Stakeholder-Identified Interventions to Address Cancer Survivors' Psychosocial Needs after Completing Treatment.

The interventions used in cancer-survivorship care do not always address outcomes important to survivors. This study sought to understand stakeholders' views on the key concerns of cancer survivors after treatment and the interventions needed to meet survivors' and families' psychosocial needs after completing cancer treatment. We conducted a descriptive qualitative study using semi-structured interviews with stakeholders (survivors, family/friend caregivers, oncology providers, primary care providers, and cancer system decision-/policy-makers) from across Canada. For the data analysis, we used techniques commonly employed in descriptive qualitative research, such as coding, grouping, detailing, and comparing the data. There were 44 study participants: 11 survivors, seven family/friend caregivers, 18 health care providers, and eight decision-/policy-makers. Stakeholder-relevant interventions to address survivors' psychosocial needs were categorized into five groups, as follows: information provision, peer support, navigation, knowledge translation interventions, and caregiver-specific supports. These findings, particularly interventions that deliver timely and relevant information about the post-treatment period and knowledge translation interventions that strive to integrate effective tools and programs into survivorship care, have implications for future research and practice.

What Matters in Cancer Survivorship Research? A Suite of Stakeholder-Relevant Outcomes.

The outcomes assessed in cancer survivorship research do not always match the outcomes that survivors and health system stakeholders identify as most important in the post-treatment follow-up period. This study sought to identify stakeholder-relevant outcomes pertinent to post-treatment follow-up care interventions. We conducted a descriptive qualitative study using semi-structured telephone interviews with stakeholders (survivors, family/friend caregivers, oncology providers, primary care providers, and cancer system decision-/policy-makers) across Canada. Data analysis involved coding, grouping, detailing, and comparing the data by using the techniques commonly employed in descriptive qualitative research. Forty-four participants took part in this study: 11 survivors, seven family/friend caregivers, 18 health care providers, and eight decision-makers. Thirteen stakeholder-relevant outcomes were identified across participants and categorized into five outcome domains: psychosocial, physical, economic, informational, and patterns and quality of care. In the psychosocial domain, one's reintegration after cancer treatment was described by all stakeholder groups as one of the most important challenges faced by survivors and identified as a priority outcome to address in future research. The outcomes identified in this study provide a succinct suite of stakeholder-relevant outcomes, common across cancer types and populations, that should be used in future research on cancer survivorship care.

Psychosocial Distress in Adult Patients Awaiting Cancer Surgery during the COVID-19 Pandemic.

Cancer causes substantial emotional and psychosocial distress, which may be exacerbated by delays in treatment. The COVID-19 pandemic has resulted in increased wait times for many patients with cancer. In this study, the psychosocial distress associated with waiting for cancer surgery during the pandemic was investigated. This cross-sectional, convergent mixed-methods study included patients with lower priority disease during the first wave of COVID-19 at an academic, tertiary care hospital in eastern Canada. Participants underwent semi-structured interviews and completed two questionnaires: Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS). Qualitative analysis was completed through a thematic analysis approach, with integration achieved through triangulation. Fourteen participants were recruited, with cancer sites including thyroid, kidney, breast, prostate, and a gynecological disorder. Increased anxiety symptoms were found in 36% of patients and depressive symptoms in 14%. Similarly, 64% of patients experienced moderate or high stress. Six key themes were identified, including uncertainty, life changes, coping strategies, communication, experience, and health services. Participants discussed substantial distress associated with lifestyle changes and uncertain treatment timelines. Participants identified quality communication with their healthcare team and individualized coping strategies as being partially protective against such symptoms. Delays in surgery for patients with cancer during the COVID-19 pandemic resulted in extensive psychosocial distress. Patients may be able to mitigate these symptoms partially through various coping mechanisms and improved communication with their healthcare teams.

Uptake of elective laparoscopic colectomy for colon cancer in Canada from 2004/05 to 2014/15: a descriptive analysis.

