Search

No population-based study exists to demonstrate the full-spectrum impact of COVID-19 on hindering incident cancer detection in a large cancer system. Building upon our previous publication in JNCCN, we conducted an updated analysis using 12 months of new data accrued in the pandemic era (extending the study period from September 26, 2020, to October 2, 2021) to demonstrate how multiple COVID-19 waves affected the weekly cancer incidence volume in Ontario, Canada, and if we have fully cleared the backlog at the end of each wave.

Purpose Neoadjuvant chemotherapy (NAC) for triple negative (TN) and Her2 positive (HER2) breast cancers is supported by international guidelines as it can decrease extent of surgery, provide prognostic information and allow response-driven adjuvant therapies. Our goal was to describe practice patterns for patients with TN and HER2 breast cancer and identify factors associated with the receipt of NAC versus surgery as initial treatment. Methods A retrospective population-based cohort study of adult women diagnosed with stage I-III TN or HER2 breast cancer (2012-2019) in Ontario was completed using linked administrative datasets. The primary outcome was NAC as first treatment. The association between NAC and patient, tumour, and practice-related factors were examined using multivariable logistic regression models. Results Of 12,881 patients included, 22.9% (n = 2952) underwent NAC as first treatment. Patients who underwent NAC were more likely to be younger, have larger tumors, node positive disease and stage 3 disease. Of patients who underwent surgery first, 8.4% were seen by a medical oncologist prior to surgery. On multivariable analysis, increasing tumor size (T2 vs T1/T0: 2.63 (2.13 - 3.25)) and node positive (N1 vs N0: 3.60 (2.88 - 4.50)) disease were both associated increased odds of receiving NAC. Conclusion A considerable proportion of patients with TN and HER2 breast cancer do not receive NAC as first treatment. Of those, most were not assessed by both a surgeon and medical oncologist prior to initiating therapy. This points towards potential gaps in multidisciplinary assessment and disparities in receipt of guideline-concordant care.

Background Few studies have explored why older women (≥70 years old) avoid breast cancer surgery. This study aimed to identify physician- and patient-perceived attitudes that influence the decision to avoid surgery among older women with invasive breast cancer. Methods Semi-structured in-depth interviews were conducted with multidisciplinary breast cancer specialists and older women (≥70 years old) with breast cancer who declined surgery. Transcripts were iteratively coded using a theoretical framework to guide identification of common themes. Thematic comparison was performed between patients and physicians. Results Ten breast cancer specialists and eleven patients participated. Physicians believed older women declined surgery because they did not perceive breast cancer as a life-threatening ailment compared to other medical comorbidities. Physicians did not discuss breast reconstruction, as it was perceived to be unimportant. Treatment side effects, length of treatment, impact on quality of life, and minimal survival benefit strongly influenced patients' decision to decline surgery. Patients valued independence and quality of life over quantity of life. Patients felt empowered to participate in the decision-making process but appreciated having support. Both phyisicians and patients had congruent beliefs with respect to age impacting treatment decision, cosmesis playing a minor factor in treatment decisions, and importance of quality of life; however, they were discordant in their perceptions about the amount of support that patients have from their families. Conclusions The decision to avoid surgery in older women stems from a variety of individual beliefs. Acknowledging patient values early in treatment planning may facilitate a patient-centered approach to the decision-making process.

Background This study was conducted in order to develop a model for predicting response to neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer (LABC) using pretreatment quantitative ultrasound (QUS) radiomics. Methods This was a multicenter study involving four sites across North America, and appropriate approval was obtained from the individual ethics committees. Eighty‐two patients with LABC were included for final analysis. Primary tumors were scanned using a clinical ultrasound system before NAC was started. The tumors were contoured, and radiofrequency data were acquired and processed from whole tumor regions of interest. QUS spectral parameters were derived from the normalized power spectrum, and texture analysis was performed based on six QUS features using a gray level co‐occurrence matrix. Patients were divided into responder or nonresponder classes based on their clinical‐pathological response. Classification analysis was performed using machine learning algorithms, which were trained to optimize classification accuracy. Cross‐validation was performed using a leave‐one‐out cross‐validation method. Results Based on the clinical outcomes of NAC treatment, there were 48 responders and 34 nonresponders. A K‐nearest neighbors (K‐NN) approach resulted in the best classifier performance, with a sensitivity of 91%, a specificity of 83%, and an accuracy of 87%. Conclusion QUS‐based radiomics can predict response to NAC based on pretreatment features with acceptable accuracy., This multi‐institutional study investigated the role of radiomics from quantitative ultrasound (QUS) in predicting the final response to neoadjuvant chemotherapy (NAC) for 82 patients with locally advanced breast cancer (LABC). We had shown the QUS‐radiomics model can predict the response to treatment with an accuracy of 87% from spectroscopic features obtained before the start of NAC.

