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Cancer Statistics
Population in 2012: 34.7m
People newly diagnosed with cancer (excluding NMSC) / yr: 182,200
Age-standardised rate, incidence per 100,000 people/yr: 295.7
Risk of getting cancer before age 75:29.1%
People dying from cancer /yr: 74,100
Data from IARC GlobalCan (2012)

National Organisations: Canada
Cancer Centers
Latest Research Publications from Canada
Alberta / Northwest Territories
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National Organisations: Canada (19 links)

Cancer Centers (17 links)

Latest Research Publications from Canada

Brunet V, Marouan S, Routy JP, et al.
Retrospective study of intravascular large B-cell lymphoma cases diagnosed in Quebec: A retrospective study of 29 case reports.
Medicine (Baltimore). 2017; 96(5):e5985 [PubMed] Free Access to Full Article Related Publications
INTRODUCTION: Intravascular large B-cell lymphoma (IVL) is an extremely rare malignancy, mainly studied through European and Asian series. Due to the low incidence of this condition, our understanding of the clinical presentation as well as the management of IVL relies on a limited number of patients.We report the largest North American study to date on IVL with 29 cases from Quebec hospital diagnosed between 1990 and 2016. The aim of our study is to describe the clinical presentations, diagnostic and staging procedures, therapeutic management and clinical outcomes of IVL patients in our population and compare the disease phenotype to European and Asian series reported.In our cohort, all patients had stage IV IVL at diagnosis, with a median age of 66.7 years (range 47.2-90.8). Clinical presentation was characterized by constitutional symptoms (100%), poor ECOG-PS (100% ≥ 2), cytopenias (93% anemia), and elevated lactate dehydrogenase (97%) and C-reactive protein (96%). Our cohort presented with mainly cutaneous and neurological symptoms. However, neurological involvement (75.9%) was predominant and no "cutaneous variant" was observed; this differs from European literature, where "classical" IVL is reported with mainly cutaneous involvement. Two of our Caucasian patients presented "Asian variant" IVL; this observation is not unusual, as cases of "classical" IVL have been reported in Asians and "Asian variant" IVL has been reported in Europeans. All patients were classified according to their immunophenotypic features in 3 different subgroups (CD5 or CD5CD10, CD5CD10, CD5CD10) with no difference in outcome. Finally, 62% of our cohort received anthracycline-based chemotherapy and 53% of them achieved a complete response. After a median follow-up of 328 days, OS at 3 years was 42.7% for the entire cohort and 47.4% for the cases with in vivo diagnosis.
CONCLUSION: Unlike European studies on "classical" IVL, our study showed that the French Canadian presentation of this subtype of IVL is more frequently observed with neurological rather than cutaneous involvement. Finally, an early diagnosis is of primary importance since almost a quarter of patients receive a post-mortem diagnosis. A prompt diagnosis allows the introduction of an early treatment, associated with a CR in 53% of patients.

McInnes MD, Nanji S, Mackillop WJ, et al.
Utilization of pre-operative imaging for colon cancer: A population-based study.
J Surg Oncol. 2017; 115(2):202-207 [PubMed] Related Publications
OBJECTIVE: To assess the use of pre-operative imaging for colon cancer and to identify factors associated with utilization in routine clinical practice.
METHODS: This population-based, retrospective cohort study used a random sample of 25% of colon cancer patients treated with surgery in the province of Ontario (2002-2008). Pre-operative imaging (<16 weeks from surgery) of the chest, abdomen-pelvis was identified. Modified poisson regression was used to analyze factors associated with practice patterns.
RESULTS: Of the 7,249 included patients, 48% had pre-operative imaging (CT abdomen and imaging of the chest) in keeping with guideline recommendations. The rate of guideline concordant pre-operative imaging increased over time: 64% in the most recent study period (2006-2008) versus 31% (2002-2004); P < 0.001. Variables associated with use of chest imaging: Age, co-morbidity, surgeon volume, and geographic region; no association with gender, hospital volume, or socio-economic status. Variables associated with use of abdomen imaging: Hospital volume and geographic region; no association with age, gender, comorbidity, socio-economic status, or surgeon volume.
CONCLUSION: In clinical practice, the majority of patients were not receiving pre-operative imaging that was in line with clinical practice guidelines; however, use increased over time indicating a possible association with dissemination of clinical practice guidelines. J. Surg. Oncol. 2017;115:202-207. © 2016 Wiley Periodicals, Inc.

Théberge I, Vandal N, Langlois A, et al.
Detection Rate, Recall Rate, and Positive Predictive Value of Digital Compared to Screen-Film Mammography in the Quebec Population-Based Breast Cancer Screening Program.
Can Assoc Radiol J. 2016; 67(4):330-338 [PubMed] Related Publications
PURPOSE: The study sought to compare performance indicators of computed radiography (CR) using different plate readers, digital direct radiography (DR), and screen-film mammography (SFM) in a population-based screening program.
METHODS: This analysis involved women 50-69 years of age who participated in the breast screening program of Quebec (Canada) and who had screening mammogram between January 1, 2007, and September 30, 2012. The detection rate, recall rate, and positive predictive value of CR (n = 672,125 mammograms) and DR (n = 60,023) were compared to SFM (n = 782,894) using mixed-effect logistic regression, adjusting for potential confounders. No institutional review board approval was required.
RESULTS: CR was not associated with change in cancer detection rate (odds ratio [OR]: 0.95; 95% confidence interval [CI]: 0.88-1.03), but with a small increase in recall rate (OR: 1.03; 95% CI: 1.01-1.06) compared to SFM. The association of CR with recall rate varies with the CR plate reader manufacturer (P < .0001). DR was not associated with change in detection rate (OR: 1.06; 95% CI: 0.89-1.25), but with an increase in the recall rate (OR: 1.25; 95% CI: 1.19-1.30) compared to SFM.
CONCLUSIONS: In our screening program, digital mammograms gave detection rates equivalent to those of SFM, but with an increase of recall rate, particularly for DR. If this situation persists, the adoption of DR may increase the adverse effects of screening with little or no benefit for women.

