Associations between clinical pathway concordance, cost, and survival outcomes for stage II colon cancer: a population-based study.

This study measures patient's concordance between clinical reference pathways with survival or cost among a population-based cohort of colon cancer patients applying a continuous measure of concordance. The primary hypothesis is that a higher concordance score with the clinical pathway is significantly associated with longer survival or lower cost. The study informs whether patient's adherence to a defined clinical pathway is beneficial to patients' outcomes or health system. An externally determined clinical pathway for colon cancer was used to identify treatment nodes in colon cancer care. Using observational data up to 2019, the study generated a continuous measure of pathway concordance. The study measured whether incremental improvements in pathway concordance were associated with survival and treatment costs. Concordance between patients' reference pathways and their observed trajectories of care was highly statistically associated with survivorship [hazard ratio: 0.95 (95% confidence interval, CI, 0.95-0.96)], showing that adherence to the clinical pathway was associated with a lower mortality rate. An increase in concordance was statistically significantly associated with a decrease in health system cost. When patients' care followed the clinical pathway, survival outcomes were better and total health system costs were lower in this cohort. This finding creates a compelling case for further research into understanding the barriers to pathway concordance and developing interventions to improve outcomes and help providers implement best practice care where appropriate.

The effect of age on the opportunity to receive cancer treatment.

INTRODUCTION: Older adults with cancer may not receive the same opportunities for treatment as younger patients. In this retrospective population-based cohort study, we explored whether age was an independent predictor of receiving specialist consultation and treatment. METHODS: Patients age 45-99 were identified from the Ontario Cancer Registry having a primary solid tumor diagnosed between 01/Jan/2010 and 31/Dec/2019. We used logistic regression adjusted sociodemographic and clinical characteristics to compare the likelihood of consultation or receipt of treatment using linear splines at critical ages of 65, 80, and 90 years. RESULTS: A total 168,232 (42%), 165,205 (41%), 57,360 (14%), and 7810 (2%) patients were diagnosed age 45-64, 65-79, 80-89, and 90-99, respectively. The likelihood of surgical consultation decreased as patients reached 65 years [adjusted odds ratio (aOR) 0.86 (0.84-0.89)], which decreased further among octogenarians [aOR 0.63 (0.59-0.67)]. Similar results were observed for consultation with a medical oncologist and radiation oncologist. Receipt of surgery also decreased with age. Three-month post-operative mortality was higher among older patients [aRR 1.38 (1.26-1.50) per 10 years, p < 0.0001], an effect that remained similar as patients reached age 65 + years of age (p = 0.09 for change). For stage I patients, 3-month post-operative survival was high across all age groups, ranging from 99.8% in 45-64 year-olds, 99.4% in 65-79 year-olds, and 98.1% among octogenarians and nonagenarians (lung, colorectal, breast, cervical cancer patients). CONCLUSION: Older patients were less likely to have specialist consultations. More comprehensive data collection on clinical factors and referral patterns is needed to improve care for elderly cancer patients.

Identifying Breast Cancer Recurrence in Administrative Data: Algorithm Development and Validation.

Breast cancer recurrence is an important outcome for patients and healthcare systems, but it is not routinely reported in cancer registries. We developed an algorithm to identify patients who experienced recurrence or a second case of primary breast cancer (combined as a "second breast cancer event") using administrative data from the population of Ontario, Canada. A retrospective cohort study design was used including patients diagnosed with stage 0-III breast cancer in the Ontario Cancer Registry between 1 January 2009 and 31 December 2012 and alive six months post-diagnosis. We applied the algorithm to healthcare utilization data from six months post-diagnosis until death or 31 December 2013, whichever came first. We validated the algorithm's diagnostic accuracy against a manual patient record review (n = 2245 patients). The algorithm had a sensitivity of 85%, a specificity of 94%, a positive predictive value of 67%, a negative predictive value of 98%, an accuracy of 93%, a kappa value of 71%, and a prevalence-adjusted bias-adjusted kappa value of 85%. The second breast cancer event rate was 16.5% according to the algorithm and 13.0% according to manual review. Our algorithm's performance was comparable to previously published algorithms and is sufficient for healthcare system monitoring. Administrative data from a population can, therefore, be interpreted using new methods to identify new outcome measures.