We aim to delineate the relationship between breast and axillary pathologic complete response (pCR) in patients receiving neoadjuvant chemotherapy for breast cancer. We performed a retrospective cohort study of patients with clinical T1–4N0–3M0 breast cancer receiving neoadjuvant chemotherapy followed by surgical therapy at Sunnybrook Health Sciences Centre in Toronto, Canada between 2014 and 2019. Clinicopathologic data were abstracted from the electronic medical record. Women were stratified into receptor subtypes as follows: hormone receptor positive (HR+)/human epidermal growth factor receptor 2 negative (HER2–), HR+/HER2+, HR–/HER2+ and HR–/HER2– (triple negative) and compared with Fisher’s exact test. Our primary outcome was to assess the positive predictive value of breast pCR for determining axillary pCR, and vice versa. There were 374 breast cancers, with 109 (29.1%) achieving breast pCR (ypT0/Tis). Amongst node-positive tumours achieving breast pCR, rates of associated axillary pCR (ypN0/0i+) were as follows: HR+/HER2– (2/6, 33.3%), HR+/HER2+ (12/13, 92.3%), HR–/HER2+ (15/17, 88.2%) and triple negative (15/17, 88.2%) (P = 0.02). Conversely, amongst node-positive tumours achieving axillary pCR, rates of associated breast pCR were: HR+/HER2– (2/10, 20.0%), HR+/HER2+ (12/23, 52.2%), HR–/HER2+ (15/24, 62.5%) and triple negative (15/26, 57.7%) (P = 0.1). Breast pCR is a strong predictor of axillary pCR in women with HER2-positive and triple-negative breast cancers. Conversely, axillary pCR is a modest predictor of breast pCR for these subtypes. There is a poor relationship between breast and axillary pCR in women with hormone receptor-positive disease. These data may inform future de-escalation of surgery in women with HER2-positive and triple-negative disease.

Phyllodes tumors are rare tumors of the breast, with most literature being retrospective with limited guidelines on the management of these patients. Scoping review was performed to highlight themes and gaps in the available literature. A scoping review of the literature was performed as per PRISMA-ScR guidelines with titles, abstracts, and full texts reviewed in duplicate. Data were abstracted and summarized in categories of diagnostics, surgical management, adjuvant therapies, treatment of recurrence, and surveillance. Quality assessment was performed for each paper. The search identified 4498 references, 434 full-text papers were reviewed, and 183 papers were included. Ultrasound, magnetic resonance imaging, and core needle biopsy are valuable preoperative diagnostics tools. Pathology reporting should include stromal overgrowth, stromal cellularity, nuclear atypia, mitotic rate, borders, and presence of heterologous elements. Ki67 may have a role in grading and prognosticating. Breast conservation is safe in all grades of phyllodes but may be associated with increased local recurrence in malignant phyllodes. Surgical margins should depend on grade. Axillary node positivity rate is very low, even with clinically enlarged lymph nodes. Adjuvant radiation is a useful tool to decrease local recurrence in malignant phyllodes tumors, tumors > 5 cm, age < 45 years, close margins, and breast conservation. There is no evidence supporting adjuvant chemotherapy. Recurrence can be managed with repeat wide excision; however, mastectomy is associated with lower re-recurrence. Surveillance protocols are variable in the literature. There is heterogeneity in the literature on phyllodes tumors. Consensus guidelines based on the literature will help provide evidence-based care.

Background The experience of older women during breast cancer treatment is insufficiently described by quantitative studies. This study aimed to systematically review qualitative data describing factors that influence older women’s (≥65 years old) experience with breast cancer treatment. Methods A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) principles. MEDLINE, CINAHL, PsycINFO, and EMBASE were searched (inception – 2020). Quality assessment of essential item reporting was performed using the Standards for Reporting Qualitative Research (SRQR) criteria. Common ideas were coded, thematically organized, and synthesized within a theoretical framework. Results Of 7,773 studies identified, twelve were included. The median SRQR score was 13.4 (range 11.3–15.9) (maximum score: 21). Data synthesis revealed that older women experienced breast cancer as a journey with challenges during each phase. During diagnosis, they delayed seeking medical help despite symptoms. Age and experience gave them perspective on the impact of their diagnosis. During decision-making, preconceptions and personal values determined choices. In the treatment phase, women experienced medical and social barriers to care. During the post-treatment phase, many experienced treatment adverse effects, but could move on or compartmentalize as coping mechanisms. Conclusion Older women with breast cancer have unique challenges specific to each phase of their treatment journey. Older women may benefit from proactive treatment discussions with health care providers to address their specific needs, individualize care, and assist with cancer care navigation., Highlights • Older women have challenges specific to each phase of their treatment journey. • Older women experience barriers to care and depended on their social network. • Older women could conceptually move on or compartmentalize as coping mechanisms. • Physicians should be aware of the unique features of each treatment phase.

Melanoma and the immune system are intimately related. However, the association of immunosuppressive medications (ISMs) with survival in melanoma is not well understood. The study evaluated this at a population level. A cohort of patients with a diagnosis of invasive cutaneous melanoma (2007–2015) was identified from the Ontario Cancer Registry and linked to identify demographics, stage at diagnosis, prescription of immunosuppressive medications (both before and after diagnosis), and outcomes. The demographics of patients with and without prescriptions for ISM were compared. Patients eligible for Ontario’s Drug Benefit Plan were included to ensure accurate prescription data. The primary outcome was overall survival. Cox Proportional Hazards Regression models identified factors associated with mortality, including use of ISM as a time-varying covariate. Of the 4954 patients with a diagnosis of cutaneous melanoma, 1601 had a prescription for ISM. The median age of the patients was 74 years. Overall, 58.4% of the patients were men (60.5% of those without ISM and 54% of those using ISM; p