BACKGROUND: Evidence from randomized controlled trials published since 2004 shows that elective laparoscopic colectomy for colon cancer improves short-term postoperative outcomes with equivalent oncologic outcomes compared to open colectomy. The objective of this study was to examine the uptake of elective laparoscopic colectomy in Canada and compare its use among Canadian provinces. METHODS: In this descriptive analysis, we identified from hospital discharge abstracts all patients in the Canadian provinces (except Quebec) who underwent elective colectomy for colon cancer between 2004/05 and 2014/15. We compared temporal changes in the proportion of patients who underwent laparoscopic colectomy or open colectomy among provinces using logistic regression. RESULTS: Of 63 504 patients who underwent elective colectomy between 2004/05 and 2014/15, 19 691 (31.0%) underwent laparoscopic colectomy. The annual proportion of patients who underwent laparoscopic colectomy increased from 9.2% in 2004/05 to 51.5% in 2014/15 (mean annual percent increase 4.2%). There were significant differences between provinces in the overall proportion of patients who underwent laparoscopic colectomy (p < 0.001), ranging from 7.6% in Newfoundland and Labrador to 36.9% in Ontario. By 2014/15, most colectomy procedures were performed laparoscopically in 3 provinces; British Columbia (60.2%), Ontario (59.4%) and Alberta (53.1%). In addition to year and province, urban residence, younger age, female sex, fewer medical comorbidities, high surgeon volume, high hospital volume and right-sided tumours were significantly associated with increased likelihood of laparoscopic colectomy. INTERPRETATION: Although the use of laparoscopic colectomy increased rapidly between 2004/05 and 2014/15 in Canada, substantial interprovincial variation exists. Further knowledge-translation strategies are needed to ensure equal access to laparoscopic colectomy for all Canadians.

Decision-making by surgeons about referral for adjuvant therapy for patients with non-small-cell lung, breast or colorectal cancer: a qualitative study.

BACKGROUND: Because surgeons are the main gatekeepers to oncology services, understanding how they make decisions related to referral for adjuvant therapies is important to optimize referral rates and use of oncology services for patients with potentially curable disease. We examined decision-making by surgeons related to referral to oncology services for patients having undergone curative-intent surgery for non-small-cell lung, breast or colorectal cancer. METHODS: We conducted a qualitative study, whose design was guided by the principles of grounded theory. Semi-structured interviews were held with 29 surgeons who performed non-small-cell lung, breast or colorectal cancer surgery in the province of Nova Scotia. Data were collected and analyzed concurrently. Analysis involved an inductive, grounded approach using constant comparative analysis. Data collection and analysis continued until theoretical saturation was reached. RESULTS: Seven factors influenced the surgeons' decision-making related to referral to oncology services: indications and contraindications for therapy; patients' beliefs and preferences; a belief that oncologists are the experts; knowledge of local standards of care; consultation with oncology colleagues; navigating patient logistics (e.g., lodging, caregiving responsibilities, insurance coverage); and system resources and capacity. INTERPRETATION: Our study's findings provide a novel understanding of how surgeons make decisions about oncology referral and point to potential areas for intervention to promote referral to oncology services for patients for whom adjuvant therapy is recommended.

Health System-Level Factors Influence the Implementation of Complex Innovations in Cancer Care.

BACKGROUND: The movement of new knowledge and tools into healthcare settings continues to be a slow, complex and poorly understood process. In this paper, we present the system-level factors important to the implementation of synoptic reporting tools in two initiatives (or cases) in Nova Scotia, Canada. METHODS: This study used case study methodology. Data were collected through interviews with key informants, document analysis, non-participant observation and tool use/examination. Analysis involved production of case histories, analysis of each case and a cross-case analysis. RESULTS: The healthcare system's delivery and support structure, information technology infrastructure, policy environment and history of collaboration and inter-organizational relationships influenced tool implementation in the two cases. CONCLUSIONS: The findings provide an in-depth, nuanced understanding of how healthcare system components can influence the implementation of a new tool in clinical practice.

Multi-level factors influence the implementation and use of complex innovations in cancer care: a multiple case study of synoptic reporting.

