Assessing the management of hepatic colorectal cancer metastases: is treatment consistent in Ontario?

OBJECTIVES: Advances in surgical techniques and chemotherapeutic options have expanded indications for surgery in patients with metastatic colorectal cancer. This study aimed to examine how hepatopancreatobiliary (HPB) surgeons approach the management of patients with hepatic colorectal cancer metastases (HCCM). METHODS: A web-based survey utilizing 10 clinical scenarios was distributed by e-mail to 37 HPB surgeons in Ontario, Canada. The study region has a population of approximately 13 million people and a universal, single-payer health care system. Descriptive analyses were used to tabulate results. RESULTS: Twenty-two (59%) surgeons responded to the survey. The majority (19/22, 86%) of respondents favoured neoadjuvant chemotherapy for patients with multiple synchronous and unilobar metastases; only nine of 22 (41%) respondents favoured neoadjuvant chemotherapy for patients with a single synchronous metastasis. In the setting of residual resectable disease following downstaging chemotherapy, 77% (17/22) of surgeons advocated hepatic resection with either radiofrequency ablation (RFA) or wedge resection of the 'ghost' lesions. Over 80% of surgeons would perform a liver and pulmonary resection in a patient with hepatic and multiple unilobar lung metastases. None would offer liver resection to patients with multiple retroperitoneal node involvement, although 55% (12/22) would do so if a single retroperitoneal node was involved. Preoperative portal vein embolization was favoured over RFA in patients with a small metastasis and inadequate functional hepatic volume. CONCLUSIONS: Notable heterogeneity was observed among Ontario's HPB surgeons in approaches to HCCM.

Vitamin D from dietary intake and sunlight exposure and the risk of hormone-receptor-defined breast cancer.

Evidence has emerged for a role of vitamin D in the development of breast cancer, and there is some suggestion that its antiproliferative effect is greater in hormone-receptor-positive cells. Few epidemiologic studies have considered the association between vitamin D and hormone-receptor-defined breast cancer, and the results are conflicting. Considering 759 cases and 1,135 controls from a case-control study (Ontario, Canada, 2003-2005), the authors examined the association between vitamin D intake at specific ages and combined estrogen-receptor- (ER) and progesterone-receptor- (PR) defined breast cancer. While increased intake of vitamin D (from the sun and diet) was most consistently associated with a significantly reduced risk of ER+/PR+ tumors (e.g., odds ratio = 0.76, 95% confidence interval: 0.59, 0.97 for use of cod liver oil during adolescence), comparable nonsignificant associations were found for receptor-negative (ER-/PR-) (odds ratio = 0.74, 95% confidence interval: 0.53, 1.04) and mixed (ER+/PR-) (odds ratio = 0.79, 95% confidence interval: 0.51, 1.22) tumors. This study suggests that vitamin D is associated with a reduced risk of breast cancer regardless of ER/PR status of the tumor. Future studies with a larger number of receptor-negative and mixed tumors are required.

Association of vitamin D related information from a telephone interview with 25-hydroxyvitamin D.

Vitamin D may be associated with reduced risks of several types of cancer, including colon, prostate, and breast. We examined the relationship between vitamin D-related questions administered in a telephone interview and serum 25-hydroxyvitamin D [25(OH)D]. Three hundred and eight eligible women were randomly selected from controls in a breast cancer case-control study. Questions pertaining to sun exposure and dietary sources of vitamin D over the previous 4 weeks were asked in both summer and winter. We assessed the association between questionnaire-derived items and 25(OH)D using multiple linear regression. There were 217 participating women, 203 in summer and 213 in winter. Models were adjusted for age, body mass index, and skin color. Number of days when more than 0.5 hour was spent outdoors per week ("7" versus "<7" beta = 11.12; P = 0.01), limb coverage ("no" beta = 24.90 and "partial" beta = 8.15 versus "yes"; P = 0.0001), and milk intake (glasses/wk; ">10" beta = 18.94, ">5-10" beta = 9.16, and "1-5" beta = 7.90 versus "<1"; P = 0.02) best predicted 25(OH)D in the summer. The best predictors in the winter were sunlamp use ("yes" beta = 27.97 versus "no"; P = 0.01), milk intake (glasses/wk; ">10" beta = 14.54, ">5-10" beta = 11.54, and "1-5" beta = 2.15 versus "<1"; P = 0.01), and vitamin D-containing supplements ("high" beta = 17.30 and "moderate" beta = 13.82 versus "none"; P = 0.0006). The R(2) was 0.29 for the summer model and was 0.21 for the winter model. Overall, there was evidence to suggest that questions designed to assess vitamin D exposure were in fact related to serum 25(OH)D.

Vitamin D and reduced risk of breast cancer: a population-based case-control study.

BACKGROUND: Vitamin D, antiproliferative and proapoptotic in breast cancer cell lines, can reduce the development of mammary tumors in carcinogen-exposed rats. Current evidence in humans is limited with some suggestion that vitamin D-related factors may reduce the risk of breast cancer. We conducted a population-based case-control study to assess the evidence for a relationship between sources of vitamin D and breast cancer risk. METHODS: Women with newly diagnosed invasive breast cancer were identified from the Ontario Cancer Registry. Women without breast cancer were identified through randomly selected residential telephone numbers. Telephone interviews were completed for 972 cases and 1,135 controls. Odds ratios (OR) and 95% confidence intervals (CI) for vitamin D-related variables were estimated using unconditional logistic regression with adjustment for potential confounders. RESULTS: Reduced breast cancer risks were associated with increasing sun exposure from ages 10 to 19 (e.g., OR, 0.65; 95% CI, 0.50-0.85 for the highest quartile of outdoor activities versus the lowest; P for trend = 0.0006). Reduced risk was also associated with cod liver oil use (OR, 0.76; 95% CI, 0.62-0.92) and increasing milk consumption (OR, 0.62 95% CI 0.45-0.86 for >or=10 glasses per week versus none; P for trend = 0.0004). There was weaker evidence for associations from ages 20 to 29 and no evidence for ages 45 to 54. CONCLUSION: We found strong evidence to support the hypothesis that vitamin D could help prevent breast cancer. However, our results suggest that exposure earlier in life, particularly during breast development, maybe most relevant. These results should be confirmed.

Comparison of self-reported lifetime sun exposure with two methods of cutaneous microtopography.

There is currently no "gold standard" for measuring lifetime sun exposure. Exploration of alternatives to self-reports is important for examining illnesses related to ultraviolet light exposure. Using skin replicas obtained from 184 controls in a breast cancer case-control study (Toronto, Ontario, Canada, 2004-2005), the authors compared self-reported indicators of lifetime sun exposure with two measures of cutaneous microtopography, the Beagley-Gibson system and skin line counts. With the Beagley-Gibson system, significantly increased odds ratios were found for age (odds ratio (OR) = 1.10, 95% confidence interval (CI): 1.05, 1.16), spending 7 days outside per week during the summer (OR = 3.33, 95% CI: 1.48, 7.50), and lifetime number of sunlamp sessions. Significantly decreased odds ratios were found for having darker skin, ever giving birth, and ever using sunlamps. With the skin line count approach, significant positive associations were found for age (OR = 2.31, 95% CI: 1.23, 4.35), age squared, duration of working in outdoor jobs (OR = 0.88, 95% CI: 0.79, 0.98), and average number of outdoor activities per week at ages 20-29 years (OR = 1.05, 95% CI: 1.00, 1.10). While the Beagley-Gibson method was associated with more variables than the skin line count method, both methods require further refinement before graded skin replicas can be recommended as a substitute for self-report measures.