Few studies have examined outcomes in immunosuppressed patients who develop melanoma. The purpose of this study is to compare survival in immunosuppressed patients who developed melanoma with that in patients with melanoma who are not immunosuppressed. Immunosuppressed patients were defined as having solid organ transplant, lymphoma, leukemia, or human immunodeficiency virus prior to diagnosis of melanoma. Patients with cutaneous melanoma with and without immunosuppression were identified retrospectively from the Ontario Cancer Registry (2007–2015) and linked with administrative databases to identify demographics, treatment, and outcomes. Immunosuppressed patients were matched with non-immunosuppressed patients based on age at diagnosis, sex, birth year, stage at diagnosis, and propensity score. The primary outcome was overall survival. Multivariable Cox proportional hazard regression was used to identify factors associated with survival. Baseline characteristics were well balanced in 218 immunosuppressed patients matched to 436 controls. Of the patients, 186 (28.4%) were female, and median age at melanoma diagnosis was 69 (interquartile range, IQR 59–78) years. Three-year overall survival (OS) was 65% for immunosuppressed patients and 79% for non-immunosuppressed patients. Melanoma was the leading cause of death for both groups. On multivariable analysis, immunosuppression was associated with increased mortality [hazard ratio (HR) 1.70, 95% confidence interval (CI) 1.30–2.23]. Adequate treatment (HR 0.36, 95% CI 0.22–0.58) and dermatologist visits either before (HR 0.52, 95% CI 0.36–0.73) or after (HR 0.61, 95% CI 0.41–0.90) melanoma diagnosis were associated with improved OS. Immunosuppressed patients who develop melanoma have worse outcomes when matched to non-immunosuppressed patients. This decrease in survival appears related to the underlying condition rather than diagnosis of melanoma.

Background Women with ductal carcinoma in situ (DCIS) report poor patient-clinician communication, and long-lasting confusion and anxiety about their treatment and prognosis. Research shows that patient-centred care (PCC) improves patient experience and outcomes. Little is known about the clinician experience of delivering PCC for DCIS. This study characterized communication challenges faced by clinicians, and interventions they need to improve PCC for DCIS. Methods Purposive and snowball sampling were used to recruit Canadian clinicians by specialty, gender, years of experience, setting, and geographic location. Qualitative interviews were conducted by telephone. Data were analyzed using constant comparison. Findings were mapped to a cancer-specific, comprehensive PCC framework to identify opportunities for improvement. Results Clinicians described approaches they used to address the PCC domains of fostering a healing relationship, exchanging information, and addressing emotions, but do not appear to be addressing the domains of managing uncertainty, involving women in making decisions, or enabling self-management. However, many clinicians described challenges or variable practices for all PCC domains but fostering a healing relationship. Clinicians vary in describing DCIS as cancer based on personal beliefs. When exchanging information, most find it difficult to justify treatment while assuring women of a good prognosis, and feel frustrated when women remain confused despite their efforts to explain it. While they recognize confusion and anxiety among women, clinicians said that patient navigators, social workers, support groups and high-quality information specific to DCIS are lacking. Despite these challenges, clinicians said they did not need or want communication interventions. Conclusions Findings represent currently unmet opportunities by which to help clinicians enhance PCC for DCIS, and underscore the need for supplemental information and supportive care specific to DCIS. Future research is needed to develop and test communication interventions that improve PCC for DCIS. If effective and widely implemented, this may contribute to improved care experiences and outcomes for women diagnosed with and treated for DCIS.

Background Patient-centred care (PCC) improves health-care experiences and outcomes. Women with ductal carcinoma in situ (DCIS) and clinicians have reported communication difficulties. Little prior research has studied how to improve communication and PCC for DCIS. Objective This study explored how to achieve PCC for DCIS. Design Canadian women treated for DCIS from five provinces participated in semi-structured focus groups based on a 6-domain cancer-specific PCC framework to discuss communication about DCIS. Data were analysed using constant comparative technique. Setting and participants Thirty-five women aged 30 to 86 participated in five focus groups at five hospitals. Results Women said their clinicians used multiple approaches for fostering a healing relationship; however, most described an absence of desired information or behaviour to exchange information, respond to emotions, manage uncertainty, make decisions and enable self-management. Most women were confused by terminology, offered little information about the risks of progression/recurrence, uninformed about treatment benefits and risks, frustrated with lack of engagement in decision making, given little information about follow-up plans or self-care advice, and received no acknowledgement or offer of emotional support. Discussion and conclusions By comparing the accounts of women with DCIS to a PCC framework, we identified limitations and inconsistencies in women's lived experience of communication about DCIS, and approaches by which clinicians can more consistently achieve PCC for DCIS. Future research should develop and evaluate informational tools to support PCC for DCIS.

ImportanceThe impact of COVID-19 on the modality and timeliness of first-line cancer treatment is unclear yet critical to the planning of subsequent care.ObjectiveTo explore the association of the COVID-19 pandemic with modalities of and wait times for first cancer treatment.Design, Setting, and ParticipantsThis retrospective population-based cohort study using administrative data was conducted in Ontario, Canada, among adults newly diagnosed with cancer between January 3, 2016, and November 7, 2020. Participants were followed up from date of diagnosis for 1 year, until death, or until June 26, 2021, whichever occurred first, to ensure a minimum of 6-month follow-up time.ExposuresReceiving a cancer diagnosis in the pandemic vs prepandemic period, using March 15, 2020, the date when elective hospital procedures were halted.Main Outcomes and MeasuresThe main outcome was a time-to-event variable describing number of days from date of diagnosis to date of receiving first cancer treatment (surgery, chemotherapy, or radiation) or to being censored. For each treatment modality, a multivariable competing-risk regression model was used to assess the association between time to treatment and COVID-19 period. A secondary continuous outcome was defined for patients who were treated 6 months after diagnosis as the waiting time from date of diagnosis to date of treatment.ResultsAmong 313 499 patients, the mean (SD) age was 66.4 (14.1) years and 153 679 (49.0%) were male patients. Those who were diagnosed during the pandemic were less likely to receive surgery first (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99) but were more likely to receive chemotherapy (sHR, 1.26; 95% CI, 1.23-1.30) or radiotherapy (sHR, 1.16; 95% CI, 1.13-1.20) first. Among patients who received treatment within 6 months from diagnosis (228 755 [73.0%]), their mean (SD) waiting time decreased from 35.1 (37.2) days to 29.5 (33.6) days for surgery, from 43.7 (34.1) days to 38.4 (30.6) days for chemotherapy, and from 55.8 (41.8) days to 49.0 (40.1) days for radiotherapy.Conclusions and RelevanceIn this cohort study, the pandemic was significantly associated with greater use of nonsurgical therapy as initial cancer treatment. Wait times were shorter in the pandemic period for those treated within 6 months of diagnosis. Future work needs to examine how these changes may have affected patient outcomes to inform future pandemic guideline development.

