Comparing Time to Diagnosis and Treatment Between Younger and Older Adults With Colorectal Cancer: A Population-Based Study.

BACKGROUND & AIMS: Younger adults (aged <50 years) with colorectal cancer (CRC) may have prolonged delays to diagnosis and treatment that are associated with adverse outcomes. We compared delay intervals by age for patients with CRC in a large population. METHODS: This was a population-based study of adults diagnosed with CRC in Ontario, Canada, from 2003 to 2018. We measured the time between presentation and diagnosis (diagnostic interval), diagnosis and treatment start (treatment interval), and the time from presentation to treatment (overall interval). We compared interval lengths between adults aged <50 years, 50 to 74 years, and 75 to 89 years using multivariable quantile regression. RESULTS: Included were 90,225 patients with CRC. Of these, 6853 patients (7.6%) were aged <50 years. Younger patients were more likely to be women, present emergently, have stage IV disease, and have rectal cancer compared with middle-aged patients. Factors associated with significantly longer overall intervals included female sex (8.7 days; 95% confidence interval [CI], 6.6-10.9 days) and rectal cancer compared with proximal colon cancer (9.8 days; 95% CI, 7.4-2.2 days). After adjustment, adults aged <50 years had significantly longer diagnostic intervals (4.3 days; 95% CI. 1.3-7.3 days) and significantly shorter treatment intervals (-4.5 days; 95% CI, -5.3 to -3.7 days) compared with middle-aged patients. However, there was no significant difference in the overall interval (-0.6 days; 95% CI, -4.3 to 3.2 days). In stratified models, younger adults with stage IV disease who presented emergently and patients aged >75 years had longer overall intervals. CONCLUSIONS: Younger adults present more often with stage IV CRC but have overall similar times from presentation to treatment as screening-eligible older adults.

Long-term survival in elderly women receiving chemotherapy for non-metastatic breast cancer: a population-based analysis.

BACKGROUND: Older women are poorly represented in trials evaluating chemotherapy for breast cancer (BC). This study aimed to describe survival and associated factors among elderly women receiving chemotherapy for non-metastatic BC. METHODS: This was a population-based cohort study including women ≥ 70 years old diagnosed with invasive, non-metastatic BC from 2010 to 2017 in SEER. Among those who received chemotherapy, overall survival (OS) was determined using Kaplan-Meier curves and hazard ratios were reported with 95% confidence intervals (CIs). Adjustment was made for available confounders. Co-morbidity is not available in SEER. BC-specific survival (BCSS) and subdistribution hazard ratios were determined using competing risks analysis. RESULTS: The cohort consisted of 109,239 women aged 70+, of whom 17,961 (16%) received chemotherapy. Chemotherapy patients were younger (median 73.0 years vs. 77.0), had more advanced disease (25% stage III vs. 5.2%), and were more likely to receive mastectomy (50% vs. 33%). Among chemotherapy patients, 5-year OS was 77.8% (95% CI 76.9-78.6%), and for women 80+ was 60.2% (95% CI 57.5-63.1%). More recent diagnoses, no previous history of cancer, and receipt of radiotherapy were all associated with improved BCSS. Conversely, older age, higher tumour grade, advanced stage, and human epidermal growth factors receptor (HER)2 negative tumours were associated with worse BCSS. 56% of deaths were due to BC, and women aged 80+ had worse BCSS compared to those aged 70-79 (adjusted sdHR 1.62, 95% CI 1.43-1.84). CONCLUSIONS: Elderly women with advanced disease can achieve good survival after chemotherapy for non-metastatic BC. Those with HER2+ disease have superior survival, reinforcing benefit in this population.

Patient opinions on contralateral prophylactic mastectomy: A patient-driven discussion in need of tuning?