Larouche G, Chiquette J, Plante M, et al.
Usefulness of Canadian Public Health Insurance Administrative Databases to Assess Breast and Ovarian Cancer Screening Imaging Technologies for BRCA1/2 Mutation Carriers.
Can Assoc Radiol J. 2016; 67(4):308-312 [PubMed] Related Publications
PURPOSE: In Canada, recommendations for clinical management of hereditary breast and ovarian cancer among individuals carrying a deleterious BRCA1 or BRCA2 mutation have been available since 2007. Eight years later, very little is known about the uptake of screening and risk-reduction measures in this population. Because Canada's public health care system falls under provincial jurisdictions, using provincial health care administrative databases appears a valuable option to assess management of BRCA1/2 mutation carriers. The objective was to explore the usefulness of public health insurance administrative databases in British Columbia, Ontario, and Quebec to assess management after BRCA1/2 genetic testing.
METHODS: Official public health insurance documents were considered potentially useful if they had specific procedure codes, and pertained to procedures performed in the public and private health care systems.
RESULTS: All 3 administrative databases have specific procedures codes for mammography and breast ultrasounds. Only Quebec and Ontario have a specific procedure code for breast magnetic resonance imaging. It is impossible to assess, on an individual basis, the frequency of others screening exams, with the exception of CA-125 testing in British Columbia. Screenings done in private practice are excluded from the administrative databases unless covered by special agreements for reimbursement, such as all breast imaging exams in Ontario and mammograms in British Columbia and Quebec. There are no specific procedure codes for risk-reduction surgeries for breast and ovarian cancer.
CONCLUSION: Population-based assessment of breast and ovarian cancer risk management strategies other than mammographic screening, using only administrative data, is currently challenging in the 3 Canadian provinces studied.

Pelletier E, Daigle JM, Defay F, et al.
Frequency and Determinants of a Short-Interval Follow-up Recommendation After an Abnormal Screening Mammogram.
Can Assoc Radiol J. 2016; 67(4):322-329 [PubMed] Related Publications
PURPOSE: After imaging assessment of an abnormal screening mammogram, a follow-up examination 6 months later is recommended to some women. Our aim was to identify which characteristics of lesions, women, and physicians are associated to such short-interval follow-up recommendation in the Quebec Breast Cancer Screening Program.
METHODS: Between 1998 and 2008, 1,839,396 screening mammograms were performed and a total of 114,781 abnormal screens were assessed by imaging only. Multivariate analysis was done with multilevel Poisson regression models with robust variance and generalized linear mixed models.
RESULTS: A short-interval follow-up was recommended in 26.7% of assessments with imaging only, representing 2.3% of all screens. Case-mix adjusted proportion of short-interval follow-up recommendations varied substantially across physicians (range: 4%-64%). Radiologists with high recall rates (≥15%) had a high proportion of short-interval follow-up recommendation (risk ratio: 1.82; 95% confidence interval: 1.35-2.45) compared to radiologists with low recall rates (<5%). The adjusted proportion of short-interval follow-up was high (22.8%) even when a previous mammogram was usually available.
CONCLUSIONS: Short-interval follow-up recommendation at assessment is frequent in this Canadian screening program, even when a previous mammogram is available. Characteristics related to radiologists appear to be key determinants of short-interval follow-up recommendation, rather than characteristics of lesions or patient mix. Given that it can cause anxiety to women and adds pressure on the health system, it appears important to record and report short-interval follow-up and to identify ways to reduce its frequency. Short-interval follow-up recommendations should be considered when assessing the burden of mammography screening.

El-Hage A, Ruel C, Afif W, et al.
Metastatic pattern of invasive lobular carcinoma of the breast-Emphasis on gastric metastases.
J Surg Oncol. 2016; 114(5):543-547 [PubMed] Related Publications
BACKGROUND AND OBJECTIVES: Breast invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) have different metastatic patterns, but the exact pattern of metastases from ILC is poorly known. This study aimed to determine the frequency of ILC metastases in atypical locations, with an emphasis on gastric metastases.
METHODS: Patients with ILC treated at the Saint-Sacrement Hospital (Quebec City, Canada) and the Maisonneuve-Rosemont Hospital (Montreal, Canada) between January 2003 and December 2009 were retrospectively reviewed. Demographic, clinical, and follow-up data were retrieved from the medical charts. Metastases that were diagnosed during follow-up were recorded.
RESULTS: Among the 481 patients with ILC, 74 (15.4%) were diagnosed with metastases after a median follow-up of 46 months. Among these 74 patients, 41.9% had metastases in atypical sites. Five patients were diagnosed with histologically confirmed gastric metastases of ILC.
CONCLUSION: Metastases of breast ILC to atypical sites might be more frequent than previously reported. Clinicians should keep a high level of suspicion when a patient with a history of ILC develops digestive symptoms. It is important to differentiate metastases from a primary GI tumor by using immunohistochemical markers. J. Surg. Oncol. 2016;114:543-547. © 2016 Wiley Periodicals, Inc.

Buchman S, Rozmovits L, Glazier RH
Equity and practice issues in colorectal cancer screening: Mixed-methods study.
Can Fam Physician. 2016; 62(4):e186-93 [PubMed] Free Access to Full Article Related Publications
OBJECTIVE: To investigate overall colorectal cancer (CRC) screening rates, patterns in the use of types of CRC screening, and sociodemographic characteristics associated with CRC screening; and to gain insight into physicians' perceptions about and use of fecal occult blood testing [FOBT] and colonoscopy for patients at average risk of CRC.
DESIGN: Mixed-methods study using cross-sectional administrative data on patient sociodemographic characteristics and semistructured telephone interviews with physicians.
SETTING: Toronto, Ont.
PARTICIPANTS: Patients aged 50 to 74 years and physicians in family health teams in the Toronto Central Local Health Integration Network.
MAIN OUTCOME MEASURES: Rates of CRC screening by type; sociodemographic characteristics associated with CRC screening; thematic analysis using constant comparative method for semistructured interviews.
MAIN FINDINGS: Ontario administrative data on CRC screening showed lower overall screening rates among those who were younger, male patients, those who had lower income, and recent immigrants. Colonoscopy rates were especially low among those with lower income and those who were recent immigrants. Semistructured interviews revealed that physician opinions about CRC screening for average-risk patients were divided: one group of physicians accepted the evidence and recommendations for FOBT and the other group of physicians strongly supported colonoscopy for these patients, believing that the FOBT was an inferior screening method. Physicians identified specialist recommendations and patient expectations as factors that influenced their decisions regarding CRC screening type.
CONCLUSION: There was considerable variation in CRC screening by sociodemographic characteristics. A key theme that emerged from the interviews was that physicians were divided in their preference for FOBT or colonoscopy; factors that influenced physician preference included the health care system, recommendations by other specialists, and patient characteristics. Providing an informed choice of screening method to patients might result in higher screening rates and fewer disparities. Changes in policy and physician attitudes might be needed in order for this to occur.