Esophagogastric cancer (EGC) is one of the deadliest and costliest malignancies to treat. Care by high-volume providers can provide better outcomes for patients with EGC. Cost implications of volume-based cancer care are unclear. We examined the cost-effectiveness of care by high-volume medical oncology providers for non-curative management of EGC. We conducted a population-based cohort study of non-curative EGC over 2005–2017 by linking administrative datasets. High-volume was defined as ≥ 11 patients/provider/year. Healthcare costs ($USD/patient/month-survived) were computed from diagnosis to death or end of follow-up from the perspective of the healthcare system. Multivariable quantile regression examined the association between care by high-volume providers and costs. Sensitivity analyses were conducted by varying costing horizons and high-volume definitions. Among 7011 non-curative EGC patients, median overall survival was superior with care by high-volume providers with 7.0 (IQR 3.3–13.3) compared to 5.9 (IQR 2.6–12.1) months (p

Purpose The neoadjuvant treatment of breast cancer (NABC) is a rapidly changing area that benefits from guidelines integrating evidence with expert consensus to help direct practice. This can optimize patient outcomes by ensuring the appropriate use of evolving neoadjuvant principles. Methods An expert panel formulated evidence-based practice recommendations spanning the entire neoadjuvant breast cancer treatment journey. These were sent for practice-based consensus across Canada using the modified Delphi methodology, through a secure online survey. Final recommendations were graded using the GRADE criteria for guidelines. The evidence was reviewed over the course of guideline development to ensure recommendations remained aligned with current relevant data. Results Response rate to the online survey was almost 30%; representation was achieved from various medical specialties from both community and academic centres in various Canadian provinces. Two rounds of consensus were required to achieve 80% or higher consensus on 59 final statements. Five additional statements were added to reflect updated evidence but not sent for consensus. Conclusions Key highlights of this comprehensive Canadian guideline on NABC include the use of neoadjuvant therapy for early stage triple negative and HER2 positive breast cancer, with subsequent adjuvant treatments for patients with residual disease. The use of molecular signatures, other targeted adjuvant therapies, and optimal response-based local regional management remain actively evolving areas. Many statements had evolving or limited data but still achieved high consensus, demonstrating the utility of such a guideline in helping to unify practice while further evidence evolves in this important area of breast cancer management.

Cutaneous squamous cell carcinoma (cSCC) of the trunk/extremities with nodal metastasis represents a rare but significant clinical challenge. Treatment patterns and outcomes are poorly described. Patients with cSCC who developed axilla/groin lymph node metastasis and underwent curative-intent surgery between 2005 and 2015 were identified at four Canadian academic centers. Demographics, tumor characteristics, treatment patterns, recurrence rates, and mortality were described. Overall survival (OS) and disease-free survival (DFS) were calculated using Kaplan–Meier analysis. Predictors of survival and any recurrence were explored using Cox regression and logistic regression models, respectively. Of 43 patients, 70% were male (median age 74 years). Median follow-up was 38 months. Median time to nodal metastasis was 11.3 months. Thirty-one and 12 patients had nodal metastasis to the axilla and groin, respectively. A total of 72% and 7% received adjuvant and neoadjuvant radiation, respectively, while 5% received adjuvant chemotherapy. Following surgery, 26% patients developed nodal and/or distant disease recurrence. Crude mortality rate was 39.5%. Mean OS was 5.3 years [95% confidence interval (CI) 3.9–6.8 years], and 5-year OS was 55.1%. Mean DFS was 4.8 years (95% CI 3.3–6.2 years), and five-year DFS was 49.3%. Any recurrence was the only independent predictor of death [p = 0.036, odds ratio (OR) = 29.5], and extracapsular extension (p = 0.028, OR = 189) and age (p = 0.017, OR = 0.823) were independent predictors of recurrence. This represents the largest contemporary series to date of outcomes for patients with axilla/groin nodal metastases from cSCC. Despite aggressive treatment, outcomes remain modest, indicating the need for a continued multidisciplinary approach and integration of new systemic agents.

