Impact of COVID-19 pandemic on overall and exams-related energy drinks consumption among students of the University of Sarajevo, Bosnia and Herzegovina.

Background: A pilot study conducted in academic 2017/18 among undergraduates of the University of Sarajevo showed energy drinks to be most frequently consumed during academic activity, less frequently mixed with alcohol in leisure, and rarely in the sports activity. The aim of this study was to assess the impact of the COVID-19 pandemic on energy drinks consumption among undergraduates of the same University, with a focus on their consumption during exams. Study design: A cross-sectional study was conducted by an online questionnaire. Methods: The questionnaire, mainly based on the Consortium Nomisma-Areté questionnaire, was customized to compare energy drinks consumption before and during the COVID-19 pandemic, and distributed among students between July 26th, 2020 and April 3rd, 2021. Results: Out of 1,045 students who chose to participate in the study (participation rate of 14.7%), 653 students, mostly women, attending the lower study years, reported energy drinks consumption. Both be-fore and during pandemic, overall energy drinks consumption was most frequently reported as rare [281 (43.9%) before, 326 (51.2%) during the pandemic], and exams-related energy drinks consumption as once or twice a week [156 (43.8%) before, 130 (42.1%) during pandemic]. The pandemic increased the number of frequent consumers (consumption of 4-5 energy drinks per week) in both overall [35 (5.5%) before, 46 (7.2%) during pandemic] and exams-related energy drinks consumption [42 (11.8%) before, 48 (15.5%) during pandemic]. Study year (OR=0.842; 95% CI 0.77-0.921; p<0.001), being single and living alone [OR=0.512; 95% CI 0.296-0.883; p=0.016), or living with a partner and children [OR=0.377; 95% CI 0.168-0.847; p=0.018) were identified as negative independent predictors for exams-related energy drinks consumption, while being a regular smoker (OR=0.429; 95% CI 0.223-0.875; p=0.011) appeared its new negative independent predictor during pandemic. Conclusions: The pandemic seemed to decrease both the overall and exam-related energy drinks consumption among undergraduates of the University of Sarajevo with the exception of a portion of already frequent energy drinks consumers.

Canada follows the US in the rise of bilateral mastectomies for unilateral breast cancer: a 23-year population cohort study.

INTRODUCTION: The use of contralateral prophylactic mastectomy (CPM) continues to grow despite the absence of evidence supporting a survival benefit. This study's objectives were to (1) describe the trends in the rates of unilateral and bilateral mastectomy (BM) in women diagnosed with unilateral breast cancer (UBC) in Ontario, Canada from 1991 to 2013, and (2) identify factors associated with BM to treat UBC. METHODS: This retrospective cohort analysis included all women aged 18 and older diagnosed with UBC between January 1991 and December 2013. Health administrative data from the Institute for Clinical Evaluative Sciences, the Ontario Cancer Registry, and the Discharge Abstract Database were used to identify all breast cancer and mastectomy cases. Age-adjusted mastectomy rates were plotted over time. Univariable and multivariable analyses included clinically significant covariates. RESULTS: From 1991 to 2013 there were 172,165 cases of UBC and 64,886 mastectomies (37.7%) performed in Ontario. 13.6% of the mastectomies were bilateral. BM rates increased over sixfold (from 4 to 25%) across all age groups under age 70 over a 23-year period. On multivariable analysis, younger age, higher income, rural community, earlier breast cancer stage, lobular histology, availability of reconstruction and teaching hospitals were associated with increased odds of BM. CONCLUSIONS: This is the largest population study of breast cancer patients in Canada and shows an increasing rate of BM for UBC. The results are similar to those already described in the US and highlight the importance of continued efforts to promote efficient communication and evidence-based decision-making prior to breast surgery.

Interpregnancy interval and risk of perinatal death: a systematic review and meta-analysis.

