Crucial Conversations: An interprofessional learning opportunity for senior healthcare students.

Clinical errors due to human mistakes are estimated to result in 400,000 preventable deaths per year. Strategies to improve patient safety often rely on healthcare workers' ability to speak up with concerns. This becomes difficult during critical decision-making as a result of conflicting opinions and power differentials, themes underrepresented in many interprofessional initiatives. These elements are prominent in our interprofessional initiative, namely Crucial Conversations. We sought to evaluate this initiative as an interprofessional learning (IPL) opportunity for pre-licensure senior healthcare students, as a way to foster interprofessional collaboration, and as a method of empowering students to vocalise their concerns. The attributes of this IPL opportunity were evaluated using the Points for Interprofessional Education Score (PIPES). The University of the West of England Interprofessional Questionnaire was administered before and after the course to assess changes in attitudes towards IPL, relationships, interactions, and teamwork. Crucial Conversations strongly attained the principles of interprofessional education on the PIPES instrument. A total of 38 volunteers completed the 16 hours of training: 15 (39%) medical rehabilitation, 10 (26%) medicine, 7 (18%) pharmacy, 5 (13%) nursing, and 1 (2%) dentistry. Baseline attitude scores were positive for three of the four subscales, all of which improved post-intervention. Interprofessional interactions remained negative possibly due to the lack of IPL opportunities along the learning continuum, the hidden curriculum, as well as the stereotyping and hierarchical structures in today's healthcare environment preventing students from maximising the techniques learned by use of this interprofessional initiative.

Synoptic operative reports enhance documentation of best practices for rectal cancer.

BACKGROUND: Implementation of best practices surgical checklists improves patient safety and outcomes. However, documenting performance of these practices can be challenging. The American Society of Colon and Rectal Surgeons developed a Best Practices for Rectal Cancer Checklist (RCC) to standardize and improve the quality of rectal cancer surgery. This study compared the degree to which synoptic (SR) and narrative (NR) operative reports document RCC items. METHODS: Two reviewers independently reviewed a cohort of prospectively collected SR for rectal cancer surgery and a case-matched historical cohort of NR. Reports were reviewed for documentation of performance of operative items on the RCC. Abstraction time and inter-rater agreement were also measured. RESULTS: SR scored significantly higher than NR on the overall checklist score (mean adjusted score ± standard deviation 12.4 ± 0.9 vs. 5.7 ± 1.9, maximum possible score 18, P < 0.001). Reviewers abstracted data significantly faster from SR. Inter-rater agreement between reviewers was high for both types of reports. CONCLUSIONS: SR were associated with reliable and more complete and reliable documentation of items on the RCC. Use of an SR system standardizes operative reporting, providing the opportunity to enhance checklist compliance, and enable timely feedback to improve surgical outcomes for rectal cancer patients.

Diagnosis of VTE postdischarge for major abdominal and pelvic oncologic surgery: implications for a change in practice.

BACKGROUND: Extended thromboprophylaxis after hospital discharge following cancer surgery has been shown to reduce the incidence of venous thromboembolism (VTE); however, this practice has not been universally adopted. We conducted a population-based analysis to determine the proportion of patients with symptomatic VTE diagnosed within 90 days after initial discharge following major abdominopelvic cancer surgery who might have benefited from extended thromboprophylaxis. METHODS: We used the Manitoba Cancer Registry to identify patients who underwent major abdominopelvic cancer surgery between 2004 and 2009. The proportion in whom VTE was diagnosed during the initial hospital stay was determined by accessing the Hospital Separations Abstracts. The proportion in whom VTE was diagnosed after discharge was determined by examining repeat admissions within 90 days and by accessing Drug Programs Information Network records for newly prescribed anticoagulants. Detailed tumour and treatment-specific data allowed calculation of VTE predictors. RESULTS: Of 6612 patients identified, 106 (1.60%) had VTE diagnosed during the initial stay and 96 (1.45%) presented with VTE after discharge. Among patients in whom VTE developed after discharge, 33.3% had a pulmonary embolus, 24% had deep vein thrombosis, and 6.3% had both. Predictors of presenting with VTE after discharge within 90 days of surgery included advanced disease, presence of other complications, increased hospital resource utilization, primary tumours of noncolorectal gastrointestinal origin and age younger than 45 years. The development of VTE was an independent predictor of decreased 5-year overall survival. CONCLUSION: The cumulative incidence of VTE within 90 days of major abdominopelvic oncologic surgery was 3.01%, with about half (1.45%) having been diagnosed within 90 days after discharge.