Differences in breast cancer diagnosis by patient presentation in Ontario: a retrospective cohort study.

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.

Patient opinions on contralateral prophylactic mastectomy: A patient-driven discussion in need of tuning?

BACKGROUND: Rates of contralateral prophylactic mastectomy (CPM) are increasing among women with unilateral breast cancer despite low rates of contralateral recurrence and lack of survival benefit. We aimed to investigate the decisional needs and supports required to ensure adequate and quality decision-making by patients with breast cancer facing the decision regarding CPM. METHODS: In this qualitative study, we used semistructured interviews developed with the use of the Ottawa Decision Support Framework to investigate the decisional needs and supports of women (aged > 18 yr) with nonhereditary breast cancer who had previously discussed CPM with their care provider. Patients were recruited from 2 academic cancer centres in Toronto, Ontario. Interviews were conducted between June 2016 and October 2017. We analyzed responses to the open-ended questions iteratively and inductively to establish major themes within the results. RESULTS: Ten patients were recruited. Eight patients reported having initiated the discussion about CPM. Although most patients reported feeling supported, 6 mentioned some degree of decisional conflict. Cancer risk reduction was the most commonly reported perceived benefit of CPM (9 patients), followed by improved psychologic well-being (7). Most patients (8) did not mention the lack of survival benefit of CPM as a disadvantage of the procedure. Patients indicated that information resources (in 8 cases) and improved counselling from their health care team (in 7) would assist in decision-making. CONCLUSION: Our findings illustrate the disconnect between true and perceived risks (i.e., surgical risk) and benefits (potential recurrence and survival benefit) of CPM, which is not being managed adequately despite support from the health care team. A decision aid may address unmet patient need by providing a reliable resource regarding the benefits and risks of this procedure, while helping patients understand their values and realign their expectations.

Development of population-level colon cancer pathway concordance measures and association with survival.

Clinical cancer pathways help standardize healthcare delivery to optimize patient outcomes and health system costs. However, population-level measurement of concordance between standardized pathways and actual care received is lacking. Two measures of pathway concordance were developed for a simplified colon cancer pathway map for Stage II-III colon cancer patients in Ontario, Canada: a cumulative count of concordant events (CCCE) and the Levenshtein algorithm. Associations of concordance with patient survival were estimated using Cox proportional hazards models adjusted for patient characteristics and time-dependent cancer-related activities. Models were compared and the impact of including concordance scores was quantified using the likelihood ratio chi-squared test. The ability of the measures to discriminate between survivors and decedents was compared using the C-index. Normalized concordance scores were significantly associated with patient survival in models for cancer stage-a 10% increase in concordance for Stage II patients resulted in a CCCE score adjusted hazard ratio (aHR) of death of 0.93, 95% CI 0.88-0.98 and a Levenshtein score aHR of 0.64, 95% CI 0.60-0.67. A similar relationship was found for Stage III patients-a 10% increase in concordance resulted in a CCCE aHR of 0.85, 95% CI 0.81-0.88 and a Levenshtein aHR of 0.78, 95% CI, 0.74-0.81. Pathway concordance can be used as a tool for health systems to monitor deviations from established clinical pathways. The Levenshtein score better characterized differences between actual care and clinical pathways in a population, was more strongly associated with survival and demonstrated better patient discrimination.

Variation in Diagnosis, Treatment, and Outcome of Esophageal Cancer in a Regionalized Care System in Ontario, Canada.

