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-32032155

RESUMO

An infectious trigger for childhood acute lymphoblastic leukemia is hypothesized and we assessed the association between the rate, type, and critical exposure period for infections and the development of acute lymphoblastic leukemia. We conducted a matched case-control study using administrative databases to evaluate the association between the rate of infections and childhood acute lymphoblastic leukemia diagnosed between the ages of 2-14 years from Ontario, Canada and we used a validated approach to measure infections. In 1600 cases of acute lymphoblastic leukemia, and 16 000 matched cancer-free controls aged 2-14 years, having >2 infections/year increased the odds of childhood acute lymphoblastic leukemia by 43% (odds ratio = 1.43, 95% confidence interval 1.13-1.81) compared to children with ≤0.25 infections/year. Having >2 respiratory infections/year increased odds of acute lymphoblastic leukemia by 28% (odds ratio =1.28, 95% confidence interval 1.05-1.57) compared to children with ≤0.25 respiratory infections/year. Having an invasive infection increased the odds of acute lymphoblastic leukemia by 72% (odds ratio =1.72, 95% confidence interval 1.31-2.26). Having an infection between the age of 1-1.5 years increased the odds of acute lymphoblastic leukemia by 20% (odds ratio = 1.20, 95% confidence interval 1.04-1.39). Having more infections increased the odds of developing childhood acute lymphoblastic leukemia and having an infection between the ages of 1-1.5 years increased the odds of childhood acute lymphoblastic leukemia.

4.
Support Care Cancer ; 2020 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-32020357

RESUMO

BACKGROUND: The use of patient-reported outcomes (PROs) for routine cancer distress screening is endorsed globally as a quality-care standard. However, there is little research on the integration of PROs in "real-world" oncology practices using implementation science methods. The Improving Patient Experience and Health Outcome Collaborative (iPEHOC) intervention was established at multisite disease clinics to facilitate the use of PRO data by clinicians for precision symptom care. The aim of this study was to examine if patients exposed to the intervention differed in their healthcare utilization compared with contemporaneous controls in the same time frame. METHODS: We used a PRE- and DURING-intervention population cohort comparison study design to estimate the effects of the iPEHOC intervention on the difference in difference (DID) for relative rates (RR) for emergency department (ED) visits, hospitalizations, psychosocial oncology (PSO), palliative care visits, and prescription rates for opioids and antidepressants compared with controls. RESULTS: A small significantly lower Difference in Difference (DID) (- 0.223) in the RR for ED visits was noted for the intervention compared with controls over time (0.947, CI 0.900-0.996); and a DID (- 0.0329) for patients meeting ESAS symptom thresholds (0.927, CI 0.869-0.990). A lower DID in palliative care visits (- 0.0097), psychosocial oncology visits (- 0.0248), antidepressant prescriptions (- 0.0260) and an increase in opioid prescriptions (0.0456) in the exposed population compared with controls was also noted. A similar pattern was shown for ESAS as a secondary exposure variable. CONCLUSION: Facilitating uptake of PROs data may impact healthcare utilization but requires examination in larger scale "real-world" trials.

