[Show abstract][Hide abstract] ABSTRACT: Timely follow-up of fecal occult blood screening with colonoscopy is essential for achieving colorectal cancer mortality reduction. This study evaluates the effectiveness of two ongoing interventions designed to improve colonoscopy uptake after a positive fecal occult blood test (FOBT) result within Ontario's population-wide ColonCancerCheck program. The first was a revision of mailed FOBT lab results to physicians to explicitly define a positive FOBT and to recommend colonoscopy. The second was a letter to participants informing them of the positive FOBT and urging them to seek appropriate follow-up.
Prospective cohort study using Ontario's ColonCancerCheck program data sets (2008-2011), linked to provincial administrative health databases. Crude rate ratios were calculated to assess determinants of colonoscopy uptake among an Ontario-wide FOBT-positive cohort with rolling enrolment, followed from October 2008 through February 2011. Segmented time-series regression was used to assess the average additional change in colonoscopy uptake after FOBT-positive status following the introduction of two ongoing interventions among the same cohort.
A notification mailed directly to FOBT-positive screening participants was observed to increase colonoscopy uptake, beyond the modest average underlying increase throughout the study period, by an average of 3% per month (multivariable-adjusted RR: 1.03, 95% CI: 1.00-1.06). However, revision of the existing FOBT result notification to physicians was observed to have no effect.
Direct participant notification of a positive FOBT result improved adherence with follow-up colonoscopy in Ontario's population-wide ColonCancerCheck program. Further participant-directed interventions may be an effective means of maximizing adherence in population-wide screening.
[Show abstract][Hide abstract] ABSTRACT: Validated biomarkers are needed to improve risk assessment and treatment decision-making for women with ductal carcinoma in situ (DCIS) of the breast. The Oncotype DX(®) DCIS Score (DS) was shown to predict the risk of local recurrence (LR) in individuals with low-risk DCIS treated by breast-conserving surgery (BCS) alone. Our objective was to confirm these results in a larger population-based cohort of individuals. We used an established population-based cohort of individuals diagnosed with DCIS treated with BCS alone from 1994 to 2003 with validation of treatment and outcomes. Central pathology assessment excluded cases with invasive cancer, DCIS < 2 mm or positive margins. Cox model was used to determine the relationship between independent covariates, the DS (hazard ratio (HR)/50 Cp units (U)) and LR. Tumor blocks were collected for 828 patients. Final evaluable population includes 718 cases, of whom 571 had negative margins. Median follow-up was 9.6 years. 100 cases developed LR following BCS alone (DCIS, N = 44; invasive, N = 57). In the primary pre-specified analysis, the DS was associated with any LR (DCIS or invasive) in ER+ patients (HR 2.26; P < 0.001) and in all patients regardless of ER status (HR 2.15; P < 0.001). DCIS Score provided independent information on LR risk beyond clinical and pathologic variables including size, age, grade, necrosis, multifocality, and subtype (adjusted HR 1.68; P = 0.02). DCIS was associated with invasive LR (HR 1.78; P = 0.04) and DCIS LR (HR 2.43; P = 0.005). The DCIS Score independently predicts and quantifies individualized recurrence risk in a population of patients with pure DCIS treated by BCS alone.
Breast Cancer Research and Treatment 06/2015; 152(2). DOI:10.1007/s10549-015-3464-6 · 4.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Ontario Breast Screening Program (OBSP) is a population-based breast screening programme, not requiring physician referral. OBSP invites women by mail to book their next screens. However, women who do not participate in the OBSP, may be referred by physicians to non-OBSP mammography facilities, which do not remind women to book their next screen.
We identified women without breast cancer prior to June 30, 2011, having bilateral mammography (M) during a baseline period at age 50 - 69 at OBSP or non-OBSP facilities, and during a re-exposure period, at the same facility type. We used a case-control design to study the association of facility type and having M during an outcome period. Cases were women failing to receive the outcome M. Controls were matched by age, census tract, and socioeconomic status. Exposure was baseline facility type. Covariates were comorbidity, residential mobility, and primary care physician (PCP) characteristics. Conditional logistic regression analysis was performed.
Cases were less likely to have been screened at OBSP facilities. Failure to receive the outcome M was associated with having moved after re-exposure M (OR = 1.61, 95% confidence interval (CI) 1.52, 1.71), having a male PCP (OR = 1.05, 95% CI 1.02, 1.05), or a higher Charlson score (OR = 1.06 per unit increase, 95% CI 1.03, 1.09). Having re-exposure M at an OBSP facility (OR = 0.18, 95% CI 0.18, 0.19)., having a Canadian trained PCP (OR = 0.83, 95% CI 0. 8, 0.87), and having a PCP one year after the re-exposure M (OR = 0.81, 95% CI 0.68, 0.97) were protective against failure to receive the outcome M.
