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Importance: Tranexamic acid reduces bleeding and blood transfusion in many types of surgery, but its effect in patients undergoing liver resection for a cancer-related indication remains unclear. Objective: To determine whether tranexamic acid reduces red blood cell transfusion within 7 days of liver resection. Design, Setting, and Participants: Multicenter randomized clinical trial of tranexamic acid vs placebo conducted from December 1, 2014, to November 8, 2022, at 10 hepatopancreaticobiliary sites in Canada and 1 site in the United States, with 90-day follow-up. Participants, clinicians, and data collectors were blinded to allocation. A volunteer sample of 1384 patients undergoing liver resection for a cancer-related indication met eligibility criteria and consented to randomization. Interventions: Tranexamic acid (1-g bolus followed by 1-g infusion over 8 hours; n = 619) or matching placebo (n = 626) beginning at induction of anesthesia. Main Outcomes and Measures: The primary outcome was receipt of red blood cell transfusion within 7 days of surgery. Results: The primary analysis included 1245 participants (mean age, 63.2 years; 39.8% female; 56.1% with a diagnosis of colorectal liver metastases). Perioperative characteristics were similar between groups. Red blood cell transfusion occurred in 16.3% of participants (n = 101) in the tranexamic acid group and 14.5% (n = 91) in the placebo group (odds ratio, 1.15 [95% CI, 0.84-1.56]; P = .38; absolute difference, 2% [95% CI, -2% to 6%]). Measured intraoperative blood loss (tranexamic acid, 817.3 mL; placebo, 836.7 mL; P = .75) and total estimated blood loss over 7 days (tranexamic acid, 1504.0 mL; placebo, 1551.2 mL; P = .38) were similar between groups. Participants receiving tranexamic acid experienced significantly more complications compared with placebo (odds ratio, 1.28 [95% CI, 1.02-1.60]; P = .03), with no significant difference in venous thromboembolism (odds ratio, 1.68 [95% CI, 0.95-3.07]; P = .08). Conclusions and Relevance: Among patients undergoing liver resection for a cancer-related indication, tranexamic acid did not reduce bleeding or blood transfusion but increased perioperative complications. Trial Registration: ClinicalTrials.gov Identifier: NCT02261415.
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INTRODUCTION: Peritoneal mesothelioma (PM) is a rare malignancy originating from the peritoneal lining. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is the standard-of-care for patients with isolated PM. Due to a paucity of prospective data there are several different HIPEC protocols. The aims of this study are to describe the CRS and HIPEC protocols for PM and patient outcomes across Canada. METHODS: A multicenter retrospective study was performed on patients diagnosed and treated for PM with CRS and HIPEC in four major peritoneal disease centers in Canada between 2000 and 2021. Data on patient characteristics, treatment patterns, postoperative morbidity, recurrence, and survival were collected. RESULTS: A total of 72 patients were identified. Mean age was 52 years (17-75) and 37.5% were male. Epithelioid (70.1%) and multicystic (13%) mesothelioma were the most common subtypes. Twenty-one patients (30%) were treated with neoadjuvant chemotherapy. CRS and HIPEC was performed in 64 patients (91.4%). Of these, the mean PCI was 22 (2-39) and cisplatin+doxorubicin was the most common HIPEC regimen (n = 33, 51.6%). A semi-closed coliseum technique was used in 68.8% of HIPECs and the mean duration of surgery was 486 min (90-1052). Clavien-Dindo III or IV complications occurred in 12 patients (16.9%). With a median follow-up of 24 months (0.2-104.4), we found a 5-year overall survival of 61% and a 5-year recurrence-free survival of 35%. CONCLUSION: CRS and HIPEC is a safe and effective treatment modality for well-selected patients with PM, with some achieving prolonged survival.