CONTEXTE: La thromboprophylaxie prolongée après le congé hospitalier suite à une chirurgie pour cancer a permis de réduire l'incidence de la thrombo-embolie veineuse (TEV); or, cette pratique n'a pas été universellement adoptée. Nous avons procédé à une analyse de population afin de déterminer la proportion de patients qui ont reçu un diagnostic de TEV symptomatique dans les 90 jours suivant leur congé à la suite d'une chirurgie majeure pour cancer abdomino-pelvien et qui auraient pu bénéficier d'une thromboprophylaxie prolongée. MÉTHODES: Nous avons utilisé le registre du cancer du Manitoba pour recenser les patients ayant subi une chirurgie majeure pour cancer abdomino-pelvien entre 2004 et 2009. La proportion de patients chez qui une TEV a été diagnostiquée au cours du séjour hospitalier initial a été calculée à partir des sommaires d'hospitalisation préparés au congé du patient. La proportion de patients chez qui la TEV a été diagnostiquée après le congé provient de l'examen des dossiers de réadmission dans les 90 jours et du réseau provincial d'information sur les programmes de médicaments pour les anticoagulants nouvellement prescrits. L'analyse des données détaillées sur les tumeurs et les traitements a permis d'établir les prédicteurs de la TEV. RÉSULTANTS: Sur 6612 patients recensés, 106 (1,60 %) ont reçu un diagnostic de TEV durant leur séjour initial et 96 (1,45 %), après leur congé. Parmi les patients chez qui la TEV est survenue après le congé, 33,3 % ont souffert d'une embolie pulmonaire, 24 %, d'une thrombose veineuse profonde et 6,3 %, des deux. Les prédicteurs de la TEV consécutive au congé hospitalier dans les 90 jours suivant une chirurgie incluaient : maladie avancée, présence d'autres complications, utilisation accrue des ressources hospitalières, tumeur primitive d'origine gastro-intestinale non colorectale et âge < 45 ans. La TEV s'est révélée être un prédicteur indépendant d'une plus brève survie globale à 5 ans. CONCLUSION: L'incidence cumulative des TEV dans les 90 jours suivant une chirurgie majeure pour cancer abdomino-pelvien a été de 3,01 %, environ la moitié des cas (1,45 %) ayant été diagnostiqués dans les 90 jours suivant le congé.

Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports.

BACKGROUND: Operative reports are a source of clinical data that can, for quality assurance purposes, be used to document the performance of processes that affect the care of surgical patients. We assessed the degree to which synoptic reports document operative quality indicators for colon cancer surgery. METHODS: Two reviewers independently reviewed 80 prospectively collected synoptic colon cancer operative reports and a case-matched historical cohort of 80 dictated reports. Reviewers rated how well reports documented performance of quality of care indicators using two checklists of previously validated, colon cancer-specific quality measures. Interrater agreement and time to extract data were also recorded. RESULTS: Synoptic reports had significantly higher overall scores on the quality indictors in comparison to dictated reports for both checklist 1 [mean adjusted score ± standard deviation 18.6 ± 1.3 vs. 9.2 ± 3.6, p < 0.01 (maximum score 38)] and checklist 2 [2.0 ± 0.3 vs. 1.3 ± 1.1, p < 0.01 (maximum score 3)]. Interrater agreement was significantly higher between synoptic reports for both checklists (data not shown). Data were extracted significantly more quickly from synoptic reports than dictated reports [mean time (minutes:seconds) ± standard deviation 2:32 ± 0:44 vs. 4:01 ± 1:14, p < 0.01]. CONCLUSIONS: Synoptic reports were associated with more complete documentation of quality indicators for colon cancer resection compared to dictated reports. Although synoptic reports may improve the documentation of quality of care data, further refinement may help to better document performance of quality measures and improve reporting standards.