BACKGROUND: Rates of contralateral prophylactic mastectomy (CPM) are increasing among women with unilateral breast cancer despite low rates of contralateral recurrence and lack of survival benefit. We aimed to investigate the decisional needs and supports required to ensure adequate and quality decision-making by patients with breast cancer facing the decision regarding CPM. METHODS: In this qualitative study, we used semistructured interviews developed with the use of the Ottawa Decision Support Framework to investigate the decisional needs and supports of women (aged > 18 yr) with nonhereditary breast cancer who had previously discussed CPM with their care provider. Patients were recruited from 2 academic cancer centres in Toronto, Ontario. Interviews were conducted between June 2016 and October 2017. We analyzed responses to the open-ended questions iteratively and inductively to establish major themes within the results. RESULTS: Ten patients were recruited. Eight patients reported having initiated the discussion about CPM. Although most patients reported feeling supported, 6 mentioned some degree of decisional conflict. Cancer risk reduction was the most commonly reported perceived benefit of CPM (9 patients), followed by improved psychologic well-being (7). Most patients (8) did not mention the lack of survival benefit of CPM as a disadvantage of the procedure. Patients indicated that information resources (in 8 cases) and improved counselling from their health care team (in 7) would assist in decision-making. CONCLUSION: Our findings illustrate the disconnect between true and perceived risks (i.e., surgical risk) and benefits (potential recurrence and survival benefit) of CPM, which is not being managed adequately despite support from the health care team. A decision aid may address unmet patient need by providing a reliable resource regarding the benefits and risks of this procedure, while helping patients understand their values and realign their expectations.

Challenges in Cross-Cultural Communication in Breast Cancer Surgery: Is there a Gender Gap?

The aim of this study is to identify [1] facilitators and barriers to cross-cultural communication with Canadian immigrants during the breast cancer (BC) surgical consultation and [2] the impact of cultural sensitivity training on the perception of cross-cultural communication barriers. A 29-item questionnaire mailed to 450 surgeons was developed based on the Ottawa Decision Support Framework, informed by interviews with BC practitioners and a literature review. The inclusion criteria are English-speaking general surgeons practicing in Vancouver, Montréal, and Toronto, home to > 60% of Canada's immigrant population. The association between surgeon characteristics and barriers to communication was assessed using the chi-square or Fisher's exact test. Univariate and multivariable logistic regression models estimated odds ratios and 95% confidence intervals for the association between frequent perception of each barrier to communication and gender, career stage, and percentage of foreign-born patients. Between June and September 2017, 130 surveys were returned for a 29% response rate. The majority of practitioners reported experiencing language barriers in consultation with immigrant patients (71.4%). In the patient-provider relationship, the most commonly reported barrier was the patient's lack of medical understanding (81.4%). At the system level, the absence of a relative for translation was the most frequently encountered challenge (77.1%). On multivariable analysis adjusting for career stage and percentage of foreign-born patients, female gender of a surgeon was associated with more frequent perception of barriers related to language (OR 4.91, [95% CI 1.43, 16.82; p = 0.0114]), the patient's desired role in decision-making (OR 3.000 [95% CI 1.116-8.059; p = 0.0294]), and poor access to interpreters (OR 3.63 [95% CI 1.24, 10.64; p = 0.0189]). Furthermore, on multivariable analysis adjusting for gender and career stage, surgeons identified as having < 25% foreign-born patients in their practice were less likely to identify communication barriers due to the patients' perception and understanding of their healthcare (OR 0.32 [95% CI 0.11, 0.95; p = 0.041]). Cultural sensitivity training did not appear to be an influential factor though this may be due to the low number of surgeons who received training (5.7%). There are multiple cross-cultural communication challenges. Gender, years in practice, and the cultural diversity of a practice might play significant roles in the identification and perception of these barriers.

Psychological consequences of MRI-based screening among women with strong family histories of breast cancer.

