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PURPOSE: The time from breast cancer surgery to chemotherapy has been shown to affect survival outcomes; however, the effect of time from first breast cancer-related healthcare contact to first cancer specialist consultation, or the time from first breast cancer-related healthcare contact to adjuvant chemotherapy on survival has not been well explored. We aimed to determine whether various wait times along the breast cancer treatment pathway (contact-to-consultation, contact-to-chemotherapy, surgery-to-chemotherapy) were associated with overall survival in women within the Canadian province of Ontario. METHODS: We performed a population-based retrospective cohort study of women diagnosed with stage I-III breast cancer in Ontario between 2007 and 2011 who received surgery and adjuvant chemotherapy. This was the Ontario cohort of a larger, nationwide study (the Canadian Team to improve Community-Based Cancer Care along the Continuum - CanIMPACT). We used Cox-proportional hazards regression to determine the association between the contact-to-consultation, contact-to-chemotherapy, and surgery-to-chemotherapy intervals and overall survival while adjusting for cancer stage, age, comorbidity, neighborhood income, immigration status, surgery type, and method of cancer detection. RESULTS: Among 12,782 breast cancer patients, longer surgery-to-chemotherapy intervals (HR 1.13, 95% CI 1.03-1.18 per 30-day increase), but not the contact-to-consultation (HR 0.979, 95% CI 0.95-1.01 per 30-day increase), nor the more comprehensive contact-to-chemotherapy intervals (HR 1.00, 95% CI 0.98-1.02 per 30-day increase) were associated with decreased survival in our adjusted analyses. CONCLUSION: Our findings emphasize the prognostic importance of a shorter surgery-to-chemotherapy interval, whereas the contact-to-consultation and contact-to-chemotherapy intervals have less impact on survival outcomes.
Subject(s)
Breast Neoplasms , Humans , Female , Breast Neoplasms/mortality , Breast Neoplasms/therapy , Breast Neoplasms/pathology , Retrospective Studies , Middle Aged , Ontario/epidemiology , Aged , Adult , Time-to-Treatment/statistics & numerical data , Waiting Lists/mortality , Chemotherapy, Adjuvant/statistics & numerical data , Cohort StudiesABSTRACT
OBJECTIVES: The aim of this study was to determine the associations between glucocorticoid administration during chemotherapy for hematologic malignancy and hyperglycemia, new-onset diabetes, and mortality in Ontario, Canada. Hospitalization and emergency room utilization during the chemotherapy treatment period were also described. METHODS: We conducted a retrospective cohort study using health administrative data from ICES, Ontario, to assess risk of new-onset diabetes, new-onset hyperglycemia, and hyperglycemia for individuals with leukemia, non-Hodgkin lymphoma (NHL), and Hodgkin lymphoma (HL) receiving glucocorticoids during chemotherapy between 2006 and 2016. Using multivariable regression models, we determined the associations between glucocorticoid exposure and our outcomes of interest, controlling for age, sex, marginalization, and comorbidities. RESULTS: Our cohort included 19,530 individuals; 71.1% (n=13,893) received a glucocorticoid. The highest proportion of hyperglycemia occurred with leukemia (25.4%, n=1,301). Of the 15,580 individuals with no history of diabetes, those with leukemia had the highest rate of new-onset diabetes (7.1%, n=279) and new-onset hyperglycemia (18.1%, n=641), and glucocorticoid exposure increased the risk of new-onset diabetes (hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.01 to 1.64, p=0.04) and new-onset hyperglycemia (HR 1.28, 95% CI 1.09 to 1.5, p=0.003). Hyperglycemia during chemotherapy increased the risk of all-cause mortality for the combined (HR 1.18, 95% CI 1.09 to 1.27, p<0.0001) and NHL (HR 1.16, 95% CI 1.04 to 1.28, p=0.007) cohorts. CONCLUSIONS: Hyperglycemia is common during hematologic chemotherapy treatment and is associated with a modest increased risk of all-cause mortality. Routine screening, monitoring, and management of hyperglycemia should be an integral part of treatment plans for leukemia, NHL, or HL, with or without glucocorticoid administration.
