Comparison of wait times across the breast cancer treatment pathway among screened women undergoing organized breast assessment versus usual care.

OBJECTIVE: The benefit of organized breast assessment on wait times to treatment among asymptomatic women is unknown. The Ontario Breast Screening Program (OBSP) offers screening and organized assessment through Breast Assessment Centres (BAC). This study compares wait times across the treatment pathway among screened women diagnosed with breast cancer through BAC and usual care (UC). METHODS: A retrospective design identified two concurrent cohorts of postmenopausal women aged 50-69 within the OBSP diagnosed with screen-detected invasive breast cancer and assessed in BAC (n = 2010) and UC (n = 1844) between 2002 and 2010. Demographic characteristics were obtained from the OBSP. Medical chart abstraction provided prognostic and treatment data. Multinomial logistic regression examined associations of assessment type with wait times from abnormal mammogram to surgery, chemotherapy or radiotherapy. RESULTS: Compared with through UC, postmenopausal women diagnosed through BAC were significantly less likely to have longer wait times (days) from an abnormal mammogram to definitive surgery (> 89 vs. ≤ 47; OR = 0.63; 95% CI = 0.52-0.77), from final surgery to radiotherapy (> 88 vs. ≤ 55; OR = 0.71; 95% CI = 0.54-0.93) and from final chemotherapy to radiotherapy (> 41 vs. ≤ 28; OR = 0.52; 95% CI = 0.36-0.76). Conversely, women assessed through BAC compared with through UC were more likely to experience longer wait times from final surgery to chemotherapy (> 64 vs. ≤ 40; OR = 1.49; 95% CI = 1.04-2.14). CONCLUSION: Shorter wait times to most treatments for postmenopausal women diagnosed in BAC further supports that women with an abnormal mammogram should be managed through organized assessment. Continued evaluation of factors influencing wait times to treatment is essential for quality improvement and patient outcomes.

The impact of organized breast assessment on survival by stage for screened women diagnosed with invasive breast cancer.

PURPOSE: Since 1998, the Ontario Breast Screening Program (OBSP) has offered organized assessment through Breast Assessment Centres (BAC). This study compares survival between screened women diagnosed with breast cancer who have undergone assessment through a BAC and usual care (UC). METHODS: A retrospective design identified two concurrent cohorts of women aged 50 to 69 within the OBSP diagnosed with screen-detected invasive breast cancer at a BAC (n = 2010) and UC (n = 1844) between 2002 and 2010 and followed until 2016. Demographic and assessment characteristics were obtained from the OBSP. Abstraction of medical charts provided prognostic and treatment data. Death data were assessed from the Registered Person's Database and the Ontario Registrar General All-Cause Mortality File. Multivariable Cox proportional hazards models compared overall survival by assessment type (BAC/UC), stratified by stage. RESULTS: There were 505 deaths during the study (BAC = 239; UC = 266). Among women with stage I screen-detected breast cancer, those diagnosed through a BAC had 31% reduced risk of all-cause mortality (HR = 0.69, 95% CI = 0.53-0.90) compared to UC. Diagnosis within 7 weeks of an abnormal mammogram reduced the hazard of death from all causes by 34% among all women with stage I breast cancers (HR = 0.66, 95% CI = 0.47-0.91), and was more likely in BAC (79.7%) than UC (66.9%). CONCLUSION: The significant improvement in overall survival for women with stage I screen-detected invasive breast cancer assessed through BACs further supports the recommendation that women with abnormal mammograms should be managed through organized assessment.

Validity of Administrative Databases in Comparison to Medical Charts for Breast Cancer Treatment Data.

OBJECTIVE: Medical chart abstraction is the gold standard for collecting breast cancer treatment data for monitoring and research. A less costly alternative is the use of administrative databases. This study will evaluate administrative data in comparison to medical charts for breast cancer treatment information. STUDY DESIGN AND SETTING: A retrospective cohort design identified 2,401 women in the Ontario Breast Screening Program diagnosed with invasive breast cancer from 2006 to 2009. Treatment data were obtained from the Activity Level Reporting and Canadian Institute of Health Information databases. Medical charts were abstracted at cancer centres. Sensitivity, specificity, positive and negative predictive value, and kappa were calculated for receipt and type of treatment, and agreement was assessed for dates. Logistic regression evaluated factors influencing agreement. RESULTS: Sensitivity and specificity for receipt of radiotherapy (92.0%, 99.3%), chemotherapy (77.7%, 99.2%), and surgery (95.8%, 100%) were high but decreased slightly for specific radiotherapy anatomic locations, chemotherapy protocols, and surgeries. Agreement increased by radiotherapy year (trend test, p < 0.0001). Stage II/III compared to stage I cancer decreased odds of agreement for chemotherapy (OR = 0.66, 95% CI: 0.48-0.91) and increased agreement for partial mastectomy (OR = 3.36, 95% CI: 2.27-4.99). Exact agreement in treatment dates varied from 83.0% to 96.5%. CONCLUSION: Administrative data can be accurately utilized for future breast cancer treatment studies.