PURPOSE: MRI-based screening in women with a ≥ 25% lifetime risk of breast cancer , but no identifiable genetic mutations may be associated with false positives. This study examined the psychological impact of abnormal screens and biopsies in non-mutation carriers participating in high-risk screening with no personal history of breast cancer. METHODS: Non-mutation carriers participating in the High-Risk Ontario Breast Screening Program at two sites were mailed demographic surveys, psychological scales, and chart review consent. Scales included the Consequences of Screening in Breast Cancer questionnaire, Lerman Breast Cancer Worry Scale, and Worry Interference Scale. Missing data were managed with multiple imputation. Multivariable regression was used to assess whether abnormal screens or biopsies were associated with adverse psychological effects. RESULTS: After contacting 465 participants, 169 non-mutation carriers were included. Median age was 46 years (range 30-65). Over a median 3 years of screening, 63.9% of women experienced at least one abnormal screen, and 24.9% underwent biopsies. Statements relating to cancer worry/anxiety scored highest, with 19.5% indicating they worried "a lot". Higher scores among anxiety-related statements were strongly associated with higher dejection scores. Overall, coping and daily functioning were preserved. Women indicated some positive reactions to screening, including improved existential values and reassurance they do not have breast cancer. Abnormal screens and biopsies were not significantly associated with any psychological scale, even after adjustment for patient characteristics. CONCLUSION: Non-mutation carriers undergoing MRI-based screening had considerable baseline anxiety and cancer worry, although daily functioning was not impaired. Abnormal screens and biopsies did not appear to have adverse psychological effects.

Abnormal screens among nonmutation carriers in the High Risk Ontario Breast Screening Program.

BACKGROUND: The Ontario Breast Screening Program was expanded in 2011 to offer annual MRI and mammography to women with high-risk genetic mutations (e.g., BRCA1/2) and women with strong family histories and ≥25% estimated lifetime risk of breast cancer. Data to support high-risk screening is less clear in the nonmutation carrier group, as MRI has lower specificity among this population. The potential unintended consequences may be considerable and need to be explored. We aimed to describe the frequency of abnormal screens and biopsies. METHODS: Demographic surveys and chart review consent were sent to a sample of 441 individuals enrolled in a high-risk screening program at two tertiary care hospitals in Toronto, Ontario. Retrospective cross-sectional chart review was undertaken for clinicopathologic data. The frequencies of abnormal screens and biopsies were calculated. RESULTS: One hundred sixty-nine nonmutation carriers were included. The majority were white, employed, and highly educated. The median International Breast Cancer Intervention Study lifetime risk of breast cancer was 28.0% (range 24.5%-89.0%). 108 individuals (64%) experienced at least 1 abnormal screen and 13 (8%) had 3 or more over a median 3 years of screening (range 1-6 years). Of 55 biopsies, 3 (5.5%) were malignant. The cancer detection rate was 8.4/1000 screens (95% CI 3.2-22.4). CONCLUSIONS: An MRI-based screening program for nonmutation carriers was effective at diagnosing breast cancer. However, this population experienced a high rate of abnormal screens and intervention. Further research is needed to improve the performance of MRI-based screening in these women.

Comparing Observation, Axillary Radiotherapy, and Completion Axillary Lymph Node Dissection for Management of Axilla in Breast Cancer in Patients with Positive Sentinel Nodes: A Systematic Review.

PURPOSE: Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND) for management of positive sentinel nodes (SNs) in clinically node-negative women with breast cancer. The optimal treatment strategy for this population is not known. METHODS: MEDLINE, Embase, and EBM Reviews-NHS Economic Evaluation Database were searched from inception until July 2019. A systematic review and narrative summary was performed of RCTs comparing observation or ART versus cALND in clinically node-negative female breast cancer patients with positive SNs. The Cochrane risk of bias tool for RCTs was used to assess risk of bias. Outcomes of interest included overall survival (OS), disease-free survival (DFS), axillary recurrence, and axillary surgery-related morbidity. RESULTS: Three trials compared observation with cALND, and two trials compared ART with cALND. No studies blinded participants or personnel, and there was heterogeneity in inclusion criteria, study design, and follow-up. Neither observation nor ART resulted in statistically inferior 5- or 8-year OS or DFS compared with cALND. There was also no statistically significant increase in axillary recurrences associated with either approach. Four trials reported morbidity outcomes, and all showed cALND was associated with significantly more lymphedema, paresthesia, and shoulder dysfunction compared with observation or ART. CONCLUSIONS: Women with clinically node-negative breast cancer and positive SNs can safely be managed without cALND.