Subject(s)
Diabetes Mellitus , Glucocorticoids , Hematologic Neoplasms , Hyperglycemia , Humans , Female , Hyperglycemia/epidemiology , Hyperglycemia/chemically induced , Hyperglycemia/mortality , Male , Glucocorticoids/adverse effects , Glucocorticoids/therapeutic use , Middle Aged , Retrospective Studies , Diabetes Mellitus/epidemiology , Diabetes Mellitus/mortality , Aged , Hematologic Neoplasms/mortality , Hematologic Neoplasms/drug therapy , Hematologic Neoplasms/epidemiology , Adult , Cohort Studies , Ontario/epidemiology , Antineoplastic Agents/adverse effects , Antineoplastic Agents/therapeutic use , Lymphoma, Non-Hodgkin/drug therapy , Lymphoma, Non-Hodgkin/mortality , Lymphoma, Non-Hodgkin/epidemiologyABSTRACT
BACKGROUND: Protracted times to diagnosis of cancer can lead to increased patient anxiety, and in some cases, disease progression and worse outcomes. This study assessed the time to diagnosis for melanoma, and its variability, according to patient-, disease-, and system-level factors. METHODS: This is a descriptive, cross-sectional study in Ontario, Canada from 2007-2019. We used administrative health data to measure the diagnostic interval (DI)-and its two subintervals-the primary care subinterval (PCI) and specialist care subinterval (SCI). Multivariable quantile regression was used. RESULTS: There were 33,371 melanoma patients. The median DI was 36 days (interquartile range [IQR]: 8-85 days), median PCI 22 days (IQR: 6-54 days), and median SCI 6 days (IQR: 1-42 days). Increasing comorbidity was associated with increasing DI. Residents in the most deprived neighbourhoods and those in rural areas experienced shorter DIs and PCIs, but no differences in SCI. There was substantial variation in the DI and SCI across health regions, but limited differences in the PCI. Finally, patients with a history of non-melanoma skin cancer, and those previously established with a dermatologist experienced significantly longer DI, PCI, and SCI. DISCUSSION: This study found variability in the melanoma DI, notably by system-level factors.
Subject(s)
Melanoma , Photochemotherapy , Humans , Melanoma/diagnosis , Melanoma/epidemiology , Ontario/epidemiology , Cross-Sectional Studies , Time FactorsABSTRACT
BACKGROUND: Total hip arthroplasty (THA) for displaced femoral neck fractures in older patients remains a controversial topic. This study describes patient and surgeon factors that are associated with surgeons' recommendation of THA for this patient population. Furthermore, this study explores surgeon perceptions on why most patients are treated with hemiarthroplasty over THA. METHODS: In October 2019, a cross-sectional survey was mailed to practicing orthopaedic surgeons in Ontario, Canada. The questionnaire included paper patient cases to capture surgical practice variation using a full factorial, vignette-based experimental design. Multilevel linear regression and multivariable linear regression were used to determine patient and surgeon factors that are associated with treatment recommendations. RESULTS: Of a target population of 494 practicing surgeons, 302 (61.1%) responded. Sixty percent of respondents worked in the community, and most respondents (89.4%) had fellowship training. Surgeon-level predictors of treatment with THA included higher volume of THA for fracture in the last 12 months, having an elective THA practice, and increasing years in practice. Pre-existing hip arthritis increased likelihood to recommend THA, while increasing patient age and comorbidity burden decreased likelihood to recommend THA. There are medical, institutional, financial, and historic reasons why most patients are treated with hemiarthroplasty over THA. INTERPRETATION: This survey identified several patient and surgeon-level factors that were associated with treatment recommendation for THA. Hemiarthroplasty remains the more common treatment for this patient population for multiple reasons. There is potential for differential access to care when the factors driving treatment decisions are unrelated to the patient.