Background Adhesive small-bowel obstruction (aSBO) is among the most common reasons for admission to a surgical service. While operative intervention for aSBO is associated with a lower risk of recurrence, current guidelines continue to advocate a trial of nonoperative management. The impact of the increased risk for recurrence on long-term survival is unknown. We sought to explore the potential for improved survival with operative management through the prevention of admissions for recurrence of aSBO and the associated risks. Methods This is a population-based retrospective cohort study using administrative data. We identified patients admitted to hospital for their first episode of aSBO from 2005 to 2014 and created a propensity-matched cohort to compare survival of patients managed operatively with those managed nonoperatively. To test whether survival differences were mediated by recurrence prevention, a competing risk regression was used to model the subdistribution hazard of death when accounting for the risk of recurrence. An instrumental variable approach was used as a secondary analysis to compare survival while accounting for unmeasured confounding. Results There were 27,904 patients admitted for their first episode of aSBO between 2005 and 2014. The mean age was 61.2 years (std dev, 13.6), and 51% were female. Operative management was associated with a significantly lower risk of death (hazard ratio, 0.80; 95% confidence interval, 0.75-0.86), which was robust to instrumental variable analyses, and a lower risk of recurrence (hazard ratio, 0.59; 95% confidence interval, 0.54-0.65). When adjusting for the risk of recurrence, operative intervention was not associated with improved survival, suggesting that the survival benefit is mediated through prevention of recurrences of aSBO. Conclusion In patients admitted for their first episode of aSBO, operative intervention is associated with a significant long-term survival benefit. This survival benefit appears to be mediated through the prevention of recurrences of aSBO. Study type Retrospective cohort study. Level of evidence Therapeutic study, Level II.

Purpose The purpose of this research was to generate recommendations on strategies to achieve patient-centered care (PCC) for ductal carcinoma in situ (DCIS). Methods Thirty clinicians (surgeons, medical/radiation oncologists, radiologists, nurses, navigators) who manage DCIS and 32 DCIS survivors aged 18 or older were nominated. Forty-six recommendations to support PCC for DCIS were derived from primary research, and rated in a two-round Delphi process from March to June 2018. Results A total of 29 clinicians and 27 women completed Round One, and 28 clinicians and 22 women completed Round Two. The 29 recommendations retained by both women and clinicians reflected the PCC domains of fostering patient–physician relationship (5), exchanging information (5), responding to emotions (1), managing uncertainty (4), making decisions (9), and enabling patient self-management (5). An additional 13 recommendations were retained by women only: fostering patient–physician relationship (1), exchanging information (3), responding to emotions (2), making decisions (3), and enabling patient self-management (4). Some recommendations refer to processes (i.e., ask questions about lifestyle or views about risks/outcomes to understand patient preferences); others to tools (i.e., communication aid). Panelists recommended a separate consensus process to refine the language that clinicians use when describing DCIS. Conclusions This is the first study to generate guidance on how to achieve PCC for DCIS. Organizations that deliver or oversee health care can use these recommendations on PCC for DCIS to plan, evaluate, or improve services. Ongoing research is needed to develop communication tools, and establish labels and language for DCIS that optimize communication. Electronic supplementary material The online version of this article (10.1007/s10549-019-05132-z) contains supplementary material, which is available to authorized users.

Objective: This study aims to determine an appropriate timeline to monitor indeterminate pulmonary nodules (IPN) in melanoma patients to confirm metastatic origin. Materials and Methods: 588 clinically non-metastatic melanoma patients underwent curative intent surgery during 3 years. Patients with baseline chest CT and at least one follow-up (FU) CT were retrospectively analyzed to assess for IPN. Patients with definitely benign nodules, metastases and non-melanoma malignancies were excluded. Change in volume from first to FU CT, initial diameter (D1) and volume (V1), distance from pleura, peripheral and perifissural location, density and clinical stage were evaluated. Nodules were volumetrically measured on CTs and were considered metastases if they increased in size between two CTs or if increase was accompanied by multiple new nodules or extrapulmonary metastases. Results: 148 patients were included. Two out of 243 baseline IPN detected in 70 patients, increased significantly in volume in 3 and 5 months and were proven metastases. During FU, 86% of 40 interval IPN detected in 28 patients, were proven metastases. Interval nodule (p

Phyllodes tumors are rare tumors of the breast, with most literature being retrospective with limited guidelines on the management of these patients. Scoping review was performed to highlight themes and gaps in the available literature.A scoping review of the literature was performed as per PRISMA-ScR guidelines with titles, abstracts, and full texts reviewed in duplicate. Data were abstracted and summarized in categories of diagnostics, surgical management, adjuvant therapies, treatment of recurrence, and surveillance. Quality assessment was performed for each paper.The search identified 4498 references, 434 full-text papers were reviewed, and 183 papers were included. Ultrasound, magnetic resonance imaging, and core needle biopsy are valuable preoperative diagnostics tools. Pathology reporting should include stromal overgrowth, stromal cellularity, nuclear atypia, mitotic rate, borders, and presence of heterologous elements. Ki67 may have a role in grading and prognosticating. Breast conservation is safe in all grades of phyllodes but may be associated with increased local recurrence in malignant phyllodes. Surgical margins should depend on grade. Axillary node positivity rate is very low, even with clinically enlarged lymph nodes. Adjuvant radiation is a useful tool to decrease local recurrence in malignant phyllodes tumors, tumors5 cm, age45 years, close margins, and breast conservation. There is no evidence supporting adjuvant chemotherapy. Recurrence can be managed with repeat wide excision; however, mastectomy is associated with lower re-recurrence. Surveillance protocols are variable in the literature.There is heterogeneity in the literature on phyllodes tumors. Consensus guidelines based on the literature will help provide evidence-based care.