Practitioner Opinion on Contralateral Prophylactic Mastectomy: How Do We Steer a Patient-Driven Discussion?

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is increasing despite a recent statement from The American Society of Breast Surgeons discouraging average-risk women with unilateral breast cancer (BC) from undergoing CPM. The objective of our study was to conduct a needs assessment of BC health practitioners to gather information about their opinions, attitudes, and experiences surrounding CPM. METHODS: The Ottawa Decision Support Framework was the theoretical framework for the development of the interview guide. Semistructured interviews were conducted until data saturation with a convenience sample of 16 BC practitioners (Ontario, Canada), including oncologic and reconstructive surgeons, medical oncologists, and nurse navigators. RESULTS: Nearly all practitioners identified the discussion regarding CPM as patient-initiated. The majority of practitioners (13/16) described their role as supporting the patient in the decision-making process. Practitioners described educating patients on the lack of survival benefit and in general discouraging CPM. Practitioners agreed that most patients demonstrate decisional conflict (11/16) as a barrier to decision-making, and it is a challenge to realign patients' understanding and expectations. Almost all practitioners (15/16) identified a need for information materials to help educate patients on the risks and benefits of CPM and to help realign expectations. CONCLUSIONS: Practitioners have identified CPM in average-risk women with unilateral BC as a patient-driven phenomenon that is on the rise, despite highlighting the increased risk of complications and lack of survival benefit. Our practitioner needs assessment identifies the need for a dynamic decision aid to help guide the shared decision-making process for practitioners and patients.

The "Begin Exploring Fertility Options, Risks and Expectations" (BEFORE) decision aid: development and alpha testing of a fertility tool for premenopausal breast cancer patients.

BACKGROUND: Premenopausal breast cancer patients are at risk of treatment-related infertility. Many patients do not receive sufficient fertility information before treatment. As such, our team developed and alpha tested the Begin Exploring Fertility Options, Risks, and Expectations decision aid (BEFORE DA). METHODS: The BEFORE DA development process was guided by the International Patient Decision Aids Standards and the Ottawa Decision Support Framework. Our team used integrated knowledge translation by collaborating with multiple stakeholders throughout the development process including breast cancer survivors, multi-disciplinary health care providers (HCPs), advocates, and cancer organization representatives. Based on previously conducted literature reviews and a needs assessment by our team - we developed a paper prototype. The paper prototype was finalized at an engagement meeting with stakeholders and created into a graphically designed paper and mirrored online decision aid. Alpha testing was conducted with new and previously engaged stakeholders through a questionnaire, telephone interviews, or focus group. Iterative reviews followed each step in the development process to ensure a wide range of stakeholder input. RESULTS: Our team developed an 18-page paper prototype containing information deemed valuable by stakeholders for fertility decision-making. The engagement meeting brought together 28 stakeholders to finalize the prototype. Alpha testing of the paper and online BEFORE DA occurred with 17 participants. Participants found the BEFORE DA usable, acceptable, and most provided enthusiastic support for its use with premenopausal breast cancer patients facing a fertility decision. Participants also identified areas for improvement including clarifying content/messages and modifying the design/photos. The final BEFORE DA is a 32-page paper and mirrored online decision aid ( https://fertilityaid.rethinkbreastcancer.com ). The BEFORE DA includes information on fertility, fertility options before/after treatment, values clarification, question list, next steps, glossary and reference list, and tailored information on the cost of fertility preservation and additional resources by geographic location. CONCLUSION: The BEFORE DA, designed in collaboration with stakeholders, is a new tool for premenopausal breast cancer patients and HCPs to assist with fertility discussions and decision-making. The BEFORE DA helps to fill the information gap as it is a tool that HCPs can refer patients to for supplementary information surrounding fertility.