BACKGROUND: The implementation of innovations (i.e., new tools and practices) in healthcare organizations remains a significant challenge. The objective of this study was to examine the key interpersonal, organizational, and system level factors that influenced the implementation and use of synoptic reporting tools in three specific areas of cancer care. METHODS: Using case study methodology, we studied three cases in Nova Scotia, Canada, wherein synoptic reporting tools were implemented within clinical departments/programs. Synoptic reporting tools capture and present information about a medical or surgical procedure in a structured, checklist-like format and typically report only items critical for understanding the disease and subsequent impacts on patient care. Data were collected through semi-structured interviews with key informants, document analysis, nonparticipant observation, and tool use/examination. Analysis involved production of case histories, in-depth analysis of each case, and a cross-case analysis. Numerous techniques were used during the research design, data collection, and data analysis stages to increase the rigour of this study. RESULTS: The analysis revealed five common factors that were particularly influential to implementation and use of synoptic reporting tools across the three cases: stakeholder involvement, managing the change process (e.g., building demand, communication, training and support), champions and respected colleagues, administrative and managerial support, and innovation attributes (e.g., complexity, compatibility with interests and values). The direction of influence (facilitating or impeding) of each of these factors differed across and within cases. CONCLUSIONS: The findings demonstrate the importance of a multi-level contextual analysis to gaining both breadth and depth to our understanding of innovation implementation and use in health care. They also provide new insights into several important issues under-reported in the literature on moving innovations into healthcare practice, including the role of middle managers in implementation efforts and the importance of attending to the interpersonal aspects of implementation.

Survey of American and Canadian general surgeons' perceptions of margin status and practice patterns for breast conserving surgery.

Although breast conservation surgery (BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross-sectional survey to compare Canadian (CDN) and American (AM) general surgeons' reported BCS practice patterns to better understand the cross-border differences in early-stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re-excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re-excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country.

Timely access and quality of care in colorectal cancer: a population-based cohort study using administrative data.

BACKGROUND: While efforts to improve cancer outcomes have typically focused on improving quality of care, recently, a growing emphasis has been placed on timely access to quality cancer care. This retrospective cohort study examines, at a population level, the relationship between quality and timeliness of colorectal cancer (CRC) care in a single Canadian province (Nova Scotia). Through the provincial cancer registry, we identified all residents diagnosed with invasive CRC between 2001 and 2005 that underwent a non-emergent resection. Using anonymized administrative databases that are individually linked at the patient level, we obtained clinicodemographic, diagnostic, and treatment event data. Selected charts were reviewed to ensure completeness of chemotherapy data. Performance on six quality indicators and the percentage of patients achieving wait-time benchmarks for diagnosis, surgery, and adjuvant therapy were calculated. The relationship between quality indicators and wait-time benchmarks was examined using logistic regression. RESULTS: Where an association was identified, patients who received 'higher quality care' had longer wait times. Individuals who received a complete preoperative colonoscopy were less likely to meet benchmarks for time from presentation to diagnosis and from diagnosis to surgery. Those who received an appropriate radiation oncology consultation were less likely to meet benchmarks for time from diagnosis to surgery and from surgery to adjuvant therapy. CONCLUSIONS: As governments and other organizations move forward with strategies to reduce wait times, they must also focus on how to define and monitor quality care, and consider the relationship between these two dimensions of health care. Similarly, when developing quality improvement initiatives, the impact on resource utilization and potential to create longer waits for care must be considered.

Screening for new primary cancers in cancer survivors compared to non-cancer controls: a systematic review and meta-analysis.

PURPOSE: The goal of this study was to synthesize evidence comparing cancer screening receipt between cancer survivors and non-cancer controls by conducting a systematic review and meta-analysis. METHODS: We searched PubMed, EMBASE, and CINAHL databases from inception through April 1, 2010 using search terms related to cancer, survivorship, and cancer screening. Studies were included if they reported a comparison of cancer screening receipt between cancer survivors and non-cancer controls. We performed a meta-analysis on the effect of cancer survivorship on breast, cervical, colorectal, and prostate cancer screening receipt. RESULTS: Our search strategy identified 1,778 titles, of which 20 met our inclusion/exclusion criteria. In our meta-analyses, cancer survivors were more likely to be screened for breast, cervical, colorectal, and prostate cancer than non-cancer controls (pooled odds ratio, 1.27; 95 % CI, 1.19-1.36). We observed significant heterogeneity between studies, most of which remained unexplained after subgroup and sensitivity analyses. Important contextual factors, such as how screening programs operate, were not reported in the primary literature. Many cancer survivors (along with non-cancer controls) still did not receive cancer screening. CONCLUSION: Compared with non-cancer controls, cancer survivors receive more frequent screening for new primary breast, cervical, colorectal, and prostate cancers. Future research should seek to determine whether increased uptake of cancer screening is associated with improved outcomes during cancer survivorship. IMPLICATIONS FOR CANCER SURVIVORS: Our systematic review and meta-analysis demonstrated that cancer survivors received more frequent screening for second primary breast, cervical, colorectal, and prostate cancers than non-cancer controls. As many cancer survivors are at an increased risk of developing a second primary cancer, future research should seek to determine whether this increased uptake of cancer screening in cancer survivors leads to improved outcomes during cancer survivorship.

Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia.

PURPOSE: The purpose of this study was to examine colorectal cancer (CRC) follow-up care in Nova Scotia, Canada. More specifically, the objectives were to describe adherence to two elements of follow-up guidelines (colonoscopies and physician visits) and to identify factors associated with receiving at least guideline-recommended care. METHODS: All patients with stage II or III CRC undergoing curative-intent surgery in Nova Scotia, Canada, were identified through the provincial cancer registry and anonymously linked to additional administrative health databases. For a 3-year follow-up period, beginning 1 year after the diagnosis date, descriptive statistics were calculated for physician visits and colonoscopies. Factors associated with receiving at least guideline-recommended care were identified using logistic regression. RESULTS: Most patients received follow-up care from multiple physician specialties. In year 3, 58.1% of patients received oncologist follow-up care. Guideline adherence for colonoscopies was 52.4%, whereas guideline adherence for physician visits decreased from 41.9% to 25.4%. Receipt of at least guideline-recommended care was inversely associated with age and comorbidity for colonoscopy and inversely associated with age for physician visits. CONCLUSION: Receipt of follow-up care from oncologists and primary care physicians, prolonged oncologist care, and receipt of care inconsistent with guideline recommendations suggest there may be potential issues with inefficient use of cancer system resources and integration of guidelines into follow-up care practices in Nova Scotia. Transitioning routine follow-up to primary care could potentially increase guideline adherence by improving access to and continuity of care. CRC may be well suited to targeted knowledge translation strategies to improve guideline adherence.

How do surgeons decide to refer patients for adjuvant cancer treatment? Protocol for a qualitative study.

BACKGROUND: Non-small cell lung cancer, breast cancer, and colorectal cancer are commonly diagnosed cancers in Canada. Patients diagnosed with early-stage non-small cell lung, breast, or colorectal cancer represent potentially curable populations. For these patients, surgery is the primary mode of treatment, with (neo)adjuvant therapies (e.g., chemotherapy, radiotherapy) recommended according to disease stage. Data from our research in Nova Scotia, as well as others', demonstrate that a substantial proportion of non-small cell lung cancer and colorectal cancer patients, for whom practice guidelines recommend (neo)adjuvant therapy, are not referred for an oncologist consultation. Conversely, surveillance data and clinical experience suggest that breast cancer patients have much higher referral rates. Since surgery is the primary treatment, the surgeon plays a major role in referring patients to oncologists. Thus, an improved understanding of how surgeons make decisions related to oncology services is important to developing strategies to optimize referral rates. Few studies have examined decision making for (neo)adjuvant therapy from the perspective of the cancer surgeon. This study will use qualitative methods to examine decision-making processes related to referral to oncology services for individuals diagnosed with potentially curable non-small cell lung, breast, or colorectal cancer. METHODS: A qualitative study will be conducted, guided by the principles of grounded theory. The study design is informed by our ongoing research, as well as a model of access to health services. The method of data collection will be in-depth, semi structured interviews. We will attempt to recruit all lung, breast, and/or colorectal cancer surgeons in Nova Scotia (n ≈ 42), with the aim of interviewing a minimum of 34 surgeons. Interviews will be audiotaped and transcribed verbatim. Data will be collected and analyzed concurrently, with two investigators independently coding and analyzing the data. Analysis will involve an inductive, grounded approach using constant comparative analysis. DISCUSSION: The primary outcomes will be (1) identification of the patient, surgeon, institutional, and health-system factors that influence surgeons' decisions to refer non-small cell lung, breast, and colorectal cancer patients to oncology services when consideration for (neo)adjuvant therapy is recommended and (2) identification of potential strategies that could optimize referral to oncology for appropriate individuals.

Practice patterns and perceptions of margin status for breast conserving surgery for breast carcinoma: National Survey of Canadian General Surgeons.