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BACKGROUND: The optimal treatment of older patients with a displaced femoral neck fracture remains a controversial topic. This study aimed to compare clinical outcomes across a matched group of patients with a femoral neck fracture treated with either hemiarthroplasty or total hip arthroplasty (THA). METHODS: Routinely collected health-care databases were linked to create a population-based cohort of 49,597 patients ≥60 years old from Ontario, Canada, who underwent hemiarthroplasty or THA for a femoral neck fracture between 2002 and 2017. A propensity-score-matched cohort was created using relevant and available predictors of treatment assignment and outcomes of interest. Clinical outcomes consisting of hip dislocation, revision surgery, hospital readmission, and death were compared in the matched cohort using survival analysis. RESULTS: Over 99% of THA patients (4,612) were adequately matched 1:1 to hemiarthroplasty patients (total matched cohort = 9,224). Patients treated with THA were at higher risk for hip dislocation at 30 days and 1 and 2 years postoperatively (2-year risk, 1.8% for THA versus 0.8% for hemiarthroplasty; p < 0.001). There was no difference in the short-term (30-day) or long-term (up to 10-year) risk of revision surgery between treatment groups. There was no significant difference in the risk of 30-day hospital readmission between groups. The risk of death at 1 year and 2 years postoperatively was lower for patients treated with THA. CONCLUSIONS: For patients with a hip fracture, shared decision-making should involve discussion of the potential higher risk of short-term hip dislocation after THA compared with hemiarthroplasty. The risk of revision surgery was similar between treatment groups at up to 10 years of follow-up. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Subject(s)
Arthroplasty, Replacement, Hip , Femoral Neck Fractures , Hemiarthroplasty , Hip Dislocation , Humans , Middle Aged , Arthroplasty, Replacement, Hip/adverse effects , Cohort Studies , Hip Dislocation/surgery , Hemiarthroplasty/adverse effects , Femoral Neck Fractures/surgery , Femoral Neck Fractures/etiology , Reoperation , OntarioABSTRACT
AIMS: This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. METHODS: We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. RESULTS: Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. CONCLUSION: The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients.Cite this article: Bone Joint J 2023;105-B(2):180-189.
Subject(s)
Arthroplasty, Replacement, Hip , Femoral Neck Fractures , Hemiarthroplasty , Humans , Male , Middle Aged , Aged , Ontario/epidemiology , Cross-Sectional Studies , Femoral Neck Fractures/surgeryABSTRACT
The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007-2010), Manitoba (2007-2011), Ontario (2007-2010), Nova Scotia (2007-2012), and Alberta (2004-2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient's cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.
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OBJECTIVES: Regional variation in cancer survival is an important health system performance measurement. We evaluated if regional variation in colon cancer survival may be driven by differences in the patient population, their health and healthcare utilisation, and/or cancer care delivery. DESIGN: Population-based retrospective cohort study using routinely collected linked health administrative data. SETTING: Ontario, Canada. PARTICIPANTS: Patients with colon cancer diagnosed between 1 January 2009 and 31 December 2012. OUTCOME: Cancer-specific survival was compared across the province's 14 health regions. Using accelerated failure time models, we assessed whether regional survival variations were mediated through differences in case mix, including age, sex, comorbidities, stage at diagnosis and colon subsite, potential marginalisation and/or prediagnosis healthcare. RESULTS: The study population included 16 895 patients with colon cancer. There was statistically significant regional variation in cancer-specific survival. Three regions had cancer-specific survival that was between 30% (95% CI 1.03 to 1.65) and 39% (95% CI 1.13 to 1.71) longer and one region had cancer-specific survival that was 26% shorter (95% CI 0.58 to 0.93) than the reference region. For three of these regions, case mix explained between 26% and 56% of the survival variation. Further adjustment for rurality explained 22% of the remaining survival variation in one region. Adjustment for continuity of primary care and the diagnostic interval length explained 10% and 11% of the remaining survival variation in two other regions. Socioeconomic marginalisation, recent immigration and colonoscopy history did not explain colon cancer survival variation. CONCLUSIONS: Case mix accounted for much of the regional variation in colon cancer survival, indicating that efforts to monitor the quality of cancer care through survival metrics should consider case mix when reporting regional survival differences. Future work should repeat this approach in other settings and other cancer sites considering a broad range of potential mediators.