Post-mastectomy Radiation: Should Subtype Factor into the Decision?

BACKGROUND: Traditional indications do not factor molecular subtype into the decision making for post-mastectomy radiation (PMRT). We sought to determine whether constructed subtype was associated with receipt of PMRT in an academic cancer center and to assess differences in locoregional recurrence (LRR) by constructed subtype. METHODS: Patients treated with mastectomy as the primary surgical therapy were identified. Univariate and stepwise multivariate logistic regression analyses examined the association between covariates and PMRT. Kaplan-Meier estimates for the time to either the earlier of LRR or last follow-up were obtained for each subtype, and Cox proportional hazards regression examined the effect of covariates on time to LRR in both univariate analyses and stepwise multivariate analysis. RESULTS: Overall, 884 patients with invasive breast cancer who underwent a primary mastectomy between January 2002 and May 2012 were included in the study. A total of 359 patients (41.6 %) received PMRT. Compared with other subtypes, triple negative (TN; HR-/HER2-) cancers were more likely to be smaller (95 % T1/T2; p = 0.02) and have a lower nodal burden (N0 65 %; p < 0.0001). On multivariate analysis, age < 50 years, lymphovascular invasion (LVI), T stage, N stage, and close or positive margins remained significantly associated with PMRT, while constructed subtype was not associated with PMRT. Compared with all other subtypes, TN had the highest rate of LRR [hazard ratio (HR) 5.70; p < 0.0001]. On multivariable analysis, TN status, LVI, and not receiving chemotherapy were significantly associated with LRR. CONCLUSIONS: Despite significant differences in LRR by constructed subtype, receptor status does not appear to be associated with the receipt of PMRT. In our series, TN cancers had the highest risk of LRR despite their relatively smaller size and limited nodal disease.

The impact of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction on pancreatic fistula after pancreaticoduodenectomy: meta-analysis of randomized controlled trials.

BACKGROUND: Pancreatic fistula (PF) remains a common source of morbidity following pancreaticoduodenectomy (PD). Despite numerous studies, the optimal method of pancreatic remnant reconstruction is controversial. This study examines the hypothesis that pancreaticogastrostomy (PG) is associated with a lower risk for PF after PD compared with pancreaticojejunostomy (PJ). METHODS: Five electronic databases and the grey literature were searched for randomized controlled trials (RCTs) comparing PJ and PG after PD. Two reviewers independently selected studies, extracted data and assessed methodology. The primary outcome was the occurrence of PF of International Study Group on Pancreatic Fistula (ISGPF) Grade B or C. RESULTS: Four RCTs including 676 patients were included. Pancreaticogastrostomy reduced the risk for PF [relative risk (RR) 0.41, 95% confidence interval (CI) 0.21-0.62] without any difference between high- and low-risk patients. Absolute risk reduction for PF was 4% (95% CI 2.4-5.6) in low-risk patients compared with 10% (95% CI 6.5-14.8) in high-risk patients undergoing PG rather than PJ. The strength of evidence for PF outcome was moderate according to the GRADE classification. CONCLUSIONS: Reconstruction by PG decreases the rate of PF in comparison with PJ. Surgeons should consider reconstructing the pancreatic remnant following PD with PG, particularly in patients at high risk for PF.

Clinical research in surgical oncology: an analysis of ClinicalTrials.gov.