We aim to delineate the relationship between breast and axillary pathologic complete response (pCR) in patients receiving neoadjuvant chemotherapy for breast cancer.We performed a retrospective cohort study of patients with clinical T1-4N0-3M0 breast cancer receiving neoadjuvant chemotherapy followed by surgical therapy at Sunnybrook Health Sciences Centre in Toronto, Canada between 2014 and 2019. Clinicopathologic data were abstracted from the electronic medical record. Women were stratified into receptor subtypes as follows: hormone receptor positive (HR+)/human epidermal growth factor receptor 2 negative (HER2-), HR+/HER2+, HR-/HER2+ and HR-/HER2- (triple negative) and compared with Fisher's exact test. Our primary outcome was to assess the positive predictive value of breast pCR for determining axillary pCR, and vice versa.There were 374 breast cancers, with 109 (29.1%) achieving breast pCR (ypT0/Tis). Amongst node-positive tumours achieving breast pCR, rates of associated axillary pCR (ypN0/0i+) were as follows: HR+/HER2- (2/6, 33.3%), HR+/HER2+ (12/13, 92.3%), HR-/HER2+ (15/17, 88.2%) and triple negative (15/17, 88.2%) (P = 0.02). Conversely, amongst node-positive tumours achieving axillary pCR, rates of associated breast pCR were: HR+/HER2- (2/10, 20.0%), HR+/HER2+ (12/23, 52.2%), HR-/HER2+ (15/24, 62.5%) and triple negative (15/26, 57.7%) (P = 0.1).Breast pCR is a strong predictor of axillary pCR in women with HER2-positive and triple-negative breast cancers. Conversely, axillary pCR is a modest predictor of breast pCR for these subtypes. There is a poor relationship between breast and axillary pCR in women with hormone receptor-positive disease. These data may inform future de-escalation of surgery in women with HER2-positive and triple-negative disease.

Purpose: Limited data exists about why older women (≥70 years old) with breast cancer avoid surgery. This study aimed to identify physician- and patient-perceived attitudes that influence the decision to avoid surgery among older women with invasive breast cancer.Methods: Semi-structured in-depth interviews were conducted with multidisciplinary breast cancer specialists and with older women with breast cancer who declined surgery. Transcripts were iteratively coded using a theoretical framework to guide identification of common themes. Thematic comparison was performed between patients and physicians. Results: Ten breast cancer specialists and eleven patients participated. Physicians believed older women declined surgery because they did not perceive their breast cancer as a life-threatening ailment compared to other medical comorbidities. Physicians did not discuss breast reconstruction, as it was perceived to be unimportant. Treatment side effects, length of treatment, impact on quality of life, and minimal survival benefit strongly influenced a patient’s decision to decline surgery. Patients valued independence and quality of life over quantity of life. Patients felt empowered to participate in the decision-making process but appreciated having support. Both groups had congruent beliefs with respect to age impacting treatment decision, cosmesis playing a minor factor in treatment decisions, and importance of quality of life; however, they were discordant in their perceptions about the amount of support that patients have from their families.Conclusion: The decision to avoid surgery in older women stems from a variety of individual beliefs. Acknowledging patient values early in treatment planning may facilitate a patient-centered approach to treatment decision making.

Objectives To assess the cost-effectiveness of using maintenance hormonal therapy in patients with low grade serous ovarian cancer (LGSC). Methods A simulated decision analysis with a Markov decision model over a lifetime horizon was performed using the base case of a 47-year old patient with stage IIIC, LGSC following first-line treatment with primary cytoreductive surgery and adjuvant chemotherapy. Two treatment strategies were analyzed - maintenance daily letrozole until disease progression and routine observation. The analysis was from the perspective of the healthcare payer. Direct medical costs were estimated using public data sources and previous literature and were reported in adjusted 2018 Canadian dollars. The model estimated lifetime cost, quality-adjusted life years (QALY), life years (LY), median overall survival (OS), and number of recurrences with each strategy. Cost-effectiveness was compared using an incremental cost-effectiveness ratio (ICER). A strategy was considered cost-effective when the ICER was less than the willingness to pay (WTP) threshold of $50,000 CAD per QALY. Deterministic sensitivity analysis was performed to assess the impact of changing key clinical and cost variables. Results Maintenance letrozole was the preferred strategy with an associated lifetime cost of $69,985 CAD ($52,620 USD) and an observed improvement of 0.91 QALYs and 1.55 LYs. The ICER for letrozole maintenance therapy was an additional $11,037 CAD ($8298 USD) per QALY. The modeled median OS was 150 months with maintenance letrozole and 126 months in the observation strategy. The maintenance letrozole strategy resulted in 34% and 17% fewer first recurrences at 5-year and 10-year follow-up, respectively. Conclusion Maintenance letrozole is a cost-effective treatment strategy in patients with advanced LGSC resulting in clinically-relevant improvement in QALYs, LYs, and fewer disease recurrences.

