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Canada: cancer statistics from IARC GlobalCan (2012)

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

Menu: Canadian Cancer Resources Directory

National Organisations: Canada
Cancer Centers
Latest Research Publications from Canada
Alberta / Northwest Territories
British Columbia / Yukon Territory
New Brunswick
Nova Scotia
Prince Edward Islands

National Organisations: Canada (19 links)

Cancer Centers (17 links)

Latest Research Publications from Canada

Bak K, Murray E, Gutierrez E, et al.
IMRT utilization in Ontario: qualitative deployment evaluation.
Int J Health Care Qual Assur. 2014; 27(8):742-59 [PubMed] Related Publications
PURPOSE: The purpose of this paper is to describe a jurisdiction-wide implementation and evaluation of intensity-modulated radiation therapy (IMRT) in Ontario, Canada, highlighting innovative strategies and lessons learned.
DESIGN/METHODOLOGY/APPROACH: To obtain an accurate provincial representation, six cancer centres were chosen (based on their IMRT utilization, geography, population, academic affiliation and size) for an in-depth evaluation. At each cancer centre semi-structured, key informant interviews were conducted with senior administrators. An electronic survey, consisting of 40 questions, was also developed and distributed to all cancer centres in Ontario.
FINDINGS: In total, 21 respondents participated in the interviews and a total of 266 electronic surveys were returned. Funding allocation, guidelines and utilization targets, expert coaching and educational activities were identified as effective implementation strategies. The implementation allowed for hands-on training, an exchange of knowledge and expertise and the sharing of responsibility. Future implementation initiatives could be improved by creating stronger avenues for clear, continuing and comprehensive communication at all stages to increase awareness, garner support and encourage participation and encouraging expert-based coaching. IMRT utilization for has increased without affecting wait times or safety (from fiscal year 2008/2009 to 2012/2013 absolute increased change: prostate 46, thyroid 36, head and neck 29, sarcoma 30, and CNS 32 per cent).
ORIGINALITY/VALUE: This multifaceted, jurisdiction-wide approach has been successful in implementing guideline recommended IMRT into standard practice. The expert based coaching initiative, in particular presents a novel training approach for those who are implementing complex techniques. This paper will be of interest to those exploring ways to fund, implement and sustain complex and evolving technologies.

Related: Cancer Prevention and Risk Reduction

Porter J, Earle C, Atzema C, et al.
Initiation of chemotherapy in cancer patients with poor performance status: a population-based analysis.
J Palliat Care. 2014; 30(3):166-72 [PubMed] Related Publications
OBJECTIVE: Practice guidelines indicate that patients who have months to weeks left to live should not be offered chemotherapy. We examined factors associated with clinician-reported poor performance status as determined by the Palliative Performance Scale (PPS) and subsequent initiation of intravenous (IV) chemotherapy in an ambulatory cancer population in Ontario, Canada.
METHODS: In this retrospective study, patients who had at least one PPS assessment indicating poor performance status (a PPS score of 50 or lower) comprised the study cohort. Using linked administrative databases, we observed the cohort for initiation of IV chemotherapy within 30 days of the first (index) poor PPS assessment.
RESULTS: We excluded patients for whom IV or oral chemotherapy was ongoing or recently completed or whose performance status improved following the index assessment. Of the remaining cohort, 9.3 percent (264/2,842) received IV chemotherapy within 30 days of the index PPS.
CONCLUSION: A small number of cancer patients with poor performance status began IV chemotherapy in the month following assessment.

Related: Cancer Prevention and Risk Reduction

Cole EB, Zhang Z, Marques HS, et al.
Impact of computer-aided detection systems on radiologist accuracy with digital mammography.
AJR Am J Roentgenol. 2014; 203(4):909-16 [PubMed] Free Access to Full Article Related Publications
OBJECTIVE: The purpose of this study was to assess the impact of computer-aided detection (CAD) systems on the performance of radiologists with digital mammograms acquired during the Digital Mammographic Imaging Screening Trial (DMIST).
MATERIALS AND METHODS: Only those DMIST cases with proven cancer status by biopsy or 1-year follow-up that had available digital images were included in this multireader, multicase ROC study. Two commercially available CAD systems for digital mammography were used: iCAD SecondLook, version 1.4; and R2 ImageChecker Cenova, version 1.0. Fourteen radiologists interpreted, without and with CAD, a set of 300 cases (150 cancer, 150 benign or normal) on the iCAD SecondLook system, and 15 radiologists interpreted a different set of 300 cases (150 cancer, 150 benign or normal) on the R2 ImageChecker Cenova system.
RESULTS: The average AUC was 0.71 (95% CI, 0.66-0.76) without and 0.72 (95% CI, 0.67-0.77) with the iCAD system (p = 0.07). Similarly, the average AUC was 0.71 (95% CI, 0.66-0.76) without and 0.72 (95% CI 0.67-0.77) with the R2 system (p = 0.08). Sensitivity and specificity differences without and with CAD for both systems also were not significant.
CONCLUSION: Radiologists in our studies rarely changed their diagnostic decisions after the addition of CAD. The application of CAD had no statistically significant effect on radiologist AUC, sensitivity, or specificity performance with digital mammograms from DMIST.

Related: Breast Cancer Cancer Screening and Early Detection USA

Chen BQ, Parmar MP, Gartshore K
Supporting women with advanced breast cancer: the impact of altered functional status on their social roles.
Can Oncol Nurs J. 2014; 24(3):194-203 [PubMed] Related Publications
Despite early detection of breast cancer and the progress of treatment modalities, metastasis-specific symptoms continue to impact women's functional status and daily living. The aim of this study was to explore the experience of altered functional status and social roles of women with advanced breast cancer. Using qualitative descriptive methodology, semi-structured interviews were conducted with 10 women diagnosed with advanced breast cancer and altered functional status attending a tertiary care cancer centre. Results illustrated the adaptive experience of women living with their illness as they reshaped their social roles to fit with their altered functional status and advanced disease. These findings highlight the opportunity for supportive care nursing interventions to facilitate the behavioural and cognitive transitions that are experienced by women with advanced breast cancer and altered functional status. These results may have implications for women with other advanced chronic diseases, though more research is required.