BACKGROUND: The objective of this study was to provide a descriptive analysis of registered clinical trials in surgical oncology at ClinicalTrials.gov. METHODS: Data was extracted from ClinicalTrials.gov using the following search engine criteria: "Cancer" as Condition, "Surgery OR Operation OR Resection" as Intervention, and Non-Industry sponsored. The search was limited to Canada and the United States and included trials registered from January 1, 2001 to January 1, 2011. RESULTS: Of 9,961 oncology trials, 1,049 (10.5%) included any type of surgical intervention. Of these trials, 125 (11.9%, 1.3% of all oncology trials) assessed a surgical variable, 773 (73.7%) assessed adjuvant/neoadjuvant therapies, and 151 (14.4%) were observational studies. Of the trials assessing adjuvant therapies, systemic treatment (362 trials, 46.8%) and multimodal therapy (129 trials, 16.7%) comprised a large focus. Of the 125 trials where surgery was the intervention, 59 trials (47.2%) focused on surgical techniques or devices, 45 trials (36.0%) studied invasive diagnostic methods, and 21 trials (16.8%) evaluated surgery versus no surgery. The majority of the 125 trials were nonrandomized (72, 57.6%). CONCLUSIONS: The number of registered surgical oncology trials is small in comparison to oncology trials as a whole. Clinical trials specifically designed to assess surgical interventions are vastly outnumbered by trials focusing on adjuvant therapies. Randomized surgical oncology trials account for <1% of all registered cancer trials. Barriers to the design and implementation of randomized trials in surgical oncology need to be clarified in order to facilitate higher-level evidence in surgical decision-making.

Analysis of Time to Treatment and Survival Among Adults Younger Than 50 Years of Age With Colorectal Cancer in Canada.

Importance: Colorectal cancer (CRC) is uncommon in adults younger than 50 years of age, so this population may experience delays to treatment that contribute to advanced stage and poor survival. Objective: To investigate whether there is an association between time from presentation to treatment and survival in younger adults with CRC. Design, Setting, and Participants: This retrospective cohort study used linked population-based data in Ontario, Canada. Participants included patients with CRC aged younger than 50 years who were diagnosed in Ontario between 2007 and 2018. Analysis was performed between December 2019 and December 2022. Exposure: Administrative and billing codes were used to identify the number of days between the date of first presentation and treatment initiation (overall interval). Main Outcomes and Measures: The associations between increasing overall interval, overall survival (OS), and cause-specific survival (CSS) were explored with restricted cubic spline regression. Multivariable Cox proportional hazards models were also fit for OS and CSS, adjusted for confounders. Analyses were repeated in a subset of patients with lower urgency, defined as those who did not present emergently, did not have metastatic disease, did not have cross-sectional imaging or endoscopy within 14 days of first presentation, and had an overall interval of at least 28 days duration. Results: Among 5026 patients included, the median (IQR) age was 44.0 years (40.0-47.0 years); 2412 (48.0%) were female; 1266 (25.2%) had metastatic disease and 1570 (31.2%) had rectal cancer. The lower-urgency subset consisted of 2548 patients. The median (IQR) overall interval was 108 days (55-214 days) (15.4 weeks [7.9-30.6 weeks]). Patients with metastatic CRC had shorter median (IQR) overall intervals (83 days [39-183 days]) compared with those with less advanced disease. Five-year overall survival was 69.8% (95% CI, 68.4%-71.1%). Spline regression showed younger patients with shorter overall intervals (<108 days) had worse OS and CSS with no significant adverse outcomes of longer overall intervals. In adjusted Cox models, overall intervals longer than 18 weeks were not associated with significantly worse OS or CSS compared with those waiting 12 to 18 weeks (OS: HR, 0.83 [95% CI, 0.67-1.03]; CSS: HR, 0.90 [95% CI, 0.69-1.18]). Results were similar in the subset of lower-urgency patients, and when stratified by stage. Conclusions and relevance: In this cohort study of 5026 patients with CRC aged younger than 50 years of age in Ontario, time from presentation to treatment was not associated with advanced disease or poor survival. These results suggest that targeting postpresentation intervals may not translate to improved outcomes on a population level.

The myth of informed consent in rectal cancer surgery: what do patients retain?