Background Nonoperative management of rectal cancer was introduced for patients with clinical complete response after neoadjuvant chemoradiotherapy to avoid short- and long-term surgical morbidity related to radical resection. Objective The purpose of this study was to determine the expected life-years and quality-adjusted life-years for nonoperative management and radical resection of locally advanced rectal cancer after clinical complete response following neoadjuvant chemoradiotherapy. Design Markov modeling was used to simulate nonoperative management and radical surgery for a base case scenario over a 10-year time horizon. Estimates for various clinical variables were obtained after extensive literature search. Outcome was expressed in both life-years and quality-adjusted life-years. Deterministic sensitivity analyses were completed to assess the impact of variation in key parameters. Setting A decision model using a Markov model was designed. Patients The base case was a 65-year-old man with a distal rectal tumor who had achieved clinical complete response after neoadjuvant chemoradiotherapy. Main outcome measures Life-years and quality-adjusted life-years were measured. Results Quality-adjusted life-years (5.79 for nonoperative management vs 5.62 for radical surgery) and life-years (6.92 for nonoperative management vs 6.96 for radical surgery) were similar between nonoperative management and radical surgery. The preferred treatment strategy changed with variations in the probability of local regrowth in nonoperative management, the probability of salvage surgery for regrowth in nonoperative management, utilities associated with nonoperative management and low anterior resection, and the utility of low anterior resection syndrome. The model was not sensitive to (dis)utilities associated with stoma, chemotherapy, or postoperative morbidity and mortality. Limitations The study was limited by assumptions inherent to modeling studies. Conclusions Nonoperative management and radical surgery resulted in similar (quality-adjusted) life-years. Nonoperative management should therefore be considered as a reasonable treatment option. See Video Abstract at http://links.lww.com/DCR/B246. MANEJO NO-QUIRURGICO VERSUS CIRUGIA RADICAL DEL CANCER RECTAL DESPUES DE LA RESPUESTA CLINICA COMPLETA INDUCIDA POR TERAPIA NEOADYUVANTE: UN ANALISIS DE DECISION DE MARKOV: Se introdujo el tratamiento no quirurgico del cancer rectal para pacientes con respuesta clinica completa despues de la quimiorradioterapia neoadyuvante para evitar la morbilidad quirurgica a corto y largo plazo relacionada con la reseccion radical.Determinar los anos de vida esperados y los anos de vida ajustados por calidad para el tratamiento no-quirurgico y la reseccion radical del cancer rectal localmente avanzado, despues de la respuesta clinica completa siguiente de la quimiorradioterapia neoadyuvante.El modelo de Markov se uso para simular el manejo no-quirurgico y la cirugia radical para un escenario de caso base en un horizonte temporal de 10 anos. Se obtuvieron estimaciones para diversas variables clinicas despues de una extensa busqueda bibliografica. El resultado se expreso tanto en anos de vida como en anos de vida ajustados por calidad. Se completaron analisis deterministicos de sensibilidad para evaluar el impacto de la variacion en los parametros clave.Se diseno un modelo de decision utilizando un modelo de Markov.El caso base fue un hombre de 65 anos con un tumor rectal distal que habia logrado una respuesta clinica completa despues de la quimiorradioterapia neoadyuvante.Anos de vida y anos de vida ajustados por calidad.Los anos de vida ajustados por calidad (5.79 para el tratamiento no-quirurgico frente a 5.62 para la cirugia radical) y los anos de vida (6.92 para el tratamiento no-quirurgico frente a 6.96 para la cirugia radical) fueron similares entre el tratamiento no-quirurgico y la cirugia radical. La estrategia de tratamiento preferida cambio con las variaciones en la probabilidad de nuevo crecimiento local en el manejo no-operatorio, la probabilidad de cirugia de rescate para el rebrote en el manejo no-operatorio, las utilidades asociadas con el manejo no-operatorio, y la reseccion anterior baja y la utilidad de el syndrome de reseccion anterior baja. El modelo no era sensible a las (des) utilidades asociadas con el estoma, la quimioterapia o la morbilidad y mortalidad postoperatorias.El estudio estuvo limitado por suposiciones inherentes a los estudios de modelado.El manejo no-quirurgico y la cirugia radical resultaron en anos de vida similares (ajustados por calidad). Por lo tanto, el tratamiento no-quirurgico debe considerarse como una opcion de tratamiento razonable. Consulte Video Resumen en http://links.lww.com/DCR/B246.

PURPOSE: This study evaluates whether an intervention to identify Canadian patients eligible for a palliative approach changes the use of health care resources and costs within the final month of life. METHODS: Between 2014 and 2017, physicians identified 1,187 patients in family practice units and cancer centers who were likely to die within 1 year based on diagnosis, symptom assessment, and performance status. A multidisciplinary intervention that included activation of community resources and initiation of palliative planning was started. By using propensity-score matching, patients in the intervention group were matched 1:1 with nonintervention controls selected from provincial administrative data. We compared health care use and costs (using 2017 Canadian dollars) for 30 days before death between patients who died within the 1-year follow-up and matched controls. RESULTS: Groups (n = 629 in each group) were well-balanced in sociodemographic characteristics, comorbidities, and previous health care use. In the last 30 days, there was no differences in proportions between the two groups of patients regarding emergency department visits, intensive care unit admissions, or inpatient hospitalizations. However, patients in the intervention group had greater use of palliative physician encounters, community home care visits, and/or physician home visits (92.8% v 88.4%; P = .007). In the 507 pairs with cancer, more patients in the intervention group underwent chemotherapy (44% v 33%; P < .001) and radiation (18.7% v 3.2%; P = .043) in the last 30 days. Mean cost per patient was similar for the intervention group (mean, $17,231; 95% CI, $16,027 to $18,436) and for the control group (mean, $16,951; 95% CI, $15,899 to $18,004). CONCLUSION: Even with the limitations in our observational study design, identification of palliative patients did not significantly change overall costs but may shift resources toward palliative services.