Related: Breast Cancer

Leboeuf I, Lachapelle D, Dubois S, Genest C
Contribution of the pivot nurse in oncology to the experience of receiving a diagnosis of cancer by the patient and their loved ones.
Can Oncol Nurs J. 2014; 24(3):189-93, 184-8 [PubMed] Related Publications
The announcement of a cancer diagnosis represents a difficult situation for the patient, their loved ones and professionals (Reich, Vennin & Belkacémie, 2008). Until now, few studies have described nurses' contribution to this critical moment along the care trajectory (Tobin, 2012) and even fewer, the contribution of the pivot nurse in oncology (OPN) or infirmière pivot en oncologie (PNO) as this specialist is called in Quebec. This study aims to document the OPN's contribution to the cancer experience of the patient and their loved ones, from the time the diagnosis is communicated to the period immediately following (four to six weeks). Fourteen PNOs from a Montreal university health centre took part in two individual interviews. Results show that PNOs offer personalized support which draws on their expertise to better understand the experience lived by patients and their loved ones, and adapt their interventions according to their needs and the timing of these interventions. These results support issuing three recommendations for nursing practice in the areas of PNOs; development of expertise, interprofessional collaboration and environment.

Related: Cancer Prevention and Risk Reduction

Ristovski-Slijepcevic S, Bell K
Rethinking assumptions about cancer survivorship.
Can Oncol Nurs J. 2014; 24(3):166-8, 174-7 [PubMed] Related Publications
A growing body of research informed by theories and methods in the social sciences and humanities indicates that certain problematic messages are commonly embedded in popular and oncological representations of cancer. Becoming more aware of these underlying messages has the potential to improve the ways clinicians think about and manage cancer. (Note: A written response to this article appears in Truant, Kohli, & Stephens (2014), Response to "Rethinking Assumptions about Cancer Survivorship": A Nursing Disciplinary Perspective, Canadian Oncology Nursing Journal, Vol. 24, Issue 3, p. 169).

Related: Cancer Prevention and Risk Reduction

Absolon NA, Truant TL, Balneaves LG, et al.
"I can't sleep!": gathering the evidence for an innovative intervention for insomnia in cancer patients.
Can Oncol Nurs J. 2014; 24(3):154-65 [PubMed] Related Publications
Sleep-wake disturbances, in particular insomnia, are experienced by 30%-75% of oncology patients, yet no effective interventions have been designed to address this distressing symptom in the ambulatory setting. In response to an identified gap in care, I share the development and evaluation of an innovative sleep intervention designed specifically for the ambulatory setting. Preliminary findings, as well as an informative blueprint for conducting point-of-care research, are described. As a "bedside" nurse it is possible and within our moral imperative and social justice mandate to take action to find evidence-informed solutions to improve care for populations of patients experiencing gaps in care. The "I" used throughout the article refers to the lead author Surya.

Related: Cancer Prevention and Risk Reduction

Stajduhar KI, Tayler C
Taking an "upstream" approach in the care of dying cancer patients: the case for a palliative approach.
Can Oncol Nurs J. 2014; 24(3):144-53 [PubMed] Related Publications
Advances in technology and drug therapy have resulted in cancer patients living longer with malignant disease. However, most of these patients will face the end of life much sooner than the general population. Adopting a "palliative approach" is one innovation that has the potential to promote anticipatory planning and promote enhanced end-of-life care. Yet, in much of the western world, this upstream orientation has rarely been achieved. An emphasis on providing palliative care late in the illness trajectory has resulted in many challenges for the care of people with advanced cancer. We highlight a nursing research initiative, The Initiative for a Palliative Approach in Nursing: Evidence and Leadership (iPANEL), that aims to develop evidence to inform the integration of a palliative approach into the care of people with advancing chronic life-limiting conditions. Oncology nurses have an important role to play in facilitating a palliative approach, transforming the ways in which cancer patients are cared for within our health care system.

Related: Cancer Prevention and Risk Reduction

Eblan MJ, Vanderwalde NA, Zeman EM, Jones E
Hypofractionation for breast cancer: lessons learned from our neighbors to the north and across the pond.
Oncology (Williston Park). 2014; 28(6):536-46 [PubMed] Related Publications
Adjuvant whole breast irradiation was established within the standard of care for breast-conserving therapy in the early 1980s, following the results of major randomized trials comparing mastectomy vs breast-conserving surgery and radiation. Since that time, techniques and treatment strategies have evolved, but one major thread that carries forward is the need to balance cost, efficacy, complications, and convenience. Fortunately, data from randomized trials conducted in Canada and Great Britain provide a solid framework for the consideration of hypofractionated radiation in the treatment of breast cancer. In this review we discuss the rationale and underlying radiobiologic concepts for hypofractionation, and review the clinical trials and American Society for Radiation Oncology (ASTRO) guidelines supporting this approach. We also review the practical considerations for treatment planning, including dosimetric criteria and how to approach treatment of the node-positive patient. In the current era of healthcare reform and cost awareness, thoughtful utilization of hypofractionation may offer considerable savings to individual patients and the healthcare system--without compromising clinical outcomes or quality of life.

Related: Breast Cancer

Bottorff JL, Struik LL, Bissell LJ, et al.
A social media approach to inform youth about breast cancer and smoking: an exploratory descriptive study.
Collegian. 2014; 21(2):159-68 [PubMed] Related Publications
Tobacco exposure during periods of breast development has been shown to increase risk of premenopausal breast cancer. An urgent need exists, therefore, to raise awareness among adolescent girls about this new evidence, and for adolescent girls and boys who smoke to understand how their smoking puts their female peers at risk for breast cancer. The purpose of this study was to develop two youth-informed, gender specific YouTube-style videos designed to raise awareness among adolescent girls and boys about tobacco exposure as a modifiable risk factor for breast cancer and to assess youths' responses to the videos and their potential for inclusion on social media platforms. Both videos consisted of a combination of moving text, novel images, animations, and youth-friendly music. A brief questionnaire was used to gather feedback on two videos using a convenience sample of 135 youth in British Columbia, Canada. The overall positive responses by girls and boys to their respective videos and their reported interest in sharing these videos via social networking suggests that this approach holds potential for other types of health promotion messaging targeting youth. The videos offer a promising messaging strategy for raising awareness about tobacco exposure as a modifiable risk factor for breast cancer. Tailored, gender-specific messages for use on social media hold the potential for cost-effective, health promotion and cancer prevention initiatives targeting youth.