BACKGROUND: Previous research in colorectal cancer has focused on survival, recurrence, and functional outcomes. Few have assessed the decisional needs of patients or the information patients are retaining from the informed consent process. OBJECTIVES: The aims of this study were to describe the decisional needs of adult patients with rectal cancer when deciding on the surgical treatment of their disease and to identify gaps in patients' recollection of the informed consent discussion. DESIGN: Face-to-face interviews were conducted with the use of a questionnaire based on the validated Ottawa Decision Support Framework Needs Assessment. SETTING: This study was performed at a university-based academic Cancer Assessment Center, in Ottawa, Ontario, Canada. PATIENTS: Adult patients with rectal cancer treated with low anterior resection or abdominoperineal resection were included. MAIN OUTCOME MEASURES: The primary outcomes measured were patients' knowledge and understanding of decision and their decisional needs. RESULTS: Thirty patients were interviewed between November 2009 and July 2010. Eighty percent were male, with a median age of 65. None of the patients perceived having a choice of surgical options. When questioned about the main outcomes of rectal cancer surgery, 47% could not recall a preoperative discussion of risks to bowel function, 47% could not recall a preoperative discussion of risks to sexual function, and 57% could not recall a preoperative discussion of risks to urinary function. Patients would like information regarding functional outcomes, body image, and the immediate postoperative period. A minority of patients desire information regarding cure rate, need for a second surgery, or the ability of surgery to treat their symptoms. Patients would like information that is portable and trusted by their health care team that they can review at their own time. LIMITATIONS: To avoid introducing decisional conflict before surgery, patients were interviewed at the first postoperative visit. Preoperative informed consent discussions were not standardized. CONCLUSION: Despite a comprehensive educational oncology pathway, patients retain little of the informed consent discussion. This study highlights the dichotomy between the outcomes that surgeons and patients value most. The results of this study will guide future efforts to improve informed consent.

Omission of Axillary Staging and Survival in Elderly Women With Early Stage Breast Cancer: A Population-Based Cohort Study.

Objectives: Determine if axillary staging is associated with survival in elderly women with breast cancer. Background: Axillary staging in women ≥ 70 years with early-stage breast cancer is controversial. Older randomized evidence has not shown axillary staging improves survival, but recent observational studies have been mixed and widespread de-implementation of the practice has not occurred. Methods: This was a population-based cohort study using the Surveillance, Epidemiology, and End Results registry. Women ≥ 70 years diagnosed with T1-T2 invasive breast cancer from 2005 to 2015 were included. Overlap propensity score weighting was used to adjust for confounders. Overall survival (OS) was determined and hazard ratios (HRs) reported with 95% confidence intervals (CIs). Breast cancer-specific survival (BCSS) was determined using competing risks analysis and subdistribution hazard ratios (sdHRs) reported. Additional adjustment was performed for receipt of chemotherapy and radiotherapy. Results: One hundred forty-four thousand three hundred twenty-nine elderly women were included, of whom 22,621 (15.7%) did not undergo axillary staging. After overlap propensity score weighting, baseline characteristics were well balanced between the 2 groups. Women who did not undergo axillary staging were significantly less likely to receive chemotherapy (adjusted relative risk, 0.58; 95% CI, 0.54-0.62) or radiotherapy (adjusted relative risk, 0.53; 95% CI, 0.52-0.54), and had significantly worse OS (adjusted HR, 1.22; 95% CI, 1.19-1.25), and BCSS (adjusted sdHR, 1.14; 95% CI, 1.08-1.21) compared to those that had staging. Conclusions: These findings suggest elderly women with early-stage breast cancer who do not undergo axillary staging experience worse outcomes. Reasons for this disparity may be multifactorial and require further investigation.

Measurement of clinical delay intervals among younger adults with colorectal cancer using health administrative data: a population-based analysis.

