Factors Associated with the Breast Cancer Diagnostic Interval across Five Canadian Provinces: A CanIMPACT Retrospective Cohort Study.

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.

Late Effects in Childhood Cancer Survivors: Early Studies, Survivor Cohorts, and Significant Contributions to the Field of Late Effects.

With improvement in cure of childhood cancer came the responsibility to investigate the long-term morbidity and mortality associated with the treatments accountable for this increase in survival. Several large cohorts of childhood cancer survivors have been established throughout Europe and North America to facilitate research on long-term complications of cancer treatment. The cohorts have made significant contributions to the understanding of early mortality, somatic late complications, and psychosocial outcomes among childhood cancer survivors, which has been translated into the design of new treatment protocols for pediatric cancers, with the goal to reduce the potential risk and severity of late effects.

Comparing Childhood Cancer Care Costs in Two Canadian Provinces.

BACKGROUND: Cancer in children presents unique issues for diagnosis, treatment and survivorship care. Phase-specific comparative cost estimates are important for informing healthcare planning. OBJECTIVE: The aim of this paper is to compare direct medical costs of childhood cancer by phase of care in British Columbia (BC) and Ontario (ON). METHODS: For cancer patients diagnosed at <15 years of age and propensity-score-matched non-cancer controls, we applied standard costing methodology using population-based healthcare administrative data to estimate and compare phase-based costs by province. RESULTS: Phase-specific cancer-attributable costs were 2%-39% higher for ON than for BC. Leukemia pre-diagnosis costs and annual lymphoma continuing care costs were >50% higher in ON. Phase-specific in-patient hospital costs (the major cost category) represented 63%-82% of ON costs, versus 43%-73% of BC costs. Phase-specific diagnostic tests and procedures accounted for 1.0%-3.4% of ON costs and 2.8%-13.0% of BC costs. CONCLUSION: There are substantial cost differences between these two Canadian provinces, BC and ON, possibly identifying opportunities for healthcare planning improvement.

Inter- and intra-provincial variation in screen-detected breast cancer across five Canadian provinces: a CanIMPACT study.

OBJECTIVE: Breast cancer screening aims to identify cancers in early stages when prognosis is better and treatments less invasive. We describe inter- and intra-provincial variation in the percentage of screen-detected cases under publicly funded healthcare systems and factors related to having screen- vs non-screen-detected breast cancer across five Canadian provinces. METHODS: Women aged 40+ diagnosed with incident breast cancer from 2007 to 2012 in five Canadian provinces were identified from their respective provincial cancer registries. Standardized provincial datasets were created linking screening, health administrative, and claims data. Province-specific logistic regression models were used to evaluate the association of demographic and healthcare utilization factors in each province with the odds of screen-detected cancer. RESULTS: There was significant inter- and intra-provincial variation by age. Screen detection ranged from 42% to 52% in ages 50-69 but women aged 50-59 had approximately 4-8% lower screen detection than those aged 60-69 in all provinces. Screening associations with income quintile and rurality varied across provinces. Those least likely to be screen-detected within a province were consistently in the lowest income quintile; OR ranged from 0.62-0.89 relative to highest income quintile/urban patients aged 50-69. Lack of visits to primary care 30 months prior to diagnosis was also consistently associated with lower odds of screen detection (OR range, 0.37-0.76). CONCLUSION: Breast cancer screen detection rates in the Canadian provinces examined are relatively high. Associations with income-rurality indicate a need for greater attention and/or targeted outreach to specific communities and/or provincial regions to improve access to breast cancer screening services intra-provincially.

Psychiatric Disorders in Adolescent and Young Adult-Onset Cancer Survivors: A Systematic Review and Meta-Analysis.