Does young age influence the prognosis of colorectal cancer: a population-based analysis.

BACKGROUND: Controversy exists whether young patients diagnosed with colorectal cancer have a poorer prognosis. Although younger patients are more likely to have certain poor prognostic factors, prior studies have shown mixed results in terms of overall prognosis, which may be due to lack of adjustment for confounding factors. The primary objective of our study was to determine the effect of age on survival following treatment of colorectal cancer in the Province of Manitoba, Canada, while controlling for important cofactors. METHODS: This was a population-based analysis of all adult patients (age≥18 years) diagnosed with adenocarcinoma of the colon or rectum between 1 January 2004 and 31 December 2006 in the Province of Manitoba. Patient, tumor, and treatment factors were identified using administrative data. Five-year Kaplan-Meier survival and Cox proportional hazards model were analyzed to determine whether young age (45 years of age or younger) was associated with a poorer prognosis, while controlling for confounding variables. RESULTS: Of the 2,086 patients identified, 70 (3.36%) were considered young. These patients were more likely to have T4 tumors and node-positive disease. Older patients had more advanced comorbidities. Young age was an independent predictor of better survival. Poorer survival was associated with male gender, increasing stage, higher grade, comorbidity, lower socioeconomic status, and lack of receipt of surgery or chemotherapy. CONCLUSIONS: Young people make up a small minority of patients with colorectal cancer. Young patients present with more locally advanced colorectal cancer. Despite this, on a population basis, their prognosis may be more favorable than their older counterparts when controlling for disease, patient, and treatment factors.

The location of surgical care for rural patients with rectal cancer: patterns of treatment and patient perspectives.

BACKGROUND: Where cancer patients receive surgical care has implications on policy and planning and on patients' satisfaction and outcomes. We conducted a population- based analysis of where rectal cancer patients undergo surgery and a qualitative analysis of rectal cancer patients' perspectives on location of surgical care. METHODS: We reviewed Manitoba Cancer Registry data on patients with colorectal cancer (CRC) diagnosed between 2004 and 2006. We interviewed rural patients with rectal cancer regarding their preferences and the factors they considered when deciding on treatment location. Interview data were analyzed using a grounded theory approach. RESULTS: From 2004 to 2006, 2086 patients received diagnoses of CRC in Manitoba (colon: 1578, rectal: 508). Among rural patients (n = 907), those with rectal cancer were more likely to undergo surgery at an urban centre than those with colon cancer (46.5% v. 28.8%, p < 0.001). Twenty rural patients with rectal cancer participated in interviews. We identified 3 major themes from the interview data: the decision-maker, treatment factors and personal factors. Participants described varying input into referral decisions, and often they did not perceive a choice regarding treatment location. Treatment factors, including surgeon factors and hospital factors, were important when considering treatment location. Personal factors, including travel, support, accommodation, finances and employment, also affected participants' treatment experiences. CONCLUSION: A substantial proportion of rural patients with rectal cancer undergo surgery at urban centres. The reasons are complex and only partly related to patient choice. Further studies are required to better understand cancer system access in geographically dispersed populations and to support cancer patients through the decision-making and treatment processes.