BACKGROUND: Interpregnancy interval (IPI) <6 months is a potentially modifiable risk factor for adverse perinatal health outcomes. OBJECTIVE: This systematic review evaluated the international literature on the risk of perinatal death associated with IPI. SEARCH STRATEGY: Two independent reviewers screened titles and abstracts identified in MEDLINE, EMBASE and Scopus from inception to 4 April 2019 (Prospero Registration #CRD42018092792). SELECTION CRITERIA: Studies were included if they provided a description of IPI measurement and perinatal death, including stillbirth and neonatal death. DATA COLLECTION AND ANALYSIS: A narrative review was performed for all included studies. Random effects meta-analysis was used to compare unadjusted odds of perinatal death associated with IPI <6 months and IPI ≥6 months. Analyses were performed by outcome of the preceding pregnancy and study location. MAIN RESULTS: Of the 624 unique articles identified, 26 met the inclusion criteria. The pooled unadjusted odds ratio of perinatal death for IPI <6 months was 1.34 (95% CI 1.17-1.53) following a previous live birth, 0.85 (95% CI 0.73-0.99) following a previous miscarriage and 1.07 (95% CI 0.84-1.36) following a previous stillbirth compared with IPI ≥6 months. However, few high-income country studies reported an association after adjustment. Fewer studies evaluated the impact of long IPI on perinatal death and what evidence was available showed mixed results. CONCLUSIONS: Results suggest a possible association between short IPI and risk of perinatal death following a live birth, particularly in low- to middle-income countries. TWEETABLE ABSTRACT: Short IPI <6 months after a live birth was associated with greater risk of perinatal death than IPI ≥6 months.

How do the characteristics of breast cancer diagnostic assessment programmes influence service delivery: A mixed methods study.

Diagnostic assessment programmes (DAPs) coordinate multidisciplinary teamwork (MDT), and improve wait times and patient satisfaction. No research has established optimal DAP design. This study explored how DAP characteristics influence service delivery. A mixed methods case study of four breast cancer DAPs was conducted including qualitative interviews with health-care providers and retrospective chart review. Data were integrated using multiple approaches. Twenty-three providers were interviewed; 411 medical records were reviewed. The number of visits and wait times from referral to diagnosis and consultation were lowest at a one-stop model. DAP characteristics (rural-remote region, human resources, referral volume, organisation of services, adherence to service delivery targets and one-stop model) may influence service delivery (number of visits, wait times). MDT, influenced by other DAP characteristics (co-location of staff, patient navigators, team functioning), may also influence service delivery. While the one-stop model may be ideal, all sites experienced similar and unique challenges. Further research is needed to understand how to optimise the organisation and delivery of DAP services. Measures reflecting individual, team and patient-reported outcomes should be used to assess the effectiveness and impact of DAPs in addition to more traditional measures such as wait times.

Estrogen, progesterone, and HER2/neu receptor discordance between primary and metastatic breast tumours-a review.

Discordance in estrogen (ER), progesterone (PR), and HER2/neu status between primary breast tumours and metastatic disease is well recognized. In this review, we highlight how receptor discordance between primary tumours and paired metastasis can help elucidate the mechanism of metastasis but can also effect patient management and the design of future trials. Discordance rates and ranges were available from 47 studies (3384 matched primary and metastatic pairs) reporting ER, PR, and HER2/neu expression for both primary and metastatic sites. Median discordance rates for ER, PR, and HER2/neu were 14 % (range 0-67 %, IQR 9-25 %), 21 % (range 0-62 %, IQR 15-41 %), and 10 % (range 0-44 %, IQR 4-17 %), respectively. Loss of receptor expression was more common (9.17 %) than gain (4.51 %). Discordance rates varied amongst site of metastasis with ER discordance being highest in bone metastases suggesting that discordance is a true biological phenomenon. Discordance rates vary for both the biomarker and the metastatic site. Loss of expression is more common than gain. This can affect patient management as it can lead to a reduction in both the efficacy and availability of potential therapeutic agents. Future studies are recommended to explore both the mechanisms of discordance as well as its impact on patient outcome and management.

Training oncoplastic breast surgeons: the Canadian fellowship experience.