Although a cancer diagnosis during the adolescent and young adult (AYA) years is a traumatic event, and psychiatric disorders generally manifest during the AYA period, the impact of a cancer diagnosis on long-term mental health outcomes in this population is not well characterized. We conducted a systematic review and meta-analysis to determine if survivors of AYA cancers are more likely to develop psychiatric disorders. A systematic literature search of five databases, MEDLINE, CINAHL, Web of Science, EMBASE, and PsycINFO, was conducted from their inception to November 2018. The outcome measures were psychiatric disorders as per the Diagnostic Statistical Manual criteria, or psychiatric medication use. Study eligibility, appraisal, and data abstraction were independently conducted by two reviewers. Of 7934 total studies, four met eligibility criteria for the systematic review, three of which were included in the meta-analysis. Compared to cancer-free controls, survivors were at an elevated risk of mood disorders (odds ratio [OR] 1.36; 95% CI 1.19-1.55) and anxiety disorders (OR 1.16; 95% CI 1.05-1.28), but not substance-related disorders, (OR 0.88; 95% CI 0.63-1.22). The most commonly identified risk factors were the female sex and older age at diagnosis. We found higher odds of anxiety and mood disorders in AYA-onset cancer survivors. However, few AYA-specific studies currently exist that analyze psychiatric disorders using consistent and standardized methods. Additional studies confirming these findings are warranted.

Multiple event times in the presence of informative censoring: modeling and analysis by copulas.

Motivated by a breast cancer research program, this paper is concerned with the joint survivor function of multiple event times when their observations are subject to informative censoring caused by a terminating event. We formulate the correlation of the multiple event times together with the time to the terminating event by an Archimedean copula to account for the informative censoring. Adapting the widely used two-stage procedure under a copula model, we propose an easy-to-implement pseudo-likelihood based procedure for estimating the model parameters. The approach yields a new estimator for the marginal distribution of a single event time with semicompeting-risks data. We conduct both asymptotics and simulation studies to examine the proposed approach in consistency, efficiency, and robustness. Data from the breast cancer program are employed to illustrate this research.

Patterns of comorbidities in women with breast cancer: a Canadian population-based study.

PURPOSE: Improving the understanding of co-existing chronic diseases prior to and after the diagnosis of cancer may help to facilitate therapeutic decision making in clinical practice. This study aims to examine patterns of comorbidities in Canadian women with breast cancer. METHODS: We conducted a retrospective cohort study using provincial linked administrative health datasets from British Columbia, Canada, between 2000 and 2013. Women diagnosed with breast cancer between 2005 and 2009 were identified. The index date was defined as the date of diagnosis of breast cancer. Subsets of the breast cancer cohort were identified based on the absence of individual type of comorbidity of interest within 5 years prior to breast cancer diagnosis. For each subset, cases were then individually matched by year of birth at 1:2 ratios with controls without a history of cancer and the individual type of comorbidity of interest within 5 years prior to the assigned index year, matching with the year of breast cancer diagnosis of the corresponding case. Baseline comorbidities were measured over a 1-year period prior to the index date using two comorbidity indices, Rx-Risk-V and Aggregated Diagnosis Groups (ADG). Cox regression model was used to assess the development of seven specific comorbidities after the index date between women with breast cancer and non-cancer women. RESULTS: The most prevalent baseline comorbidity in the breast cancer cohort measured using the Rx-Risk-V model was cardiovascular conditions (39.0%), followed by pain/pain-inflammation (34.8%). The most prevalent category measured using the ADG model was major signs or symptoms (71.8%), followed by stable chronic medical conditions (52.2%). The risks of developing ischemic heart disease, heart failure, depression, diabetes, osteoporosis, and hypothyroidism were higher in women with breast cancer compared to women without cancer, with the hazard ratios ranging from 1.09 (95 CI% 1.03-1.16) for ischemic heart disease to 2.10 (95% CI 1.99-2.21) for osteoporosis in the model adjusted for baseline comorbidity measured using Rx-Risk-V score. CONCLUSION: Women with breast cancer had a higher risk of developing new comorbidities than women without cancer. Development of coordinated care models to manage multiple chronic diseases among breast cancer patients is warranted.

Adherence to quality breast cancer survivorship care in four Canadian provinces: a CanIMPACT retrospective cohort study.