Van Ryswyk K, Villeneuve PJ, Johnson KC, Epidemiology Research Group TC
Dietary patterns and the risk of female breast cancer among participants of the Canadian National Enhanced Cancer Surveillance System.
Can J Public Health. 2016; 107(1):e49-55 [PubMed] Related Publications
OBJECTIVES: The role of diet in the etiology of breast cancer is not well understood despite extensive research. In the majority of this work, a single nutrient-based approach has been used which does not take into account combinations of food that are consumed. An alternative to the single nutrient approach is to identify patterns in the dietary intake information and relate these patterns to disease incidence. This investigation characterized dietary patterns among participants of a Canadian case-control study and related these dietary patterns to the incidence of breast cancer.
METHODS: Dietary and other risk factor data from cases and controls of the Canadian National Enhanced Cancer Surveillance System were collected using self-administered questionnaires. Principal component factor analysis was used to classify individuals based on their dietary patterns. The relationship between these dietary patterns and breast cancer was evaluated using logistic regression. The derived odds ratios and their 95% confidence limits were adjusted for several factors, such as smoking, alcohol intake, environmental tobacco smoke exposure and obesity.
RESULTS: In the 2,009 cases and 2,086 controls, three dietary patterns were identified: western, healthy and vitamin. The highest quartile of the "healthy" dietary pattern was related to a 22% decrease in breast cancer risk (95% CI: 0.61-1.00), relative to the lowest quartile. The fourth quartile of the "vitamin" dietary pattern was associated with a 14% decrease in breast cancer risk (95% CI: 0.70-1.04) relative to the first. No statistically significant associations between the "western" dietary pattern and breast cancer were found. These associations were neither confounded nor modified by menopausal status.
CONCLUSION: Our analyses reveal that individual dietary items tend to cluster together in such a way that there are three distinct dietary patterns in this sample of Canadian women. Some of these patterns, in turn, were associated with the risk of breast cancer.

Yuan Y, Shi Q, Li M, et al.
Canadian brain cancer survival rates by tumour type and region: 1992-2008.
Can J Public Health. 2016; 107(1):e37-42 [PubMed] Related Publications
OBJECTIVES: To investigate patterns of survival among brain cancer patients in Canada.
METHODS: Canadian Cancer Registry data were obtained for all patients with first-ever primary malignant brain tumours diagnosed between 1992 and 2008 (n = 38,095). Follow-up ended with patient death or December 31, 2008, whichever occurred first. Crude Kaplan-Meier estimates were calculated at one, two and five years post-diagnosis. Cox proportional hazard models were used to obtain adjusted hazard ratios by region for major histology types. A time-specific generalized linear model was used to obtain 5-year survival estimates for specific age group, sex and region for major histology types.
RESULTS: The overall five-year survival rate was 27%. No significant difference in survival rate over time is observed. The highest 5-year survival rate was 65% (95% CI: 62.5%-67.4%) for oligodendrogliomas and the lowest was 4.0% (95% CI: 3.7%-4.3%) for glioblastomas. Compared to Ontario, the adjusted 5-year glioblastoma survival estimates were lower in British Columbia, Alberta and the Prairie provinces (Manitoba and Saskatchewan), while the survival estimates were lower in all other regions for diffuse astrocytoma, and lower in Manitoba and Saskatchewan for anaplastic astrocytomas. Estimates were significantly higher for oligodendrogliomas in Alberta, and for anaplastic oligodendrogliomas in Alberta and Quebec (p < 0.05).
CONCLUSION: These data are consistent with previous literature in observing higher survival rates at younger ages, in female patients and for tumours with mixed oligo components. There is a need to further explore the underlying reasons for the observed variation in survival rates by region in an effort to improve the prognosis of brain cancer in the Canadian patient population.

LeBlanc R, Hollmann S, Tay J
Canadian cost analysis comparing maintenance therapy with bortezomib versus lenalidomide for patients with multiple myeloma post autologous stem cell transplant.
J Popul Ther Clin Pharmacol. 2016; 23(1):e103-13 [PubMed] Related Publications
BACKGROUND: Multiple myeloma (MM) is a cancer caused by malignant plasma cells that accumulate mostly in the bone marrow. In Canada, the most common maintenance therapy options after autologous stem cell transplant (ASCT) are bortezomib and lenalidomide.
OBJECTIVE: To determine the incremental cost between bortezomib and lenalidomide maintenance therapies for patients with MM post ASCT.
METHODS: Analyses were conducted to compare the annual costs of bortezomib and lenalidomide maintenance treatments for patients with MM post ASCT in Canada. The base case analysis included the acquisition costs of the drugs and administration costs. Additional analyses were conducted which considered the cost of experiencing adverse events (AEs) and the cost of treating second primary malignancies (SPMs).
RESULTS: In the Canadian healthcare system, the total annual per patient cost was $33,967 for bortezomib maintenance therapy versus $131,765 for lenalidomide maintenance therapy. One-way sensitivity analyses demonstrated that both AEs and SPMs had little impact on the incremental cost, and that differences between the two maintenance therapies were mainly due to the acquisition costs of the drugs.
CONCLUSIONS: Bortezomib is significantly less costly than lenalidomide, and is an economically reasonable maintenance treatment option for patients with MM post ASCT.

Doumouras AG, Tsao MW, Saleh F, Hong D
A population-based comparison of 30-day readmission after surgery for colon and rectal cancer: How are they different?
J Surg Oncol. 2016; 114(3):354-60 [PubMed] Related Publications
BACKGROUND: An implicit assumption in the analysis of colorectal readmission is that colon and rectal cancer patients are similar enough to analyze together. However, no studies have examined this assumption and whether substantial differences exist between colon and rectal cancer patients.
METHODS: This was a retrospective analysis of the differences in predictors, diagnoses, and costs of readmission between colon and rectal cancer cohorts for 30-day readmission. This study included all patients aged >18 who received an elective colectomy or low anterior resection for colorectal cancer from April 2008 until March 2012 in the province of Ontario.
RESULTS: Overall, 13,571 patients were identified and the readmission rates significantly differed between rectal and colon cancer patients (7.1% colon and 10.7% rectal P = 0.001). Diabetes, age, and discharge to long term care were significantly different among colon and rectal patients in the prediction of readmission. Readmission for renal and stoma causes was more prominent in the rectal cohort. The adjusted cost difference for readmission did not significantly differ between rectal and colon cancer $178 ($1,924-1,568 P = 0.84) CONCLUSION: Several important differences in predictors and diagnoses exist between the two cohorts. Conversely, the costs associated with readmission were homogenous between rectal and colon cancer patients. J. Surg. Oncol. 2016;114:354-360. © 2016 Wiley Periodicals, Inc.