Related: Breast Cancer

Kendzerska T, Leung RS, Hawker G, et al.
Obstructive sleep apnea and the prevalence and incidence of cancer.
CMAJ. 2014; 186(13):985-92 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: A link between obstructive sleep apnea and cancer development or progression has been suggested, possibly through chronic hypoxemia, but supporting evidence is limited. We examined the association between the severity of obstructive sleep apnea and prevalent and incident cancer, controlling for known risk factors for cancer development.
METHODS: We included all adults referred with possible obstructive sleep apnea who underwent a first diagnostic sleep study at a single large academic hospital between 1994 and 2010. We linked patient data with data from Ontario health administrative databases from 1991 to 2013. Cancer diagnosis was derived from the Ontario Cancer Registry. We assessed the cross-sectional association between obstructive sleep apnea and prevalent cancer at the time of the sleep study (baseline) using logistic regression analysis. Cox regression models were used to investigate the association between obstructive sleep apnea and incident cancer among patients free of cancer at baseline.
RESULTS: Of 10 149 patients who underwent a sleep study, 520 (5.1%) had a cancer diagnosis at baseline. Over a median follow-up of 7.8 years, 627 (6.5%) of the 9629 patients who were free of cancer at baseline had incident cancer. In multivariable regression models, the severity of sleep apnea was not significantly associated with either prevalent or incident cancer after adjustment for age, sex, body mass index and smoking status at baseline (apnea-hypopnea index > 30 v. < 5: adjusted odds ratio [OR] 0.96, 95% confidence interval [CI] 0.71-1.30, for prevalent cancer, and adjusted hazard ratio [HR] 1.02, 95% CI 0.80-1.31, for incident cancer; sleep time spent with oxygen saturation < 90%, per 10-minute increase: adjusted OR 1.01, 95% CI 1.00-1.03, for prevalent cancer, and adjusted HR 1.00, 95% CI 0.99-1.02, for incident cancer).
INTERPRETATION: In a large cohort, the severity of obstructive sleep apnea was not independently associated with either prevalent or incident cancer. Additional studies are needed to elucidate whether there is an independent association with specific types of cancer.

Related: Cancer Prevention and Risk Reduction

Bergman H, Walton T, Del Bel R, et al.
Managing skin toxicities related to panitumumab.
J Am Acad Dermatol. 2014; 71(4):754-9 [PubMed] Related Publications
BACKGROUND: Dermatologic toxicities from targeted agents such as panitumumab can interfere with cancer treatment.
OBJECTIVE: We sought to evaluate the rash assessment and management in a consecutive patient cohort who received panitumumab for colorectal cancer treatment.
METHODS: This was a retrospective chart review.
RESULTS: Skin toxicity, consisting of papulopustular rash, was experienced by 32 of 34 patients. The majority (85%) developed the rash by the end of the second infusion cycle. Patients presented with a mild (41%), moderate (38%), and severe (21%) rash, and progressed to an extensive rash without appropriate treatment. A grading system was used for 65% of patients to document severity.
LIMITATIONS: Small sample size limited power in analysis. Rash severity had to be inferred based on rash description and management in 11 of the patients.
CONCLUSION: Dermatologic toxicities related to panitumumab are common; however, the way they are reported and managed varies among physicians. To prevent progression, toxicities must be assessed and treated early and aggressively, according to severity grading. Dermatologists could aid oncologists in choosing the best management strategies.

Related: Monoclonal Antibodies Colorectal (Bowel) Cancer Panitumumab (Vectibix)

Aparicio-Ting FE, Friedenreich CM, Kopciuk KA, et al.
Intrapersonal and social environment correlates of leisure-time physical activity for cancer prevention: a cross-sectional study among Canadian adults.
J Phys Act Health. 2014; 11(4):790-800 [PubMed] Related Publications
BACKGROUND: Little is known about the intrapersonal and social factors associated with sufficient physical activity (PA) for cancer prevention, which is greater than for cardiovascular health.
METHODS: 1087 and 1684 randomly selected men and women, age 35-64, completed self-administered questionnaires on PA behavior and psycho-social characteristics. Using gender-stratified logistic regression, we investigated correlates of compliance with Canadian Society for Exercise Physiology PA guidelines for general health (150 min/wk), and the American Cancer Society (ACS; 225 min/wk) and World Cancer Research Fund/American Institute for Cancer Research (WCRF/AIRC; 420 min/wk) guidelines for cancer prevention.
RESULTS: Only 39% and 19% of men and women met ACS and WCRF/AICR guidelines, respectively. Self-efficacy, scheduling PA and friend social support were positively correlated with recommended PA for cancer prevention. In men, poor self-rated health and perceived negative outcomes were negatively correlated and hypertension was positively correlated with meeting cancer prevention guidelines. For women, not being married and having a companion for PA were positively correlated with meeting cancer prevention guidelines.
CONCLUSIONS: Few adults participate in sufficient PA for cancer risk reduction. Multidimensional public health strategies that incorporate intrapersonal and social factors and are tailored for each gender are needed to promote PA for cancer prevention.