5.
Diabetologia ; 2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-31993714

RESUMO

AIMS/HYPOTHESIS: Diabetes is associated with an increased incidence of colorectal cancer (CRC). There exists conflicting evidence regarding the impact of diabetes on CRC-specific mortality (herein also referred to as cancer-specific mortality). The objectives of this study were to determine whether diabetes is associated with a more advanced CRC stage at diagnosis and with higher all-cause and cancer-specific mortality. METHODS: This retrospective cohort study used linked, population-based health databases from Ontario, Canada. Among individuals diagnosed with CRC from 2007 to 2015, we compared the likelihood of presenting with later- (III or IV) vs early- (I or II) stage CRC between patients with and without diabetes adjusting for relevant covariates. We then determined the association between diabetes and all-cause and CRC-specific mortality, after adjusting for CRC stage at diagnosis and other covariates. RESULTS: Of the 44,178 individuals with CRC, 11,822 (26.7%) had diabetes. After adjustment for CRC screening and other covariates, individuals with diabetes were not more likely to present with later-stage CRC (adjusted OR 0.97, 95% CI 0.93, 1.01). Over a median follow-up of 2.63 (interquartile range [IQR] 0.97-5.10) years, diabetes was associated with higher all-cause mortality (adjusted HR 1.08, 95% CI 1.04, 1.12) but similar cancer-specific survival (adjusted HR 1.0, 95% CI 0.95, 1.06). CONCLUSIONS/INTERPRETATION: Individuals with diabetes who develop CRC are not more likely to present with a later stage of CRC and have similar cancer-specific mortality compared with those without diabetes. Diabetes was associated with higher all-cause mortality in CRC patients, indicating that greater attention to non-cancer care is needed for CRC survivors with diabetes.

6.
Med Hypotheses ; 137: 109554, 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31945656

RESUMO

Leukemia is the most common childhood cancer. While infections are a frequent and potentially severe complication while on treatment, less is known about the risk for infections following therapy completion. In this article, we propose that leukemia survivors might be at increased risk of infections following therapy completion than the general population, independently of potential confounders such as age, sex and Down syndrome. This association is conceivably due to several factors. First, therapy-induced immune dysfunction of both the humoral and cellular compartments appears to last for several years following anti-cancer therapy and after hematopoietic stem cell transplantation. Second, clinical and epidemiological research has shown leukemia survivors are disproportionally affected by comorbidities related to leukemia treatment and its complications, such as diabetes and obesity, which may induce secondary immunodeficiency and infections. Last, differences in health-related behaviors between leukemia survivors and the general population (such as re-vaccination practices) may affect the baseline risk of infections. Although under-represented in the epidemiological literature as a possible late effect of childhood leukemia and its treatment, it is plausible that leukemia survivors are at increased risk of infections for several years when compared to the general population and their siblings. Further research is needed to empirically test these hypotheses.

7.
J Palliat Med ; 2020 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-31944866

RESUMO

Background: Early referral of cancer patients for palliative care significantly improves the quality of life. It is not clear which patients can benefit from an early referral, and when the referral should occur. A Delphi Panel study proposed 11 major criteria for an outpatient palliative care referral. Objective: To operationalize major Delphi criteria in a cohort of lung cancer patients, using a prospective approach, by linking health administrative data. Design: Population-based observational cohort study. Setting/Subjects: The study population comprised 38,851 cases of lung cancer in the Ontario Cancer Registry, diagnosed from January 1, 2012, to December 31, 2016. Measurements: We operationalized 6 of the 11 major criteria (4 diagnosis or prognosis based and 2 symptom based). Patients were considered eligible (index event) for palliative care if they qualified for any criterion. Among eligible patients, we identified those who received palliative care. Results: Twenty-eight thousand one hundred sixty-four patients were eligible for palliative care by qualifying for either the diagnosis- or prognosis-based criteria (n = 21,036, 76.5%), or for symptom-based criteria (n = 7128, 23.5%). A total of 23,199 (82.4%) patients received palliative care. The median time from palliative care eligibility to the receipt of first palliative care or death or maximum study follow-up was 56 days (range = 17-348). Conclusions: We operationalized six major criteria that identified the majority of lung cancer patients who were eligible for palliative care. Most eligible patients received the palliative care before death. Future research is warranted to test these criteria in other cancer populations.