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Hipertermia Induzida , Mesotelioma Maligno , Mesotelioma , Intervenção Coronária Percutânea , Neoplasias Peritoneais , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Estudos Prospectivos , Procedimentos Cirúrgicos de Citorredução/métodos , Quimioterapia Intraperitoneal Hipertérmica , Hipertermia Induzida/métodos , Canadá/epidemiologia , Mesotelioma Maligno/tratamento farmacológico , Mesotelioma/patologia , Neoplasias Peritoneais/patologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Combinada , Taxa de SobrevidaRESUMO
OBJECTIVE: To provide the first international comparison of oesophageal and gastric cancer survival by stage at diagnosis and histological subtype across high-income countries with similar access to healthcare. METHODS: As part of the ICBP SURVMARK-2 project, data from 28 923 patients with oesophageal cancer and 25 946 patients with gastric cancer diagnosed during 2012-2014 from 14 cancer registries in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK) were included. 1-year and 3-year age-standardised net survival were estimated by stage at diagnosis, histological subtype (oesophageal adenocarcinoma (OAC) and oesophageal squamous cell carcinoma (OSCC)) and country. RESULTS: Oesophageal cancer survival was highest in Ireland and lowest in Canada at 1 (50.3% vs 41.3%, respectively) and 3 years (27.0% vs 19.2%) postdiagnosis. Survival from gastric cancer was highest in Australia and lowest in the UK, for both 1-year (55.2% vs 44.8%, respectively) and 3-year survival (33.7% vs 22.3%). Most patients with oesophageal and gastric cancer had regional or distant disease, with proportions ranging between 56% and 90% across countries. Stage-specific analyses showed that variation between countries was greatest for localised disease, where survival ranged between 66.6% in Australia and 83.2% in the UK for oesophageal cancer and between 75.5% in Australia and 94.3% in New Zealand for gastric cancer at 1-year postdiagnosis. While survival for OAC was generally higher than that for OSCC, disparities across countries were similar for both histological subtypes. CONCLUSION: Survival from oesophageal and gastric cancer varies across high-income countries including within stage groups, particularly for localised disease. Disparities can partly be explained by earlier diagnosis resulting in more favourable stage distributions, and distributions of histological subtypes of oesophageal cancer across countries. Yet, differences in treatment, and also in cancer registration practice and the use of different staging methods and systems, across countries may have impacted the comparisons. While primary prevention remains key, advancements in early detection research are promising and will likely allow for additional risk stratification and survival improvements in the future.
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Adenocarcinoma , Neoplasias Esofágicas , Neoplasias Gástricas , Adenocarcinoma/diagnóstico , Adenocarcinoma/epidemiologia , Austrália/epidemiologia , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/patologia , Humanos , Sistema de Registros , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiologia , Neoplasias Gástricas/patologiaRESUMO
BACKGROUND: For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality. METHODS: In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events. RESULTS: Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality. CONCLUSIONS: Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.
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Neoplasias Retais , Humanos , Margens de Excisão , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/etiologia , Ontário/epidemiologia , Cuidados Pré-Operatórios , Neoplasias Retais/cirurgiaRESUMO
BACKGROUND: Moving toward a funding standard similar to that for clinical services for roles essential to the functioning of education, research and leadership services within divisions of general surgery is necessary to strengthen divisional resilience. We aimed to identify roles and underlying tasks in these services central to sustainable functioning of Canadian academic divisions of general surgery. METHODS: Between June 2018 and October 2020, we used a 4-step modified Delphi method (online survey, face-to-face nominal group technique [n = 12], semistructured telephone interview [n = 8] and nominal group technique [n = 12]) to achieve national consensus from an expert panel of all 17 heads of academic divisions of general surgery in Canada on the roles and accompanying tasks essential to education, research and leadership services within an academic division of general surgery. We used 70% agreement to determine consensus. RESULTS: The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary. Consensus was reached for 7 roles within the educational service, 3 roles within the research service and 5 roles within the leadership service. CONCLUSION: Our framework represents a national consensus that defines role standards for education, research and leadership services in Canadian academic divisions of general surgery. The framework can help divisions build resiliency, and enable sustained and deliberate advances in these services.
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Atenção à Saúde , Liderança , Canadá , Consenso , Técnica Delphi , HumanosRESUMO
OBJECTIVES: As part of the International Cancer Benchmarking Partnership (ICBP) SURVMARK-2 project, we provide the most recent estimates of colon and rectal cancer survival in seven high-income countries by age and stage at diagnosis. METHODS: Data from 386 870 patients diagnosed during 2010-2014 from 19 cancer registries in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK) were analysed. 1-year and 5-year net survival from colon and rectal cancer were estimated by stage at diagnosis, age and country, RESULTS: (One1-year) and 5-year net survival varied between (77.1% and 87.5%) 59.1% and 70.9% and (84.8% and 90.0%) 61.6% and 70.9% for colon and rectal cancer, respectively. Survival was consistently higher in Australia, Canada and Norway, with smaller proportions of patients with metastatic disease in Canada and Australia. International differences in (1-year) and 5-year survival were most pronounced for regional and distant colon cancer ranging between (86.0% and 94.1%) 62.5% and 77.5% and (40.7% and 56.4%) 8.0% and 17.3%, respectively. Similar patterns were observed for rectal cancer. Stage distribution of colon and rectal cancers by age varied across countries with marked survival differences for patients with metastatic disease and diagnosed at older ages (irrespective of stage). CONCLUSIONS: Survival disparities for colon and rectal cancer across high-income countries are likely explained by earlier diagnosis in some countries and differences in treatment for regional and distant disease, as well as older age at diagnosis. Differences in cancer registration practice and different staging systems across countries may have impacted the comparisons.