BACKGROUND: In order to maximize later health, there are established components and guidelines for quality follow-up care of breast cancer survivors. However, adherence to quality follow-up in Canada may not be optimal, and may vary by province. We determined and compared the proportion of patients in each province who received adherent and non-adherent surveillance for recurrence, new cancers and late effects, recommended preventive care, and recommended physician visits for comorbidities. METHODS: Cohorts consisted of all adult women diagnosed with incident invasive breast cancer between 2007 and 2010/2012 in four Canadian provinces (British Columbia (BC) N = 9338; Manitoba N = 2688; Ontario N = 23,700; Nova Scotia (NS) N = 2735), identified from provincial cancer registries, alive and cancer-free at 30 months post-diagnosis. Their healthcare utilization was determined from one to 5 years post-treatment, using linked administrative databases. Adherence, underuse, and overuse of recommended services were evaluated yearly and compared using descriptive statistics. RESULTS: In all provinces and follow-up years, the majority of survivors had more than the recommended number of visits to either an oncologist or primary care physician (range 53.8% NS Year 3; 85.8% Ontario Year 4). The proportion of patients with the guideline-recommended number of oncologist visits varied by province (range 29.8% BC Year 5; 74.8% Ontario Year 5), and the proportion of patients with less than the recommended number of specified breast cancer-related visits with either an oncologist or primary care physician ranged from 32.6% (Ontario Year 2) to 84.4% (NS Year 3). Underuse of surveillance breast imaging was identified in NS and BC. The proportion of patients receiving imaging for metastatic disease (not recommended in the guidelines) in BC, Manitoba, and Ontario (not reported in NS) ranged from 20.3% (BC Year 5) to 53.3% (Ontario Year 2). Compliance with recommended physician visits for patients with several chronic conditions was high in Ontario and NS. Preventive care was less than optimal in all provinces with available data. CONCLUSIONS: Quality of breast cancer survivor follow-up care varies among provinces. Results point to exploration of factors affecting differences, province-specific opportunities for care improvement, and the value of administrative datasets for health system assessment.

Resource Utilization and Costs in Adolescents Treated for Cancer in Pediatric vs Adult Institutions.

BACKGROUND: Adolescents with cancer can receive care in pediatric or adult institutions. Survival often differs by locus, but little is known about relative health care utilization and costs. We estimated these in a population-based cohort of adolescents. METHODS: All Ontario adolescents (15.0-17.9 years) diagnosed with cancer between 1995 and 2010 were identified from provincial cancer registries. We compared health care resource utilization (hospitalizations, emergency department visits, same-day surgeries, outpatient chemotherapy, radiation, diagnostic/laboratory tests, physician services, home care) and costs (2012 Canadian dollars) during four discrete care phases-prediagnosis (60 days), initial (360 days), continuing (variable), and terminal (360 days)-between adolescents treated in pediatric vs adult institutions, for the whole cohort and within seven diagnostic categories. All statistical tests were two-sided. RESULTS: Of 1356 eligible adolescents, 691 and 665 were treated in adult and pediatric institutions, respectively. Hospitalization rates were higher in pediatric institutions during prediagnosis (14.9% vs 6.9%, P < .001), initial (95.1% vs 73.3%, P < .001), and continuing phases (43.2% vs 34.4%, P = .002), but similar (96.1% vs 96.3%, P = .93) during the terminal phase. Average length of stay was higher at pediatric institutions within most diagnoses and phases. For all diagnoses, median initial phase costs were higher in pediatric than adult institutions (eg, leukemia: $153 926 vs $102 418 per 360 days, P < .001; lymphoma: $65 025 vs $19 846, P < .001, respectively). CONCLUSIONS: The costs of caring for adolescents with the same malignancy are considerably higher in pediatric than adult institutions during most phases. Resource utilization, particularly hospitalization, drives much of the cost difference, making these data applicable to other jurisdictions.

Long-term effects of cancer on earnings of childhood, adolescent and young adult cancer survivors - a population-based study from British Columbia, Canada.

BACKGROUND: The patterns and determinants of long-term income among young people surviving cancer, and differences compared to peers, have not yet been fully explored. The objectives of this paper are to describe long-term income among young survivors of cancer, the impact of socio-demographic, disease, and treatment factors on long-term income, and income relative to the general population. METHODS: Retrospective cohort study with comparison group from the general population, using linked population-based registries, clinical data, and tax-records. Multivariate random effects regression models were used to determine survivor income, compare long-term income between survivors and comparators, and assess income determinants. Subjects included all residents of British Columbia (BC), Canada, diagnosed with cancer before 25 years of age and surviving 5 years or more. Comparators were selected from the BC general population matched by gender and birth year. RESULTS: Young cancer survivors earned significantly less than the general population. In addition, survivors of central nervous system tumors have significantly lower incomes than lymphoma survivors. Survivors who received radiation therapy have significantly lower income. Results should be interpreted with caution as the comparator group was matched by gender and date of birth. CONCLUSIONS: Depending on original diagnosis, treatment, and other characteristics, survivors face significantly lower income than peers and may require supports to gain and retain paid employment. Lower income will affect their opportunity for independent living, and will reduce productivity in the labour force.