8.
J Adolesc Young Adult Oncol ; 9(1): 12-22, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31674879

RESUMO

Although a cancer diagnosis during the adolescent and young adult (AYA) years is a traumatic event, and psychiatric disorders generally manifest during the AYA period, the impact of a cancer diagnosis on long-term mental health outcomes in this population is not well characterized. We conducted a systematic review and meta-analysis to determine if survivors of AYA cancers are more likely to develop psychiatric disorders. A systematic literature search of five databases, MEDLINE, CINAHL, Web of Science, EMBASE, and PsycINFO, was conducted from their inception to November 2018. The outcome measures were psychiatric disorders as per the Diagnostic Statistical Manual criteria, or psychiatric medication use. Study eligibility, appraisal, and data abstraction were independently conducted by two reviewers. Of 7934 total studies, four met eligibility criteria for the systematic review, three of which were included in the meta-analysis. Compared to cancer-free controls, survivors were at an elevated risk of mood disorders (odds ratio [OR] 1.36; 95% CI 1.19-1.55) and anxiety disorders (OR 1.16; 95% CI 1.05-1.28), but not substance-related disorders, (OR 0.88; 95% CI 0.63-1.22). The most commonly identified risk factors were the female sex and older age at diagnosis. We found higher odds of anxiety and mood disorders in AYA-onset cancer survivors. However, few AYA-specific studies currently exist that analyze psychiatric disorders using consistent and standardized methods. Additional studies confirming these findings are warranted.

9.
J Clin Oncol ; 38(1): 51-62, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31714869

RESUMO

PURPOSE: Although a diagnosis of childhood cancer can have a profound effect on the entire family unit, its impact on the long-term mental health of family members is not well characterized. METHODS: A provincial childhood cancer registry in Ontario, Canada, was linked to birth records to identify separate population-based cohorts of mothers and siblings of children diagnosed with cancer between 1998 and 2014. The mother and sibling cohorts were matched to corresponding population controls and linked to health services data. The rate of mental health-related outpatient visits (family physician, psychiatrist) and the incidence of severe psychiatric events (psychiatric emergency department visit, psychiatric hospitalization, suicide) were compared between mothers and siblings and their controls. Possible predictors of mental health outcomes were examined, including demographics, characteristics of the cancer-affected child, and cancer treatment. RESULTS: We identified 4,773 mothers and 7,897 siblings of children diagnosed with cancer during the study period. Compared with controls, both groups experienced elevated rates of outpatient visits (mothers: rate ratio [RR], 1.4; P < .0001; siblings: RR, 1.1; P < .0001). The risk of severe psychiatric events was not increased in either cohort. Mother and sibling demographic factors associated with increased risk of adverse mental health included younger maternal age at cancer diagnosis, low socioeconomic status, and rural residence among mothers and older sibling age among siblings. Treatment-related variables pertaining to the cancer-affected child were not associated with mental health outcomes. Mental health outcomes clustered within families. CONCLUSION: Both mothers and siblings experience elevated and prolonged need for mental health-related health care as compared with the general population. Demographic risk factors predict subpopulations at highest risk. Increased psychosocial support for family members during and after cancer therapy is warranted.

10.
J Pain Symptom Manage ; 59(1): 58-66.e4, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31430522

RESUMO

CONTEXT: Understanding the magnitude and risk factors for symptom burden of patients with cancer at the end of life is critical to guiding effective patient- and system-level interventions. OBJECTIVES: We aimed to estimate the prevalence of severe patient-reported symptoms among cancer outpatients during the six months before death and to identify patient groups at a higher risk for reporting severe symptoms. METHODS: This was a retrospective cohort study of cancer decedents at regional cancer centers from 2010 to 2016. Patient-reported Edmonton Symptom Assessment System (ESAS) scores from the last six months of life were linked to administrative databases. The proportion of patients reporting severe symptom scores (≥7) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and overall well-being during the six months before death was described. Multivariable modified Poisson regression analyses were used to identify risk factors for reporting severe symptom scores. RESULTS: Of 39,084 cancer decedents, 22,650 had one or more symptom assessments recorded in the last six months of life, resulting in 92,757 ESAS assessments. Severe scores were highest for tiredness (56%), lack of appetite (46%), and impaired well-being (45%). The proportion of patients reporting severe symptom scores was stable before progressively increasing at three months before death. Elderly, women, patients with high comorbidity, immigrants, and living in urban areas or with high material deprivation were at increased risk of reporting severe scores. CONCLUSIONS: Despite an integrated symptom screening program, rates of severe patient-reported symptom scores before death were high for outpatients with cancer. Patient subgroups at increased risk of severe symptom burden may benefit from targeted interventions. Ongoing review of routinely collected symptom data may be used to assess the supportive care needs and guide targeted interventions at the health-system level.