Related: Cancer Prevention and Risk Reduction USA

Cheung P, Faria S, Ahmed S, et al.
Phase II study of accelerated hypofractionated three-dimensional conformal radiotherapy for stage T1-3 N0 M0 non-small cell lung cancer: NCIC CTG BR.25.
J Natl Cancer Inst. 2014; 106(8) [PubMed] Related Publications
BACKGROUND: A multi-institutional phase II trial was performed to assess a hypofractionated accelerated radiotherapy regimen for early stage non-small cell lung cancer (NSCLC) in an era when stereotactic body radiotherapy was not widely available.
METHODS: Eighty patients with biopsy-proven, peripherally located, T1-3 N0 M0 NSCLC were enrolled. Eligible patients received 60 Gy in 15 fractions using a three-dimensional conformal technique without inhomogeneity correction. The gross tumour volume (GTV) was the primary tumor only, and the planning target volume (PTV) margin was 1.0 to 1.5cm. The primary endpoint was the 2-year primary tumor control rate. Toxicities were measured using the Common Terminology Criteria for Adverse Events version 3.0.
RESULTS: The median follow-up of patients was 49 months (range = 21-63 months). The median age of patients was 75.9 years. The actuarial rate of primary tumor control was 87.4% (95% confidence interval [CI] = 76.2% to 93.5%) at 2 years. Overall survival was 68.7% (95% CI = 57.2% to 77.6%) at 2 years. The actuarial rates of developing regional and distant relapse at 2 years were 8.8% (95% CI = 4.1% to 18.7%) and 21.6% (95% CI = 13.5% to 33.5%), respectively. Tumor size greater than 3cm was associated with an increased risk of developing distant relapse (hazard ratio = 3.11; 95% CI = 1.30 to 7.42; two-sided log-rank test P = .007). The most common grade 3+ toxicities were fatigue (6.3%), cough (7.5%), dyspnea (13.8%), and pneumonitis (10.0%)
CONCLUSIONS: Conformal radiotherapy to a dose of 60 Gy in 15 fractions resulted in favorable primary tumor control and overall survival rates in patients with T1-3 N0 M0 NSCLC. Severe toxicities were uncommon with this relatively simple treatment technique.

Related: Non-Small Cell Lung Cancer Lung Cancer

Sutradhar R, Atzema C, Seow H, et al.
Is performance status associated with symptom scores? A population-based longitudinal study among cancer outpatients.
J Palliat Care. 2014; 30(2):99-107 [PubMed] Related Publications
BACKGROUND: Symptom scores and performance status are both important measures for patients with cancer. However, since performance status is not often part of routinely collected data, there is interest in exploring whether it can be calculated from symptom scores.
METHODS: This was a population-based longitudinal study of cancer outpatients in Ontario, Canada in the year following their cancer diagnosis and among the subset of patients during the last year of their lives.
RESULTS: In the first year after diagnosis, there was a significant relationship between performance status and fatigue and appetite; fatigue and well-being had a significant association with performance status in the last year of life. In both periods, the associations, although statistically significant, were not large enough to be clinically meaningful.
CONCLUSION: Performance status is an important measurement that cannot be substituted or captured with symptom scores; it is important for healthcare providers to record performance scores on a regular basis.

Related: Cancer Prevention and Risk Reduction

Denholm R, Schüz J, Straif K, et al.
Is previous respiratory disease a risk factor for lung cancer?
Am J Respir Crit Care Med. 2014; 190(5):549-59 [PubMed] Article available free on PMC after 01/09/2015 Related Publications
RATIONALE: Previous respiratory diseases have been associated with increased risk of lung cancer. Respiratory conditions often co-occur and few studies have investigated multiple conditions simultaneously.
OBJECTIVES: Investigate lung cancer risk associated with chronic bronchitis, emphysema, tuberculosis, pneumonia, and asthma.
METHODS: The SYNERGY project pooled information on previous respiratory diseases from 12,739 case subjects and 14,945 control subjects from 7 case-control studies conducted in Europe and Canada. Multivariate logistic regression models were used to investigate the relationship between individual diseases adjusting for co-occurring conditions, and patterns of respiratory disease diagnoses and lung cancer. Analyses were stratified by sex, and adjusted for age, center, ever-employed in a high-risk occupation, education, smoking status, cigarette pack-years, and time since quitting smoking.
MEASUREMENTS AND MAIN RESULTS: Chronic bronchitis and emphysema were positively associated with lung cancer, after accounting for other respiratory diseases and smoking (e.g., in men: odds ratio [OR], 1.33; 95% confidence interval [CI], 1.20-1.48 and OR, 1.50; 95% CI, 1.21-1.87, respectively). A positive relationship was observed between lung cancer and pneumonia diagnosed 2 years or less before lung cancer (OR, 3.31; 95% CI, 2.33-4.70 for men), but not longer. Co-occurrence of chronic bronchitis and emphysema and/or pneumonia had a stronger positive association with lung cancer than chronic bronchitis "only." Asthma had an inverse association with lung cancer, the association being stronger with an asthma diagnosis 5 years or more before lung cancer compared with shorter.
CONCLUSIONS: Findings from this large international case-control consortium indicate that after accounting for co-occurring respiratory diseases, chronic bronchitis and emphysema continue to have a positive association with lung cancer.

Related: Lung Cancer

Olson RA, Tiwana MS, Barnes M, et al.
Use of single- versus multiple-fraction palliative radiation therapy for bone metastases: population-based analysis of 16,898 courses in a Canadian province.
Int J Radiat Oncol Biol Phys. 2014; 89(5):1092-9 [PubMed] Related Publications
PURPOSE: There is abundant evidence that a single fraction (SF) of palliative radiation therapy (RT) for bone metastases is equivalent to more protracted and costly multiple fraction courses. Despite this, there is low utilization of SFRT internationally. We sought to determine the utilization of SFRT in a population-based, publicly funded health care system.
METHODS AND MATERIALS: All consecutive patients with bone metastases treated with RT during 2007 to 2011 in British Columbia (BC) were identified. Associations between utilization of SFRT and patient and provider characteristics were investigated.
RESULTS: A total of 16,898 courses of RT were delivered to 8601 patients. SFRT was prescribed 49% of the time. There were positive relationships among SFRT utilization and primary tumor group (P<.001; most commonly in prostate cancer), worse prognosis (P<.001), increasing physician experience (P<.001), site of metastases (P<.001; least for spine metastases), and area of training (P<.001; most commonly for oncologists trained in the United Kingdom). There was wide variation in the prescription of SFRT across 5 regional cancer centers, ranging from 25.5% to 73.4%, which persisted after controlling for other, potentially confounding factors (P<.001).
CONCLUSIONS: The large variability in SFRT utilization across BC Cancer Agency (BCCA) cancer centers suggests there is a strong cultural effect, where physicians' use of SFRT is influenced by their colleagues' practice. SFRT use in BC was similar to that in other Canadian and western European reports but strikingly higher than in the United States. Further work is needed to standardize SFRT prescribing practices internationally for this common indication for RT, with the potential for huge health system cost savings and substantial improvements in patients' quality of life.