Nayak L, Miyake KK, Leung JW, et al.
Impact of Breast Density Legislation on Breast Cancer Risk Assessment and Supplemental Screening: A Survey of 110 Radiology Facilities.
Breast J. 2016; 22(5):493-500 [PubMed] Related Publications
Breast density notification laws, passed in 19 states as of October 2014, mandate that patients be informed of their breast density. The purpose of this study is to assess the impact of this legislation on radiology practices, including performance of breast cancer risk assessment and supplemental screening studies. A 20-question anonymous web-based survey was emailed to radiologists in the Society of Breast Imaging between August 2013 and March 2014. Statistical analysis was performed using Fisher's exact test. Around 121 radiologists from 110 facilities in 34 USA states and 1 Canadian site responded. About 50% (55/110) of facilities had breast density legislation, 36% of facilities (39/109) performed breast cancer risk assessment (one facility did not respond). Risk assessment was performed as a new task in response to density legislation in 40% (6/15) of facilities in states with notification laws. However, there was no significant difference in performing risk assessment between facilities in states with a law and those without (p < 0.831). In anticipation of breast density legislation, 33% (16/48), 6% (3/48), and 6% (3/48) of facilities in states with laws implemented handheld whole breast ultrasound (WBUS), automated WBUS, and tomosynthesis, respectively. The ratio of facilities offering handheld WBUS was significantly higher in states with a law than in states without (p < 0.001). In response to breast density legislation, more than 33% of facilities are offering supplemental screening with WBUS and tomosynthesis, and many are performing formal risk assessment for determining patient management.

Singh S, Asa SL, Dey C, et al.
Diagnosis and management of gastrointestinal neuroendocrine tumors: An evidence-based Canadian consensus.
Cancer Treat Rev. 2016; 47:32-45 [PubMed] Related Publications
The majority of neuroendocrine tumors originate in the digestive system and incidence is increasing within Canada and globally. Due to rapidly evolving evidence related to diagnosis and clinical management, updated guidance on the diagnosis and treatment of gastrointestinal neuroendocrine tumors (GI-NETs) are of clinical importance. Well-differentiated GI-NETs may exhibit indolent clinical behavior and are often metastatic at diagnosis. Some NET patients will develop secretory disease requiring symptom control to optimize quality of life and clinical outcomes. Optimal management of GI-NETs is in a multidisciplinary environment and is multimodal, requiring collaboration between medical, surgical, imaging and pathology specialties. Clinical application of advances in pathological classification and diagnostic technologies, along with evolving surgical, radiotherapeutic and medical therapies are critical to the advancement of patient care. We performed a systematic literature search to update our last set of published guidelines (2010) and identified new level 1 evidence for novel therapies, including telotristat etiprate (TELESTAR), lanreotide (CLARINET), everolimus (RADIANT-2; RADIANT-4) and peptide receptor radionuclide therapy (PRRT; NETTER-1). Integrating these data with the clinical knowledge of 16 multi-disciplinary experts, we devised consensus recommendations to guide state of the art clinical management of GI-NETs.

Srikanthan A, Amir E, Warner E
Does a dedicated program for young breast cancer patients affect the likelihood of fertility preservation discussion and referral?
Breast. 2016; 27:22-6 [PubMed] Related Publications
PURPOSE: To assess whether a dedicated program for young breast cancer patients, including a nurse navigator, improves the frequency of: a) fertility discussion documentation and b) fertility preservation (FP) referrals.
METHODS: A retrospective chart review and prospective survey were undertaken of breast cancer patients diagnosed at age 40 or younger between 2011 and 2013 who received adjuvant or neo-adjuvant chemotherapy at two academic cancer centers in Toronto, Canada. The Odette Cancer Centre (OCC) has a dedicated program for young breast cancer patients while Princess Margaret Cancer Centre (PM) does not. Patient demographics, tumor pathology, treatment and fertility discussion documentation prior to systemic chemotherapy administration were extracted from patient records. Prospective surveys were administered to the same cohort to corroborate data collected.
RESULTS: Eighty-one patient charts were reviewed at both OCC and PM. Forty-seven and 49 at OCC and PM returned surveys for a response rate of 58% and 60% respectively. Chart reviews demonstrated no difference in the frequency of fertility discussion documentation (78% versus 75% for OCC and PM, p = 0.71); however, surveys demonstrated higher rates of recall of fertility discussion at OCC (96% versus 80%, p = 0.02). A greater proportion of women were offered FP referrals at OCC, as observed in chart reviews (56% versus 41%, p = 0.09), and surveys (73% versus 51%, p = 0.04). Time to initiation of chemotherapy did not differ between women who underwent FP and those who did not.
CONCLUSION: A dedicated program for young breast cancer patients is associated with a higher frequency of FP referrals without delaying systemic therapy.

Le MT, Mothersill CE, Seymour CB, McNeill FE
Is the false-positive rate in mammography in North America too high?
Br J Radiol. 2016; 89(1065):20160045 [PubMed] Article available free on PMC after 01/09/2017 Related Publications
The practice of investigating pathological abnormalities in the breasts of females who are asymptomatic is primarily employed using X-ray mammography. The importance of breast screening is reflected in the mortality-based benefits observed among females who are found to possess invasive breast carcinoma prior to the manifestation of clinical symptoms. It is estimated that population-based screening constitutes a 17% reduction in the breast cancer mortality rate among females affected by invasive breast carcinoma. In spite of the significant utility that screening confers in those affected by invasive cancer, limitations associated with screening manifest as potential harms affecting individuals who are free of invasive disease. Disease-free and benign tumour-bearing individuals who are subjected to diagnostic work-up following a screening examination constitute a population of cases referred to as false positives (FPs). This article discusses factors contributing to the FP rate in mammography and extends the discussion to an assessment of the consequences associated with FP reporting. We conclude that the mammography FP rate in North America is in excess based upon the observation of overtreatment of in situ lesions and the disproportionate distribution of detriment and benefit among the population of individuals recalled for diagnostic work-up subsequent to screening. To address the excessive incidence of FPs in mammography, we investigate solutions that may be employed to remediate the current status of the FP rate. Subsequently, it can be suggested that improvements in the breast-screening protocol, medical litigation risk, image interpretation software and the implementation of image acquisition modalities that overcome superimposition effects are promising solutions.