The OBSP, not requiring physician referral, and inviting women by mail to book their next screen, is associated with a lower probability of failure to reattend for subsequent screening than screening by PCP referral to non-OBSP facilities.
BMC Cancer 04/2015; 15(1):315. DOI:10.1186/s12885-015-1346-2 · 3.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Women with diabetes have higher breast cancer incidence and mortality. The purpose of this study was to examine the impact of diabetes on stage at breast cancer diagnosis, as a possible reason for their higher mortality. Using population-based health databases from Ontario, Canada, this retrospective cohort study examined stage at diagnosis (II, III, or IV vs I) among women aged 20-105 years who were newly diagnosed with invasive breast cancer between 2007 and 2012. We compared those with diabetes to those without diabetes. Diabetes was defined based on medical records using a validated algorithm. Among 38,407 women with breast cancer, 6115 (15.9 %) women had diabetes. Breast cancer patients with diabetes were significantly more likely to present with advanced-stage breast cancer than those without diabetes. After adjustment for mammograms and other covariates, diabetes was associated with a significantly increased risk of Stage II [adjusted odds ratio (aOR) 1.14, 95 % confidence interval (CI) 1.07, 1.22], Stage III (aOR 1.21, 95 % CI 1.11, 1.33), and Stage IV (aOR 1.16, 95 % CI 1.01, 1.33) versus Stage I breast cancer. Women with diabetes had a higher risk of lymph node metastases (aOR 1.16, 95 % CI 1.06, 1.27) and tumors with size over 2 cm (aOR 1.16, 95 % CI 1.06, 1.28). Diabetes was associated with more advanced-stage breast cancer, even after accounting for differences in screening mammogram use and other factors. Our findings suggest that diabetes may predispose to more aggressive breast cancer, which may be a contributor to their higher cancer mortality.
Breast Cancer Research and Treatment 03/2015; 150(3). DOI:10.1007/s10549-015-3323-5 · 4.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The potential for cancers to not be detected on colonoscopy is increasingly recognised, but little is known about patient outcomes. The objective of this study was to assess the outcomes of patients diagnosed with postcolonoscopy colorectal cancers (PCCRCs).
We conducted a population-based retrospective cohort study, including all patients diagnosed with colorectal cancer (CRC) in Ontario, Canada from 2003 to 2009. Patients were categorised into three groups: DETECTED (diagnosed within 6 months of first colonoscopy), PCCRC (diagnosed 6-36 months after first colonoscopy) or NOSCOPE (no colonoscopy within 36 months of diagnosis). Univariate and multivariable analyses were conducted to study overall survival, surgical treatment, emergency presentation and surgical complications.
Overall, 45 104 patients were included, with 2804 being classified as having a PCCRC. Compared with the DETECTED group, PCCRC was associated with a significantly higher likelihood of stage IV disease (17.2% vs 12.9%), worse overall survival (5 year OS: 60.8% vs 68.3%, p<0.0001; adjusted HR: 1.25, 95% CI 1.17 to 1.32, p<0.0001), a higher likelihood of emergency presentation (OR: 2.86, 95% CI 2.56 to 3.13, p<0.001) and lower likelihood of surgical resection (OR: 0.61, 95% CI 0.55 to 0.67, p<0.001). However, patients with PCCRC had significantly better outcomes than those in the NOSCOPE group (stage IV: 37.1%, 5 year OS: 38.9%) CONCLUSIONS: Compared with CRC detected by colonoscopy, PCCRCs are associated with a higher risk of emergent presentation, a lower likelihood of surgical resection and most notably, significantly worse oncological outcomes. However, they have better outcomes than patients with no recent colonoscopy.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Gut 03/2015; DOI:10.1136/gutjnl-2014-308578 · 13.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: To define the patterns of care of women after they have been referred to a colposcopic service. Methods: We carried out this population-based study by linking databases of health care provision for 2010. We defined "colposcopic episodes of care" as a series of colposcopic evaluations beginning at the time of referral for colposcopy because of a new cervical cytology abnormality and continuing until no colposcopy or cytology service had been performed for ≥ 365 days. Results: Cytology reports indicating low-grade squamous intraepithelial lesions and atypical squamous cells of uncertain significance account for 88% of referrals of women for colposcopy. Women aged 20 to 29 had the highest rates of referral and treatments. Up to 87% of women referred for low-grade squamous intraepithelial lesions cytology did not require treatment after colposcopic evaluation, while 54% of women referred for high-grade squamous intraepithelial lesions cytology required treatment. The duration of colposcopic episodes of care in which treatment was carried out lasted up to 327 days, with a median three colposcopic evaluations per episode, whereas episodes of care in which no treatment was carried out lasted up to 190 days with a median of one or two colposcopic examinations per episode. Conclusion: Young women aged 20 to 29 have the highest rates of colposcopic services. Women referred because of cytology showing high-grade squamous intraepithelial lesions in whom treatment is not carried out require more extensive follow-up to ensure that lesions are not missed. We recommend the incorporation of colposcopy services into centralized cervical cancer screening programs.