Ho AL, Bovill ES, Macadam SA, et al.
Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective.
Plast Reconstr Surg. 2014; 134(1):1e-10e [PubMed] Related Publications
BACKGROUND: An increasing number of women who undergo immediate two-stage tissue expander/implant breast reconstruction will require postmastectomy radiation therapy. An important variable is the timing of radiotherapy relative to surgery. The authors report their experience treating a large consecutive series of patients who underwent postmastectomy radiation therapy to the tissue expander before exchange for a permanent implant.
METHODS: Patients who had their tissue expander irradiated before implant exchange were identified. Complications, capsular contracture, revision surgery, and autologous salvage rates of irradiated patients were compared with a control group of nonirradiated patients.
RESULTS: Immediate two-stage tissue expander/implant reconstruction was initiated in 604 patients, with 113 irradiated breasts meeting inclusion criteria. Three hundred thirty-nine nonirradiated breasts constituted the control group. There was a 4.2 increased odds of major complications in the irradiated group, after adjusting for plastic surgeon, age, body mass index, smoking, chemotherapy, and cancerous breast (OR, 4.2; p=0.001). The grade III and IV capsular contracture rate was significantly higher in the irradiated group compared with the control group (21.7 percent versus 10 percent; p<0.008). The revision rate in the control group was higher compared with the irradiated group (30.2 percent versus 20.9 percent; p<0.001).
CONCLUSIONS: Postmastectomy irradiation to the tissue expander is associated with high complications; however, these patients have an acceptable capsular contracture rate that compares favorably with other implant-based radiotherapy algorithms. Revision rates were less than expected in irradiated breasts. This study suggests that immediate tissue expander/implant reconstruction is a reasonable surgical option in the setting of postmastectomy radiation therapy.

Related: Breast Cancer

Chui MH, Ryan P, Radigan J, et al.
The histomorphology of Lynch syndrome-associated ovarian carcinomas: toward a subtype-specific screening strategy.
Am J Surg Pathol. 2014; 38(9):1173-81 [PubMed] Related Publications
Women with Lynch syndrome (LS) are at increased risk for the development of epithelial ovarian cancer (OC). Analogous to previous studies on BRCA1/2 mutation carriers, there is evidence to suggest a histotype-specific association in LS-associated OCs (LS-OC). Whereas the diagnosis of high-grade serous carcinoma is an indication for BRCA1/2 germline testing, in contrast, there are no screening guidelines in place for triaging OC patients for LS testing based on histotype. We performed a centralized pathology review of tumor subtype on 20 germline mutation-confirmed LS-OCs, on the basis of morphologic assessment of hematoxylin and eosin-stained slides, with confirmation by immunohistochemistry when necessary. Results from mismatch-repair immunohistochemistry (MMR-IHC) and microsatellite instability (MSI) phenotype status were documented, and detailed pedigrees were analyzed to determine whether previously proposed clinical criteria would have selected these patients for genetic testing. Review of pathology revealed all LS-OCs to be either pure endometrioid carcinoma (14 cases), mixed carcinoma with an endometrioid component (4 cases), or clear cell carcinoma (2 cases). No high-grade or low-grade serous carcinomas or mucinous carcinomas of intestinal type were identified. Tumor-infiltrating lymphocytes were prominent (≥40 per 10 high-powered fields) in 2 cases only. With the exception of 1 case, all tumors tested for MMR-IHC or MSI had an MMR-deficient phenotype. Within this cohort, 50%, 55%, 65%, and 85% of patients would have been selected for genetic workup by Amsterdam II, revised Bethesda Guidelines, SGO 10% to 25%, and SGO 5% to 10% criteria, respectively, with <60% of index or sentinel cases detected by any of these schemas. To further support a subtype-driven screening strategy, MMR-IHC reflex testing was performed on all consecutive non-serous OCs diagnosed at 1 academic hospital over a 2-year period; MMR deficiency was identified in 10/48 (21%) cases, all with endometrioid or clear cell histology. We conclude that there is a strong association between endometrioid and clear cell ovarian carcinomas and hereditary predisposition due to MMR gene mutation. These findings have implications for the role of tumor subtype in screening patients with OC for further genetic testing and support reflex MMR-IHC and/or MSI testing for newly diagnosed cases of endometrioid or clear cell ovarian carcinoma.

Related: Lynch Syndrome - HNPCC Cancer Screening and Early Detection Ovarian Cancer

Osmond A, Li-Chang H, Kirsch R, et al.
Interobserver variability in assessing dysplasia and architecture in colorectal adenomas: a multicentre Canadian study.
J Clin Pathol. 2014; 67(9):781-6 [PubMed] Related Publications
AIMS: Following the introduction of colorectal cancer screening programmes throughout Canada, it became necessary to standardise the diagnosis of colorectal adenomas. Canadian guidelines for standardised reporting of adenomas were developed in 2011. The aims of the present study were (a) to assess interobserver variability in the classification of dysplasia and architecture in adenomas and (b) to determine if interobserver variability could be improved by the adoption of criteria specified in the national guidelines.
METHODS: An a priori power analysis was used to determine an adequate number of cases and participants. Twelve pathologists independently classified 40 whole-slide images of adenomas according to architecture and dysplasia grade. Following a wash-out period, participants were provided with the national guidelines and asked to reclassify the study set.
RESULTS: At baseline, there was moderate interobserver agreement for architecture (K=0.4700; 95% CI 0.4427 to 0.4972) and dysplasia grade (K=0.5680; 95% CI 0.5299 to 0.6062). Following distribution of the guidelines, there was improved interobserver agreement in assessing architecture (K=0.5403; 95% CI 0.5133 to 0.5674)). For dysplasia grade, overall interobserver agreement remained moderate but decreased significantly (K=0.4833; 95% CI 0.4452 to 0.5215). Half of the cases contained high-grade dysplasia (HGD). Two pathologists diagnosed HGD in ≥75% of cases.
CONCLUSIONS: The improvement in interobserver agreement in classifying adenoma architecture suggests that national guidelines can be useful in disseminating knowledge, however, the variability in the diagnosis of HGD, even following guideline review suggests the need for ongoing knowledge-transfer exercises.