Raman S, Ding K, Chow E, et al.
A prospective study validating the EORTC QLQ-BM22 bone metastases module in patients with painful bone metastases undergoing palliative radiotherapy.
Radiother Oncol. 2016; 119(2):208-12 [PubMed] Related Publications
PURPOSE: Quality of life (QOL) can be compromised in patients with bone metastases, and validated QOL instruments are required to accurately measure QOL outcomes in this population. This study investigated the validity, reliability and responsiveness of the EORTC QLQ-BM22 module with the EORTC QLQ-C15-PAL instrument in bone metastases.
METHODS: The studied patients underwent palliative radiotherapy to bone metastases in the randomized NCIC CTG SC 23 trial. Multi-trait scaling analysis was performed to determine convergent and divergent validity among scales. Pearson coefficients were calculated to determine the correlation between items of the two instruments. The clinical validity and responsiveness of the QLQ-BM22 was tested by known group comparisons of different performance status and response to radiotherapy.
RESULTS: 204 patients completed both questionnaires at baseline and 42day follow-up. On multi-trait scaling analysis, there was mixed evidence of construct validity (explained by the questionnaire format and population characteristics). There was little correlation between most QLQ-BM22 and QLQ-C15-PAL items (except for conceptually related scales) validating their complementary nature. There were statistically significant differences in all QLQ-BM22 scale scores in groups with KPS<80 vs. KPS⩾80 and three out of four QLQ-BM22 scale scores in "responders" vs. "non-responders" to radiotherapy. In patients who responded to radiotherapy, there were statistically significant differences in all QLQ-BM22 scale scores between baseline and follow-up.
CONCLUSION: This study further validates the use of the QLQ-BM22 as a robust and sensitive instrument to assess QOL in patients with bone metastases treated with palliative radiotherapy.

Kolthoff SK, Hestbech MS, Jørgensen KJ, Brodersen J
Do invitations for cervical screening provide sufficient information to enable informed choice? A cross-sectional study of invitations for publicly funded cervical screening.
J R Soc Med. 2016; 109(7):274-81 [PubMed] Article available free on PMC after 01/09/2017 Related Publications
OBJECTIVE: To investigate whether invitations for publicly funded cervical screening provide sufficient information to enable an informed choice about participation.
DESIGN: Cross-sectional study using a checklist of 23 information items on benefits and harms from cervical screening and the risks related to cervical cancer.
MATERIAL: Invitations to publicly funded cervical screening in 10 Scandinavian and English-speaking countries.
SETTING: Ten Scandinavian and English speaking countries.
PARTICIPANTS: Sixteen screening units representing 10 Scandinavian and English speaking countries.
MAIN OUTCOME MEASURES: Number of information items presented in invitations for cervical screening.
RESULTS: We contacted 21 coordinating units from 11 countries and 20 (95%) responded. Of these, four units did not issue invitations, but the remaining 16 coordinating units in 10 different countries supplied a sample. The invitations for cervical screening were generally information poor and contained a median of only four out of 23 information items possible (17%), ranging from 0 to 12 (0-52%). The most important harms of cancer screening, overdiagnosis and overtreatment, were typically downplayed or unmentioned. The same applied to other important harms, such as false-positive results and the psychological consequences from an abnormal test result. The majority of invitations took a paternalistic approach. While only two invitations (17%) included a pre-assigned appointment date, eight (70%) of the invitations contained strong appeals for participation.
CONCLUSIONS: Invitations to cervical cancer screening were information poor and biased in favour of participation. This means that informed choice is not possible, which is in conflict with modern requirements for personal involvement in medical decisions.

Minimal Residual Disease Evaluation in Childhood Acute Lymphoblastic Leukemia: An Economic Analysis.
Ont Health Technol Assess Ser. 2016; 16(8):1-83 [PubMed] Article available free on PMC after 01/09/2017 Related Publications
BACKGROUND: Minimal residual disease (MRD) testing by higher performance techniques such as flow cytometry and polymerase chain reaction (PCR) can be used to detect the proportion of remaining leukemic cells in bone marrow or peripheral blood during and after the first phases of chemotherapy in children with acute lymphoblastic leukemia (ALL). The results of MRD testing are used to reclassify these patients and guide changes in treatment according to their future risk of relapse. We conducted a systematic review of the economic literature, cost-effectiveness analysis, and budget-impact analysis to ascertain the cost-effectiveness and economic impact of MRD testing by flow cytometry for management of childhood precursor B-cell ALL in Ontario.
METHODS: A systematic literature search (1998-2014) identified studies that examined the incremental cost-effectiveness of MRD testing by either flow cytometry or PCR. We developed a lifetime state-transition (Markov) microsimulation model to quantify the cost-effectiveness of MRD testing followed by risk-directed therapy to no MRD testing and to estimate its marginal effect on health outcomes and on costs. Model input parameters were based on the literature, expert opinion, and data from the Pediatric Oncology Group of Ontario Networked Information System. Using predictions from our Markov model, we estimated the 1-year cost burden of MRD testing versus no testing and forecasted its economic impact over 3 and 5 years.
RESULTS: In a base-case cost-effectiveness analysis, compared with no testing, MRD testing by flow cytometry at the end of induction and consolidation was associated with an increased discounted survival of 0.0958 quality-adjusted life-years (QALYs) and increased discounted costs of $4,180, yielding an incremental cost-effectiveness ratio (ICER) of $43,613/QALY gained. After accounting for parameter uncertainty, incremental cost-effectiveness of MRD testing was associated with an ICER of $50,249/QALY gained. In the budget-impact analysis, the 1-year cost expenditure for MRD testing by flow cytometry in newly diagnosed patients with precursor B-cell ALL was estimated at $340,760. We forecasted that the province would have to pay approximately $1.3 million over 3 years and $2.4 million over 5 years for MRD testing by flow cytometry in this population.
CONCLUSIONS: Compared with no testing, MRD testing by flow cytometry in newly diagnosed patients with precursor B-cell ALL represents good value for money at commonly used willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY.