BACKGROUND: Oncoplastic breast surgery combines traditional oncologic breast conservation with plastic surgery techniques to achieve improved aesthetic and quality-of-life outcomes without sacrificing oncologic safety. Clinical uptake and training remain limited in the Canadian surgical system. In the present article, we detail the current state of oncoplastic surgery (ops) training in Canada, the United States, and worldwide, as well as the experience of a Canadian clinical fellow in ops. METHODS: The clinical fellow undertook a 9-month audit of breast surgical cases. All cases performed during the fellow's ops fellowship were included. The fellowship ran from October 2015 to June 2016. RESULTS: During the 9 months of the fellowship, 67 mastectomies were completed (30 simple, 17 modified radical, 12 skin-sparing, and 8 nipple-sparing). The fellow participated in 13 breast reconstructions. Of 126 lumpectomies completed, 79 incorporated oncoplastic techniques. CONCLUSIONS: The experience of the most recent ops clinical fellow suggests that Canadian ops training is feasible and achievable. Commentary on the current state of Canadian ops training suggests areas for improvement. Oncoplastic surgery is an important skill for breast surgical oncologists, and access to training should be improved for Canadian surgeons.

Cost implications of unwarranted imaging for distant metastasis in women with early-stage breast cancer in Ontario.

INTRODUCTION: Despite the publication of multiple evidence-based guidelines recommending against routine imaging for distant metastasis in patients with early-stage (i/ii) breast cancer, such imaging is frequently performed. The present retrospective cohort study was conducted to estimate the cost of unnecessary imaging tests in women with stage i and ii breast cancer diagnosed between 1 January 2007 and 31 December 2012 in Ontario. METHODS: We obtained patient-level demographic and tumour data from a large provincial dataset. The total cost of unwarranted imaging tests (in 2015 Canadian dollars) was considered to be equal to the sum of imaging costs incurred between 2007 and 2012 and was stratified by disease stage, imaging modality, and body site. RESULTS: Of the 26,547 identified patients with early-stage breast cancer, 22,811 (85.9%) underwent at least 1 imaging test, with an average of 3.7 tests per patient (3.2 for stage i patients and 4.0 for stage ii patients) over 5 years. At least 1 imaging test was performed in 79.6% of stage i and 92.7% of stage ii patients. During a 5-year period, the cost of unwarranted imaging in patients with early-stage breast cancer ranged from CA$4,418,139 to CA$6,865,856, depending on guideline recommendations. CONCLUSIONS: Our study highlights the substantial cost of excess imaging that could be saved and re-allocated to patient care if evidence-based guidelines are followed. Future studies should assess strategies to ensure that evidence-based guidelines are followed and to increase awareness of the cost implications of nonadherence to guidelines.

Can the referring surgeon enhance accrual of breast cancer patients to medical and radiation oncology trials? The ENHANCE study.

INTRODUCTION: The accrual rate to clinical trials in oncology remains low. In this exploratory pilot study, we prospectively assessed the role that engaging a referring surgeon plays in enhancing nonsurgical oncologic clinical trial accrual. METHODS: Newly diagnosed breast cancer patients were seen by a surgeon who actively introduced specific patient-and physician-centred strategies to increase clinical trial accrual. Patient-centred strategies included providing patients, before their oncology appointment, with information about specific clinical trials for which they might be eligible, as evaluated by the surgeon. The attitudes of the patients about clinical trials and the interventions used to improve accrual were assessed at the end of the study. The primary outcome was the clinical trial accrual rate during the study period. RESULTS: Overall clinical trial enrolment during the study period among the 34 participating patients was 15% (5 of 34), which is greater than the institution's historical average of 7%. All patients found the information delivered by the surgeon before the oncology appointment to be very helpful. Almost three quarters of the patients (73%) were informed about clinical trials by their oncologist. The top reasons for nonparticipation reported by the patients who did not participate in clinical trials included lack of interest (35%), failure of the oncologist to mention clinical trials (33%), and inconvenience (19%). CONCLUSIONS: Accrual of patients to clinical trials is a complex multistep process with multiple potential barriers. The findings of this exploratory pilot study demonstrate a potential role for the referring surgeon in enhancing nonsurgical clinical trial accrual.

Neoadjuvant endocrine therapy and window of opportunity trials: new standards in the treatment of breast cancer?