BACKGROUND: We surveyed Canadian General Surgeons to examine decision-making in early stage breast cancer. METHODS: A modified Dillman Method was used for this mail survey of 1443 surgeons. Practice patterns and factors that influence management choices for: preoperative assessment, definition of margin status, surgical techniques and recommendations for re-excision were assessed. RESULTS: The response rate was 51% with 41% treating breast cancer. Most (80%) were community surgeons, with equal distribution of low/medium/high volume and years of practice categories. Approximately 25% of surgeons "sometimes or frequently" performed diagnostic excisional biopsies while 90% report "frequently" or "always" performing preoperative core biopsies. There was marked variation in defining negative and close margins, in the use of intra-operative margin assessment techniques and recommendations for re-excision. CONCLUSIONS: Responses revealed significant variation in attitudes and practices. These findings likely reflect an absence of consensus in the literature and potential gaps between best evidence and practice.

Examining stage IIB survival in a population-based cohort of patients with colorectal cancer.

BACKGROUND: In Nova Scotia, Canada, a previous study of colorectal cancer (CRC) cases diagnosed between January 1, 2001, and December 31, 2005, found that patients with stage IIB CRC had similar 5-year overall survival (OS) to those with stage IIIC cancer. This study sought to examine factors contributing to the observed stage IIB outcome, specifically nodal harvest, receipt of chemotherapy, and use of a new coding system to derive stage. METHODS: The provincial cancer registry identified all CRC cases diagnosed during the study period and staged this cohort using the Collaborative Stage (CS) Data Collection System. All patients with stage II and III cancer in the cohort were examined. Kaplan-Meier (KM) survival curves compared 5-year OS for patients with stage IIB cancer based on the factors of interest, and compared patients with stage IIB cancer to those with stage IIA and III cancer. RESULTS: OS for patients with stage IIB cancer (n = 187) was 44.7%, and differed depending on adequacy of nodal harvest (P = .005) and whether pathological or clinical/mixed evidence was used to derive stage (P = .013). Pathologically-staged patients with stage IIB cancer who had adequate nodal harvest had marginally improved OS compared to pathologically-staged patients who had inadequate nodal harvest (P = .07), and improved survival compared to patients with clinical/mixed stage (P = .004). Pathologically-staged patients with stage IIB cancer with adequate nodal harvest demonstrated similar 5-year OS to those with stage IIA and III cancer (P = .52 and P = .25, respectively). Cox proportional hazards models supported these findings. CONCLUSIONS: The inclusion of clinical/mixed evidence into staging classification and, perhaps to a lesser extent, the adequacy of nodal harvest appear to contribute to the observed worse survival for patients with stage IIB versus stage III cancer.

A randomized, controlled trial comparing acetaminophen plus ibuprofen versus acetaminophen plus codeine plus caffeine (Tylenol 3) after outpatient breast surgery.

BACKGROUND: The combination of acetaminophen, codeine, and caffeine (Tylenol 3, T3) is a standard postoperative analgesia after breast surgery despite the adverse effects and variable efficacy of narcotics. This study compared the efficacy of a nonnarcotic approach (acetaminophen and ibuprofen; AcIBU) to T3 after outpatient breast surgery. METHODS: This double-blind randomized equivalence trial involved patients undergoing outpatient breast surgery. Patients were randomized (stratified by procedure type) to receive AcIBU or T3 four times daily for 7 days, or until free of pain. Pain intensity, measured four times daily by the visual analog scale, was the primary outcome; secondary outcomes were pain relief with analgesic, days until freedom from pain, adverse effects, discontinuation of drug as a result of adverse effects, and patient satisfaction. RESULTS: There were 71 patients randomized to AcIBU and 70 patients to T3. Repeated measures analysis showed no significant difference in average pain intensity over 7 days (AcIBU 19.9 mm vs. T3 20.6 mm; P = 0.78). Similarly, there was no significant difference in pain relief with analgesic (P = 0.46). Although no difference in the incidence of adverse effects was observed (P = 0.94), discontinuation of the study drug as a result of adverse effects was more common with T3 (19 % vs. 6 %; P = 0.018). No significant differences were identified in days until freedom from pain or patient satisfaction; 92 % of AcIBU and 89 % of T3 patients were satisfied with their pain control (P = 0.55). CONCLUSIONS: AcIBU is a safe, effective method of pain control after outpatient breast surgery. Compared to T3, it provides at least equivalent analgesia and has a more tolerable adverse effect profile.