11.
JAMA Surg ; 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31577348

RESUMO

Importance: Sex-based income disparities are well documented in medicine and most pronounced in surgery. These disparities are commonly attributed to differences in hours worked. One proposed solution to close the earnings gap is a fee-for-service payment system, which is theoretically free of bias. However, it is unclear whether a sex-based earnings gap persists in a fee-for-service system when earnings are measured on the basis of hours worked. Objective: To determine whether male and female surgeons have similar earnings for each hour spent operating in a fee-for-service system. Design, Setting, and Participants: This cross-sectional, population-based study used administrative databases from a fee-for-service, single-payer health system in Ontario, Canada. Surgeons who submitted claims for surgical procedures performed between January 1, 2014, and December 31, 2016, were included. Data analysis took place from February 2018 to December 2018. Exposures: Surgeon sex. Main Outcomes and Measures: This study compared earnings per hour spent operating between male and female surgeons and earnings stratified by surgical specialty in a matched analysis. We explored factors potentially associated with earnings disparities, including differences in procedure duration and type between male and female surgeons and hourly earnings for procedures performed primarily on male vs female patients. Results: We identified 1 508 471 surgical procedures claimed by 3275 surgeons. Female surgeons had practiced fewer years than male surgeons (median [interquartile range], 8.4 [2.9-16.6] vs 14.7 [5.9-25.7] years; P < .001), and the largest proportion of female surgeons practiced gynecology (400 of 819 female surgeons [48.8%]). Hourly earnings for female surgeons were 24% lower than for male surgeons (relative rate, 0.76 [95% CI, 0.74-0.79]; P < .001). This disparity persisted after adjusting for specialty and in matched analysis stratified by specialty, with the largest mean differences in cardiothoracic surgery (in US dollars: $59.64/hour) and orthopedic surgery ($55.45/hour). There were no differences in time taken by male and female surgeons to perform common procedures; however, female surgeons more commonly performed procedures with the lowest hourly earnings. Conclusions and Relevance: Even within a fee-for-service system, male and female surgeons do not have equal earnings for equal hours spent working, suggesting that the opportunity to perform the most lucrative surgical procedures is greater for men than women. These findings call for a comprehensive analysis of drivers of sex-based earning disparities, including referral patterns, and highlight the need for systems-level solutions.

12.
Breast J ; 2019 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-31515910

RESUMO

The use of hypofractionated radiotherapy (HFRT) in patients with breast cancer and ductal carcinoma in situ (DCIS) in Ontario, Canada, from 2009 to 2015 was reported. A retrospective cohort study was conducted using data from the Institute for Clinical Evaluative Sciences (ICES). Patients with a breast cancer or DCIS diagnosis between 2009 and 2015 who received adjuvant breast or chest wall radiation were included. Trends in HFRT use (≤16 fractions) and factors associated with HFRT use in a multivariable logistic regression model with physician-level random effect were reported. The approximate number of hours that could be saved if all patients were to receive HFRT was calculated. A total of 42 072 patients were included. All included characteristics were significantly associated with HFRT use. Hypofractionated radiotherapy use in patients with breast cancer and DCIS increased to around 75% in 2015. In stage I/II patients with mastectomy and chest wall radiation, HFRT use increased to 40% in 2015. Hypofractionated radiotherapy use in patients with regional nodal radiation or reconstruction has increased but remains under 20%. For breast cancer patients with breast-conserving surgery (BCS) and breast radiation, 56 265 visits corresponding to 7200 hours of treatment or 3500 additional HFRT courses could have been saved. In conclusion, HFRT use in Ontario has increased in all patient populations but is nonuniform among physicians and institutions. Use of HFRT in chest wall and regional nodal radiation remains relatively lower than in breast cancer and DCIS patients with BCS.