Until recently, the use of neoadjuvant endocrine therapy was mainly restricted to those patients whose general frailty or comorbidities were contraindications to surgery. There is now increased evidence that certain patient populations (i.e. older patients with hormone-receptor positive disease) can gain as good a pathologic response, with considerably less toxicity, from neoadjuvant endocrine therapy than from neoadjuvant chemotherapy. Optimization of neoadjuvant endocrine therapy is therefore an important therapeutic goal. However, possibly of greater importance in the overall management of breast cancer, is the increased interest in exploring the effects of brief periods of endocrine therapy on in vivo biomarkers, in so called window of opportunity trials. These trials can not only be used to identify the mechanisms of action of novel agents but also to predict optimal subsequent adjuvant therapy for individual patients. While this paper will briefly review the history of neoadjuvant endocrine therapy, more emphasis will be on the evaluation of pivotal window of opportunity trials that will likely lead to a long awaited paradigm shift in the management of breast cancer.

Concurrent chemoradiotherapy for locally advanced breast cancer-time for a new paradigm?

BACKGROUND: In cases of locally advanced breast cancer (labc), preoperative ("neoadjuvant") therapy was traditionally reserved to render the patient operable. More recently, neoadjuvant therapy, particularly chemotherapy, is being used in patients with operable disease to increase the opportunity for breast conservation. Despite the increasing use of preoperative chemotherapy, rates of pathologic complete response, a surrogate marker for disease-free survival, remain modest in patients with locally advanced disease and particularly so when the tumour is estrogen or progesterone receptor-positive and her2-negative. A new paradigm for labc patients is needed. In other solid tumours (for example, rectal, esophageal, and lung cancers), concurrent chemoradiotherapy (ccrt) is routinely used in neoadjuvant and adjuvant treatment protocols alike. RESULTS: The literature suggests that ccrt in labc patients with inoperable disease is associated with response rates higher than would be anticipated with systemic therapy alone. CONCLUSIONS: Ongoing trials in this field are eagerly awaited to determine if ccrt should become the new paradigm.

Neoadjuvant endocrine treatment for breast cancer: from bedside to bench and back again?

In recent years, considerable attention has been paid to the role of neoadjuvant chemotherapy as a pluripotential test bed for the treatment of breast cancer. Although traditionally reserved to render inoperable disease operable, neoadjuvant chemotherapy is increasingly being used to improve the chance for breast-conserving surgery, to gain information on pathologic response rates for a more rapid assessment of new chemotherapy-biologic regimens, and also to study in vivo tumour sensitivity or resistance to the agent being used. Similarly, use of neoadjuvant endocrine treatment was also traditionally restricted to elderly or frail patients who were felt to be unsuitable for chemotherapy. It is therefore not surprising that, given the increasing realization of the pivotal role of endocrine therapy in patient care, there is enhanced interest in neoadjuvant endocrine therapy not only as a less-toxic alternative to chemotherapy, but also to assess tumour sensitivity or resistance to endocrine agents. The availability of newer endocrine manipulations and increasing evidence that the benefits of chemotherapy are frequently marginal in many hormone-positive patients is making endocrine therapy increasingly important in the clinical setting. The hope is that, one day, instead of preoperative endocrine therapy being restricted to the infirm and the elderly, it will be used in the time between biopsy diagnosis and surgery to predict which patients will or will not benefit from chemotherapy in the adjuvant setting.

Do alternative methods of measuring tumor size, including consideration of multicentric/multifocal disease, enhance prognostic information beyond TNM staging in women with early stage breast cancer: an analysis of the NCIC CTG MA.5 and MA.12 clinical trials.