CONTEXTE: Le lieu où les patients atteints du cancer subissent une intervention chirurgicale a des répercussions sur les politiques et la planification, et sur la satisfaction du patient et ses résultats. Nous avons étudié dans une population le lieu où des patients atteints de cancer du rectum subissent leur chirurgie et effectué une analyse qualitative des points de vue exprimés par les patients au sujet du lieu où les soins chirurgicaux sont dispensés. MÉTHODES: Nous avons consulté le Registre du cancer du Manitoba pour trouver des données sur des patients atteints de cancer colorectal diagnostiqué entre 2004 et 2006. Nous avons interviewé des patients de régions rurales atteints de cancer du rectum pour connaître leurs préférences et les facteurs dont ils avaient tenu compte en choisissant le lieu où ils allaient être traités. Nous avons analysé les données recueillies à l'aide d'une méthode théorique fondées sur les faits. RÉSULTATS: Entre 2004 et 2006, au Manitoba, 2086 patients ont reçu un diagnostic de cancer colorectal (cancer du côlon : 1578; cancer du rectum : 508). Parmi les patients qui vivaient en milieu rural (n = 907), ceux atteints d'un cancer du rectum avaient plus tendance à subir leur chirurgie dans un établissement urbain que ceux atteints de cancer du côlon (46,5 % c. 28,8 %, p < 0,001). Vingt patients de milieu rural atteitns de cancer du rectum ont participé aux entrevues. Trois principaux éléments se dégagent des données recueillies : le décideur, des facteurs reliés au traitement et des facteurs d'ordre personnel. Les participants ont décrit diverses contributions qu'ils ont apportées à la décision relative à la référence de leur cas et dit que souvent, ils n'ont pas senti qu'un choix de lieux de traitement leur était offert. Les facteurs liés au traitement lui-même, y compris ceux liés au chirurgien et à l'hôpital, ont été importants dans le choix du lieu de traitement. Les facteurs d'ordre personnel, dont le déplacement, le soutien, l'hébergement, la situation financière et l'emploi ont aussi influé sur l'expérience thérapeutique des participants. CONCLUSION: Une proportion considérable de patients atteints du cancer du rectum et vivant en milieu rural subissent leur chirurgie dans des établissements urbains. Les raisons sont complexes et ne sont qu'en partie reliées au choix du patient. Il faudrait mener d'autres études pour mieux comprendre l'accès aux services offerts aux personnes atteintes de cancer dans les populations géographiquement dispersées et pour les appuyer dans le processus de prise de décision et de traitement.

A RAND/UCLA appropriateness study of the management of familial gastric cancer.

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.

Geographical disparities of rectal cancer local recurrence and outcomes: a population-based analysis.

BACKGROUND: Challenges exist in providing high-quality cancer treatments to populations spread over large geographical areas. Local recurrence of rectal cancer is a complicated clinical problem associated with high morbidity and mortality. OBJECTIVES: objectives of this study were to evaluate population-based rates and predictors of local recurrence of rectal cancer in the Province of Manitoba, Canada, with emphasis on the effects of geography. DESIGN: : This was a population-based retrospective analysis. Administrative data from the Manitoba Cancer Registry and individual patient charts were reviewed. SETTINGS: Patients with stages I to III rectal cancer who underwent surgery with curative intent in Manitoba between 2004 and 2006 were included. MAIN OUTCOME MEASURES: The primary outcome was the development of local recurrence after surgical resection. RESULTS: Three hundred seventy patients with a mean age of 67 years were identified. The 5-year local recurrence rate was 17.4%. In multivariate analysis, relative to Winnipeg residents, rural residents, regardless of where they underwent surgery, had an increased risk of local recurrence (HR, 3.47; 95% CI, 1.74-6.92 for surgery in Winnipeg; HR, 2.98; 95% CI, 1.59-5.57 for surgery in rural Manitoba). The absence of both neoadjuvant radiotherapy and adjuvant chemotherapy was associated with a higher risk of local recurrence. Higher risk of mortality was noted for rural patients (HR, 1.90; 95% CI, 1.24-2.89) and for those who developed local recurrence (HR, 2.01; 95% CI, 1.27-3.19). CONCLUSION: Local recurrence rates for rectal cancer are high in Manitoba. Geography is an important variable, because rural status is associated with higher local recurrence rates and decreased survival. The use of neoadjuvant radiotherapy was an important predictor of lower local recurrence rates. Further initiatives are imperative to identify why rural patients experience differences in outcomes in Manitoba.

Longer waiting times for patients undergoing colorectal cancer surgery are not associated with decreased survival.