13.
Breast Cancer Res Treat ; 178(1): 221-230, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31368035

RESUMO

BACKGROUND: A better understanding underlying radiation (RT) response after breast-conserving surgery (BCS) is needed to mitigate over-treatment of DCIS. The hazard ratio (HR) measures the effect of RT but assumes the effect is constant over time. We examined the hazard function adjusted for adherence to surveillance mammography to examine variations in LR risk and the effect of RT over time. METHODS: Crude hazard estimates for the development of LR in a population cohort of DCIS treated by BCS ± RT were computed. Multivariable extended Cox models and hazard plots were used to examine the association between receipt of RT and risk of each outcome adjusted for baseline covariates and adherence to mammography. RESULTS: Population cohort includes 3262 women treated by BCS; 1635 received RT. Median follow-up was 13 years. LR developed in 364 women treated by BCS alone and 274 treated with RT. LR risk peaked at 2 years, declined until year 7, and then remained steady. The peak hazard of LR was associated with adverse features of DCIS. Early LR risk was attenuated in patients treated with RT but late annual risks of LR and invasive LR were similar among the two treatment groups. On multivariate analysis, RT was associated with a reduction in early LR risk (HR = 0.52, 95% CI 0.43-0.63, p < 0.0001) but did not reduce the risk of late LR (HR = 0.89, 95% CI: 0.67, 1.19, p = 0.44) (interaction, p = 0.002). CONCLUSIONS: The effect of RT is not uniform over time and greatest in the first 7 years after BCS for DCIS, which can guide future research to understand mechanisms underlying RT response and optimize future management of DCIS.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/terapia , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/terapia , Mastectomia Segmentar/métodos , Feminino , Humanos , Mamografia , Cooperação do Paciente , Vigilância da População , Modelos de Riscos Proporcionais , Radioterapia Adjuvante , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
14.
J Clin Oncol ; 37(29): 2651-2660, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31393747

RESUMO

PURPOSE: Infections are a frequent complication during childhood leukemia treatment. Little is known about the infectious risk in survivors. We compared the relative rate (RR) of infections after treatment completion between pediatric leukemia survivors and the general population. METHODS: We performed a retrospective, population-based cohort study of children diagnosed with leukemia between 1992 and 2015 in Ontario, Canada, who were alive and relapse free 30 days after treatment completion (index date). Leukemia survivors were matched 5:1 with the general population by year of birth, sex, and rural status and stratified by initial treatment, including and excluding hematopoietic stem-cell transplantation (HSCT). The primary outcome was time to infections, as identified using validated diagnostic codes from administrative databases. Individuals were censored at the earliest of death, first relapse, loss to follow-up, or end of study. RESULTS: A total of 2,204 leukemia survivors were included and matched with 11,020 controls. The rate of infections was elevated after treatment completion compared with controls (RR, 1.51; 95% CI, 1.45 to 1.57) and at less than 1 year (RR, 1.77; 95% CI, 1.69 to 1.86); 1 to 4.99 years (RR, 1.66; 95% CI, 1.62 to 1.71), and 5 or more years (RR, 1.29; 95% CI, 1.22 to 1.36) from the index date. Among those whose initial treatment excluded HSCT, the rate remained elevated more than 5 years from the index date (RR, 1.29; 95% CI, 1.23 to 1.35). Infection-related death was significantly increased in leukemia survivors both among the entire cohort (hazard ratio, 149.3; 95% CI, 20.4 to 1,091.9) and among those without HSCT (hazard ratio, 92.7; 95% CI, 12.4 to 690.7). CONCLUSION: A significant association was found between a history of leukemia therapy and an increased risk of infections. Additional study is needed to establish which exposures in patients with leukemia lead to late infections.