The AJCC staging criteria consider tumor size to be the largest dimension of largest tumor. Some case series suggest using summation of all tumor dimensions in patients with multicentric/multifocal (MC/MF) disease. We used data from NCIC CTG MA.5 and MA.12 clinical trials to examine alternative methods of assessing tumor size on breast-cancer-free-interval (BCFI). The 710 MA.5 pre-/peri-menopausal node positive and 672 MA.12 pre-menopausal node-negative/-positive patients have 10-year median follow-up. All patients received adjuvant chemotherapy. Tumors were centrally reviewed for grade, hormone receptor, and HER2 status. Continuous pathologic tumor size was: (1) largest dimension of largest tumor (cm); (2) tumor area (cm(2)); (3) volume of tumor (cm(3)); (4) with MC/MF disease, summation of (1)-(3) for up to 3 foci. We examined univariate and multivariate effects of tumor size on BCFI utilizing (un)stratified Cox regression and the Wald test statistic. In univariate analysis, larger tumor dimension was significantly associated with worse BFCI in node positive patients: p < 0.0001 for MA.5; p = 0.01 for MA.12. In MA.5 multivariate analysis, larger summation of largest tumor dimensions was associated with worse BCFI (p = 0.0003), while larger single dimension was associated with worse BCFI (p = 0.02) for MA.12. Presence of MC/MF and other tumor size measurements were not associated (p > 0.05) with BFCI. While physicians could consider the largest diameter of the largest focus of disease or the sum of the largest diameters of all foci in their T-stage determination, it appears that the current method of T-staging offers equivalent determinations of prognosis.

Accuracy of multidetector computed tomography in identifying poor prognostic factors in colonic cancer.

BACKGROUND: Recent neoadjuvant strategies for high-risk colonic tumours have renewed interest in accurate preoperative staging. The aim of this study was to validate prospectively the accuracy of multidetector computed tomography (MDCT) in stratifying patients into good and poor prognostic groups in a multicentre setting. METHODS: Staging MDCT scans of 84 patients with colonic cancer were reviewed by two independent radiologists and stratified into low-risk (T1/T2 and T3 with extramural tumour depth (EMD) of less than 5 mm) and high-risk (T3 with EMD of at least 5 mm and T4) tumours. Nodal status and extramural venous invasion (EMVI) were also assessed. RESULTS: The accuracy, sensitivity, specificity and positive predictive value of stratification by CT compared with histological examination was 74 (95 per cent confidence interval 64 to 82), 78 (65 to 87), 67 (49 to 81) and 81 (68 to 89) per cent respectively. Accuracy for detecting malignant lymph nodes and EMVI was 58 and 70 per cent respectively. The agreement for predicting prognostic stratification was moderate (kappa = 0.54). CONCLUSION: As the ability of CT to identify node status is poor, the depth of tumour invasion beyond the muscularis propria is the most accurate way to identify patients with a poor prognosis who may be suitable for neoadjuvant treatment.

Baseline staging imaging for distant metastasis in women with stages I, II, and III breast cancer.

Background: In Ontario, there is no clearly defined standard of care for staging for distant metastasis in women with newly diagnosed and biopsy-confirmed breast cancer whose clinical presentation is suggestive of early-stage disease. This guideline addresses baseline imaging investigations for women with newly diagnosed primary breast cancer who are otherwise asymptomatic for distant metastasis. Methods: The medline and embase databases were systematically searched for evidence from January 2000 to April 2019, and the best available evidence was used to draft recommendations relevant to the use of baseline imaging investigation in women with newly diagnosed primary breast cancer who are otherwise asymptomatic. Final approval of this practice guideline was obtained from both the Staging in Early Stage Breast Cancer Advisory Committee and the Report Approval Panel of the Program in Evidence-Based Care. Recommendations: These recommendations apply to all women with newly diagnosed primary breast cancer (originating in the breast) who have no symptoms of distant metastasis Staging tests using conventional anatomic imaging [chest radiography, liver ultrasonography, chest-abdomen-pelvis computed tomography (ct)] or metabolic imaging modalities [integrated positron-emission tomography (pet)/ct, integrated pet/magnetic resonance imaging (mri), bone scintigraphy] should not be routinely ordered for women newly diagnosed with clinical stage i or stage ii breast cancer who have no symptoms of distant metastasis, regardless of biomarker status. In women newly diagnosed with stage iii breast cancer, baseline staging tests using either anatomic imaging (chest radiography, liver ultrasonography, chest-abdomen-pelvis ct) or metabolic imaging modalities (pet/ct, pet/mri, bone scintigraphy) should be considered regardless of whether the patient is symptomatic for distant metastasis and regardless of biomarker profile.