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Neoplasias do Colo/mortalidade , Neoplasias do Colo/patologia , Países Desenvolvidos , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Austrália , Canadá , Dinamarca , Feminino , Humanos , Irlanda , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Nova Zelândia , Noruega , Taxa de Sobrevida , Reino UnidoRESUMO
BACKGROUND: Data from population-based cancer registries are often used to compare cancer survival between countries or regions. The ICBP SURVMARK-2 study is an international partnership aiming to quantify and explore the reasons behind survival differences across high-income countries. However, the magnitude and relevance of differences in cancer survival between countries have been questioned, as it is argued that observed survival variations may be explained, at least in part, by differences in cancer registration practice, completeness and the availability and quality of the respective data sources. METHODS: As part of the ICBP SURVMARK-2 study, we used a simulation approach to better understand how differences in completeness, the characteristics of those missed and inclusion of cases found from death certificates can impact on cancer survival estimates. RESULTS: Bias in 1- and 5-year net survival estimates for 216 simulated scenarios is presented. Out of the investigated factors, the proportion of cases not registered through sources other than death certificates, had the largest impact on survival estimates. CONCLUSION: Our results show that the differences in registration practice between participating countries could in our most extreme scenarios explain only a part of the largest observed differences in cancer survival.
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Sobreviventes de Câncer/estatística & dados numéricos , Simulação por Computador , Neoplasias/mortalidade , Vigilância da População , Sistema de Registros/estatística & dados numéricos , Humanos , Agências Internacionais , Neoplasias/epidemiologia , Prognóstico , Taxa de SobrevidaRESUMO
OBJECTIVE: The study aims to evaluate the differences in ovarian cancer survival by age and stage at diagnosis within and across seven high-income countries. METHODS: We analyzed data from 58,161 women diagnosed with ovarian cancer during 2010-2014, followed until 31 December 2015, from 21 population-based cancer registries in Australia, Canada, Denmark, Ireland, New Zealand, Norway, and United Kingdom. Comparisons of 1-year and 3-year age- and stage-specific net survival (NS) between countries were performed using the period analysis approach. RESULTS: Minor variation in the stage distribution was observed between countries, with most women being diagnosed with 'distant' stage (ranging between 64% in Canada and 71% in Norway). The 3-year all-ages NS ranged from 45 to 57% with Australia (56%) and Norway (57%) demonstrating the highest survival. The proportion of women with 'distant' stage was highest for those aged 65-74 and 75-99 years and varied markedly between countries (range:72-80% and 77-87%, respectively). The oldest age group had the lowest 3-year age-specific survival (20-34%), and women aged 65-74 exhibited the widest variation across countries (3-year NS range: 40-60%). Differences in survival between countries were particularly stark for the oldest age group with 'distant' stage (3-year NS range: 12% in Ireland to 24% in Norway). CONCLUSIONS: International variations in ovarian cancer survival by stage exist with the largest differences observed in the oldest age group with advanced disease. This finding endorses further research investigating international differences in access to and quality of treatment, and prevalence of comorbid conditions particularly in older women with advanced disease.