Promoting bone health management in women diagnosed with breast cancer: a pilot randomized controlled trial.

This study investigates, in women diagnosed with breast cancer, the feasibility of evaluating the effects of educational material and its delivery method, on bone health management. The study results suggest educational material may improve rates of bone mineral density testing. INTRODUCTION: Educational materials improve bone mineral density (BMD) testing rates in high-risk patients, but the effect is unknown in women diagnosed with breast cancer. Methods of delivering educational materials may also affect testing rates. The purposes of this study were to determine the feasibility of the protocol and to pilot-test the effects of educational material and its delivery methods on BMD testing rates. METHOD: Pilot randomized controlled trial with block randomization. Fifty-four women (aged 65-75 and diagnosed with breast cancer ≥ 3 years ago (2010-2012) and not taking osteoporosis medication) were recruited from February to May 2016 and randomized to three groups: control without educational material, educational material delivered by postal mail, and educational material delivered by patient choice of postal mail, email, or text messaging. Outcome measures were primarily evaluated using self-report questionnaires. RESULTS: The participation rate, defined as the proportion of eligible participants who consented to participate, was 39.1%. Primary outcome measure was obtained for 98% of the recruited women. During the 6-month follow-up period, BMD testing rates were significantly higher in the groups receiving educational materials by mail (26%, 95%CI = 10 to 49) and by patient choice (18%, 95%CI = 5 to 41), when compared with the control group (6%, 95%CI = 0.3 to 25). Educational material was associated with a 17% higher BMD testing rate. CONCLUSIONS: The study protocol is feasible for a large-scale study. The educational material intervention is broadly accepted by the study participants with a promising positive effect on BMD testing rates.

Aromatase inhibitors are associated with a higher fracture risk than tamoxifen: a systematic review and meta-analysis.

BACKGROUND: In this paper, our aim was to systematically evaluate published evidence of bone fracture risk associated with tamoxifen and aromatase inhibitors in women aged 65 and under, and diagnosed with nonmetastatic breast cancer. METHODS: We comprehensively searched MEDLINE, EMBASE and CINAHL databases from January 1997 through May 2015, and reference lists of the selected articles to identify English-language randomized controlled trials and cohort studies of fracture risk. Two independent reviewers screened articles and assessed methodological quality using Risk of Bias assessment for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Fracture risk was estimated as pooled risk ratios using a random-effects model and inverse variance method. RESULTS: Of 1926 identified articles, 21 independent studies fulfilled our selection criteria. Similar fracture risk was observed in women treated and not treated with tamoxifen [pooled risk ratio (RR) 0.95; 95% confidence interval (CI) 0.84-1.07]. A 35% (95% CI 1.21-1.51) higher fracture risk was observed in the aromatase inhibitor group compared with the tamoxifen group. A 17% (95% CI 1.07-1.28) higher fracture risk was observed in the aromatase inhibitor group than the no aromatase inhibitor group. Compared with the tamoxifen group, aromatase inhibitor-associated fracture risk increased by 33% (pooled RR 1.33; 95% CI 1.21-1.47) during the tamoxifen/aromatase inhibitor treatment period, but did not increase (pooled RR 0.99; 95% CI 0.72-1.37) during the post-tamoxifen/aromatase inhibitor treatment period. CONCLUSIONS: Fracture risk is significantly higher in women treated with aromatase inhibitors, especially during the treatment period. Tamoxifen is not associated with lower fracture risk while tamoxifen could potentially preserve bone mass. Better osteoporosis management programs, especially during the treatment period, are needed for this group of women.

Lessons Learned: It Takes a Village to Understand Inter-Sectoral Care Using Administrative Data across Jurisdictions.