Background Previous costing and resource estimates for cancer have not been complete owing to lack of comprehensive data on cancer-related medication and radiation treatment. Our objective was to calculate the mean overall costs per patient of cancer-related medications and radiation, as well as by disease subtype and stage, in the first year after diagnosis for the 4 most prevalent cancers in Ontario. Methods We conducted a retrospective cohort study using provincial health administrative databases to identify population health system resources and costs for all patients diagnosed with breast, colorectal, lung or prostate cancer between Jan. 1, 2010, and Dec. 31, 2015 in Ontario. The primary outcome measure was the overall average cost per patient in the 365 days after diagnosis for cancer-related medications and radiation treatment, calculated with the use of 2 novel costing algorithms. We determined the cost by disease, disease subtype and stage as secondary outcomes. Results There were 168 316 Ontarians diagnosed with cancer during the study period, 50 141 with breast cancer, 38 108 with colorectal cancer, 34 809 with lung cancer and 45 258 with prostate cancer. The mean per-patient cost for cancer-related medications was $8167 (95% confidence interval [CI] $8023-$8311), $6568 (95% CI $6446-$6691), $2900 (95% CI $2816-$2984) and $1211 (95% CI $1175-$1247) for breast, colorectal, lung and prostate cancer, respectively. The corresponding mean radiation treatment costs were $18 529 (95% CI $18 415-$18 643), $15 177 (95% CI $14 899-$15 456), $10 818 (95% CI $10 669-$10 966) and $16 887 (95% CI $16 648-$17 125). In general, stage III and IV cancers were the most expensive stages for both medications and radiation across all 4 disease sites. Interpretation Our work updates previous costing estimates to help understand costs and resources critical to health care system planning in a single-payer system. More refined costing estimates are useful as inputs to allow for more robust health economic modelling and health care system planning.

In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO in a large North American population. We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005–2014. We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable logistic regressions were used to assess trends when controlling for potential confounders. Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p

Background Emerging new treatments and indications for melanoma therapy lend uncertainty to changing costs. We present a contemporary real-world microcosting analysis of initial melanoma therapy over twelve years. Methods Patients with invasive cutaneous melanoma were identified retrospectively from the Ontario Cancer Registry (2003–2014) and deterministically linked with administrative databases through three separate algorithms. We identified comprehensively publicly funded resources utilized within a year of diagnosis, and costs related to various aspects of the healthcare continuum. Disaggregated, average-per-patient, and overall costs were presented, undiscounted, and from the perspective of the Canadian single-payer health system. Costs were ascribed to surgery, radiation, systemic therapy, physician billings, inpatient, and outpatient hospital sources. Results 28,708 patients with invasive melanoma were identified. Median age at diagnosis was 63 years and 54% were male. The most common cost contributor was ambulatory surgery (48–62% of patients diagnosed each year) with a mean per-patient cost of $1796 CAD. Rates of systemic therapy use have remained stable over time (6–9% of patients diagnosed each year). Mean cost per-patient has increased starting in 2012, reflecting use of new medications with a maximum cost of $24,348 CAD reached in 2013. The total burden of cost was a maximum of $46.6MCAD for 3083 patients diagnosed in 2014 with a mean overall cost per patient of $15,132 CAD. Conclusion Patterns of resource utilization and costs for initial treatment of melanoma are changing, particularly due to systemic therapy. Understanding these patterns and forecasting of future changes are critical for sustainable budgetary planning.

To reach a consensus about contralateral prophylactic mastectomy in unilateral breast cancer.There has been a substantial increase in the number of North American women with unilateral breast cancer undergoing a therapeutic mastectomy and a contralateral prophylactic mastectomy (CPM) either simultaneously or sequentially. The purpose of this project was to create a nationally endorsed consensus statement for CPM in women with unilateral breast cancer using modified Delphi consensus methodology.A nationally representative expert panel of 19 general surgeons, 2 plastic surgeons, 2 medical oncologists, 2 radiation oncologists, and 1 psychologist was invited to participate in the generation of a consensus statement. Thirty-nine statements were created in 5 topic domains: predisposing risk factors for breast cancer, tumor factors, reconstruction/symmetry issues, patient factors, and miscellaneous factors. Panelists were asked to rate statements on a 7-point Likert scale. Two electronic rounds of iterative rating and feedback were anonymously completed, followed by an in-person meeting. Consensus was reached when there was at least 80% agreement.Our panelists did not recommend for average risk women with unilateral breast cancer. The panel recommended CPM for women with a unilateral breast cancer and previous Mantle field radiation or a BrCa1/2 gene mutation. The panel agreed that CPM could be considered by the surgeon on an individual basis for: women with unilateral breast cancer and a genetic mutation in the CHEK2/PTEN/p53/PALB2/CDH1 gene, and in women who may have significant difficulty achieving symmetry after unilateral mastectomy.Contralateral prophylactic mastectomy is rarely recommended for women with unilateral breast cancer.

Purpose Prognostic and treatment uncertainty make ductal carcinoma in situ (DCIS) complex to manage. The purpose of this study was to describe research that evaluated DCIS communication experiences, needs and interventions among DCIS patients or physicians. Methods MEDLINE, EMBASE, CINAHL and The Cochrane Library were searched from inception to February 2017. English language studies that evaluated patient or physician DCIS needs, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings. Results A total of 51 studies published from 1997 to 2016 were eligible for review, with a peak of 8 articles in year 2010. Women with DCIS lacked knowledge about the condition and its prognosis, although care partners were more informed, desired more information and experienced decisional conflict. Many chose mastectomy or prophylactic mastectomy, often based on physician’s recommendation. Following treatment, women had anxiety and depression, often at levels similar to those with invasive breast cancer. Disparities were identified by education level, socioeconomic status, ethnicity and literacy. Physicians said that they had difficulty explaining DCIS and many referred to DCIS as cancer. Despite the challenges reported by patients and physicians, only two studies developed interventions designed to improve patient–physician discussion and decision-making. Conclusions As most women with DCIS undergo extensive treatment, and many experience treatment-related complications, the paucity of research on PE to improve and support informed decision-making for DCIS is profound. Research is needed to improve patient and provider discussions and decision-making for DCIS management. Electronic supplementary material The online version of this article (10.1007/s10549-017-4613-x) contains supplementary material, which is available to authorized users.