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Carcinoma Epitelial do Ovário/mortalidade , Neoplasias Ovarianas/mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Canadá/epidemiologia , Carcinoma Epitelial do Ovário/patologia , Feminino , Humanos , Irlanda/epidemiologia , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Nova Zelândia/epidemiologia , Noruega/epidemiologia , Neoplasias Ovarianas/patologia , Sistema de Registros , Reino Unido/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Population-based cancer survival estimates provide valuable insights into the effectiveness of cancer services and can reflect the prospects of cure. As part of the second phase of the International Cancer Benchmarking Partnership (ICBP), the Cancer Survival in High-Income Countries (SURVMARK-2) project aims to provide a comprehensive overview of cancer survival across seven high-income countries and a comparative assessment of corresponding incidence and mortality trends. METHODS: In this longitudinal, population-based study, we collected patient-level data on 3·9 million patients with cancer from population-based cancer registries in 21 jurisdictions in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway, and the UK) for seven sites of cancer (oesophagus, stomach, colon, rectum, pancreas, lung, and ovary) diagnosed between 1995 and 2014, and followed up until Dec 31, 2015. We calculated age-standardised net survival at 1 year and 5 years after diagnosis by site, age group, and period of diagnosis. We mapped changes in incidence and mortality to changes in survival to assess progress in cancer control. FINDINGS: In 19 eligible jurisdictions, 3â764â543 cases of cancer were eligible for inclusion in the study. In the 19 included jurisdictions, over 1995-2014, 1-year and 5-year net survival increased in each country across almost all cancer types, with, for example, 5-year rectal cancer survival increasing more than 13 percentage points in Denmark, Ireland, and the UK. For 2010-14, survival was generally higher in Australia, Canada, and Norway than in New Zealand, Denmark, Ireland, and the UK. Over the study period, larger survival improvements were observed for patients younger than 75 years at diagnosis than those aged 75 years and older, and notably for cancers with a poor prognosis (ie, oesophagus, stomach, pancreas, and lung). Progress in cancer control (ie, increased survival, decreased mortality and incidence) over the study period was evident for stomach, colon, lung (in males), and ovarian cancer. INTERPRETATION: The joint evaluation of trends in incidence, mortality, and survival indicated progress in four of the seven studied cancers. Cancer survival continues to increase across high-income countries; however, international disparities persist. While truly valid comparisons require differences in registration practice, classification, and coding to be minimal, stage of disease at diagnosis, timely access to effective treatment, and the extent of comorbidity are likely the main determinants of patient outcomes. Future studies are needed to assess the impact of these factors to further our understanding of international disparities in cancer survival. FUNDING: 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; The Scottish Government; Western Australia Department of Health; and Wales Cancer Network.
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Países Desenvolvidos/economia , Disparidades em Assistência à Saúde/tendências , Renda , Neoplasias/epidemiologia , Neoplasias/terapia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Canadá/epidemiologia , Sobreviventes de Câncer , Europa (Continente)/epidemiologia , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/mortalidade , Nova Zelândia/epidemiologia , Sistema de Registros , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Postirradiation pseudosclerodermatous panniculitis is a rare complication of external beam radiotherapy. This inflammatory process typically presents as an erythematous indurated plaque in a previously irradiated region of skin. To date, 13 cases have been reported worldwide. We present a case of a 70-year-old female who received breast irradiation following conservation surgery for invasive breast carcinoma. In her third year of follow-up, she developed an enlarging mass, involving the subcutis and underlying breast tissue, associated with mammographically detected coarse calcifications and density, at the surgical site. This was deemed highly suspicious of recurrent malignancy. Following several benign needle core biopsies, she had an excision of the mass. This revealed a lobular panniculitis and irradiation-induced vascular changes affecting subcutaneous fat and underlying breast tissue. This is the 14th reported case of this rare entity. It is unique in the degree of involvement, affecting breast parenchyma as well as subcutaneous fat, and in its corresponding dramatic clinical and radiographic manifestations.
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Mama/patologia , Paniculite/patologia , Lesões por Radiação/patologia , Idoso , Biópsia por Agulha Fina , Neoplasias da Mama/terapia , Feminino , Humanos , Paniculite/etiologia , Radioterapia/efeitos adversosRESUMO
OBJECTIVE: To describe primary care physician (PCP) use and continuity of PCP care across the breast cancer care continuum. DESIGN: Population-based, retrospective cohort study using provincial cancer registries linked to health administrative databases. SETTING: British Columbia, Manitoba, and Ontario. PARTICIPANTS: All women with incident invasive breast cancer from 2007 to 2012 in Manitoba and Ontario and from 2007 to 2011 in British Columbia. MAIN OUTCOME MEASURES: The number and proportions of visits to PCPs were determined. Continuity of care was measured using the Usual Provider of Care index calculated as the proportion of visits to the most-often-visited PCP in the 6 to 30 months before a breast cancer diagnosis (baseline) and from 1 to 3 years following a breast cancer diagnosis (survivorship). RESULTS: More than three-quarters of patients visited their PCPs 2 or more times during the breast cancer diagnostic period, and more than 80% of patients had at least 1 PCP visit during breast cancer adjuvant treatment. Contact with the PCP decreased over time during breast cancer survivorship. Of the 3 phases, women appeared to be most likely to not have PCP contact during adjuvant treatment, with 10.7% (Ontario) to 18.7% (British Columbia) of women having no PCP visits during this phase. However, a sizable minority of women had at least monthly visits during the treatment phase, particularly in Manitoba and Ontario, where approximately a quarter of women saw a PCP at least monthly. We observed higher continuity of care with PCPs in survivorship (compared with baseline) in all provinces. CONCLUSION: Primary care physicians were generally involved throughout the breast cancer care continuum, but the level of involvement varied across care phases and by province. Future interventions will aim to further integrate primary and oncology care.