Importance: Esophageal cancer remains one of the most deadly cancers, ranking sixth highest among cancers leading to the greatest years of life lost. Objective: To determine how patients with esophageal cancer are diagnosed and treated in Ontario's regionalized thoracic surgery centers. Design, Setting, and Participants: This cohort study included patients diagnosed with esophageal cancer between January 1, 2010, and December 31, 2018, identified from the Ontario Cancer Registry, in a single-payer health care system with regionalization of thoracic surgery in the province of Ontario, Canada. Exposures: Exposures included incidence of esophageal cancer and stage at diagnosis; time from the first health care visit until treatment; and the use of specialist consultations, endoscopic ultrasonography, positron emission tomography and computed tomography, endomucosal resection, esophagectomy, neoadjuvant therapy, adjuvant therapy, radiation alone, and chemotherapy alone or in combination with other treatment. Main Outcomes and Measures: Outcome measures included wait times, health care use, treatment, and overall survival. Data were analyzed from March 2020 to February 2021. Results: There were 10 364 patients (mean [SD] age, 68.3 [11.9] years; 7876 men [76%]) identified during the study period. The incidence of esophageal cancer increased over the study period from 1041 in 2010 to 1309 in 2018, which was driven by a 30% increase in the number of adenocarcinomas. The time from first health care encounter to start of treatment was a median 93 days (interquartile range, 56-159 days). Endoscopic ultrasonography was observed for 12% of patients, and positron emission tomography and computed tomography (CT) in 45%. Use of endoscopic mucosal resection was observed for 8% of patients with stage 0 to I disease. A total of 114 of 547 patients (21%) receiving endoscopic resection had a subsequent esophagectomy. Only 2778 patients (27%) had consultations with a thoracic surgeon, a medical oncologist, and a radiation oncologist, whereas 1514 patients (15%) did not see any of these specialists. Of 3047 patients who had an esophagectomy, those receiving neoadjuvant therapy had better overall survival (median survival, 36 months; 95% CI, 32-39 months) than patients who received esophagectomy alone (median survival, 27 months; 95% CI, 24-30 months) or those who received esophagectomy with adjuvant therapy (median survival, 36 months; 95% CI, 32-44 months) despite significant early mortality (log-rank P < .001). There was significant variation in treatment modality across hospitals: esophagectomy ranged from 5% to 39%; esophagectomy after neoadjuvant therapy ranged from 33% to 93%; and esophagectomy followed by adjuvant therapy ranged from 0 to 34% (P < .001). Perioperative mortality was higher at 30 days for patients receiving esophagectomy at low-volume centers (odds ratio [OR], 3.66; 95% CI, 2.01-6.66) and medium-volume centers (OR, 2.07; 95% CI, 1.33-3.23) compared with high-volume centers (P < .001). A longer wait time until treatment was associated with better overall survival (median overall survival was 15 to 17 days vs 5 to 8 days for patients who received treatment earlier than 30 days vs 30 days or longer after diagnosis; P < .001). Conclusions and Relevance: The results of this cohort study suggest that despite regionalization, there was significant regional variability in volumes at designated centers and in the evaluation and treatment course for patients with esophageal cancer across Ontario.

The effect of diagnostic assessment programs on the diagnosis and treatment of patients with lung cancer in Ontario, Canada.

INTRODUCTION: Diagnostic assessment programs (DAPs) were implemented in Ontario, Canada, to improve the efficiency of the lung cancer care continuum. We compared the efficiency and effectiveness of care provided to patients in DAPs relative to usual care (non-DAPs). METHODS: Lung cancer patients diagnosed between 2014 and 2016 were identified from the Ontario Cancer Registry. Using administrative databases, we identified various health-care encounters 6 months before diagnosis until the start of treatment and compared utilization patterns, timing, and overall survival between DAP and non-DAP patients. RESULTS: DAP patients were younger (P < 0.0001), had fewer comorbidities (P = 0.0006), and were more likely to have early-stage disease (36% vs. 25%) than non-DAP patients. Although DAP patients had a similar time until diagnosis as non-DAP patients, the time until treatment was 8.5 days shorter for DAP patients. DAP patients were more likely to receive diagnostic tests and specialist consultations and less likely to have duplicate chest imaging. DAP patients were more likely to receive brain imaging. Among early-stage lung cancers, brain imaging was high (74% for DAP and 67% for non-DAP), exceeding guideline recommendations. After adjustment for clinical and demographic factors, DAP patients had better overall survival than non-DAP patients (hazard ratio [HR]: 0.79 [0.76-0.82]), but this benefit was lost after adjusting for emergency presentation (HR: 0.96 [0.92-1.00]). A longer time until treatment was associated with better overall survival. CONCLUSION: DAPs provided earlier treatment and better access to care, potentially improving survival. Quality improvement opportunities include reducing unnecessary or duplicate testing and characterizing patients who are diagnosed emergently.