15.
J Pain Symptom Manage ; 58(5): 745-755, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31319103

RESUMO

CONTEXT: Prior work shows measurements of symptom severity using the Edmonton Symptom Assessment System (ESAS) which are associated with emergency department (ED) visits in patients with cancer; however, it is not known if symptom severity improves the ability to predict ED visits. OBJECTIVES: To determine whether information on symptom severity improves the ability to predict ED visits among patients with cancer. METHODS: This was a population-based study of patients who were diagnosed with cancer and had at least one ESAS assessment completed between 2007 and 2015 in Ontario, Canada. After splitting the cohort into training and test sets, two ED visit risk prediction models using logistic regression were developed on the training cohort, one without ESAS and one with ESAS. The predictive performance of each risk model was assessed on the test cohort and compared with respect to area under the curve and calibration. RESULTS: The full cohort consisted of 212,615 unique patients with a total of 1,267,294 ESAS assessments. The risk prediction model including ESAS was superior in sensitivity, specificity, accuracy, and discrimination. The area under the curve was 73.7% under the model with ESAS, whereas it was 70.1% under the model without ESAS. The model with ESAS was also better calibrated. This improvement in calibration was particularly noticeable among patients in the higher deciles of predicted risk. CONCLUSION: This study demonstrates the importance of incorporating symptom measurements when developing an ED visit risk calculator for patients with cancer. Improved predictive models for ED visits using measurements of symptom severity may serve as an important clinical tool to prompt timely interventions by the cancer care team before an ED visit is necessary.

16.
Breast Cancer Res Treat ; 178(1): 169-176, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31325071

RESUMO

PURPOSE: The impact of Ductal Carcinoma in Situ (DCIS) with multiple foci of microinvasion (MI) (≤ 1 mm) on the risks of local recurrence (LR) and invasive LR is unknown, leading to uncertainty if DCIS with multiple foci of MI requires more aggressive treatment. We report a population-based analysis of the impact of multiple foci of MI, confirmed by pathology review, on the 15-year risks of LR and invasive LR treated with breast-conserving surgery (BCS) ± radiotherapy (RT). METHODS: Cohort includes all women diagnosed with DCIS ± MI from 1994 to 2003 treated with BCS ± RT. Cox proportional hazards model was used to evaluate the impact of multiple foci of MI on the risks of LR and invasive LR, adjusting for covariates. The 15-year local and invasive local recurrence-free survival rates were calculated using the Kaplan-Meier method with differences compared by log-rank test. RESULTS: The cohort includes 2988 women treated by BCS; 2721 had pure DCIS (51% received RT), 267 had DCIS with one or more foci of MI (58% had RT). Median follow-up was 13 years. Median age at diagnosis was 58 years. On multivariable analyses, the presence of multiple foci of MI was associated with an increased risk of invasive LR (HR = 1.59, 95% CI 1.01-2.49, p = 0.04) but not DCIS LR (HR = 0.89, 95% CI 0.46, 1.76, p = 0.7). The 15-year invasive LRFS risks for cases with pure DCIS, with 1 focus or multiple foci of MI were 85.7%, 85.6%, 74.7% following treatment by BCS alone, 87.2%, 89.9%, and 77% for those treated with BCS + RT without boost and 89.2%, 91.3%, and 95% for women treated with BCS + RT and boost. CONCLUSIONS: The presence of multiple foci of MI in DCIS is associated with higher 15-year risks of invasive LR after breast-conserving therapy compared to women with pure DCIS but treatment with whole breast and boost RT can mitigate this risk.