Related: Colorectal (Bowel) Cancer

Wissing MD, Kluetz PG, Ning YM, et al.
Under-representation of racial minorities in prostate cancer studies submitted to the US Food and Drug Administration to support potential marketing approval, 1993-2013.
Cancer. 2014; 120(19):3025-32 [PubMed] Related Publications
BACKGROUND: US Food and Drug Administration (FDA) approval of new drugs depends on results from clinical trials that must be generalized to the US population. However, racial minorities are frequently under-represented in clinical studies. The enrollment of racial minorities was compared in key clinical studies submitted to the FDA in the last 10 years in support of potential marketing approval for prostate cancer (PCa) prevention or treatment.
METHODS: Patient demographic data were obtained from archival data sets of large registration trials submitted to the FDA to support proposed PCa indications. Six countries/regions were analyzed: the United States, Canada, Australia, Europe, the United Kingdom, and Eastern Europe. Background racial demographics were collected from national census data.
RESULTS: Seventeen key PCa clinical trials were analyzed. These trials were conducted in the past 20 years, comprising 39,574 patients with known racial information. Most patients were enrolled in the United States, but there appeared to be a trend toward increased non-US enrollment over time. In all countries, racial minorities were generally under-represented. There was no significant improvement in racial minority enrollment over time. The United States enrolled the largest nonwhite population (7.1%).
CONCLUSIONS: Over the past 20 years, racial minorities were consistently under-represented in key PCa trials. There is a need for effective measures that will improve enrollment of racial minorities. With increased global enrollment, drug developers should aim to recruit a patient population that resembles the racial demographics of the patient population to which drug use will be generalized upon approval.

Related: Australia Prostate Cancer USA

Blanchette PS, Spreafico A, Miller FA, et al.
Genomic testing in cancer: patient knowledge, attitudes, and expectations.
Cancer. 2014; 120(19):3066-73 [PubMed] Related Publications
BACKGROUND: Genomic testing in cancer (GTC) characterizes genes that play an important role in the development and growth of a patient's cancer. This form of DNA testing is currently being studied for its ability to guide cancer therapy. The objective of the current study was to describe patients' knowledge, attitudes, and expectations toward GTC.
METHODS: A 42-item self-administered GTC questionnaire was developed by a multidisciplinary group and patient pretesting. The questionnaire was distributed to patients with advanced cancer who were referred to the Princess Margaret Cancer Center for a phase 1 clinical trial or GTC testing.
RESULTS: Results were reported from 98 patients with advanced cancer, representing 66% of the patients surveyed. Seventy-six percent of patients were interested in learning more about GTC, and 64% reported that GTC would significantly improve their cancer care. The median score on a 12-item questionnaire to assess knowledge of cancer genomics was 8 of 12 items correct (67%; interquartile range, 7-9 of 12 items correct [58%-75%]). Scores were associated significantly with patients' education level (P < .0001). Sixty-six percent of patients would consent to a needle biopsy, and 39% would consent to an invasive surgical biopsy if required for GTC. Only 48% of patients reported having sufficient knowledge to make an informed decision to pursue GTC whereas 34% of patients indicated a need for formal genetic counseling.
CONCLUSIONS: Patients with advanced cancer are motivated to participate in GTC. Patients require further education to understand the difference between somatic and germline mutations in the context of GTC. Educational programs are needed to support patients interested in pursuing GTC.

Related: Cancer Prevention and Risk Reduction

Guertin MH, Théberge I, Dufresne MP, et al.
Clinical image quality in daily practice of breast cancer mammography screening.
Can Assoc Radiol J. 2014; 65(3):199-206 [PubMed] Related Publications
OBJECTIVE: To assess the quality of screening mammograms performed in daily practice in the Quebec Breast Cancer Screening Program.
SUBJECTS AND METHODS: Clinical image quality of a random subsample of 197 screening mammograms performed in 2004-2005 was independently evaluated by 2 radiologists based on the criteria by Canadian Association of Radiologists (CAR). When disagreement occurred for overall judgement or positioning score, the mammograms were reviewed by a third radiologist. Cohen's kappas for interrater agreement were computed. Multivariable robust Poisson regression models were used to study associations of overall quality and positioning with body mass index (BMI) and breast density.
RESULTS: The CAR criteria were not satisfied for 49.7% of the mammograms. Positioning was the quality attribute most often deficient, with 37.2% of mammograms failing positioning. Interrater agreement ranged from slight (kappa = 0.02 for compression and sharpness) to fair (kappa = 0.30 for exposure). For overall quality, women with a BMI ≥ 30 kg/m(2) had a failure proportion of 67.5% compared with 34.9% for women with a BMI<25 kg/m(2) (risk ratio 2.1 [95% confidence interval, 1.5-3.0]). For positioning, women with a BMI ≥ 30 kg/m(2) had a failure proportion of 53.8% compared with 27.9% for women with a BMI < 25 kg/m(2) (risk ratio 1.9 [95% confidence interval, 1.2-3.1]). Effects of breast density on image quality differed among radiologists.
CONCLUSION: Despite measures to ensure high-quality imaging, including CAR accreditation, approximately half of this random sample of screening mammograms failed the CAR quality standards. It would be important to define quality targets for screening mammograms carried out in daily practice to interpret such observations.