BACKGROUND AND OBJECTIVES: Wait times are a growing concern in Canada's publicly-funded healthcare system. We sought to determine if increased wait times for colorectal cancer (CRC) treatments resulted in worse outcomes. METHODS: A population-based retrospective cohort analysis of wait times for CRC patients undergoing major surgical resections in Manitoba, Canada, between 2004 and 2006 was undertaken. Administrative records were utilized to estimate total wait time (TWT), defined as the sum of time from index contact with the healthcare system to diagnosis of CRC (diagnostic wait time [DWT]) and the time from diagnosis to first cancer treatment (treatment wait time [TxWT]). Multivariate Cox regression analysis of 5-year overall survival was performed to determine the effect of TWT quartiles on survival. RESULTS: One thousand six hundred twenty eight patients with stage I-IV CRC underwent major surgery with a median TWT of 95 days. Predictors of lower 5-year survival included advanced age, higher stage, lower economic status, increased medical comorbidity, urgent presentation, living between 101 and 500 km from the Provincial cancer center, and not receiving adjuvant chemotherapy. After controlling for these variables, TWT quartiles were not associated with survival (P = 0.4898). CONCLUSIONS: On a population basis, increased TWT was not associated with worse survival, while controlling for important confounders.

Does geography influence the treatment and outcomes of colorectal cancer? A population-based analysis.

BACKGROUND: The Canadian province of Manitoba covers a large geographical area but only has one major urban center, Winnipeg. We sought to determine if regional differences existed in the quality of colorectal cancer care in a publicly funded health care system. METHODS: This was a population-based historical cohort analysis of the treatment and outcomes of Manitobans diagnosed with colorectal cancer between 2004 and 2006. Administrative databases were utilized to assess quality of care using published quality indicators. RESULTS: A total of 2,086 patients were diagnosed with stage I to IV colorectal cancer and 42.2% lived outside of Winnipeg. Patients from North Manitoba had a lower odds of undergoing major surgery after controlling for other confounders (odds ratio (OR): 0.48, 95% confidence interval (CI): 0.26 to 0.90). No geographic differences existed in the quality measures of 30-day operative mortality, consultations with oncologists, surveillance colonoscopy, and 5-year survival. However, there was a trend towards lower survival in North Manitoba. CONCLUSION: We found minimal differences by geography. However, overall compliance with quality measures is low and there are concerning trends in North Manitoba. This study is one of the few to evaluate population-based benchmarks for colorectal cancer therapy in Canada.

Management of primary rectal cancer by surgeons in Atlantic Canada: results of a regional survey.

BACKGROUND: We sought to determine the current practice patterns of general surgeons in Atlantic Canada in the management of primary rectal cancer in relation to surgeon-specific variables. METHODS: We sent mail-out surveys to all practising general surgeons (n = 183) in Atlantic Canada to determine screening preferences, preoperative assessment, the use of neoadjuvant and adjuvant therapy, surgical therapy for rectal cancer and surgeon demographics. We analyzed the responses using χ(2) tests. RESULTS: The response rate was 98 (54%) after 2 mail-outs; there were 82 (49%) eligible responses. Surgeons in practice for 21 years or more were more likely than those with fewer than 21 years of practice to order preoperative ultrasonography of the liver and were less likely to order preoperative computed tomography. Endorectal ultrasonography was ordered routinely by 23% of surgeons, whereas 71% of surgeons would order it if time and resources were available. Surgeons who were not certified by the Royal College of Physicians and Surgeons of Canada were significantly more likely than those who were certified to use neoadjuvant therapy in all patients with rectal cancer (43% v. 12%; p = 0.031). Surgeons who performed more than 10 rectal cancer surgeries per year were significantly more likely than those who performed 10 or fewer surgeries per year to use neoadjuvant treatment for T3 tumours (94% v. 61%; p = 0.007). Surgeons with medical or radiation oncology services in their communities were significantly more likely than those without such services to recommend neoadjuvant treatment in T3 rectal tumours and rectal tumours with pathologic lymph nodes. CONCLUSION: We found significant variation in the management of rectal cancer depending on surgeon-specific variables. The implications of these differences on the outcomes of patients with rectal cancer are unknown.

The history of women in surgery.