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Neoplasias da Mama/epidemiologia , Neoplasias da Mama/terapia , Continuidade da Assistência ao Paciente/organização & administração , Visita a Consultório Médico/estatística & dados numéricos , Médicos de Atenção Primária , Adulto , Idoso , Colúmbia Britânica/epidemiologia , Comorbidade , Bases de Dados Factuais , Feminino , Humanos , Manitoba/epidemiologia , Pessoa de Meia-Idade , Ontário/epidemiologia , Estudos RetrospectivosAssuntos
Betacoronavirus , Infecções por Coronavirus , Pandemias , Pneumonia Viral , COVID-19 , Humanos , SARS-CoV-2RESUMO
BACKGROUND: Understanding the predictors of a quick death following diagnosis may improve timely access to palliative care. The objective of this study was to explore whether factors in the 24 months prior to a colorectal cancer (CRC) diagnosis predict a quick death post-diagnosis. METHODS: Data were from a longitudinal study of all adult persons diagnosed with CRC in Nova Scotia, Canada, from 01Jan2001-31Dec2005. This study included all persons who died of any cause by 31Dec2010, except those who died within 30 days of CRC surgery (n = 1885 decedents). Classification and regression tree models were used to explore predictors of time from diagnosis to death for the following time intervals: 2, 4, 6, 8, 12, and 26 weeks from diagnosis to death. All models were performed with and without stage at diagnosis as a predictor variable. Clinico-demographic and health service utilization data in the 24 months pre-diagnosis were provided via linked administrative databases. RESULTS: The strongest, most consistent predictors of dying within 2, 4, 6, and 8 weeks of CRC diagnosis were related to health services utilization in the 24 months prior to diagnosis: i.e., number of specialist visits, number of days spent in hospital, and number of family physician visits. Stage at diagnosis was the strongest predictor of dying within 12 and 26 weeks of diagnosis. CONCLUSIONS: Identifying potential predictors of a short timeframe between cancer diagnosis and death may aid in the development of strategies to facilitate timely and appropriate referral to palliative care upon a cancer diagnosis.
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OBJECTIVE: Defining processes of care, which are appropriate and necessary for management of gastric cancer (GC), is an important step toward improving outcomes. METHODS: Using a RAND/UCLA Appropriateness Method, an international multidisciplinary expert panel created 22 statements reflecting optimal management. All statements were scored for appropriateness and necessity. RESULTS: The following tenets were scored appropriate and necessary: (1) preoperative staging by computed tomography of abdomen/pelvis; (2) positron-emission tomographic scans not routinely indicated; (3) consideration for adjuvant therapy; (4) further clinical trials; (5) multidisciplinary decision making; (6) sufficient support at hospitals; (7) assessment of 16 or more lymph nodes (LNs); (8) in metastatic disease, surgery only for palliation of major symptoms; (9) surgeons experienced in GC management; (10) and surgeons experienced in both GC management and advanced laparoscopic surgery for laparoscopic resection. The following were scored appropriate, but of indeterminate necessity: (1) diagnostic laparoscopy before treatment; (2) a multidisciplinary approach to linitis plastica; (3) genetic assessment for diffuse GC and family history, or age less than 45 years; (4) endoscopic removal of select T1aN0 lesions; (5) D2 LN dissection in curative intent cases; (6) D1 LN dissection for early GC or patients with comorbidities; (7) frozen section analysis of margins; (8) nonemergent cases performed in a hospital with a volume of more than 15 resections per year; and (9) by a surgeon with more than 6 resection per year. CONCLUSIONS: The expert panel has created 22 statements for the perioperative management of GC patients, to provide guidance to clinicians and improve the care received by patients.
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Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/terapia , Humanos , Internacionalidade , Metástase Linfática , Tomografia por Emissão de Pósitrons , Guias de Prática Clínica como Assunto , Neoplasias Gástricas/cirurgia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Our objective was to examine the knowledge and treatment decision practice patterns of Canadian surgeons who treat patients with rectal cancer. METHODS: A mail survey with 6 questions on staging investigations, management of low rectal cancer, lymph node harvest, surgical margins and use of adjuvant therapies was sent to all general surgeons in Canada. Appropriate responses to survey questions were defined a priori. We compared survey responses according to surgeon training (colorectal/surgical oncology v. others) and geographic region (Atlantic, Central, West). RESULTS: The survey was sent to 2143 general surgeons; of the 1312 respondents, 703 treat patients with rectal cancer. Most surgeons responded appropriately to the questions regarding staging investigations (88%) and management of low rectal cancer (88%). Only 55% of surgeons correctly identified the recommended lymph node harvest as 12 or more nodes, 45% identified 5 cm as the recommended distal margin for upper rectal cancer, and 70% appropriately identified which patients should be referred for adjuvant therapy. Surgeons with subspecialty training were significantly more likely to provide correct responses to all of the survey questions than other surgeons. There was limited variation in responses according to geographic region. Subspecialty-trained surgeons and recent graduates were more likely to answer all of the survey questions correctly than other surgeons. CONCLUSION: Initiatives are needed to ensure that all surgeons who treat patients with rectal cancer, regardless of training, maintain a thorough and accurate knowledge of rectal cancer treatment issues.