Subject(s)
Colonic Neoplasms , Cohort Studies , Colonic Neoplasms/therapy , Humans , Ontario/epidemiology , Retrospective StudiesABSTRACT
Patients with resectable esophageal cancer are recommended to undergo chemoradiotherapy before esophagectomy. A longer time to surgery (TTS) and/or time to consultation (TTC) may be associated with inferior cancer-related outcomes and heightened anxiety. Thoracic cancer surgery centers (TCSCs) oversee esophageal cancer management, but differences in TTC/TTS between centers have not yet been examined. This Ontario population-level study used linked administrative healthcare databases to investigate patients with esophageal cancer between 2013-2018, who underwent neoadjuvant chemoradiotherapy and then surgery. TTC and TTS were time from diagnosis to the first surgical consultation and then to surgery, respectively. Patients were assigned a TCSC based on the location of the surgery. Patient, disease, and diagnosing physician characteristics were investigated. Quantile regression was used to model TTS/TTC at the 50th and 90th percentiles and identify associated factors. The median TTS and TTC were 130 and 29 days, respectively. The adjusted differences between the TCSCs with the longest and shortest median TTS and TTC were 32 and 18 days, respectively. Increasing age was associated with a 16-day longer median TTS. Increasing material deprivation was associated with a 6-day longer median TTC. Significant geographic variability exists in TTS and TTC. Therefore, the investigation of TCSC characteristics is warranted. Shortening wait times may reduce patient anxiety and improve the control of esophageal cancer.
Subject(s)
Esophageal Neoplasms , Cross-Sectional Studies , Esophageal Neoplasms/surgery , Esophagectomy , Humans , Ontario , Retrospective StudiesABSTRACT
BACKGROUND: The 8th edition UICC/AJCC TNM8 (Tumour, Nodes, Metastasis) melanoma staging system introduced several modifications from the 7th edition (TNM7), resulting in changes in survival and subgroup composition. We set out to address the limited validation of TNM8 (stages I-IV) in large population-based datasets. METHODS: This retrospective cohort-study included 6,414 patients from the population-based Ontario Cancer Registry diagnosed with cutaneous melanoma between January 1, 2007 and December 31, 2012. Kaplan-Meier curves estimated the melanoma-specific survival (MSS) and overall survival (OS). Cox proportional hazard models were used to estimate adjusted hazard ratios for MSS and OS across stage groups. The Schemper-Henderson measure was used to assess the variance explained in the Cox regression. RESULTS: In our sample, 21.3% of patients were reclassified with TNM8 from TNM7; reclassifications in stage II were uncommon, and 44.1% of patients in stage III were reclassified to a higher subgroup. Minimal changes in MSS curves were observed between editions, but the stage IIB curve decreased and the stage IIIC curve increased. For TNM8, Stage I (n = 4,556), II (n = 1,206), III (n = 598), and IV (n = 54) had an estimated 5-year MSS of 98.4%, 82.5%, 66.4%, and 14.4%, respectively. Within stage III, IIIA 5-year MSS was 91.7% while stage IIID was 23.5%. HRs indicated that TNM8 more evenly separates subgroups once adjusted for patient- and disease-characteristics. The variance in MSS explained by TNM7 and TNM8 is 18.9% and 19.7%, respectively. CONCLUSION: TNM8 performed well in our sample, with more even separation of stage subgroups and a modest improvement in predictive ability compared to TNM7.