Ellison LF
Differences in cancer survival in Canada by sex.
Health Rep. 2016; 27(4):19-27 [PubMed] Related Publications
BACKGROUND: Research in the United States and Europe has found that women have an advantage over men in surviving a diagnosis of cancer, but the issue has not been systematically studied in Canada.
DATA AND METHODS: Data are from the Canadian Cancer Registry, with mortality follow-up through record linkage to the Canadian Vital Statistics Death Database. The percentage unit difference in five-year relative survival ratios (RSRs) between women and men and the relative excess risk (RER) of death for women compared with men were used as measures of differences in cancer survival.
RESULTS: A significant advantage for women compared with men was observed in 13 of the 18 cancers studied. Point estimates of RER were almost uniformly lower among those diagnosed at younger ages (15 to 54). For all cancers combined, women had a 13% lower excess risk of death-23% lower among women younger than 55. The overall advantage was greatest for thyroid cancer (RER = 0.31), skin melanoma (0.52) and Hodgkin lymphoma (0.65). The advantage for thyroid cancer was somewhat attenuated, though still significant, in earlier time periods. Bladder cancer was the only cancer for which women had a significant disadvantage (RER = 1.23); this excess risk seemed to be restricted to the first 12 to 18 months after diagnosis.
INTERPRETATION: The reasons behind sex-specific differences in cancer survival are not well understood. Many explanations are possible, and differences are best explored on a cancer-by-cancer basis. The pronounced advantage for women at younger ages lends indirect support to a hypothesized hormonal influence.

Faria SL, Neto OB, Cury F, et al.
Moderate hypofractionated external beam radiotherapy alone for intermediate risk prostate cancer: long term outcomes.
Can J Urol. 2016; 23(2):8209-14 [PubMed] Related Publications
INTRODUCTION: To report long term toxicity and efficacy of patients with intermediate risk prostate cancer treated with moderate hypofractionated radiotherapy (HypoRT).
MATERIALS AND METHODS: We studied the first consecutive 100 men with intermediate risk (stage T2b-T2c, or PSA = 10-20 ug/L, or Gleason score = 7) adenocarcinoma of the prostate treated between October 2002 and May 2010 in our institution with moderate HypoRT. Patients were treated using three-dimensional conformal HypoRT to a dose of 66 Gy in 22 daily fractions prescribed to the isocenter. Androgen suppression was not given to any patient. A uniform 7 mm margin was created around the prostate for the planning target volume. Daily ultrasound was used to guide the radiotherapy. Common Terminology Criteria for Adverse Events, version 3.0, was used to prospectively score toxicity. Biochemical failure was defined as the nadir PSA level plus 2 ng/m.
RESULTS: After a median follow up time of 80 months (range: 7-152), the 8 year actuarial freedom from biochemical relapse survival rate was 90%. The 8 year cancer specific survival and overall survival rates were 96% and 84%, respectively. Only 2 patients died from prostate cancer. The worst grade ≥ 2 late genitourinary (GU) or gastrointestinal (GI) toxicities ever documented were 19% and 20%, respectively. At the last follow up the incidence of grade ≥ 2 late GI or GU toxicity was of only 2% and 3%, respectively. No grade 4 or 5 late toxicity was seen.
CONCLUSION: Our long term experience with HypoRT delivering 66 Gy/22 fractions prescribed to the isocenter using three-dimensional conformal radiotherapy shows excellent tumor control with acceptable toxicity.

Hrbacek J, Mishra KK, Kacperek A, et al.
Practice Patterns Analysis of Ocular Proton Therapy Centers: The International OPTIC Survey.
Int J Radiat Oncol Biol Phys. 2016; 95(1):336-43 [PubMed] Related Publications
PURPOSE: To assess the planning, treatment, and follow-up strategies worldwide in dedicated proton therapy ocular programs.
METHODS AND MATERIALS: Ten centers from 7 countries completed a questionnaire survey with 109 queries on the eye treatment planning system (TPS), hardware/software equipment, image acquisition/registration, patient positioning, eye surveillance, beam delivery, quality assurance (QA), clinical management, and workflow.
RESULTS: Worldwide, 28,891 eye patients were treated with protons at the 10 centers as of the end of 2014. Most centers treated a vast number of ocular patients (1729 to 6369). Three centers treated fewer than 200 ocular patients. Most commonly, the centers treated uveal melanoma (UM) and other primary ocular malignancies, benign ocular tumors, conjunctival lesions, choroidal metastases, and retinoblastomas. The UM dose fractionation was generally within a standard range, whereas dosing for other ocular conditions was not standardized. The majority (80%) of centers used in common a specific ocular TPS. Variability existed in imaging registration, with magnetic resonance imaging (MRI) rarely being used in routine planning (20%). Increased patient to full-time equivalent ratios were observed by higher accruing centers (P=.0161). Generally, ophthalmologists followed up the post-radiation therapy patients, though in 40% of centers radiation oncologists also followed up the patients. Seven centers had a prospective outcomes database. All centers used a cyclotron to accelerate protons with dedicated horizontal beam lines only. QA checks (range, modulation) varied substantially across centers.
CONCLUSIONS: The first worldwide multi-institutional ophthalmic proton therapy survey of the clinical and technical approach shows areas of substantial overlap and areas of progress needed to achieve sustainable and systematic management. Future international efforts include research and development for imaging and planning software upgrades, increased use of MRI, development of clinical protocols, systematic patient-centered data acquisition, and publishing guidelines on QA, staffing, treatment, and follow-up parameters by dedicated ocular programs to ensure the highest level of care for ocular patients.

Liede A, Jerzak KJ, Hernandez RK, et al.
The incidence of bone metastasis after early-stage breast cancer in Canada.
Breast Cancer Res Treat. 2016; 156(3):587-95 [PubMed] Related Publications
Current information on the incidence and prevalence of bone metastases in women with breast cancer is scarce. This study examined the occurrence and predictors of bone metastases, as well as post-metastasis survival in a prospective cohort of Canadian women with breast cancer. We included women treated for early-stage (stage I, II, or III) breast cancer at the Henrietta Banting Breast Centre (HBBC) in Toronto, Canada between 1987 and 2000. Data were abstracted from medical records and pathology reports in the HBBC database; follow-up extended to end of data availability or August 31, 2015. Actuarial survival analyses provided cumulative incidence of bone metastases at 5, 10, and 15 years after breast cancer diagnosis. Kaplan-Meier curves describe breast cancer mortality. Regression models assessed patient, tumor, and treatment characteristics as predictors of bone metastases with all-cause mortality as a competing risk. Among 2097 women studied, the 5-, 10-, and 15-year probability of bone metastasis was 6.5, 10.3, and 11.3 % for the first recurrence, and 8.4, 12.5, and 13.6 % for any bone recurrence. At median follow-up (12.5 years), 13.2 % of patients had bone metastases. Median survival was 1.6 years following bone metastasis, and shorter if both bone and visceral metastases occurred. Advanced age and adjuvant treatment with tamoxifen were protective against bone metastasis. In this representative cohort of women diagnosed with early-stage breast cancer in Ontario, Canada, with long follow-up, the incidence of bone metastases was consistent with longitudinal studies from the United Kingdom, Denmark, and the US.