The history of women in surgery in Western civilization dates to 3500 before common era (BCE) and Queen Shubad of Ur. Ancient history reveals an active role of women in surgery in Egypt, Italy and Greece as detailed in surgical texts of the time. During the middle ages, regulations forbade women from practising surgery unless they assumed their husbands' practices upon their deaths or unless they were deemed fit by a "competent" jury. King Henry VIII proclaimed that "No carpenter, smith, weaver or women shall practise surgery." The modern period of surgery opens with women impersonating men to practise medicine and surgery (Dr. Miranda Stewart). The first female physicians (Dr. Elizabeth Blackwell and Dr. Emily Jennings Stowe) and surgeons (Dr. Mary Edwards Walker and Dr. Jennie Smillie Robertson) in North America found it difficult to obtain residency education after completing medical school. Dr. Jessie Gray was Canada's "First Lady of Surgery" and the first woman to graduate from the Gallie program at the University of Toronto in the 1940s. Currently, the ratio of women in surgical training is far less than that of women in medical school. The reasons that women choose surgery include appropriate role models and intellectual/technical challenge. Lack of mentorship and lifestyle issues are the strongest deterrents. Consideration of a "controllable lifestyle" by surgical administrators will help with the recruitment of women into surgery.

Canadian Association of University Surgeons annual symposium: Continuity of care: Toronto, Ontario, Sep. 6, 2007.

This 2007 symposium of the Canadian Association of University Surgeons brought together surgeons from a number of jurisdictions to discuss the challenges and opportunities that reduced physician work hours will bring to the care of the surgical patient. Dr. Brian Taylor, president of the association, underscored the need to find a balance between the benefits of diminished workloads/work hours and the loss of continuity of care. He opined that Canada needs to learn from our European colleagues' experience. Dr. Per-Olof Nyström, professor of surgery, presented the modern Swedish model of surgical care, which had to be developed as a consequence of the European Union's legal restrictions on the amount of time an individual surgeon may work. Sweden employs a team-based shared-care model driven by the individual surgeon's expertise rather than the "village factory" model of the multiskilled, multitasking approach of surgical care more prevalent in Canada. Dr. Chris de Gara, secretary treasurer of the association, presented the evidence base for (and against) work-hour restrictions and how well-designed systems can ensure effective continuity of care. Dr. Stewart Hamilton illustrated how one such system for the delivery of the emergency general surgical services has evolved at the University of Alberta Hospital, which demonstrated its effectiveness in providing quality surgical continuity of care. Dr. Debrah Wirtzfeld underscored the importance of trainee lifestyle and how modern Web-based technologies can ensure reduced errors with the implementation of a "sign-out" system.

Concordance with clinical practice guidelines for adjuvant chemotherapy in patients with stage I-III colon cancer: experience in 2 Canadian provinces.

BACKGROUND: Clinical practice guidelines (CPGs) for the adjuvant treatment of colorectal cancer were published by the National Institutes of Health in 1991. The American Society of Clinical Oncology and Cancer Care Ontario have recommended adjuvant chemotherapy for patients with high-risk stage II colon cancer. We evaluated differences in concordance with guidelines in the treatment of patients with stage I-III colon cancer in the Canadian provinces of Newfoundland and Labrador and Ontario. METHODS: We assessed clinical data and treatment from January 1999 to December 2000 for 130 patients from Newfoundland and Labrador and 315 patients from Ontario who had stage I-III colon cancer. The primary outcome was concordance with guidelines for adjuvant treatment. We evaluated factors affecting the use of chemotherapy in patients with stage II disease. RESULTS: No patients received adjuvant therapy for stage I disease. Forty-five of 52 patients (87%) in Newfoundland and Labrador and 108 of 115 patients (94%) in Ontario received adjuvant chemotherapy for stage III colon cancer. Twenty of 55 patients (36%) in Newfoundland and Labrador and 44 of 116 patients (38%) in Ontario received adjuvant therapy for stage II disease. Eighteen of 41 patients (44%) in Newfoundland and Labrador and 30 of 53 patients (57%) in Ontario with high-risk features received adjuvant treatment, which was significantly higher than patients without high-risk features. There was a strong trend toward using chemotherapy in patients with stage II disease who were 50 years or younger, independent of high-risk status. CONCLUSION: Concordance with CPGs for adjuvant chemotherapy in patients with stage II colon cancer was not optimal. This may reflect selection bias among referring surgeons, a paucity of level-I evidence and the belief that other factors such as age may play a role in predicting outcome.