BACKGROUND: Clinical delays may be important contributors to outcomes among younger adults (<50 years) with colorectal cancer (CRC). We aimed to describe delay intervals for younger adults with CRC using health administrative data to understand drivers of delay in this population. METHODS: This was a population-based study of adults <50 diagnosed with CRC in Ontario, Canada from 2003 to 2018. Using administrative code-based algorithms (including billing codes), we identified four time points along the pathway to treatment-first presentation with a CRC-related symptom, first investigation, diagnosis date and treatment start. Intervals between these time points were calculated. Multivariable quantile regression was performed to explore associations between patient and disease factors with the median length of each interval. RESULTS: 6853 patients aged 15-49 were diagnosed with CRC and met the inclusion criteria. Males comprised 52% of the cohort, the median age was 45 years (IQR 40-47), and 25% had stage IV disease. The median time from presentation to treatment start (overall interval) was 109 days (IQR 55-218). Time between presentation and first investigation was short (median 5 days), as was time between diagnosis and treatment start (median 23 days). The greatest component of delay occurred between first investigation and diagnosis (median 78 days). Women, patients with distal tumours, and patients with earlier stage disease had significantly longer overall intervals. CONCLUSIONS: Some younger CRC patients experience prolonged times from presentation to treatment, and time between first investigation to diagnosis was an important contributor. Access to endoscopy may be a target for intervention.

Time to diagnosis and treatment in younger adults with colorectal cancer: A systematic review.

BACKGROUND: The incidence of colorectal cancer is rising in adults <50 years of age. As a primarily unscreened population, they may have clinically important delays to diagnosis and treatment. This study aimed to review the literature on delay intervals in patients <50 years with colorectal cancer (CRC), and explore associations between longer intervals and outcomes. METHODS: MEDLINE, Embase, and LILACS were searched until December 2, 2021. We included studies published after 1990 reporting any delay interval in adults <50 with CRC. Interval measures and associations with stage at presentation or survival were synthesized and described in a narrative fashion. Risk of bias was assessed using the Newcastle-Ottawa Scale, Institute of Health Economics Case Series Quality Appraisal Checklist, and the Aarhus Checklist for cancer delay studies. RESULTS: 55 studies representing 188,530 younger CRC patients were included. Most studies used primary data collection (64%), and 47% reported a single center. Sixteen unique intervals were measured. The most common interval was symptom onset to diagnosis (21 studies; N = 2,107). By sample size, diagnosis to treatment start was the most reported interval (12 studies; N = 170,463). Four studies examined symptoms onset to treatment start (total interval). The shortest was a mean of 99.5 days and the longest was a median of 217 days. There was substantial heterogeneity in the measurement of intervals, and quality of reporting. Higher-quality studies were more likely to use cancer registries, and be population-based. In four studies reporting the relationship between intervals and cancer stage or survival, there were no clear associations between longer intervals and adverse outcomes. DISCUSSION: Adults <50 with CRC may have intervals between symptom onset to treatment start greater than 6 months. Studies reporting intervals among younger patients are limited by inconsistent results and heterogeneous reporting. There is insufficient evidence to determine if longer intervals are associated with advanced stage or worse survival. OTHER: This study's protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020179707).

Clinical Delays and Comparative Outcomes in Younger and Older Adults with Colorectal Cancer: A Systematic Review.

Outcome disparities between adults <50 with colorectal cancer (CRC) and older adults may be explained by clinical delays. This study synthesized the literature comparing delays and outcomes between younger and older adults with CRC. Databases were searched until December 2021. We included studies published after 1990 reporting delay in adults <50 that made comparisons to older adults. Comparisons were described narratively and stage between age groups was meta-analyzed. 39 studies were included representing 185,710 younger CRC patients and 1,422,062 older patients. Sixteen delay intervals were compared. Fourteen studies (36%) found significantly longer delays among younger adults, and nine (23%) found shorter delays among younger patients. Twelve studies compared time from symptom onset to diagnosis (N younger = 1538). Five showed significantly longer delays for younger adults. Adults <50 years also had higher odds of advanced stage (16 studies, pooled OR for Stage III/IV 1.76, 95% CI 1.52-2.03). Ten studies compared time from diagnosis to treatment (N younger = 171,726) with 4 showing significantly shorter delays for younger adults. All studies showing longer delays for younger adults examined pre-diagnostic intervals. Three studies compared the impact of delay on younger versus older adult. One showed longer delays were associated with advanced stage and worse survival in younger but not older adults. Longer delays among younger adults with CRC occur in pre-diagnostic intervals.