Cancer care is complex and exists within the broader healthcare system. The CanIMPACT team sought to enhance primary cancer care capacity and improve integration between primary and cancer specialist care, focusing on breast cancer. In Canada, all medically-necessary healthcare is publicly funded but overseen at the provincial/territorial level. The CanIMPACT Administrative Health Data Group's (AHDG) role was to describe inter-sectoral care across five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia. This paper describes the process used and challenges faced in creating four parallel administrative health datasets. We present the content of those datasets and population characteristics. We provide guidance for future research based on 'lessons learned'. The AHDG conducted population-based comparisons of care for breast cancer patients diagnosed from 2007-2011. We created parallel provincial datasets using knowledge from data inventories, our previous work, and ongoing bi-weekly conference calls. Common dataset creation plans (DCPs) ensured data comparability and documentation of data differences. In general, the process had to be flexible and iterative as our understanding of the data and needs of the broader team evolved. Inter-sectoral data inconsistencies that we had to address occurred due to differences in: 1) healthcare systems, 2) data sources, 3) data elements and 4) variable definitions. Our parallel provincial datasets describe the breast cancer diagnostic, treatment and survivorship phases and address ten research objectives. Breast cancer patient demographics reflect inter-provincial general population differences. Across provinces, disease characteristics are similar but underlying health status and use of healthcare services differ. Describing healthcare across Canadian jurisdictions assesses whether our provincial healthcare systems are delivering similar high quality, timely, accessible care to all of our citizens. We have provided a description of our experience in trying to achieve this goal and, for future use, we include a list of 'lessons learned' and a list of recommended steps for conducting this kind of work. KEY FINDINGS: The conduct of inter-sectoral research using linked administrative health data requires a committed team that is adequately resourced and has a set of clear, feasible objectives at the start.Guiding principles include: maximization of sectoral participation by including single-jurisdiction expertise and making the most inclusive data decisions; use of living documents that track all data decisions and careful consideration about data quality and availability differences.Inter-sectoral research requires a good understanding of the local healthcare system and other contextual issues for appropriate interpretation of observed differences.

Costs of cancer care in children and adolescents in Ontario, Canada.

BACKGROUND: Cancer in children and adolescents presents unique issues regarding treatment and survivorship, but few studies have measured economic burden. We estimated health care costs by phase of cancer care, from the public payer perspective, in population-based cohorts. METHODS: Children newly diagnosed at ages 0 days-14.9 years and adolescents newly diagnosed at 15-19.9 years, from January 1, 1995 to June 30, 2010, were identified from Ontario cancer registries, and each matched to three noncancer controls. Data were linked with administrative records describing resource use for cancer and other health care. Total and net (patients minus controls) resource-specific costs ($CAD2012) were estimated using generalized estimating equations for four phases of care: prediagnosis (60 days), initial (360 days), continuing (variable), final (360 days). RESULTS: Mean ages at diagnosis were 6 years for children (N = 4,606) and 17 years for adolescents (N = 2,443). Mean net prediagnosis phase 60-day costs were $6,177 for children and $1,018 for adolescents. Costs for initial, continuing, and final phases were $138,161, $15,756, and $316,303 per 360 days for children, and $62,919, $7,071, and $242,008 for adolescents. The highest initial phase costs were for leukemia patients ($156,225 per 360 days for children and $171,275 for adolescents). The final phase was the most costly ($316,303 per 360 days for children and $242,008 for adolescents). CONCLUSIONS: Costs for children with cancer are much higher than for adolescents and much higher than those reported in adults. Comprehensive population-based long-term estimates of cancer costs are useful for health services planning and cost-effectiveness analysis.

Costs for Childhood and Adolescent Cancer, 90 Days Prediagnosis and 1 Year Postdiagnosis: A Population-Based Study in Ontario, Canada.