Predictors of multivisceral resection in patients with locally advanced colorectal cancer.

BACKGROUND: Practice guidelines recommend en bloc multivisceral resection (MVR) for all involved organs in patients with locally advanced adherent colorectal cancer (LAACRC) to reduce local recurrence and improve survival. We found that MVR was performed in one-third of eligible American patients in the Surveillance, Epidemiology and End Results cancer registry but that study could not identify factors amenable to quality improvement. This study was conducted to examine rates, and predictors of MVR among Canadian patients with LAACRC. METHODS: Rates of MVR were examined by observational study. Eligible patients were aged 20-74 years who had surgery for nonmetastatic LAACRC from July 1997 to December 2000. Patient, tumor, surgeon, and hospital characteristics were extracted from medical records. Summary statistics were compared by type of surgery (MVR, partial MVR, standard resection). To identify factors associated with MVR we analyzed operative notes and transcripts from interviews with general surgeons using standard qualitative methods. RESULTS: Factors associated with MVR included fewer years in practice, preoperative treatment planning, involvement of surgical consultants, and access to diagnostic imaging and systems to enable preoperative multidisciplinary planning. Judgments regarding the nature of peritumoral adhesions, resectability, and personal technical skill may mediate decision-making. Many surgeons would prefer to refer patients than undertake complicated, lengthy cases. CONCLUSION: Further research is required to validate these findings in larger studies and among patients undergoing surgery for conditions other than LAACRC, and evaluate strategies to improve rates of MVR through enhanced individual awareness and system capacity.

Hereditary diffuse gastric cancer: prophylactic surgical oncology implications.

Hereditary diffuse gastric cancer (HDGC) is an autosomal dominantly inherited syndrome attributed to mutations of the E-cadherin gene, CDH1. There is no proven effective screening for early HDGC, and symptomatic disease is almost universally fatal. The only available effective option for CDH1 carriers is prophylactic total gastrectomy, but the variable age of onset of HDGC and the reduced penetrance (about 70%) of the CDHI gene further complicate patients' decision making.

Viability of endoscopic and excisional treatment of early rectal carcinoids.

With the advent of endoscopy, the incidence of rectal carcinoid tumors has not only risen, but the majority are localized at presentation. This has led to excisional and/or ablative therapy in lieu of radical resections. A single institute's experience with rectal carcinoids was reviewed to determine the impact this approach has had on outcomes, and evaluate any selection criteria for optimizing patient survival. A single institute's tumor registry was retrospectively queried, identifying 14 patients with rectal carcinoid tumors over a 28-year period. The mean age at diagnosis was 52.1 +/- 14.4 years. Six of the 14 patients were female. Presenting symptoms included a change in bowel habits in six (38%), rectal bleeding in six (38%), and abdominal pain or distention in five (31%) patients. No patient had symptoms consistent with carcinoid syndrome. The rectal carcinoids were a mean 9.2 +/- 3.4 cm from the anal verge and a mean 9 +/- 6 mm in size. Endoscopic and/or transanal excision/fulguration techniques treated 11 (79%) patients, whereas two (14%) patients underwent a low anterior resection (LAR). Surveillance entailed periodic endoscopy for a median 65 months (range 8-281). No patient developed recurrent carcinoid disease for a 20-year overall survival of 70%.

Founder and recurrent CDH1 mutations in families with hereditary diffuse gastric cancer.