Colorectal Cancer Screening in Average Risk Populations: Evidence Summary.

Introduction. The objectives of this systematic review were to evaluate the evidence for different CRC screening tests and to determine the most appropriate ages of initiation and cessation for CRC screening and the most appropriate screening intervals for selected CRC screening tests in people at average risk for CRC. Methods. Electronic databases were searched for studies that addressed the research objectives. Meta-analyses were conducted with clinically homogenous trials. A working group reviewed the evidence to develop conclusions. Results. Thirty RCTs and 29 observational studies were included. Flexible sigmoidoscopy (FS) prevented CRC and led to the largest reduction in CRC mortality with a smaller but significant reduction in CRC mortality with the use of guaiac fecal occult blood tests (gFOBTs). There was insufficient or low quality evidence to support the use of other screening tests, including colonoscopy, as well as changing the ages of initiation and cessation for CRC screening with gFOBTs in Ontario. Either annual or biennial screening using gFOBT reduces CRC-related mortality. Conclusion. The evidentiary base supports the use of FS or FOBT (either annual or biennial) to screen patients at average risk for CRC. This work will guide the development of the provincial CRC screening program.

Guideline for referral of patients with suspected colorectal cancer by family physicians and other primary care providers.

OBJECTIVE: The aim of this guideline is to assist FPs and other primary care providers with recognizing features that should raise their suspicions about the presence of colorectal cancer (CRC) in their patients. COMPOSITION OF THE COMMITTEE: Committee members were selected from among the regional primary care leads from the Cancer Care Ontario Provincial Primary Care and Cancer Network, the members of the Ontario Colorectal Cancer Screening Advisory Committee, and the members of the Cancer Care Ontario Gastrointestinal Cancer Disease Site Group. METHODS: This guideline was developed through systematic review of the evidence base, synthesis of the evidence, and formal external review involving Canadian stakeholders to validate the relevance of recommendations. REPORT: Evidence-based guidelines were developed to improve the management of patients presenting with clinical features of CRC within the Canadian context. CONCLUSION: The judicious balancing of suspicion of CRC and level of risk of CRC should encourage timely referral by FPs and primary care providers. This guideline might also inform indications for referral to CRC diagnostic assessment programs.

Systematic review of clinical features of suspected colorectal cancer in primary care.

OBJECTIVE: To systematically review the diagnostic accuracy of clinical features associated with colorectal cancer (CRC) presenting in primary care. DATA SOURCES: MEDLINE and EMBASE were searched for studies in primary care that provided information on clinical features predictive of CRC. Positive predictive values were used to guide the determination of clinical features associated with increased risk of CRC. STUDY SELECTION: Systematic reviews or primary studies that provided possible clinical features predictive of CRC were included. SYNTHESIS: Clinical features of patients presenting in primary care that are associated with increased risk of CRC, listed in descending order of association, included palpable rectal or abdominal mass; rectal bleeding combined with weight loss; iron deficiency anemia; rectal bleeding mixed with stool; rectal bleeding in the absence of perianal symptoms; rectal bleeding combined with change in bowel habits; dark rectal bleeding; rectal bleeding and diarrhea; and change in bowel habits. Being male and increasing age were also, in general, associated with increased risk of CRC. CONCLUSION: Recognition of clinical features associated with increased risk of CRC by FPs might help with earlier identification and referral among patients presenting in primary care. This review might help inform providers and CRC diagnostic assessment programs about indications for assessment and further investigation.

Screening high-risk populations for lung cancer: guideline recommendations.

INTRODUCTION: The aim of this practice guideline was to develop evidence-based recommendations for screening high-risk populations for lung cancer. METHODS: The guideline was developed using the methods of Cancer Care Ontario's Program in Evidence-Based Care. The core methodology of the Program in Evidence-Based Care's guideline development process is systematic review. A systematic review had recently been completed by a collaboration of the American Cancer Society, the American College of Chest Physicians, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. The evidence from that systematic review formed the basis of the recommendations, which were reviewed, and amended where necessary, by clinical experts in the fields of medical and radiation oncology, radiology, lung disease, and population health. RESULTS: The systematic review included eight randomized controlled trials and 13 single-arm studies evaluating screening with low-dose computed tomography (LDCT) in patients at risk for lung cancer. One large randomized trial reported a statistically significant reduction in lung cancer mortality with LDCT at 6 years compared with chest radiography. The practice guideline recommendations generally align with the parameters of the National Lung Screening Study. Deviations were described and justified by the guideline working group. The recommendations support screening persons at high-risk for lung cancer with advice for determining a positive result on LDCT, appropriate follow-up, and optimal screening interval. CONCLUSION: The benefits of screening high-risk populations for lung cancer with LDCT outweigh the harms if screening is implemented in a strictly controlled manner.