[Show abstract][Hide abstract] ABSTRACT: Background:Prior randomized, controlled trials (RCTs) indicate patient navigation can boost colorectal cancer (CRC) screening in primary care. The sparse literature on pragmatic trials of interventions designed to increase CRC screening adherence motivated this trial on the impact of a patient navigation intervention that included support for performance of the participants' preferred screening test (colonoscopy or stool blood testing). Methods:Primary-care patients (n = 5240), 50-74 years of age, with no prior diagnosis of bowel cancer, and no record of a recent CRC screening test were identified at the Group Health Centre in northern Ontario. These patients were randomly assigned to an Intervention Group (N = 2629) or a usual care Control Group (N = 2611). Intervention Group participants were contacted by a trained nurse navigator by telephone to discuss CRC screening. Interested patients met with the navigator, who helped them identify and arrange for performance of the preferred screening test. Multivariate analyses were conducted using medical records data to assess intervention impact on screening adherence within 12 months after randomization. Results: Mean patient age was 59 years, and 50% of participants were women. CRC screening adherence was higher in the Intervention Group (35%) compared to the Control Group (20%), a difference that was statistically significant (OR-2.11, CI: 1.87 - 2.39). Conclusions: Preference-based patient navigation increased screening uptake in a pragmatic RCT. Impact: Patient navigation increased CRC screening rates in a pragmatic RCT in proportions similar to those observed in explanatory RCTs.
[Show abstract][Hide abstract] ABSTRACT: Objective: The aim of this study was to estimate the effect of cervical screening in the prevention of invasive cervical cancer among age groups, using a population-based case-control study in the province of Ontario, Canada. Methods: Exposure was defined as cervical cytology history greater than 3 months before the diagnosis date of cervical cancer (index date). Cases were women who were diagnosed with cervical cancer between January 1, 1998, and December 31, 2008. Controls were women without a diagnosis of cervical cancer on, or before, December 31, 2008. Two controls were matched to each case on year of birth and income quintile, as of the index date. Conditional logistic regression was used to estimate the odds ratio for having been screened among those with cervical cancer. Results: Cervical cancer screening performed between 3 and 36 months before the index date was protective against invasive cervical cancer in women aged 40 through 69 years. In women younger than 40 years, cervical cancer screening performed 3 to 36 months before the index date was not protective. Conclusions: Cervical screening is associated with a reduced risk for invasive cervical cancer among women older than 40 years. Cervical cancer resources should be focused on maximizing the risk reduction.
International Journal of Gynecological Cancer 11/2014; 25(1). DOI:10.1097/IGC.0000000000000305 · 1.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: When cervical cytology screening shows atypical squamous cells of unknown significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL), and cervical cytology screening has not been performed in the previous year, it is recommended that cytology screening be repeated six months later. Women with persistent abnormalities should be referred for colposcopy. We explored provincial databases in Ontario to determine whether these recommendations were always followed. Methods: Cervical cytology reports in Ontario are contained in a provincial database, deterministically linkable to other health services databases, including those recording physician reimbursement claims for colposcopy. We identified all women in Ontario who had a first time diagnosis of ASCUS or LSIL in 2008 or 2009. We searched for additional cytology reports and for colposcopy billing claims during the 24 months following the date of the first abnormal report. We assessed the interaction of socioeconomic status, having abnormal cytology, and having repeat cytology after a report of low-grade abnormal cervical cytology. Results: A total of 74 770 women had a first time report of low-grade abnormal cytology. Among women with ASCUS and LSIL, 69.7% and 60.3%, respectively, underwent repeat cytology. Repeat cytology following ASCUS disclosed normal (68.2%), ASCUS (19.3%), LSIL (10.6%), and high-grade squamous intraepithelial lesion (1.4%); following LSIL, the corresponding percentages were 48.3%, 18.0%, 30.8%, and 2.6%. Of women with ASCUS, 16.2% went directly for colposcopy; 14.0% did not repeat cytology or go for colposcopy. Of women with LSIL, 26.4% went directly for colposcopy but 13.4% had no follow-up. Conclusion: We have demonstrated the potential for substantial improvement in cervical cytology six months after a finding of ASCUS and LSIL. We found that many women with ASCUS and LSIL had unnecessary referrals directly for colposcopy, and we identified a lack of follow-up for one sixth of women with low-grade abnormal cytology.