CONTEXTE: Notre objectif était d'évaluer les connaissances et les processus décisionnels thérapeutiques des chirurgiens canadiens qui traitent des patients atteints de cancer rectal. MÉTHODES: Un sondage envoyé par la poste comportant 6 questions sur les épreuves de stadification, la prise en charge du cancer du bas rectum, le prélèvement des ganglions lymphatiques, les marges chirurgicales et l'utilisation de traitements adjuvants a été envoyé à tous les chirurgiens généraux au Canada. Les réponses appropriées aux questions du sondage avaient été définies au préalable. Nous avons comparé les réponses au sondage selon la formation des chirurgiens (oncologie colorectale/chirurgicale c. autres) et selon la région (Atlantique, Centre, Ouest). RÉSULTATS: Le sondage a été envoyé à 2143 chirurgiens généraux; parmi les 1312 répondants, 703 traitent des patients atteints de cancer rectal. La plupart des chirurgiens ont répondu de façon appropriée aux questions concernant les épreuves de stadification (88 %) et la prise en charge du cancer du bas rectum (88 %). Seulement 55 % des chirurgiens ont correctement répondu à la question sur le nombre optimal de ganglions lymphatiques à prélever, soit 12 ganglions ou plus, 45 % ont donné 5 cm comme marge distale recommandée pour le cancer du haut rectum et 70 % ont déterminé de manière appropriée quels patients il faut orienter vers un traitement adjuvant. Les chirurgiens qui avaient reçu une formation spécialisée étaient significativement plus susceptibles de fournir des réponses exactes à toutes les questions du sondage comparativement aux autres chirurgiens. On a noté une variation limitée entre les réponses selon les régions. Les chirurgiens spécialisés et les nouveaux diplômés étaient plus susceptibles de répondre correctement à toutes les questions du sondage comparativement aux autres chirurgiens. CONCLUSION: Des initiatives s'imposent pour s'assurer qu'indépendamment de leur formation tous les chirurgiens qui traitent des patients atteints d'un cancer rectal maintiennent des connaissances complètes et exactes sur les enjeux thérapeutiques entourant le cancer rectal.
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Competência Clínica , Conhecimentos, Atitudes e Prática em Saúde , Padrões de Prática Médica/normas , Neoplasias Retais/terapia , Cirurgiões/normas , Adulto , Idoso , Canadá , Humanos , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , Autorrelato , Cirurgiões/estatística & dados numéricosRESUMO
OBJECTIVE: To determine whether surgeon knowledge contributes to the relationship between surgeon procedure volume and patient outcomes in rectal cancer. BACKGROUND: Although previous research has shown that treatment by high-volume surgeons is associated with improved outcomes among patients with rectal cancer, the mechanisms for such an association are not well understood. METHODS: In 2009, a mail survey with 8 questions pertaining to rectal cancer care was created, modified for content validity, and sent to all general surgeons in Nova Scotia, Canada. Patients with rectal cancer, who were treated by the survey respondents between July 1, 2002, and June 30, 2006, were identified retrospectively, and a comprehensive standardized review of medical records was used to collect outcome data for this population-based cohort. The association between surgeon survey score (dichotomized into high- and low-score groups on the basis of the median score), surgeon procedure volume, and patient outcomes was examined. RESULTS: Of 521 patients who underwent treatment with curative intent from July 1, 2002, to June 30, 2006, 377 patients (72%) were treated by 25 surgeons who responded to the survey. After controlling for patient and tumor factors, patients treated by high-volume surgeons were more likely to receive a total mesorectal excision (TME) [odds ratio (OR) = 3.89; 95% confidence interval (CI), 2.20-5.83], more likely to undergo an adequate lymph node harvest (OR = 3.67; 95%CI, 2.36-5.70), less likely to have a permanent colostomy (OR = 0.53; 95%CI, 0.30-0.93), and less likely to develop local recurrence (HR = 0.54; 95%CI, 0.29-0.99). When surgeon survey score was included in the multivariate regression models, the relationship between surgeon procedure volume and permanent colostomy was diminished. There was a significant interaction between surgeon survey score and surgeon volume for the outcomes of use of TME (P < 0.01) and local recurrence (P = 0.01). CONCLUSIONS: These data suggest that surgeon knowledge may, at least in part, explain surgeon volume-associated differences in rectal cancer outcomes.