Related: Breast Cancer Breast Cancer Screening

Tremblay D, Touati N, Roberge D, et al.
Conditions for production of interdisciplinary teamwork outcomes in oncology teams: protocol for a realist evaluation.
Implement Sci. 2014; 9:76 [PubMed] Article available free on PMC after 01/09/2015 Related Publications
BACKGROUND: Interdisciplinary teamwork (ITW) is designed to promote the active participation of several disciplines in delivering comprehensive cancer care to patients. ITW provides mechanisms to support continuous communication among care providers, optimize professionals' participation in clinical decision-making within and across disciplines, and foster care coordination along the cancer trajectory. However, ITW mechanisms are not activated optimally by all teams, resulting in a gap between desired outcomes of ITW and actual outcomes observed. The aim of the present study is to identify the conditions underlying outcome production by ITW in local oncology teams.
METHODS: This retrospective multiple case study will draw upon realist evaluation principles to explore associations among context, mechanisms and outcomes (CMO). The cases are nine interdisciplinary cancer teams that participated in a previous study evaluating ITW outcomes. Qualitative data sources will be used to construct a picture of CMO associations in each case. For data collection, reflexive focus groups will be held to capture patients' and professionals' perspectives on ITW, using the guiding question, 'What works, for whom, and under what circumstances?' Intra-case analysis will be used to trace associations between context, ITW mechanisms, and patient outcomes. Inter-case analysis will be used to compare the different cases' CMO associations for a better understanding of the phenomenon under study.
DISCUSSION: This multiple case study will use realist evaluation principles to draw lessons about how certain contexts are more or less likely to produce particular outcomes. The results will make it possible to target more specifically the actions required to optimize structures and to activate the best mechanisms to meet the needs of cancer patients. This project could also contribute significantly to the development of improved research methods for conducting realist evaluations of complex healthcare interventions. To our knowledge, this study is the first to use CMO associations to improved empirical and theoretical understanding of interdisciplinary teamwork in oncology, and its results could foster more effective implementation in clinical practice.

Related: Cancer Prevention and Risk Reduction

Stull JW, Brophy J, Sargeant JM, et al.
Knowledge, attitudes, and practices related to pet contact by immunocompromised children with cancer and immunocompetent children with diabetes.
J Pediatr. 2014; 165(2):348-355.e2 [PubMed] Related Publications
OBJECTIVE: To compare knowledge, attitudes, and risks related to pet contact in households with and without immunocompromised children.
STUDY DESIGN: A questionnaire was distributed to parents of children diagnosed with cancer (immunocompromised; n=80) or diabetes (immunocompetent; n=251) receiving care at the Children's Hospital of Eastern Ontario. Information was collected on knowledge of pets as sources of disease, concerns regarding pet-derived pathogens, and pet ownership practices. Data were analyzed with multivariable logistic regression.
RESULTS: The questionnaire was completed by 65% (214 of 331) of the individuals to whom it was given. Pet ownership was common; 45% of respondents had a household pet when their child was diagnosed, and many (households with a child with diabetes, 49%; households with a child with cancer, 20%) acquired a new pet after diagnosis. Most households that obtained a new pet had acquired a pet considered high risk for infectious disease based on species/age (diabetes, 73%; cancer, 77%). Parents of children with cancer were more likely than parents of children with diabetes to recall being asked by a physician/staff member if they owned a pet (OR, 5.9) or to recall receiving zoonotic disease information (OR, 5.3), yet these interactions were reported uncommonly (diabetes, ≤13%; cancer, ≤48%). Greater knowledge of pet-associated pathogens was associated with recalled receipt of previous education on this topic (OR, 3.9). Pet exposure outside the home was reported frequently for children in non-pet-owning households (diabetes, 48%; cancer, 25%).
CONCLUSION: Improved zoonotic disease education is needed for pet-owning and non-pet-owning households with immunocompromised children, with ongoing provision of information while the children are at increased risk of disease. Additional efforts from pediatric and veterinary healthcare professionals are required.

Related: Cancer Prevention and Risk Reduction Children's Cancer Web: Home Page

Brenner H, Stock C, Hoffmeister M
Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies.
BMJ. 2014; 348:g2467 [PubMed] Article available free on PMC after 01/09/2015 Related Publications
OBJECTIVES: To review, summarise, and compare the evidence for effectiveness of screening sigmoidoscopy and screening colonoscopy in the prevention of colorectal cancer occurrence and deaths.
DESIGN: Systematic review and meta-analysis of randomised controlled trials and observational studies.
DATA SOURCES: PubMed, Embase, and Web of Science. Two investigators independently extracted characteristics and results of identified studies and performed standardised quality ratings.
ELIGIBILITY CRITERIA: Randomised controlled trials and observational studies in English on the impact of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality in the general population at average risk.
RESULTS: For screening sigmoidoscopy, four randomised controlled trials and 10 observational studies were identified that consistently found a major reduction in distal but not proximal colorectal cancer incidence and mortality. Summary estimates of reduction in distal colorectal cancer incidence and mortality were 31% (95% confidence intervals 26% to 37%) and 46% (33% to 57%) in intention to screen analysis, 42% (29% to 53%) and 61% (27% to 79%) in per protocol analysis of randomised controlled trials, and 64% (50% to 74%) and 66% (38% to 81%) in observational studies. For screening colonoscopy, evidence was restricted to six observational studies, the results of which suggest tentatively an even stronger reduction in distal colorectal cancer incidence and mortality, along with a significant reduction in mortality from cancer of the proximal colon. Indirect comparisons of results of observational studies on screening sigmoidoscopy and colonoscopy suggest a 40% to 60% lower risk of incident colorectal cancer and death from colorectal cancer after screening colonoscopy even though this incremental risk reduction was statistically significant for deaths from cancer of the proximal colon only.
CONCLUSIONS: Compelling and consistent evidence from randomised controlled trials and observational studies suggests that screening sigmoidoscopy and screening colonoscopy prevent most deaths from distal colorectal cancer. Observational studies suggest that colonoscopy compared with flexible sigmoidoscopy decreases mortality from cancer of the proximal colon. This added value should be examined in further research and weighed against the higher costs, discomfort, complication rates, capacities needed, and possible differences in compliance.