[Show abstract][Hide abstract] ABSTRACT: Purpose
Whole-breast radiation therapy (XRT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) may decrease the risk of local recurrence, but the optimal dose regimen remains unclear. Past studies administered 50 Gy in 25 fractions (conventional); however, treatment pattern studies report that hypofractionated (HF) regimens (42.4 Gy in 16 fractions) are frequently used. We report the impact of HF (vs conventional) on the risk of local recurrence after BCS for DCIS.
Methods and Materials
All women with DCIS treated with BCS and XRT in Ontario, Canada from 1994 to 2003 were identified. Treatment and outcomes were assessed through administrative databases and validated by chart review. Survival analyses were performed. To account for systematic differences between women treated with alternate regimens, we used a propensity score adjustment approach.
We identified 1609 women, of whom 971 (60%) received conventional regimens and 638 (40%) received HF. A total of 489 patients (30%) received a boost dose, of whom 143 (15%) received conventional radiation therapy and 346 (54%) received HF. The median follow-up time was 9.2 years. The median age at diagnosis was 56 years (interquartile range [IQR], 49-65 years). On univariate analyses, the 10-year actuarial local recurrence–free survival was 86% for conventional radiation therapy and 89% for HF (P=.03). On multivariable analyses, age <45 years (hazard ratio [HR] = 2.4; 95% CI: 1.6-3.4; P<.0001), high (HR=2.9; 95% CI: 1.2-7.3; P=.02) or intermediate nuclear grade (HR=2.7; 95% CI: 1.1-6.6; P=.04), and positive resection margins (HR=1.4; 95% CI: 1.0-2.1; P=.05) were associated with an increased risk of local recurrence. HF was not significantly associated with an increased risk of local recurrence compared with conventional radiation therapy on multivariate analysis (HR=0.8; 95% CI: 0.5-1.2; P=.34).
The risk of local recurrence among individuals treated with HF regimens after BCS for DCIS was similar to that among individuals treated with conventional radiation therapy.
International journal of radiation oncology, biology, physics 09/2014; 90(5). DOI:10.1016/j.ijrobp.2014.07.026 · 4.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Since the publication of two randomized controlled trials (RCT) in 1996 demonstrating the effectiveness of fecal occult blood test (FOBT) in reducing colorectal cancer (CRC) mortality, several public health initiatives have been introduced in Ontario to promote FOBT participation. We examined the effect of these initiatives on FOBT participation and evaluated temporal trends in participation between 1994 and 2012.
Using administrative databases, we identified 18 annual cohorts of individuals age 50 to 74 years eligible for CRC screening and identified those who received FOBT in each quarter of a year. We used negative binomial segmented regression to examine the effect of initiatives on trends and Joinpoint regression to evaluate temporal trends in FOBT participation.
Quarterly FOBT participation increased from 6.5 per 1000 in quarter 1 to 41.6 per 1000 in quarter 72 (January-March 2012). Segmented regression indicated increases following the publication of the RCTs in 1996 (Δ slope = 6%, 95% CI = 4.3-7.9), the primary care physician financial incentives announcement in 2005 (Δ slope = 2.2%, 95% CI = 0.68-3.7), the launch of the ColonCancerCheck (CCC) Program (Δ intercept = 35.4%, 95% CI = 18.3 -54.9), and the CCC Program 2-year anniversary (Δ slope = 7.2%, 95% CI = 3.9 – 10.5). Joinpoint validated these findings and identified the specific points when changes occurred.
Although observed increases in FOBT participation cannot be definitively attributed to the various initiatives, the results of the two statistical approaches suggest a causal association between the observed increases in FOBT participation and most of these initiatives.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2407-14-537) contains supplementary material, which is available to authorized users.
BMC Cancer 07/2014; 14(1):537. DOI:10.1186/1471-2407-14-537 · 3.32 Impact Factor