Assuntos
Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Mastectomia Segmentar/métodos , Recidiva Local de Neoplasia/epidemiologia , Idoso , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/radioterapia , Carcinoma Intraductal não Infiltrante/epidemiologia , Carcinoma Intraductal não Infiltrante/radioterapia , Feminino , Humanos , Pessoa de Meia-Idade , Invasividade Neoplásica , Medição de Risco , Análise de Sobrevida
17.
Int J Epidemiol ; 2019 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-31329872

RESUMO

BACKGROUND: This study examined the incidence of a person's first diagnosis of a selected chronic disease, and the relationships between modifiable lifestyle risk factors and age to first of six chronic diseases. METHODS: Ontario respondents from 2001 to 2010 of the Canadian Community Health Survey were followed up with administrative data until 2014 for congestive heart failure, chronic obstructive respiratory disease, diabetes, lung cancer, myocardial infarction and stroke. By sex, the cumulative incidence function of age to first chronic disease was calculated for the six chronic diseases individually and compositely. The associations between modifiable lifestyle risk factors (alcohol, body mass index, smoking, diet, physical inactivity) and age to first chronic disease were estimated using cause-specific Cox proportional hazards models and Fine-Gray competing risk models. RESULTS: Diabetes was the most common disease. By age 70.5 years (2015 world life expectancy), 50.9% of females and 58.1% of males had at least one disease and few had a death free of the selected diseases (3.4% females; 5.4% males). Of the lifestyle factors, heavy smoking had the strongest association with the risk of experiencing at least one chronic disease (cause-specific hazard ratio = 3.86; 95% confidence interval = 3.46, 4.31). The lifestyle factors were modelled for each disease separately, and the associations varied by chronic disease and sex. CONCLUSIONS: We found that most individuals will have at least one of the six chronic diseases before dying. This study provides a novel approach using competing risk methods to examine the incidence of chronic diseases relative to the life course and how their incidences are associated with lifestyle behaviours.

18.
J Thorac Cardiovasc Surg ; 158(3): 934-942.e2, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31176552

RESUMO

OBJECTIVE: Readmission following esophagectomy affects the patient experience, has important economic implications, and can be tied to hospital reimbursement. Ontario has regionalized thoracic centers; regionalized surgery may lower the readmission rate. We investigated whether surgery at regionalized thoracic centers is associated with reduced readmission following esophageal cancer resection. METHODS: A retrospective, population-based cohort study (2002-2014) was conducted in Ontario, Canada (population 13.6 million). Adults with resected esophageal cancer were identified through the Ontario Cancer Registry. Multivariable regression was used to estimate the effect of surgery at a regionalized thoracic surgery center on readmission to any Ontario hospital within 90 days following discharge. RESULTS: Of 3670 patients, 27.9% were readmitted within 90 days of discharge (n = 1022). Median hospital length of stay was 12 days (interquartile range 9-20). The readmission rate at thoracic centers was similar to other hospitals (28.1% vs 27.1%, P = .57). The readmission rate did not change during the 13-year study period. Case-mix adjusted readmission rates varied from 17.6% to 35.2% even across thoracic centers and were not related to hospital volume or perioperative mortality. After adjusting for confounders, we found that surgery at a thoracic center was not significantly associated with readmission (odds ratio, 1.10; 95% confidence interval, 0.95-1.27, P = .22). CONCLUSIONS: Surgery at a designated thoracic surgery center did not reduce the risk of 90-day readmission following esophageal cancer resection, and readmission rates varied significantly even across thoracic centers. Our results suggest that despite universal, regionalized esophageal cancer care, there appears to be a minimum readmission threshold following esophagectomy that may be clinically necessary.