Subject(s)
Melanoma , Skin Neoplasms , Humans , Melanoma/pathology , Neoplasm Staging , Retrospective Studies , Skin Neoplasms/pathology , Melanoma, Cutaneous MalignantABSTRACT
OBJECTIVE: There is substantial variation in colonoscopy use and evidence of long wait times for the procedure. Understanding the role of system-level resources in colonoscopy utilisation may point to a potential intervention target to improve colonoscopy use. This study characterises colonoscopy resource availability in Ontario, Canada and evaluates its relationship with colonoscopy utilisation. DESIGN: We conducted a population-based study using administrative health data to describe regional variation in colonoscopy availability for Ontario residents (age 18-99) in 2013. We identified 43 colonoscopy networks in the province in which we described variations across three colonoscopy availability measures: colonoscopist density, private clinic access and distance to colonoscopy. We evaluated associations between colonoscopy resource availability and colonoscopy utilisation rates using Pearson correlation and log binomial regression, adjusting for age and sex. RESULTS: There were 9.4 full-time equivalent colonoscopists per 100 000 Ontario residents (range across 43 networks 0.0 to 21.8); 29.5% of colonoscopies performed in the province were done in private clinics (range 1.2%-55.9%). The median distance to colonoscopy was 3.7 km, with 5.9% travelling at least 50 km. Lower colonoscopist density was correlated with lower colonoscopy utilisation rates (r=0.53, p<0.001). Colonoscopy utilisation rates were 4% lower in individuals travelling 50 to <200 km and 11% lower in individuals travelling ≥200 km to colonoscopy, compared to <10 km. There was no association between private clinic access and colonoscopy utilisation. CONCLUSION: The substantial variations in colonoscopy resource availability and the relationship demonstrated between colonoscopy resource availability and use provides impetus for health service planners and decision-makers to address these potential inequalities in access in order to support the use of this medically necessary procedure.
Subject(s)
Colonoscopy , Travel , Adolescent , Adult , Aged , Aged, 80 and over , Colonoscopy/methods , Humans , Middle Aged , Ontario/epidemiology , Young AdultABSTRACT
OBJECTIVE: This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups. METHODS: This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits. RESULTS: Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits. CONCLUSIONS: This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.
Subject(s)
Colorectal Neoplasms , Early Detection of Cancer , Colonoscopy , Colorectal Neoplasms/diagnosis , Colorectal Neoplasms/epidemiology , Colorectal Neoplasms/prevention & control , Cross-Sectional Studies , Early Detection of Cancer/methods , Humans , Ontario/epidemiologyABSTRACT
BACKGROUND AND OBJECTIVES: The multiple sclerosis (MS) population's survival from breast cancer and colorectal cancer is compromised. Cancer screening and timely diagnoses affect cancer survival and have not been studied in the MS cancer population. We investigated whether the diagnostic route, cancer stage, or diagnostic interval differed in patients with cancer with and without MS. METHODS: We conducted a matched population-based cross-sectional study of breast cancers (2007-2015) and colorectal cancers (2009-2012) in patients with MS from Ontario, Canada, using administrative data. Exclusion criteria included second or concurrent primary cancers, no health care coverage, and, for the patients without MS, those with any demyelinating disease. We based 1:4 matching of MS to non-MS on birth year, sex (colorectal only), postal code, and cancer diagnosis year (breast only). Cancer outcomes were diagnostic route (screen-detected vs symptomatic), stage (stage I vs all others), and diagnostic interval (time from first presentation to diagnosis). Multivariable regression analyses controlled for age, sex (colorectal only), diagnosis year, income quintile, urban/rural residence, and comorbidity. RESULTS: We included 351 patients with MS and breast cancer, 1,404 matched patients with breast cancer without MS, 54 patients with MS and colorectal cancer, and 216 matched patients with colorectal cancer without MS. MS was associated with fewer screen-detected cancers in breast (odds ratio [OR] 0.68 [95% CI 0.52, 0.88]) and possibly colorectal (0.52 [0.21, 1.28]) cancer. MS was not associated with differences in breast cancer stage at diagnosis (stage I cancer, OR 0.81 [0.64, 1.04]). MS was associated with greater odds of stage I colorectal cancer (OR 2.11 [1.03, 4.30]). The median length of the diagnostic interval did not vary between people with and without MS in either the breast or colorectal cancer cohorts. Controlling for disability status attenuated some findings. DISCUSSION: Breast cancers were less likely to be detected through screening and colorectal cancer more likely to be detected at early stage in people with MS than without MS. MS-related disability may prevent people from getting mammograms and colonoscopies. Understanding the pathways to earlier detection in both cancers is critical to developing and planning interventions to ameliorate outcomes for people with MS and cancer.