Related: Cancer Screening and Early Detection USA

Siemiatycki J, Karp I, Sylvestre MP, Pintos J
Estimating the proportion of cases of lung cancer legally attributable to smoking: a novel approach for class actions against the tobacco industry.
Am J Public Health. 2014; 104(8):e60-6 [PubMed] Related Publications
OBJECTIVES: The plaintiffs' lawyers for a class action suit, which was launched in Quebec on behalf of all patients with lung cancer whose disease was caused by cigarette smoking, asked us to estimate what proportion of lung cancer cases in Quebec, if they hypothetically could be individually evaluated, would satisfy the criterion that it is "more likely than not" that smoking caused the disease.
METHODS: The novel methodology we developed is based on the dose-response relationship between smoking and lung cancer, for which we use the pack-years as a measure of smoking, and the distribution of pack-years of smoking among cases.
RESULTS: We estimated that the amount of smoking required to satisfy the "more likely than not" criterion is between 3 and 11 pack-years. More than 90% of the Quebec cases satisfied even the most conservative of these thresholds.
CONCLUSIONS: More than 90% of cases of lung cancer in Quebec are legally attributable to smoking. The methodology enhances the ability to conduct class action suits against the tobacco industry.

Related: Lung Cancer

Chevarie-Davis M, Riazalhosseini Y, Arseneault M, et al.
The morphologic and immunohistochemical spectrum of papillary renal cell carcinoma: study including 132 cases with pure type 1 and type 2 morphology as well as tumors with overlapping features.
Am J Surg Pathol. 2014; 38(7):887-94 [PubMed] Related Publications
Papillary renal cell carcinomas (pRCC) are classically divided into type 1 and 2 tumors. However, many cases do not fulfill all the criteria for either type. We describe the clinical, morphologic, and immunohistochemical (IHC) features of 132 pRCCs to better characterize the frequency and nature of tumors with overlapping features. Cases were reviewed and classified; IHC evaluation of CK7, EMA, TopoIIα, napsin A, and AMACR was performed on 95 cases. The frequencies of type 1, type 2, and "overlapping" pRCC were 25%, 28%, and 47%, respectively. The 2 categories of "overlapping" tumors were: (1) cases with bland cuboidal cells but no basophilic cytoplasm (type A); and (2) cases with predominantly type 1 histology admixed with areas showing prominent nucleoli (type B). The pathologic stage of "overlapping" cases showed concordance with type 1 tumors. Using the 2 discriminatory markers (CK7, EMA), "type A" cases were similar to type 1. Although the high-nuclear grade areas of "type B" tumors showed some staining differences from their low-nuclear grade counterpart, their IHC profile was closer to type 1. Single nucleotide polymorphism array results, although preliminary and restricted to only 9 cases (3 with overlapping features), also seemed to confirm those findings. In conclusion, we demonstrate that variations in cytoplasmic quality and/or presence of high-grade nuclei in tumors otherwise displaying features of type 1 pRCCs are similar in stage and IHC profile those with classic type 1 histology, suggesting that their spectrum might be wider than originally described.

Related: Kidney Cancer

Lemieux J, Provencher L, Laflamme C
Survey about the use of scalp cooling to prevent alopecia during breast cancer chemotherapy treatment in Canada.
Can Oncol Nurs J. 2014; 24(2):102-8 [PubMed] Related Publications
Alopecia is a side effect of chemotherapies used in breast cancer. Scalp cooling is a technique preventing alopecia, but its use remains controversial. We conducted a survey about knowledge of scalp cooling and interest in conducting a randomized clinical trial (RCT). An invitation was sent to 1,022 participants and a total of 139 individuals responded to the survey. The majority knew about the existence of scalp cooling. Ninety per cent thought that an RCT was needed and would participate. The survey revealed different potential problems associated with the increased chair time, limited space, and safety. We concluded that an RCT is needed and that the trial must include evaluation on the impact on health care system resources and safety.

Related: Cancer Treatments and Hair Loss Breast Cancer

Vallance JK, Boyle T, Courneya KS, Lynch BM
Associations of objectively assessed physical activity and sedentary time with health-related quality of life among colon cancer survivors.
Cancer. 2014; 120(18):2919-26 [PubMed] Related Publications
BACKGROUND: The primary purpose of this study was to determine associations of accelerometer-assessed moderate- to vigorous-intensity physical activity (MVPA) and sedentary time with health-related quality of life (HRQoL) and physical function and well-being in colon cancer survivors.
METHODS: Colon cancer survivors (N = 178) from Alberta, Canada (n = 92) and Western Australia (n = 86) completed a mailed survey that assessed HRQoL (Functional Assessment of Cancer Therapy-Colorectal), physical function and well-being (Trial Outcome Index-Colorectal), and relevant covariates. MVPA and sedentary time were assessed using the Actigraph GT3X+ accelerometer (60-second epochs) via a 7-day monitoring protocol. Average daily MVPA and sedentary time was corrected for wear time and then examined as quartiles.
RESULTS: Adjusting for relevant demographic, behavioral, and clinical covariates, a significant difference in HRQoL scores emerged between quartile 1 (Q1) and Q4 (M(diff) = 11.5, P = .038). For physical function and well-being, a significant difference emerged between Q1 and Q4 (M(diff) = 9.1, P = .009). For fatigue, a significant difference emerged between Q1 and Q4 (M(diff) = 7.1, P = .05). Significant differences were also observed for between Q1 and Q3 (M(diff) = 2.4, P = .041), and Q1 and Q4 (M(diff) = 3.5, P = .002) for colorectal cancer-specific symptoms. There were no statistically significant associations of sedentary time with HRQoL, physical function and well-being, fatigue, or colorectal cancer-specific symptoms.
CONCLUSIONS: Objectively measured MVPA, but not sedentary time, was associated with better HRQoL, physical function and well-being, and colorectal cancer-specific symptoms in colon cancer survivors. For MVPA, differences met or exceeded contemporary cutpoints for determining clinically important differences.

Related: Australia

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