19.
Breast Cancer Res Treat ; 176(3): 657-667, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31076954

RESUMO

PURPOSE: Randomized trials studying endocrine therapy (ET) with and without radiation therapy (RT) following breast-conserving surgery (BCS) have detected differences in local recurrence (LR) but not survival among elderly women with hormone receptor positive stage I breast cancer (BC). We assembled a population-based cohort of such women to examine the use and outcomes associated with or without the administration of adjuvant radiotherapy (RT) or ET. METHODS: Women aged ≥ 65 years with stage I BC treated with BCS in Ontario between 2010 and 2016, their treatments and outcomes were ascertained using deterministic linkages of administrative databases. Multivariable Cox regression models were used to evaluate risks of ipsilateral LR and of any first in-breast event, categorizing women by their treatment. RESULTS: 5076 women were treated with BCS followed by RT + ET (n = 1964), RT alone (n = 1325), ET alone (n = 719), or no adjuvant treatment (n = 1068). Median follow-up was 5 years. LR occurred in 0.9% after adjuvant RT + ET, 1.4% after RT alone, 3.1% after ET alone, and 9.4% after BCS alone (p < 0.001). The adjusted risk of LR was increased in those who received no adjuvant therapy (HR = 13.43, CI: 7.89, 22.85), or ET alone (HR = 4.03, CI: 2.14, 7.59). The adjusted risk of any first in-breast event was greatest among those without any adjuvant therapy (HR = 7.61, 95%CI: 5.21, 11.11, p < 0.0001). Absolute and adjusted risks of any first in-breast event were comparable between those with ET alone (HR = 2.09, 95%CI: 1.27, 3.43, p = 0.0038) and those with RT alone (HR = 1.91, 95% CI: 1.25, 2.91, p = 0.0028). CONCLUSIONS: Older women with stage I BC who receive no adjuvant therapy have a significant absolute risk of LR and any first in-breast event, whereas the absolute risk of these events among those with either RT alone or ET alone is only slightly higher than among those treated with both.


Assuntos
Neoplasias da Mama/epidemiologia , Neoplasias da Mama/terapia , Assistência ao Paciente , Cuidados Pós-Operatórios , Padrões de Prática Médica , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais , Neoplasias da Mama/etiologia , Neoplasias da Mama/patologia , Terapia Combinada/efeitos adversos , Terapia Combinada/métodos , Feminino , Humanos , Mastectomia Segmentar , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Assistência ao Paciente/métodos , Assistência ao Paciente/estatística & dados numéricos , Vigilância da População , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Prognóstico , Cooperação e Adesão ao Tratamento , Resultado do Tratamento
20.
J Obstet Gynaecol Can ; 41(6): 813-823, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31130182

RESUMO

OBJECTIVE: Previous studies highlighting inequities in cancer screening between immigrants and non-immigrants have been methodologically limited. This longitudinal matched cohort study used a multistate modelling framework to examine associations between immigration status and cervical cancer screening adherence. METHODS: A 1:1 matched cohort of women aged 25 and older from 1992-2014 who were residing in Ontario was examined. For each woman, the proportion of time spent being non-adherent was determined. Disparities in cervical screening adherence, and specifically the association between immigration status and the rate of becoming adherent, were investigated with a three-state transitional model. The model was adjusted for individual- and physician-level characteristics, which were updated annually and incorporated as time-varying covariates. RESULTS: The matched cohort consisted of 1 156 720 immigrant and non-immigrant women. The median proportion of time spent non-adherent was 38.9% for immigrants and 24.7% for non-immigrants. The rate of becoming adherent among immigrants was lower than that among non-immigrants, after accounting for individual- and physician-level characteristics (relative rate 0.933; 95% CI 0.928-0.937). Other characteristics such as socioeconomic status, immigrant region of origin, presence of primary physician, and physician's sex were found to be significantly associated with cervical screening adherence. CONCLUSION: This study assessed the association between immigration status and adherence to cervical cancer screening. The insights from this work can be used to target groups of women vulnerable to underscreening and to minimize their time spent non-adherent to cancer screening. The methodology serves as a useful framework for examining adherence to other types of cancer screening.

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