Subject(s)
Breast Neoplasms , Colorectal Neoplasms , Multiple Sclerosis , Breast Neoplasms/diagnosis , Breast Neoplasms/epidemiology , Colorectal Neoplasms/diagnosis , Colorectal Neoplasms/epidemiology , Cross-Sectional Studies , Female , Humans , Multiple Sclerosis/diagnosis , Multiple Sclerosis/epidemiology , OntarioABSTRACT
BACKGROUND: In Ontario, patients with breast cancer typically receive their diagnoses through the Ontario Breast Screening Program (OBSP) after an abnormal screen, through screening initiated by a primary care provider or other referring physician, or through follow-up of symptoms by patients' primary care providers. We sought to explore the association of the route to diagnosis (screening within or outside the OBSP or via symptomatic presentation) with use of OBSP-affiliated breast assessment sites (O-BAS), wait times until diagnosis or treatment, health care use and overall survival for patients with breast cancer. METHODS: In this retrospective cohort study, we used the Ontario Cancer Registry to identify adults (aged 18-105 yr) who received a diagnosis of breast cancer from 2013 to 2017. We excluded patients if they were not Ontario residents or had missing age or sex, or who died before diagnosis. We used logistic regression to evaluate factors associated with categorical variables (whether patients were or were not referred to an OBAS, whether patients were screened or symptomatic) and Cox proportional hazards regression to identify factors associated with all-cause mortality. RESULTS: Of 51 460 patients with breast cancer, 42 598 (83%) received their diagnoses at an O-BAS. Patients whose cancer was first detected through the OBSP were more likely than symptomatic patients to be given a diagnosis at an O-BAS (adjusted odds ratio 1.68, 95% confidence interval [CI] 1.57 to 1.80). Patients screened by the OBSP were given their diagnoses 1 month earlier than symptomatic patients, but diagnosis at an O-BAS did not affect the time until either diagnosis or treatment. Patients referred to an O-BAS had significantly better overall survival than those who were not referred (adjusted hazard ratio 0.73, 95% CI 0.66 to 0.80). INTERPRETATION: Patients screened through the OBSP were given their diagnoses earlier than symptomatic patients and were more likely to be referred to an O-BAS, which was associated with better survival. Our findings suggest that individuals with signs and symptoms of breast cancer would benefit from similar referral processes, oversight and standards to those used by the OBSP.
Subject(s)
Breast Neoplasms , Adolescent , Adult , Aged , Aged, 80 and over , Breast , Breast Neoplasms/diagnosis , Breast Neoplasms/epidemiology , Breast Neoplasms/therapy , Female , Humans , Mammography , Middle Aged , Ontario/epidemiology , Retrospective Studies , Young AdultABSTRACT
Objective: Timely cancer treatment improves survival and anxiety for some sites. Patients with esophageal cancer require specific workup before treatment, which can prolong the time from diagnosis to treatment (treatment interval [TI]). The geographical variation of this interval remains uninvestigated in patients with esophageal cancer. Methods: This retrospective population-level study conducted in Ontario used linked administrative health care databases. Patients treated for esophageal cancer between 2013 and 2018 were included. The TI was time from diagnosis to treatment. Patients were assigned a geographical Local Health Integration Network on the basis of postal code. Covariates included patient, disease, and diagnosing physician characteristics. Quantile regression modeled TI length at the 50th and 90th percentile and identified associated factors. Results: Of 7509 patients, 78% were male and most were aged between 60 and 69 years. The 50th and 90th percentile TI was 36 (interquartile range, 22-55) and 77 days, respectively. The difference between the Local Health Integration Network with the longest and shortest TI at the 50th and 90th percentile was 18 and 25 days, respectively. Older age (P < .0001), greater comorbidity (P = .0005), greater material deprivation (P = .001), rurality (P = .03), histology (P = .02), and treatment group (P < .0001) were associated with a longer median TI. Older age (P = .03), greater comorbidity (P = .003), greater material deprivation (P = .005), rurality (P = .04), and treatment group (P < .0001) were associated with a longer 90th percentile TI. Conclusions: Geographic variability of time to treatment exists across Ontario. Investigation of facility-level differences is warranted. Patient and disease factors are associated with longer wait times. These results might inform future health care policy and resource allocation.