Incidence and real-world burden of brain metastases from solid tumors and hematologic malignancies in Ontario: a population-based study.

BACKGROUND: Although intracranial metastatic disease (IMD) is a frequent complication of cancer, most cancer registries do not capture these cases. Consequently, a data-gap exists, which thwarts system-level quality improvement efforts. The purpose of this investigation was to determine the real-world burden of IMD. METHODS: Patients diagnosed with a non-CNS cancer between 2010 and 2018 were identified from the Ontario Cancer Registry. IMD was identified by scanning hospital administrative databases for cranial irradiation or coding for a secondary brain malignancy (ICD-10 code C793). RESULTS: 25,478 of 601,678 (4.2%) patients with a diagnosis of primary cancer were found to have IMD. The median time from primary cancer diagnosis to IMD was 5.2 (0.7, 15.4) months and varied across disease sites, for example, 2.1 months for lung, 7.3 months for kidney, and 22.8 months for breast. Median survival following diagnosis with IMD was 3.7 months. Lung cancer accounted for 60% of all brain metastases, followed by breast cancer (11%) and melanoma (6%). More advanced stage at diagnosis and younger age were associated with a higher likelihood of developing IMD (P < .0001). IMD was also associated with triple-negative breast cancers and ductal histology (P < .001), and with small-cell histology in patients with lung cancer (P < .0001). The annual incidence of IMD was 3,520, translating to 24.2 per 100,000 persons. CONCLUSION: IMD represents a significant burden in patients with systemic cancers and is a significant cause of cancer mortality. Our findings support measures to actively capture incidents of brain metastasis in cancer registries.

Factors associated with waiting time to breast cancer diagnosis among symptomatic breast cancer patients: a population-based study from Ontario, Canada.

PURPOSE: A prolonged time from first presentation to cancer diagnosis has been associated with worse disease-related outcomes. This study evaluated potential determinants of a long diagnostic interval among symptomatic breast cancer patients. METHODS: This was a population-based, cross-sectional study of symptomatic breast cancer patients diagnosed in Ontario, Canada from 2007 to 2015 using administrative health data. The diagnostic interval was defined as the time from the earliest breast cancer-related healthcare encounter before diagnosis to the diagnosis date. Potential determinants of the diagnostic interval included patient, disease and usual healthcare utilization characteristics. We used multivariable quantile regression to evaluate their relationship with the diagnostic interval. We also examined differences in diagnostic interval by the frequency of encounters within the interval. RESULTS: Among 45,967 symptomatic breast cancer patients, the median diagnostic interval was 41 days (interquartile range 20-92). Longer diagnostic intervals were observed in younger patients, patients with higher burden of comorbid disease, recent immigrants to Canada, and patients with higher healthcare utilization prior to their diagnostic interval. Shorter intervals were observed in patients residing in long-term care facilities, patients with late stage disease, and patients who initially presented in an emergency department. Longer diagnostic intervals were characterized by an increased number of physician visits and breast procedures. CONCLUSIONS: The identification of groups at risk of longer diagnostic intervals provides direction for future research aimed at better understanding and improving breast cancer diagnostic pathways. Ensuring that all women receive a timely breast cancer diagnosis could improve breast cancer outcomes.

Axillary Lymph Node Ultrasound Following Neoadjuvant Chemotherapy in Biopsy-Proven Node-Positive Breast Cancer: Results from the SN FNAC Study.