Consensus statement on tumour bed localization for radiation after oncoplastic breast surgery.

Background: Oncoplastic surgery (ops) is becoming the new standard of care for breast-conserving surgery, leading to some challenges with adjuvant radiation, particularly when accurate tumour bed (tbd) delineation is needed for focused radiation (that is, accelerated partial breast irradiation or boost radiation). Currently, no guidelines have been published concerning tbd localization for adjuvant targeted radiation after ops. Methods: A modified Delphi method was used to establish consensus by a panel of 20 experts in surgical and radiation oncology at the Canadian Locally Advanced Breast Cancer National Consensus Group and in a subsequent online member survey. Results: These are the main recommendations:■ Surgical clips are necessary and should, at a minimum, be placed along the 4 side walls of the cavity, plus 1-4 clips at the posterior margin if necessary.■ Operative reports should include pertinent information to help guide the radiation oncologists.■ Breast surgeons and radiation oncologists should have a basic understanding of ops techniques and work on "speaking a common language."■ Careful consideration is needed when determining the value of targeted radiation, such as boost, in higher-level ops procedures with extensive tissue rearrangement. Conclusions: The panel developed a total of 6 recommendations on tbd delineation for more focused radiation therapy after ops, with more than 80% agreement on each statement. All are summarized, together with the corresponding evidence or expert opinion.

Position statement on defining and standardizing an oncoplastic approach to breast-conserving surgery in Canada.

Although mastectomy is an effective procedure, it can have a negative effect on body image, sense of attractiveness, and sexuality. As opposed to the combination of breast oncologic surgery and plastic surgery, whose primary focus is on replacing lost volume, breast-conserving oncoplastic surgery (ops) redistributes remaining breast tissue in a manner that requires vision, anatomic knowledge, and an appreciation of esthetics, symmetry, and breast function. Modern surgical treatment of breast cancer can be realized only with breast and plastic surgeons working together using oncoplastic techniques to deliver superior cosmetic and cancer outcomes alike. Using this collaborative approach, oncologic and plastic surgeons in Canada have a significant opportunity to improve the care of their breast cancer patients. We propose a tri-level classification for volume displacement procedures to act as a rubric for the training of general surgeons and oncologic breast surgeons in oncoplastic breast-conserving therapy techniques. It is our position that ops enhances outcomes for many women with breast cancer and should become part of the standard repertoire of procedures used by Canadian oncologic surgeons treating breast cancer.

Exploring reasons for overuse of contralateral prophylactic mastectomy in Canada.

Background: Contralateral prophylactic mastectomy (cpm) in women with known unilateral breast cancer (bca) has been increasing despite the lack of supportive evidence. The purpose of the present study was to identify the determinants of cpm in women with unilateral bca. Methods: This qualitative descriptive study used semi-structured interviews informed by the Theoretical Domains Framework. We interviewed 74 key informants (surgical oncologists, plastic surgeons, medical oncologists, radiation oncologists, nurses, women with bca) across Canada. Interviews were analyzed using thematic analysis and an analysis for shared and discipline-specific beliefs. Results: In total, 58 factors influencing the use of cpm were identified: 26 factors shared by various health care professional groups, 15 discipline-specific factors (identified by a single health care professional group), and 17 factors shared by women with unilateral bca. Health care professionals identified more factors discouraging the use of cpm (n = 26) than encouraging its use (n = 15); women with bca identified more factors encouraging use of cpm (n = 12) than discouraging its use (n = 5). The factor most commonly identified by health care professionals that encouraged cpm was lack of awareness of existing evidence or guidelines for the appropriate use of cpm (n = 44, 75%). For women with bca, the factor most likely influencing their decision for cpm was wanting a better esthetic outcome (n = 14, 93%). Conclusions: Multiple factors discouraging and encouraging the use of cpm in unilateral bca were identified. Those factors identify potential individual, team, organization, and system targets for behaviour change interventions to reduce cpm.