BACKGROUND: Childhood and adolescent cancers are uncommon, but they have important economic and health impacts on patients, families, and health care systems. Few studies have measured the economic burden of care for childhood and adolescent cancers. OBJECTIVES: To estimate costs of cancer care in population-based cohorts of children and adolescents from the public payer perspective. METHODS: We identified patients with cancer, aged 91 days to 19 years, diagnosed from 1995 to 2009 using cancer registry data, and matched each to three noncancer controls. Using linked administrative health care records, we estimated total and net resource-specific costs (in 2012 Canadian dollars) during 90 days prediagnosis and 1 year postdiagnosis. RESULTS: Children (≤14 years old) numbered 4,396: 36% had leukemia, 21% central nervous system tumors, 10% lymphoma, and 33% other cancers. Adolescents (15-19 years old) numbered 2,329: 28.9% had lymphoma. Bone and soft tissue sarcoma, germ cell tumor, and thyroid carcinoma each comprised 12% to 13%. Mean net prediagnosis costs were $5,810 and $1,127 and mean net postdiagnosis costs were $136,413 and $62,326 for children and adolescents, respectively; the highest were for leukemia ($157,764 for children and $172,034 for adolescents). In both cohorts, costs were much higher for patients who died within 1 year of diagnosis. Inpatient hospitalization represented 69% to 74% of postdiagnosis costs. CONCLUSIONS: Treating children with cancer is costly, more costly than treating adolescents or adults. Substantial survival gains in children mean that treatment may still be very cost-effective. Comprehensive age-specific population-based cost estimates are essential to reliably assess the cost-effectiveness of cancer care for children and adolescents, and measure health system performance.

Cervical cancer screening for survivors diagnosed with cancer before age 25.

PURPOSE: The study aims to better understand Pap test utilization for cancer survivors diagnosed before age 25 in British Columbia (BC), Canada. METHODS: A population-based cross-sectional data linkage study that included 1285 5-year female cancer survivors diagnosed with cancer before age 25 and 12,185 randomly selected and birth-year-matched BC female residents. Pap participation rates in 2008-2010, both uncorrected and corrected for hysterectomy status, were compared between two groups. Adjusted prevalence ratios (PRadj) were calculated to examine (1) associations between factors and Pap rates in each group and (2) interactions between factors and groups, using log-binomial regression models. RESULTS: Overall Pap rates, both uncorrected and corrected, were higher for survivors (71.8%; 72.9%) than population (69%; 69.7%). Pap rates were 4.8-5.1 and 17.8-22.4% higher for survivors aged 30-39 and 50-59 respectively. Significantly higher Pap test utilization was associated with previous Pap tests (PRadj = 1.83, 95%CI = 1.76-1.89) and previous cervical procedures (1.20, 95%CI = 1.15-1.25). Hysterectomy rates were doubled for survivors (7.4%) than population (3.7%). This did not affect Pap participation rate comparisons between two groups. In both groups, 51.6-70% of females with hysterectomies still received Pap tests. CONCLUSION: Survivors' Pap test utilization was significantly higher than population, but lower than the Canadian benchmark of 90%. Hysterectomy correction does not affect this observation. Cervical cancer screening is suboptimal for survivors. Females with prior hysterectomies might have received unnecessary Pap tests. IMPLICATIONS FOR CANCER SURVIVORS: Survivors without prior hysterectomies should continue to undergo Pap tests recommended by provincial guidelines, to optimize their health.

The Intracranial Distribution of Gliomas in Relation to Exposure From Mobile Phones: Analyses From the INTERPHONE Study.

When investigating the association between brain tumors and use of mobile telephones, accurate data on tumor position are essential, due to the highly localized absorption of energy in the human brain from the radio-frequency fields emitted. We used a point process model to investigate this association using information that included tumor localization data from the INTERPHONE Study (Australia, Canada, Denmark, Finland, France, Germany, Israel, Italy, Japan, New Zealand, Norway, Sweden, and the United Kingdom). Our main analysis included 792 regular mobile phone users diagnosed with a glioma between 2000 and 2004. Similar to earlier results, we found a statistically significant association between the intracranial distribution of gliomas and the self-reported location of the phone. When we accounted for the preferred side of the head not being exclusively used for all mobile phone calls, the results were similar. The association was independent of the cumulative call time and cumulative number of calls. However, our model used reported side of mobile phone use, which is potentially influenced by recall bias. The point process method provides an alternative to previously used epidemiologic research designs when one is including localization in the investigation of brain tumors and mobile phone use.

Primary care physician use across the breast cancer care continuum: CanIMPACT study using Canadian administrative data.