Dewa CS, Trojanowski L, Tamminga SJ, et al.
Advice about Work-Related Issues to Peers and Employers from Head and Neck Cancer Survivors.
PLoS One. 2016; 11(4):e0152944 [PubMed] Article available free on PMC after 01/09/2017 Related Publications
PURPOSE: The purpose of this exploratory and descriptive study is to contribute to the sparse return-to-work literature on head and neck cancer (HNC) survivors. Interview participants were asked to reflect upon their work-related experience with cancer by answering two specific questions: (1) What advice would you give someone who has been newly diagnosed with head and neck cancer? (2) What advice would you give to employers of these people?
METHODS: Data were gathered through 10 individual semi-structured in-depth interviews with HNC clinic patients at a regional cancer center's head and neck clinic in Ontario, Canada. A constant comparative method of theme development was used. Codes identified in and derived from the data were discussed by research team members until consensus was reached. Codes with similar characteristics were grouped together and used to develop overarching themes.
RESULTS: Work-related advice for peers focused on personal self-care and interactions within workplaces. Work-related advice to employers focused on demonstrating basic human values as well as the importance of communication.
DISCUSSION: The study results suggest HNC clinic patients should be proactive with employers and help to set reasonable expectations and provide a realistic plan for work to be successfully completed. HNC clinic patients should develop communication skills to effectively disclose their cancer and treatment to employers.
CONCLUSIONS: In this exploratory study, HNC clinic patients' advice was solution-focused underscoring the importance of self-care and pro-active communication and planning with employers. Employers were advised to demonstrate core human values throughout all phases of the work disability episode beginning at diagnosis.

Patel P, De P
Trends in colorectal cancer incidence and related lifestyle risk factors in 15-49-year-olds in Canada, 1969-2010.
Cancer Epidemiol. 2016; 42:90-100 [PubMed] Related Publications
BACKGROUND: While the overall incidence rate of colorectal cancer (CRC) in Canada has been decreasing, some countries show an increasing incidence in those under the age of 50. We examined the trends in CRC incidence and associated lifestyle risk factors in Canadians aged 15-49.
METHODS: Incidence data for colorectal, colon and rectum/rectosigmoid cancers were obtained for 1969-2010 from the Canadian Cancer Registry, and trends in age-standardized incidence rates (ASIRs) were examined by Joinpoint regression for three age groups (15-29, 30-39, 40-49 years) and by sex. Trends in the prevalence of some CRC risk factors were similarly examined from national health surveys for various periods ranging from 1970 to 2012.
RESULTS: In both sexes combined, ASIRs rose by 6.7%/year (1997-2010) for 15-29-year-olds, 2.4%/year (1996-2010) for 30-39-year-olds, and 0.8%/year (1997-2010) for 40-49-year-olds. Similar trends were observed by sex. The rise in ASIR was more rapid for cancers of the rectum/rectosigmoid compared to colon for all age groups. Risk factor trends varied: excess weight rose substantially, vegetables and fruit consumption increased slightly, physical inactivity rates declined but remained high, alcohol consumption changed little, and smoking rates declined. Data on red/processed meat consumption were unavailable.
CONCLUSION: The ASIR of CRC in young Canadians has increased since about the mid-1990s. The rising prevalence of excess weight in younger generations has likely played a role in the CRC trend, but more research is needed.

McConnell YJ
Surgical management of rectal carcinoids: trends and outcomes from the Surveillance, Epidemiology, and End Results database (1988 to 2012).
Am J Surg. 2016; 211(5):877-85 [PubMed] Related Publications
BACKGROUND: Local excision of small (<10 mm) rectal carcinoids is a standard treatment. Actual patterns of care and outcomes are understudied because of the rarity of this tumor.
METHODS: Surveillance, Epidemiology, and End Results database (1988 to 2012) was interrogated for rectal carcinoid patients. Chi-square testing and Kaplan-Meier survival analysis were used to compare survival outcomes.
RESULTS: Of all, 11,329 patients were identified-9,605 with only localized disease. The majority (77%) underwent local excision only. Full rectal resection was performed more frequently for tumors greater than 10 mm (11.7% to 12.2%) than for tumors less than 10 mm (4.5% to 4.9%, P < .001), and for higher T stage (T1: 4.0%, T2: 11.4%, T3/4:30.4%, P < .001). Nonoperative management was more common after year 2000 (11.2% to 13.7%) than prior (7.4% to 8.5%, P < .001). Cancer-specific survival improved across time periods but did not differ between nonoperative, local excision, or surgical resection.
CONCLUSIONS: Nonexcisional management of small, localized rectal carcinoids is becoming more common and may offer equivalent survival to excision or resection.

Dagan R, Lo SS, Redmond KJ, et al.
A multi-national report on stereotactic body radiotherapy for oligometastases: Patient selection and follow-up.
Acta Oncol. 2016; 55(5):633-7 [PubMed] Related Publications
Aims Stereotactic body radiotherapy (SBRT) for oligometastases is increasingly used with few evidenced-based guidelines. We conducted a survey to determine patient selection and follow-up practice patterns. Materials and methods Seven institutions from US, Canada, Europe, and Australia that recommend SBRT for oligometastases participated in a 72-item survey. Levels of agreement were categorized as strong (6-7 common responses), moderate (4-5), low (2-3), or no agreement. Results There was strong agreement for recommending SBRT for eradication of all detectable oligometastases with most members limiting the number of metastases to five (range 2-5) and three within a single organ (range 2-5). There was moderate agreement for recommending SBRT as consolidative therapy after systemic therapy. There was strong agreement for requiring adequate performance status and no concurrent chemotherapy. Additional areas of strong agreement included staging evaluations, primary diagnosis, target sites, and follow-up recommendations. Several differences emerged, including the use of SBRT for sarcoma oligometastases, treatment response evaluation, and which imaging should be performed during follow-up. Conclusion Significant commonalities and variations exist for patient selection and follow-up recommendations for SBRT for oligometastases. Information from this survey may serve to help clarify the current landscape.