Exploring the interpersonal-, organization-, and system-level factors that influence the implementation and use of an innovation-synoptic reporting-in cancer care.

BACKGROUND: The dominant method of reporting findings from diagnostic and surgical procedures is the narrative report. In cancer care, this report inconsistently provides the information required to understand the cancer and make informed patient care decisions. Another method of reporting, the synoptic report, captures specific data items in a structured manner and contains only items critical for patient care. Research demonstrates that synoptic reports vastly improve the quality of reporting. However, synoptic reporting represents a complex innovation in cancer care, with implementation and use requiring fundamental shifts in physician behaviour and practice, and support from the organization and larger system. The objective of this study is to examine the key interpersonal, organizational, and system-level factors that influence the implementation and use of synoptic reporting in cancer care. METHODS: This study involves three initiatives in Nova Scotia, Canada, that have implemented synoptic reporting within their departments/programs. Case study methodology will be used to study these initiatives (the cases) in-depth, explore which factors were barriers or facilitators of implementation and use, examine relationships amongst factors, and uncover which factors appear to be similar and distinct across cases. The cases were selected as they converge and differ with respect to factors that are likely to influence the implementation and use of an innovation in practice. Data will be collected through in-depth interviews, document analysis, observation of training sessions, and examination/use of the synoptic reporting tools. An audit will be performed to determine/quantify use. Analysis will involve production of a case record/history for each case, in-depth analysis of each case, and cross-case analysis, where findings will be compared and contrasted across cases to develop theoretically informed, generalisable knowledge that can be applied to other settings/contexts. Ethical approval was granted for this study. DISCUSSION: This study will contribute to our knowledge base on the multi-level factors, and the relationships amongst factors in specific contexts, that influence implementation and use of innovations such as synoptic reporting in healthcare. Such knowledge is critical to improving our understanding of implementation processes in clinical settings, and to helping researchers, clinicians, and managers/administrators develop and implement ways to more effectively integrate innovations into routine clinical care.

A team approach to improving colorectal cancer services using administrative health data.

BACKGROUND: Colorectal cancer (CRC) is the third most commonly diagnosed cancer in Canada and accounts for 11.9% of all cancer-related mortality. Fortunately, previous studies have provided evidence of improved outcomes from access to timely and appropriate health services along the disease trajectory in CRC. As a result, the CIHR/CCNS Team in Access to Colorectal Cancer Services in Nova Scotia (Team ACCESS) was created to build colorectal cancer (CRC) research capacity in Nova Scotia (NS) and to study access to and quality of CRC services along the entire continuum of cancer care. OBJECTIVES: The objectives of this paper are to: 1) provide a detailed description of the methodologies employed across the various studies being conducted by Team ACCESS; 2) demonstrate how administrative health data can be used to evaluate access and quality in CRC services; and 3) provide an example of an interdisciplinary team approach to addressing health service delivery issues. METHODS: All patients diagnosed with CRC in NS between 2001 and 2005 were identified through the Nova Scotia Cancer Registry (NSCR) and staged using the Collaborative Stage Data Collection System. Using administrative databases that were linked at the patient level, Team ACCESS created a retrospective longitudinal cohort with comprehensive demographic, clinical, and healthcare utilization data. These data were used to examine access to and quality of CRC services in NS, as well as factors affecting access to and quality of care, at various transition points along the continuum of care. Team ACCESS has also implemented integrated knowledge translation strategies targeting policy- and decision- makers. DISCUSSION: The development of Team ACCESS represents a unique approach to CRC research. We anticipate that the skills, tools, and knowledge generated from our work will also advance the study of other cancer disease sites in NS. Given the increasing prevalence of cancer, and with national and provincial funding agencies promoting collaborative research through increased funding for research team development, the work carried out by Team ACCESS is important in the Canadian context and exemplifies how a team approach is essential to comprehensively addressing issues surrounding not only cancer, but other chronic diseases in Canada.

Improving nodal harvest in colorectal cancer: so what?