CONTEXT: Hereditary diffuse gastric cancer is caused by germline mutations in the epithelial cadherin (CDH1) gene and is characterized by an increased risk for diffuse gastric cancer and lobular breast cancer. OBJECTIVE: To determine whether recurring germline CDH1 mutations occurred due to independent mutational events or common ancestry. DESIGN, SETTING, AND PATIENTS: Thirty-eight families diagnosed clinically with hereditary diffuse gastric cancer were accrued between November 2004 and January 2006 and were analyzed for CDH1 mutations as part of an ongoing study at the British Columbia Cancer Agency. Twenty-six families had at least 2 gastric cancer cases with 1 case of diffuse gastric cancer in a person younger than 50 years; 12 families had either a single case of diffuse gastric cancer diagnosed in a person younger than 35 years or multiple cases of diffuse gastric cancer diagnosed in persons older than 50 years. MAIN OUTCOME MEASURES: Classification of family members as carriers or noncarriers of CDH1 mutations. Haplotype analysis to assess recurring mutations for common ancestry was performed on 7 families from this study and 7 previously reported families with the same mutations. RESULTS: Thirteen mutations (6 novel) were identified in 15 of the 38 families (40% detection rate). The 1137G>A splicing mutation and the 1901C>T (A634V) missense/splicing mutation occurred on common haplotypes in 2 families but on different haplotypes in a third family. The 2195G>A (R732Q) missense/splicing mutation occurred in 2 families on different haplotypes. The 2064-2065delTG mutation occurred on a common haplotype in 2 families. Two families from this study plus 2 additional families carrying the novel 2398delC mutation shared a common haplotype, suggesting a founder effect. All 4 families originate from the southeast coast of Newfoundland. Due to concentrations of lobular breast cancer cases, 2 branches of this family had been diagnosed as having hereditary breast cancer and were tested for BRCA mutations. Within these 4 families, the cumulative risk by age 75 years in mutation carriers for clinically detected gastric cancer was 40% (95% confidence interval [CI], 12%-91%) for males and 63% (95% CI, 19%-99%) for females and the risk for breast cancer in female mutation carriers was 52% (95% CI, 29%-94%). CONCLUSIONS: Recurrent CDH1 mutations in families with hereditary diffuse gastric cancer are due to both independent mutational events and common ancestry. The presence of a founder mutation from Newfoundland is strongly supported.

National survey of mentorship in Canadian general surgery residency programs: Where are we and what do we need?

BACKGROUND: The benefits of mentorship on residents are well established. The current state of mentorship in General Surgery (GS) residency programs in Canada is unknown. The objectives of this study were to obtain GS residents' and program directors' (PD) perspectives on resident mentorship. STUDY DESIGN: An electronic survey was developed and distributed to all 601 GS residents in Canada. All 17 PDs were invited for telephone interviews. RESULTS: A total of 179 of the 601 residents responded. Ninety-seven percent (n=173) felt mentorship was important. Only 67% (n=116) identified a mentor and only 53% (n=62) reported a mentorship program. Most who identified a mentor (n=87/110, 79%) were satisfied with the mentorship received. Significant variations in mentorship existed between demographic subgroups and mentorship program types. Overall, residents (n=121, 74%) favoured having a required mentorship program.A total of 11 out of 17 PDs participated in the telephone interviews. The majority of PDs (n=9, 82%) were satisfied with current resident mentorship but most acknowledged that barriers exist (n=8, 73%). CONCLUSION: GS programs in Canada should ensure they are providing equal opportunities for mentorship across demographic subgroups. Programs are encouraged to examine both their program's and their residents' needs as well as local barriers to improve mentorship.

In their own words: describing Canadian physician leadership.

Purpose This is the first study to compile statistical data to describe the functions and responsibilities of physicians in formal and informal leadership roles in the Canadian health system. This mixed-methods research study offers baseline data relative to this purpose, and also describes physician leaders' views on fundamental aspects of their leadership responsibility. Design/methodology/approach A survey with both quantitative and qualitative fields yielded 689 valid responses from physician leaders. Data from the survey were utilized in the development of a semi-structured interview guide; 15 physician leaders were interviewed. Findings A profile of Canadian physician leadership has been compiled, including demographics; an outline of roles, responsibilities, time commitments and related compensation; and personal factors that support, engage and deter physicians when considering taking on leadership roles. The role of health-care organizations in encouraging and supporting physician leadership is explicated. Practical implications The baseline data on Canadian physician leaders create the opportunity to determine potential steps for improving the state of physician leadership in Canada; and health-care organizations are provided with a wealth of information on how to encourage and support physician leaders. Using the data as a benchmark, comparisons can also be made with physician leadership as practiced in other nations. Originality/value There are no other research studies available that provide the depth and breadth of detail on Canadian physician leadership, and the embedded recommendations to health-care organizations are informed by this in-depth knowledge.