Mulhall JP, Brock G, Oelke M, et al.
Effects of Tadalafil Once-Daily or On-Demand vs Placebo on Return to Baseline Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy--Results from a Randomized Controlled Trial (REACTT).
J Sex Med. 2016; 13(4):679-83 [PubMed] Related Publications
INTRODUCTION AND AIM: The multicenter, randomized, double-blind, double-dummy, placebo-controlled REACTT trial suggested that treatment with tadalafil once daily (OaD) started early after bilateral nerve-sparing radical prostatectomy (nsRP) for prostate cancer may contribute to erectile function (EF)-recovery, which was predefined as achieving an International Index of Erectile Function (IIEF)-EF score ≥22. Here, we report descriptive post-hoc analyses, using the more strict definition for EF-recovery of returning back to the pre-surgery IIEF-EF-level ("back-to-baseline analysis").
METHODS: REACTT included 422 men <68 years with adenocarcinoma of the prostate and preoperative IIEF-EF ≥22 who underwent nsRP at 50 centers from 9 European countries and Canada. Patients were randomized post-nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg OaD (n = 139), tadalafil 20 mg on-demand (pro-re-nata, PRN; n = 142), or placebo (n = 141), followed by 6-week drug-free washout (DFW) and 3-month open-label tadalafil OaD treatment (OLT).
MAIN OUTCOME MEASURES: Proportion of patients returning to their preoperative IIEF-EF category (22-25 or ≥26) at the end of DBT, DFW, and OLT.
RESULTS: Overall, 92.4% of patients had pre-surgery (baseline) IIEF-EF scores ≥26 (tadalafil OaD 94.2%, PRN 91.6%, placebo 91.5%), 7.4% had IIEF-EF 22-25. At the end of DBT, 22.3% of patients on tadalafil OaD had achieved "back-to-baseline" IIEF-EF, compared with 11.3% on tadalafil PRN and 7.8% on placebo. Of all 58 patients "back-to-baseline" at the end of DBT, only 1 PRN-group patient had started from a baseline IIEF-EF <26. The treatment-group difference at the end of DBT was not maintained after DFW. After 3 months of OLT with tadalafil OaD, the proportion of patients with "back-to-baseline" IIEF-EF had almost doubled in all 3 groups.
CONCLUSION: Changing the definition for EF-recovery from IIEF-EF ≥22 to the more strict definition of "returning back-to-baseline IIEF-EF" had no major impact. Tadalafil OaD started early after nsRP improved drug-assisted EF, but had no effect on unassisted EF following treatment cessation after 9 months.

El Ghorayeb N, Rondeau G, Latour M, et al.
Rapid and Complete Remission of Metastatic Adrenocortical Carcinoma Persisting 10 Years After Treatment With Mitotane Monotherapy: Case Report and Review of the Literature.
Medicine (Baltimore). 2016; 95(13):e3180 [PubMed] Article available free on PMC after 01/09/2017 Related Publications
Mitotane has been used for more than 5 decades as therapy for adrenocortical carcinoma (ACC). However its mechanism of action and the extent of tumor response remain incompletely understood. To date no cases of rapid and complete remission of metastatic ACC with mitotane monotherapy has been reported. A 52-year-old French Canadian man presented with metastatic disease 2 years following a right adrenalectomy for stage III nonsecreting ACC. He was started on mitotane which was well tolerated despite rapid escalation of the dose. The patient course was exceptional as he responded to mitotane monotherapy after only few months of treatment. Initiation of chemotherapy was not needed and he remained disease-free with good quality of life on low maintenance dose of mitotane during the following 10 years. A germline heterozygous TP53 exon 4 polymorphism c.215C>G (p. Pro72Arg) was found. Immunohistochemical stainings for IGF-2 and cytoplasmic β-catenin were positive. Advanced ACC is an aggressive disease with poor prognosis and the current therapeutic options remain limited. These findings suggest that mitotane is a good option for the treatment of metastatic ACC and might result in rapid complete remission in selected patients.

Lin CY, Pakpour AH
Assessing the EORTC QLQ-BM22 Module Using Rasch Modeling and Confirmatory Factor Analysis across Countries: a Comprehensive Psychometric Evaluation in Patients with Bone Metastases.
Asian Pac J Cancer Prev. 2016; 17(3):1405-10 [PubMed] Related Publications
BACKGROUND: The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Bone Metastases Module (EORTC QLQ-BM22) is a recently designed supplement to EORTC Quality of Life Questionnaire-C30 (EORTC QLQ-C30). Additional psychometric properties, especially using confirmatory factor analysis (CFA) and the Rasch model, are warranted.
MATERIALS AND METHODS: A total of 573 patients with bone metastases were enrolled from eight countries with a mean±SD age of 55.8±13.7 years. Slightly more than two thirds of them were female (n=383; 66.8%). CFA was used to examine the BM22 framework; Rasch models were applied to understand misfit items and differential item functioning (DIF).
RESULTS: The fit indices were satisfactory in CFA (comparative fit index=0.972, Tucker-Lewis index=0.964, root mean square error of approximation=0.076, and standardized root mean square residual=0.045). All items fit well in the Rasch models (mean square values were between 0.5 and 1.5), and only one item (number 17) displayed DIF across gender. However, there were six DIF items across Canada and Taiwan, ten across Canada and Iran, and six across Taiwan and Iran.
CONCLUSIONS: The BM22 has satisfactory psychometric properties, and could assess the QoL of patients with bone metastases specifically focusing on their symptoms. Clinicians may want to use it to capture the underlying QoL for patients with bone metastases. However, the score of item 17 should be interpreted with caution when comparing male and female patients. In addition, researchers should note that variation in DIF items may occur when conducting an international study.

Broughton J, Lipschitz J, Cantor M, et al.
Determining the natural history of pancreatic cystic neoplasms: a Manitoban cohort study.
HPB (Oxford). 2016; 18(4):383-8 [PubMed] Article available free on PMC after 01/09/2017 Related Publications
BACKGROUND: Most pancreatic cystic neoplasms (PCN) are thought to harbor a low malignant potential. This historical cohort study attempts to describe the natural history of these lesions in a provincial cohort, to assess the safety of non-surgical management. Pathological diagnosis of malignancy was the primary outcome measure of interest.
METHODS: All adult patients (age 18+) with PCN seen between 2000 and 2012 by the two main institutions in Manitoba were included in this study. PCN were graded as high and low risk, which dictated initial treatment plan (surgery or observation). Predictors of initial surgical treatment, delayed surgery in the observation group and the clinical/radiological predictors of malignancy were determined.
RESULTS: 497 patients were included in this study. 43 (8.7%) high-risk lesions underwent initial surgery, with 13 (30.2%) cases of malignancy discovered. 450 (90.5%) low-risk cysts were observed for a median of 17.3 months (range: 0.00-142.3). 29 (6.4%) cases of delayed surgery occurred, with malignancy discovered in five (17.2%).
CONCLUSIONS: This study supports current selection criteria for management of PCNs. Due to the low incidence of malignancy in low-risk PCN, it appears that long-term observation is safe and should be the treatment modality of choice in the absence of high-risk features.

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