BACKGROUND: The sentinel node biopsy following neoadjuvant chemotherapy (SN FNAC) study has shown that in node-positive (N+) breast cancer, sentinel node biopsy (SNB) can be performed following neoadjuvant chemotherapy (NAC), with a low false negative rate (FNR = 8.4%). A secondary endpoint of the SN FNAC study was to determine whether axillary ultrasound (AxUS) could predict axillary pathological complete response (ypN0) and increase the accuracy of SNB. METHODS: The SN FNAC trial is a study of patients with biopsy-proven N+ breast cancer who underwent SNB followed by completion node dissection. All patients had AxUS following NAC and the axillary nodes were classified as either positive (AxUS+) or negative (AxUS-). AxUS was compared with the final axillary pathology results. RESULTS: There was no statistical difference in the baseline characteristics of patients with AxUS+ versus those with AxUS-. Overall, 82.5% (47/57) of AxUS+ patients had residual positive lymph nodes (ypN+) at surgery and 53.8% (42/78) of AxUS- patients had ypN+. Post NAC AxUS sensitivity was 52.8%, specificity 78.3%, and negative predictive value 46.2%. AxUS FNR was 47.2%, versus 8.4% for SNB. If post-NAC AxUS- was used to select patients for SNB, FNR would decrease from 8.4 to 2.7%. However, using post-NAC AxUS in addition to SNB as an indication for ALND would have led to unnecessary ALND in 7.8% of all patients. CONCLUSION: AxUS is not appropriate as a standalone staging procedure, and SNB itself is sufficient to assess the axilla post NAC in patients who present with N+ breast cancer.

Practitioner Opinion on Contralateral Prophylactic Mastectomy: How Do We Steer a Patient-Driven Discussion?

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is increasing despite a recent statement from The American Society of Breast Surgeons discouraging average-risk women with unilateral breast cancer (BC) from undergoing CPM. The objective of our study was to conduct a needs assessment of BC health practitioners to gather information about their opinions, attitudes, and experiences surrounding CPM. METHODS: The Ottawa Decision Support Framework was the theoretical framework for the development of the interview guide. Semistructured interviews were conducted until data saturation with a convenience sample of 16 BC practitioners (Ontario, Canada), including oncologic and reconstructive surgeons, medical oncologists, and nurse navigators. RESULTS: Nearly all practitioners identified the discussion regarding CPM as patient-initiated. The majority of practitioners (13/16) described their role as supporting the patient in the decision-making process. Practitioners described educating patients on the lack of survival benefit and in general discouraging CPM. Practitioners agreed that most patients demonstrate decisional conflict (11/16) as a barrier to decision-making, and it is a challenge to realign patients' understanding and expectations. Almost all practitioners (15/16) identified a need for information materials to help educate patients on the risks and benefits of CPM and to help realign expectations. CONCLUSIONS: Practitioners have identified CPM in average-risk women with unilateral BC as a patient-driven phenomenon that is on the rise, despite highlighting the increased risk of complications and lack of survival benefit. Our practitioner needs assessment identifies the need for a dynamic decision aid to help guide the shared decision-making process for practitioners and patients.

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.

Patient-reported symptoms following mastectomy alone or lumpectomy plus radiation for early stage breast cancer: a cohort study.

PURPOSE: Studies examining symptom differences between surgeries for breast cancer patients rarely incorporate the effects of adjuvant treatment choice. We sought to understand differences in patient-reported symptoms between lumpectomy plus radiation and mastectomy in the year following surgery. METHODS: This cohort study used linked administrative datasets. The exposure was defined as lumpectomy plus radiation or mastectomy. The outcomes of moderate-to-severe (score ≥ 4) patient-reported symptoms were obtained using the Edmonton symptom assessment system (ESAS). Line plots were created to determine symptom trajectories in the 12 months following surgery, and the relationships between surgery and each of the nine symptoms were assessed using multivariable analyses. Clinical significance was determined as a difference of 10%. RESULTS: Of 13,865 Stage I-II breast cancer patients diagnosed 2007-2015, 11,497 underwent lumpectomy plus radiation and 2368 underwent mastectomy. Symptom trajectories were similar for all nine symptoms until approximately 5 months postoperatively when they diverged and mastectomy symptoms started becoming more severe. On multivariable analyses, patients undergoing mastectomy were at an increased risk of reporting moderate-to-severe depression (RR 1.19, 95% CI 1.09-1.30), lack of appetite (RR 1.11, 95% CI 1.03-1.20), and shortness of breath (RR 1.16, 95% CI 1.04-1.15) compared to those undergoing lumpectomy plus radiation. CONCLUSIONS: Even with the addition of adjuvant radiation, patients who are treated with lumpectomy fare better in three of nine patient-reported symptoms. Further examination of these differences will assist in better shared decision-making regarding surgical treatments.