Assuntos
Adenocarcinoma/cirurgia , Competência Clínica , Cirurgia Geral/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Neoplasias Retais/cirurgia , Carga de Trabalho/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Hereditary diffuse gastric cancer (HDGC) represents a minority of gastric cancer (GC) cases. The goal of this study is to use a RAND/University of California Los Angeles (UCLA) appropriateness methodology to examine indications for genetic referral, CDH1 testing, and consideration of prophylactic total gastrectomy (PTG). METHODS: A multidisciplinary expert panel of 16 physicians from six countries scored 47 scenarios. Appropriateness of scenarios was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) of 1-3 were considered inappropriate, 4-6 uncertain, and 7-9 appropriate. Agreement was reached when 12 of 16 panelists scored the statement similarly. Appropriate scenarios agreed upon were subsequently scored for necessity. RESULTS: The panel felt that patients with family history of diffuse gastric cancer (DGC), lobular breast cancer, or multiple family members with GC should be referred for genetic assessment and multidisciplinary decision-making. The panel felt that it is appropriate for patients with DGC to have CDH1 mutation testing in a family with (1) ≥2 cases of GC, with at least one case of DGC diagnosed before age of 50 years; (2) ≥3 cases of GC diagnosed at any age, one or more of which is DGC; (3) a patient diagnosed with DGC and lobular breast carcinoma; or (4) patients diagnosed with DGC under age of 35 years. The panel felt that PTG should be offered to CDH1 mutation carriers 20 years or older. CONCLUSIONS: Identification of genetic mutations in patients at risk for hereditary GC is important, and criteria for testing are suggested.
Assuntos
Neoplasias da Mama/genética , Caderinas/genética , Carcinoma Lobular/genética , Predisposição Genética para Doença , Testes Genéticos , Mutação/genética , Neoplasias Gástricas/genética , Adulto , Antígenos CD , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Carcinoma Lobular/patologia , Carcinoma Lobular/cirurgia , Gerenciamento Clínico , Família , Feminino , Gastrectomia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgiaRESUMO
BACKGROUND: Treatment of rectal cancer in North America has been associated with lower rates of sphincter-preserving surgery in comparison with other regions. It is unclear if these lower rates are due to patient, tumor, or treatment factors; thus, the potential to increase the use of sphincter-preserving surgery is unknown. OBJECTIVE: The aim of this study is to identify the factors associated with the use of sphincter-preserving surgery and to quantify the potential for an increase in sphincter preservation. DESIGN: This population-based retrospective cohort study used patient-level data collected through a comprehensive, standardized review of hospital inpatient and outpatient medical records and cancer center charts. SETTINGS: This study was conducted in all hospitals providing rectal cancer surgery in a Canadian province. PATIENTS: All patients with a new diagnosis of rectal cancer from July 1, 2002 to June 30, 2006 who underwent potentially curative radical surgery were included. MAIN OUTCOME MEASURES: Logistic regression was used to identify factors associated with receiving a permanent colostomy. Patients were categorized as having received an appropriate or potentially inappropriate colostomy based on a priori determined patient, tumor, operative, and pathologic criteria. RESULTS: Of 466 patients who underwent radical surgery, 48% received a permanent colostomy. There was significant variation in the rate of sphincter-preserving surgery among the 10 hospitals that provided rectal cancer care (12%-73%, p = 0.0001). On multivariate analysis, male sex, low tumor height, and increasing tumor stage were associated with the receipt of a permanent colostomy. Among patients who received a permanent stoma, 65 of 224 (29%) patients received a potentially inappropriate stoma. On multivariate analysis, male sex and treatment in a medium- or low-volume hospital was associated with the receipt of a potentially inappropriate colostomy. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: These data suggest that the receipt of a permanent colostomy by many patients with rectal cancer may be inappropriate, and there is potential to increase the use of sphincter-preserving surgery in patients with rectal cancer.