OBJECTIVE: To describe primary care physician (PCP) use and continuity of PCP care across the breast cancer care continuum. DESIGN: Population-based, retrospective cohort study using provincial cancer registries linked to health administrative databases. SETTING: British Columbia, Manitoba, and Ontario. PARTICIPANTS: All women with incident invasive breast cancer from 2007 to 2012 in Manitoba and Ontario and from 2007 to 2011 in British Columbia. MAIN OUTCOME MEASURES: The number and proportions of visits to PCPs were determined. Continuity of care was measured using the Usual Provider of Care index calculated as the proportion of visits to the most-often-visited PCP in the 6 to 30 months before a breast cancer diagnosis (baseline) and from 1 to 3 years following a breast cancer diagnosis (survivorship). RESULTS: More than three-quarters of patients visited their PCPs 2 or more times during the breast cancer diagnostic period, and more than 80% of patients had at least 1 PCP visit during breast cancer adjuvant treatment. Contact with the PCP decreased over time during breast cancer survivorship. Of the 3 phases, women appeared to be most likely to not have PCP contact during adjuvant treatment, with 10.7% (Ontario) to 18.7% (British Columbia) of women having no PCP visits during this phase. However, a sizable minority of women had at least monthly visits during the treatment phase, particularly in Manitoba and Ontario, where approximately a quarter of women saw a PCP at least monthly. We observed higher continuity of care with PCPs in survivorship (compared with baseline) in all provinces. CONCLUSION: Primary care physicians were generally involved throughout the breast cancer care continuum, but the level of involvement varied across care phases and by province. Future interventions will aim to further integrate primary and oncology care.

Non-oncology physician visits after diagnosis of cancer in children.

BACKGROUND: Children diagnosed with cancer often require extensive care for medical, psychosocial and educational problems during and after therapy. Part of this care is provided by family physicians and non-cancer specialists, but their involvement in the first years after diagnosis has barely been studied. Studying non-oncology physician visits may provide insight into the roles of different health care providers. METHODS: We included 757 children diagnosed with cancer under age 15 between 1991 and 2001 from a Canadian provincial registry, and matched each to 10 controls of the same birth year and sex. We determined the number of family physician and non-cancer specialist visits in the 5 years after diagnosis (for patients) or inclusion (for controls) using data from the provincial health insurance plan. RESULTS: In the first year after diagnosis, almost all patients visited both a family physician and non-cancer specialist. Although after 5 years percentages decreased to 85 and 76 %, respectively, these were still significantly higher than in controls. In the first year after diagnosis, both family physicians and non-cancer specialists were often consulted for neoplasms (62 and 90 %, respectively) and to discuss results of lab tests. In addition, family physicians were often consulted for general symptoms and non-cancer specialists for nervous system problems and complications of medical care. CONCLUSIONS: Family physicians and non-cancer specialists are highly involved in the care for children with cancer in the first years after diagnosis, including for health problems related to cancer or its treatment. This necessitates good communication among all physicians.

Non-oncology physician visits after diagnosis of cancer in adolescents and young adults.

PURPOSE: Health care needs of adolescents and young adults (AYAs) with cancer are probably different from other age groups. Studying their non-oncology physician visits in the first years after diagnosis may provide insight into the specific health problems AYA patients experience and thereby help to improve care for these patients. METHODS: Seven hundred seventy-four AYAs identified from a Canadian provincial registry diagnosed with cancer between ages 15 and 24 years in 1991/2001 were included, matched by birth year and sex to ten controls. Based on provincial health insurance plan records, we determined the number of family physician and non-cancer specialist visits in the 5 years after diagnosis (for patients) or inclusion (for controls). RESULTS: The percentage of patients visiting a non-cancer specialist decreased from 96 to 49 % over the 5-year period. The percentage visiting a family physician decreased from 96 to 84 %. Visits in all years were significantly higher than among controls. In the first year after diagnosis, many patients visited a non-cancer specialist or a family physician for neoplasm-related health problems (77 and 55 %, respectively). In addition, family physicians were also consulted for general age-specific problems, such as genitourinary symptoms CONCLUSIONS: In the first years after diagnosis of cancer in AYAs, both non-cancer specialist and family physician visits are common, although non-cancer specialist visits are less common and decline considerably faster than in younger children. IMPLICATIONS FOR CANCER SURVIVORS: The specific pattern of physician visits of this age group calls for care that is tailored to their specific needs.