Organized screening detects breast cancer at earlier stage regardless of molecular phenotype.

PURPOSE: Mortality reduction attributable to organized breast screening is modest. Screening may be less effective at detecting more aggressive cancers at an earlier stage. This study was conducted to determine the relative efficacy of screening mammography to detect cancers at an earlier stage by molecular phenotype. METHODS: We identified 2882 women with primary invasive breast cancer diagnosed between January 1, 2008 and December 31, 2012 and who had a mammogram through the Ontario Breast Screening Program in the 28 months before diagnosis. Five tumor phenotypes were defined by expression of estrogen (ER) and progesterone (PR) receptors and HER2/neu oncogene. We conducted univariable and multivariable analyses to describe the predictors of detection as an interval cancer. Additional analyses identified predictors of detection at stages II, III, or IV compared with stage I, by phenotype. Analyses were adjusted for the effects of age, grade, and breast density. RESULTS: ER negative and HER2 positive tumors were over-represented among interval cancers, and triple negative cancers were more likely than ER +/HER2 - cancers to be detected as interval cancers OR 2.5 (95% CI 2.0-3.2, p < 0.0001). Method of detection (interval vs. screen) and molecular phenotype were independently associated with stage at diagnosis (p < 0.0001), but there was no interaction between method of detection and phenotype (p = 0.44). CONCLUSION: In a screened population, triple negative and HER2 + breast cancers are diagnosed at a higher stage but this appears to be due to higher growth rates of these tumors rather than a relative inability of screening to detect them.

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.

Breast screening for survivors of breast cancer: A systematic review.

There is a large and growing population of women who have a personal history of breast cancer (PHBC). This systematic review was undertaken to explore the outcomes of surveillance mammography in breast cancer survivors, and to examine the evidence for screening these women within an organized population-based screening program. We searched Cochrane Central Register of Controlled Trials (CENTRAL Issue 6, 2015), OVID MEDLINE and EMBASE (January 2012 to June 22, 2015) for English-language studies of surveillance of the target population. A study author extracted study outcomes, which were audited by a research assistant. One systematic review and 5 primary studies were included. These showed that surveillance mammography may reduce breast cancer-specific mortality through early/asymptomatic detection (Hazard Ratio for those without compared to with symptoms:HR: 0.64, 95% CI 0.55 - 0.74). Three studies showed that semi-annual mammography is likely not of greater benefit than annual mammography. No evidence was found to suggest that surveillance mammography for women with a PHBC should not be conducted within an organized screening program. The small evidence-base had a high level of heterogeneity in populations, interventions and outcomes. Based on this review, organized screening programs should reassess their guidelines on surveillance mammography and consider including women with a PHBC.

Utilization of Percutaneous Needle Biopsy for Breast Diagnosis in a Comprehensive Breast Center: Implications for Development of Quality Indicators.