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BACKGROUND: Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigation of major liver-related postoperative complications. Currently, no standard prognostic tool exists to predict the risk of postoperative liver decompensation events (POLDEs) after partial hepatectomy for patients with cirrhosis and HCC. This study aimed to identify independent preoperative predictors of POLDEs for future development of prognostic tools to improve surgical decision-making. METHODS: This population-based, retrospective cohort study investigated patients with cirrhosis and incident HCC between 2007 and 2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years after surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. RESULTS: Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least one POLDE, and 189 (30.9%) died within 2 years after surgery. Diabetes, cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except for extent of resection, the same risk factors were associated with POLDEs in the cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. CONCLUSIONS: Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used both to inform clinical practice and to advance the development of preoperative prognostic tools, which may lead to improved outcomes for this population.
Subject(s)
Carcinoma, Hepatocellular , Liver Neoplasms , Carcinoma, Hepatocellular/surgery , Humans , Liver Cirrhosis/complications , Liver Neoplasms/surgery , Ontario/epidemiology , Retrospective StudiesABSTRACT
BACKGROUND AND OBJECTIVES: We tested the hypothesis that overall and cancer-specific survival following colorectal cancer diagnosis is lower in persons with multiple sclerosis (MS) than without MS, using a retrospective matched cohort design. METHODS: Using population-based administrative data in Manitoba and Ontario we identified persons with MS using a validated case definition, and linked these cohorts to cancer registries to identify those with colorectal cancer. We selected persons with colorectal cancer and without MS matching 4:1 on birth year, sex, cancer diagnosis year and region. We used Cox proportional hazards regression to compare all-cause survival between cohorts adjusting for age at cancer diagnosis, cancer diagnosis year, income, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a cause-specific hazards model. We pooled findings across provinces using random-effects meta-analysis. Complementary analyses using a subcohort from Ontario adjusted for cancer stage and disability status, as measured based on the use of home care or long-term care services. RESULTS: We included 338 MS cases and 1352 controls with colorectal cancer. The mean (SD) age at cancer diagnosis was 64.7 (11.1) years. After adjustment, MS was associated with an increased hazard for all-cause death which was highest six months post-diagnosis (hazard ratio [HR] 1.45; 95%CI: 1.19-1.76), then declined over time (HR [95%CI] 1 year: 1.34 [1.09-1.63], 2 years: 1.24 [0.99-1.56]; 5 years: 1.10 [0.80-1.50]). MS was associated with increased cancer-specific death at 6 months post-diagnosis only (HR 1.29; 95%CI: 1.04-1.61). After adjusting for cancer stage, MS was associated with an increased hazard of death due to any cause (1.60; 95%CI: 1.16, 2.21) and with cancer-specific death (HR 1.47; 95%CI: 1.02, 2.12). The association of MS and all cause death was partially attenuated after adjustment for disability status (HR 1.37; 95%CI: 0.97, 1.92), as was the association with cancer-specific death (HR 1.34; 95%CI: 0.91, 1.97). DISCUSSION: Overall and cancer-specific survival was lower in persons with than without MS in the early period following colorectal cancer diagnosis. Further study is warranted to determine what factors underlie these worse outcomes.
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BACKGROUND: Few reports have evaluated prognostic modelling studies of tools used for surgical decision-making. This systematic review aimed to describe and critically appraise studies that have developed or validated multivariable prognostic models for post-operative liver decompensation following partial hepatectomy. METHODS: This study was designed using the CHARMS checklist. Following a comprehensive literature search, two reviewers independently screened candidate references for inclusion and abstracted relevant study details. Qualitative assessment was performed using the PROBAST tool. RESULTS: We identified 36 prognostic modelling studies; 25 focused on development only, 3 developed and validated models, and 8 validated pre-existing models. None compared routine use of a prognostic model against standard clinical practice. Most studies used single-institution, retrospective cohort designs, conducted in Eastern populations. In total, 15 different outcome definitions for post-operative liver decompensation events were used. Statistical concerns surrounding model overfitting, performance assessment, and internal validation led to high risk of bias for all studies. CONCLUSIONS: Current prognostic models for post-operative liver decompensation following partial hepatectomy may not be valid for routine clinical use due to design and methodologic concerns. Landmark resources and reporting guidelines such as the TRIPOD statement may assist researchers, and additionally, model impact assessment studies represent opportunities for future research.