Assuntos
Adenocarcinoma/cirurgia , Canal Anal/cirurgia , Colostomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Estudos de Coortes , Colostomia/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reto/patologia , Estudos RetrospectivosRESUMO
INTRODUCTION: Previous studies, including research published more than 10 years ago in Northern Alberta, have demonstrated improved outcomes with increased surgical volume and subspecialisation in the treatment of rectal cancer. We sought to examine contemporary rectal cancer care in the same region to determine whether practice patterns have changed and whether outcomes have improved. METHODS: We reviewed the charts of all patients with rectal adenocarcinoma diagnosed between 1998 and 2003 who had a potentially curative resection. The main outcomes examined were 5-year local recurrence (LR) and disease-specific survival (DSS). Surgeons were classified into 3 groups according to training and volume, and we compared outcome measures among them. We also compared our results to those of the previous study from our region. RESULTS: We included 433 cases in the study. Subspecialty-trained colorectal surgeons performed 35% of all surgeries in our study compared to 16% in the previous study. The overall 5-year LR rate and DSS in our study were improved compared to the previous study. On multivariate analysis, the only factor associated with increased 5-year LR was presence of obstruction, and the factors associated with decreased 5-year DSS were high-volume noncolorectal surgeons, presence of obstruction and increased stage. CONCLUSION: Over the past 10 years, the long-term outcomes of treatment for rectal cancer have improved. We found that surgical subspecialization was associated with improved DSS but not LR. Increased surgical volume was not associated with LR or DSS.
CONTEXTE: Des études antérieures, y compris des recherches menées dans le nord de l'Alberta et publiées il y a plus de 10 ans, ont montré une amélioration des résultats associée à un volume chirurgical accru et à la surspécialisation dans le traitement du cancer rectal. Nous avons voulu constater le traitement actuel du cancer rectal dans cette même région pour déterminer si les modes de pratique ont évolué et si les résultats se sont améliorés. MÉTHODES: Nous avons passé en revue les dossiers de tous les patients porteurs d'un adénocarcinome du rectum diagnostiqué entre 1998 et 2003 qui ont subi une résection à visée curative. Les principaux paramètres analysés ont été la récurrence locale (RL) et la survie spécifique à la maladie (SSM) à 5 ans. Nous avons réparti les chirurgiens en 3 groupes selon leur formation et leur volume d'interventions et nous avons comparé les résultats entre eux. Nous avons aussi comparé nos résultats à ceux de l'étude précédente réalisée dans notre région. RÉSULTANTS: Nous avons inclus 433 cas dans l'étude. Les chirurgiens spécialisés en intervention colorectale ont effectué 35% de toutes les chirurgies de notre étude, contre 16% lors de l'étude précédente. Dans notre étude, les taux globaux de RL et de SSMà 5 ans se sont améliorés comparativement aux résultats de l'étude précédente. À l'analyse multivariée, le seul facteur associé à une augmentation des RL à 5 ans a été la présence d'obstruction et les facteurs associés à une diminution de la SSM à 5 ans ont été le fort volume des interventions par des chirurgiens non spécialisés en chirurgie colorectale, la présence d'obstruction et le stade plus avancé du cancer. CONCLUSIONS: Au cours des 10 dernières années, les résultats à long terme du traitement du cancer rectal se sont améliorés. Nous avons constaté qu'une surspécialisation chirurgicale était associée à une amélioration de la SSM, mais non de la RL. L'augmentation du volume de chirurgies n'a pas eu d'incidence sur la RL ou la SSM.
Assuntos
Adenocarcinoma/cirurgia , Neoplasias Retais/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Idoso , Alberta/epidemiologia , Canal Anal , Cirurgia Colorretal/educação , Cirurgia Colorretal/estatística & dados numéricos , Intervalo Livre de Doença , Feminino , Humanos , Obstrução Intestinal/complicações , Masculino , Análise Multivariada , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Tratamentos com Preservação do Órgão , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Estudos Retrospectivos , Especialidades CirúrgicasRESUMO
BACKGROUND: Currently, the dictated operative report forms the cornerstone of documenting breast cancer surgery. Synoptic electronic reporting using a standardized template has been proposed for breast cancer operative notes to improve documentation. The goal of this study was to determine the current completeness of dictated operative reports for breast cancer surgery. METHODS: An iterative, consensus-based approach to determining elements of a proposed synoptic surgical operative report identified critical elements. We then evaluated the dictated operative reports of 100 consecutive breast cancer patients for completeness of these elements. RESULTS: Details regarding presentation and diagnosis were frequently incomplete (84%). Among patients undergoing mastectomy, the potential for breast conservation was partially described in only 60%. Only 41% had data regarding intra-operative margin assessment during breast conservation surgery. In axillary lymph node dissections, 92% of patients had complete data about preservation of nerves, yet only 14% of reports contained complete information regarding sentinel lymph node biopsy. Closure was partially described in 91%. CONCLUSIONS: The dictated operative report for breast cancer surgery does not adequately capture important data. A synoptic reporting system, which requires documentation of important elements, is a potentially beneficial tool in breast cancer surgery.