BACKGROUND: Adequate nodal harvest (≥12 lymph nodes) in colorectal cancer has been shown to optimize staging and has been proposed as a quality indicator of colorectal cancer care. We previously demonstrated a population-based improvement in adequate nodal harvest over time, particularly with the use of an audit and feedback strategy. The goal of this current study is to evaluate the impact of improved adequate nodal harvest on 3 relevant clinical outcomes: node positivity rate, use of adjuvant chemotherapy, and survival. METHODS: This current population-based study included all patients undergoing resection for primary stage I-III colorectal cancer in Nova Scotia, Canada, from January 1, 2001 to December 31, 2005. Linkage of the provincial cancer registry with other administrative databases (hospital discharge data, physician claims data, and national census data) provided clinical, demographic, diagnostic, treatment event, and survival data. The association between increase in adequate node harvest and relevant clinical outcomes was examined for all patients and in a subgroup analysis of patients who received care in a health district that used audit and feedback to improve nodal harvest. RESULTS: Among the 2,250 patients, the median nodal harvest was 8, and the overall node positive rate was 35.9%. Despite significant improvement in the proportion of patients undergoing adequate nodal harvest over time (P<.0001), no significant change was observed in the node positivity rate (P=.51), proportion of patients undergoing adjuvant chemotherapy (P=.83), or survival (P=.25). In the subgroup analysis confined to patients where audit and feedback was used to improve nodal harvest rates, clinical outcomes were not improved. CONCLUSIONS: Although improvements in the rate of adequate nodal harvest did occur over time, no corresponding meaningful improvement in clinical outcomes was noted. Given the need that quality indicators not only be associated with outcome, but also that outcome improves as such indicators are optimized, this study questions the inclusion of a nodal harvest≥12 lymph nodes as a quality indicator of colorectal cancer care.

Impact of comorbidity and healthcare utilization on colorectal cancer stage at diagnosis: literature review.

PURPOSE: Individuals diagnosed with cancer close to death have low access to enrollment in palliative care programs. The purpose of this literature review was to assess the usefulness of pre-diagnostic comorbidity and healthcare utilization as indicators of late-stage colorectal cancer (CRC) diagnosis, to help with early identification of individuals who may benefit from palliative care. METHODS: A literature search was conducted in relevant databases using title/abstract terms which included "cancer," "stage," "diagnosis," "determinants," "predictors," and "associated." Included studies examined whether comorbidity and/or healthcare utilization had an impact on the stage at which CRC was diagnosed. A standardized data abstraction form was used to assess the eligibility of each study. Thirteen articles were included in the literature review. These studies were assessed and synthesized using qualitative methodology. RESULTS: We found much heterogeneity among study variables. The findings of this literature review point to the presence of comorbidity and non-emergent healthcare utilization as having no association with late-stage diagnosis. Conversely, emergency room presentation (ERP) was associated with late-stage diagnosis. CONCLUSIONS: The results of this literature review did not find strong evidence to suggest that comorbidity and healthcare utilization are potential indicators of late-stage diagnosis. However, ERP may be useful as a flag for consideration of prompt referral to palliative care. Additional research is required to identify potential indicators of late-stage diagnosis that may be available in administrative databases, particularly in the area of healthcare utilization.

Reflections on knowledge brokering within a multidisciplinary research team.

Knowledge brokering (KB) may be one approach of helping researchers and decision makers effectively communicate their needs and abilities, and move toward increased use of evidence in health care. A multidisciplinary research team in Nova Scotia, Canada, has created a dedicated KB position with the goal of improving access to quality colorectal cancer care. The purpose of this paper is to provide an in-progress perspective on KB within this large research team. A KB position ("knowledge broker") was created to perform two primary tasks: (1) facilitate ongoing communication among team members; and (2) develop and maintain collaborations between researchers and decision makers to establish partnerships for the transfer and use of research findings. In this article, we discuss our KB model and its implementation, describe the broker's functions and activities, and present preliminary outcomes. The primary functions of the KB position have included: sustaining team members' engagement; harnessing members' expertise and sharing it with others; developing and maintaining communication tools/strategies; and establishing collaborations between team members and other stakeholders working in cancer care. The broker has facilitated an integrated knowledge translation approach to research conduct and led to the development of new collaborations with external stakeholders and other cancer/health services researchers. KB roles will undoubtedly differ across contexts. However, descriptive assessments can help others determine whether such an approach could be valuable for their research programs and, if so, what to expect during the process.