Subject(s)
Hepatectomy , Liver , Bias , Hepatectomy/adverse effects , Humans , Prognosis , Retrospective StudiesABSTRACT
INTRODUCTION: There is an evidence gap regarding the duration of SARS-CoV-2 shedding and of its variability across different care settings and by age, sex, income, and co-morbidities. Such evidence is part of understanding of infectivity and reinfection. We examine direct measures of viral shedding using a linked population-based health administrative dataset. METHODS: Laboratory and sociodemographic databases for Ontario, Canada were linked to identify those testing positive (RT-PCR) between Jan. 15 and April 30, 2020 who underwent subsequent testing by May 31, 2020. To maximise use of available data, we computed two shedding duration estimates defined as the time between initial positive and most recent positive (documented shedding) or second of two negative tests (documented resolution). We also report multivariable results using quantile regression to examine subgroup differences. RESULTS: In Ontario, of the 16,595 who tested positive before April 30, 2020, 6604 had sufficient subsequent testing to allow shedding duration calculation. Documented shedding median duration calculated in 4,889 (29% of 16,595) patients was 19 days (IQR 12-28). Documented resolution median duration calculated in 3,219 (19% of the 16,595) patients was 25 days (IQR 18-34). Long-term care residents had 3-5 day longer shedding durations using both definitions. Shorter documented shedding durations of 2-4 days were observed in those living in higher income neighbourhoods. Shorter documented resolution durations of 2-3 days were observed at the 25th% of the distribution in those aged 20-49. Only 11.5% of those with definitive negative test results reverted to negative status by day 14. CONCLUSIONS: Viral shedding continued well beyond 14 days among this large subset of a population-based group with COVID-19, and longer still for long-term care residents and those living in less affluent neighborhoods. Our findings do not speak to duration of infectivity but are useful for understanding the expected duration of RT-PCR positivity and for identifying reinfection.
Subject(s)
COVID-19/diagnosis , SARS-CoV-2/genetics , Virus Shedding/genetics , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/virology , Epidemics/prevention & control , Female , Humans , Male , Middle Aged , Ontario/epidemiology , RNA, Viral/genetics , Reverse Transcriptase Polymerase Chain Reaction , SARS-CoV-2/physiology , Time Factors , Young AdultABSTRACT
BACKGROUND AND AIMS: Mortality secondary to cirrhosis in North America is increasing. We describe the incidence of cirrhosis stratified by birth cohort and cirrhosis etiology and project disease burden to 2040. APPROACH AND RESULTS: This is a retrospective cohort study in Ontario, Canada, using population-based administrative health care data. Individuals with incident cirrhosis (2000-2017) were identified, and etiology was defined as HCV, HBV, NAFLD, alcohol-associated liver disease (ALD), or autoimmune liver disease/other using validated case definitions. Annual age/sex-adjusted cirrhosis incidence rate per 100,000 person-years was calculated with incidence projection to 2040 using age-period-cohort modeling along with average annual percent change (AAPC) in cirrhosis incidence stratified by birth cohort and etiology. In total, 159,549 incident cases of cirrhosis were identified. Incidence increased by 26% with an AAPC of 2%/year (95% CI, 1.6-2.4; P < 0.001). The largest increases were for HCV (AAPC, 4.1%/year; 95% CI, 2.6-5.7; P < 0.001) and NAFLD (AAPC, 3.3%/year; 95% CI, 2.6-4.1%; P < 0.001). ALD and HCV cirrhosis in those born >1980 increased by 11.6%/year (95% CI, 9.3-13.9; P < 0.001) and 9.5%/year (95% CI, 6.2-13.0; P < 0.001), respectively. However, by 2040, cirrhosis incidence is projected to continue to increase, driven mostly by NAFLD, especially in postmenopausal women, and ALD in individuals born >1980. CONCLUSIONS: Cirrhosis incidence will continue to increase over the next two decades secondary to NAFLD with a worrisome rapid rise in ALD cirrhosis among young adults. Public education, policy, and intervention targeting NAFLD risk factors and alcohol use in young adults are urgently needed.