INTRODUCTION: Percutaneous needle biopsy (PNB) is the standard of care for diagnosis of breast lesions. Rates of excisional biopsy for breast diagnosis in North America have been reported at approximately 35 %, although significant regional variation exists. A target rate of PNB for diagnosis of breast abnormalities is needed to facilitate quality improvement. We sought to describe the use of PNB in a referral practice, the clinical scenarios prompting PNB or surgical biopsy (SB), and the accuracy and rate of PNB to inform the ultimate development of a benchmark rate of PNB in breast diagnosis. MATERIALS AND METHODS: Female patients age 18-90 years, referred to Sunnybrook Health Sciences Centre, a large teaching hospital affiliated with the University of Toronto, with a breast lesion prompting tissue diagnosis with SB and/or PNB between 2002 and 2009 were studied. Each biopsied lesion was characterized by method of biopsy: PNB, SB, or PNB followed by SB. For each lesion, we collected data on patient demographics and breast cancer risk, reason for referral, imaging characteristics (breast imaging-reporting and data system classification, full description, final impression before biopsy), and pathology from each biopsy method. We report concordance between the final impression pre-biopsy and the PNB diagnosis with final surgical diagnosis where applicable. RESULTS: One thousand and twenty-six lesions were biopsied, 987 (96 %) with PNB. The benign:malignant ratio for the entire cohort was 1.2:1. Final impression was concordant with final pathology in 674/862 (78 %) and PNB diagnosis was concordant with SB pathology in 487/556 (88 %). The reasons for SB without PNB were required pathologic evaluation of the entire lesion (n = 19), patient choice (n = 5), other biopsy technique used (n = 6), technical (n = 4), planned mastectomy (n = 3), and enlarging mass (n = 2). 155/559 (28 %) of lesions without evidence of malignancy on PNB ultimately underwent SB. Papillary lesions and radial scars were more likely to undergo SB with or without prior PNB. Lesions deemed to be suspicious or malignant on final impression were more likely to be excised after a benign diagnosis at PNB. CONCLUSION: The vast majority of lesions requiring tissue diagnosis can be accurately diagnosed with PNB. Benchmarks for rates of PNB of 90 % or greater may be considered for performance measurement in appropriate populations.

Whole-mount pathology of breast lumpectomy specimens improves detection of tumour margins and focality.

AIMS: Technical limitations in conventional pathological evaluation of breast lumpectomy specimens may reduce diagnostic accuracy in the assessment of margin and focality. A novel technique based on whole-mount serial sections enhances sampling while preserving specimen conformation and orientation. The aim of this study was to investigate assessment of focality and margin status by the use of whole-mount serial sections versus simulated conventional sections in lumpectomies. METHODS AND RESULTS: Two pathologists interpreted whole-mount serial sections and simulated conventional sections for 58 lumpectomy specimens by reporting the closest margin and focality. Measurements were compared by the use of McNemar's chi-squared test. Statistically significant differences were observed in the assignment of both margin positivity (P = 0.014) and multifocality (P = 0.021). A positive margin or multifocal disease was identified by the use of whole-mount serial sections but missed in the simulated conventional assessment in 10.3% and 17.2% of all cases, respectively. There was no case in which a positive margin was detected only in the simulated conventional assessment. CONCLUSIONS: The whole-mount technique is more sensitive than conventional assessment for identifying a positive margin or multifocal disease in breast lumpectomy specimens. Undersampling in conventional sections was implicated in almost all cases of discordance. The majority of positive margins or secondary foci identified only in whole-mount serial sections concerned in-situ disease.

Wait times for breast cancer surgery: effect of magnetic resonance imaging and preoperative investigations on the diagnostic pathway.

PURPOSE: Women with breast cancer often require an extensive diagnostic work-up. We sought to determine the overall wait time, from the patient's perspective, from identification of an imaging abnormality to definitive treatment. The objective was to identify which factors contribute to overall wait time in women with breast cancer. METHODS: A retrospective chart review in a tertiary care center was performed to identify all women who had breast surgery for invasive carcinoma and ductal carcinoma in situ. We recorded the dates of first imaging abnormality, first biopsy, subsequent imaging and biopsy, first consultation with any physician at the cancer center, first surgical consultation, and date of surgery. Clinical data that might influence these dates were then extracted. Wait times were calculated and factors associated with wait times were described. RESULTS: Eligible consecutive women with a cancer diagnosis (n = 264) were identified. The median time between first imaging abnormality and definitive surgery was 79 days. The median time from first surgical consultation to surgery was significantly longer in women who underwent magnetic resonance imaging and in women who underwent initial imaging outside of our tertiary care center (P < .05). On multivariable analysis, the modifiable factors associated with prolonged wait times included number of preoperative clinic visits, number of visits to radiology, and initial imaging outside of our center (P < .05). CONCLUSION: Extensive diagnostic work-up is an important factor that affects the time to definitive surgery. A more integrated approach using a rapid diagnostic clinic for tissue diagnosis initially, followed by facilitated preoperative evaluation, may potentially decrease wait times in breast evaluation.