Prevalence of screening in patients newly diagnosed with colorectal cancer in Ontario.

OBJECTIVES: The primary objective was to determine the proportion of individuals with a new diagnosis of colorectal cancer (CRC) in Ontario in whom the cancer was screen detected. The secondary objectives were to determine the cancer stage at diagnosis and the indications for the procedure in patients who received their first colonoscopy. PATIENTS AND METHODS: Individuals admitted to a hospital with a new diagnosis of CRC were randomly selected after stratifying by hospital type (teaching or community). The Canadian Institute for Health Information's Discharge Abstract Database was used to identify individuals with a first diagnosis of CRC during calendar year (CY) 2000, and Ontario Health Insurance Plan data were used to identify people 50 to 74 years of age who had their first colonoscopy during CY 2000. Up to 20 individuals were selected for each group (CRC or colonoscopy) in each of seven randomly selected community hospitals and three randomly selected teaching hospitals. Data were abstracted from the hospital charts. RESULTS: The hospital charts of 152 patients with a new diagnosis of CRC were examined. Of the 133 patients in whom screening status could be determined, eight had screen-detected cancers (6.0%). Of the 99 patients (65% of the sample) in whom stage could be determined, 43 (43.4%) had advanced disease (tumour-node-metastasis stage III or IV) at diagnosis. The hospital charts of 184 patients who underwent their first colonoscopy were examined. Of the 175 patients in whom the indication for colonoscopy could be determined, 45 underwent the procedure for screening purposes, 10 were for diagnostic workup of anemia and 120 for evaluation of symptoms. CONCLUSIONS: The low proportion (6%) of screen-detected CRC and the high proportion of patients (43.4%) with advanced disease at diagnosis reflect the lack of an organized screening program.     

Association between age and the utilization of radiotherapy in Ontario

PURPOSE: The purpose of this study was to assess whether: (i) radiotherapy (RT) utilization varies with age in Ontario cancer patients; (ii) age-associated differences in the use of RT (if they exist) vary with cancer site and treatment intent; (iii) the age-associated variation in RT utilization is comparable to the decline in functional status in the general population; and (iv) the variation with age is due to differences in referral to a cancer center or to subsequent decisions. METHODS AND MATERIALS: Details for several cancer sites diagnosed between 1984-1994 were obtained from the Ontario Cancer Registry (OCR). RT records from all treatment centers were linked to the OCR database. Information about the functional status of the Canadian population was obtained from the 1994 National Population Health Survey conducted by Statistics Canada. RESULTS: The rate of RT use declined with age, particularly for adjuvant and palliative indications. The relative decline in RT with age exceeded the relative decline in functional status with age in the general population. Most of the decline in RT use was related to a decline in referral to cancer centers. CONCLUSIONS: The referral for, and use of, palliative and adjuvant RT decreases more with age than can be explained by age-associated decline in functional status observed in the general population.     

Outcomes in surgery for ovarian cancer

OBJECTIVE: Theobjective was to determine the relationship among hospital volume of ovarian cancer surgery,academic status of institution, surgical specialty, and outcomes of care (30-day postoperative mortality, reoperation rate, and overall survival). METHODS: This population-based cohort study included all newly diagnosed ovarian cancer patients treated from 1992 to 1998 in Ontario, Canada. Hospitalization and surgical billing databases were used. Logistic regression was used to evaluate the importance of hospital type, hospital volume, surgical specialty, and surgeon volume of ovarian cancer operations on postoperative mortality, reoperation rates, and survival. RESULTS: Ovarian cancer surgery was performed on 3815 women between April 1992 and March 1998. When adjusted for age, comorbidity, acuity of the operation, and metastatic disease, no factors influenced postoperative mortality. The adjusted relative risk for reoperation within 3 months of the initial surgery showed that patients were less likely to have a repeat operation if the initial operation was done in a high- or intermediate-volume hospital (RR 0.24 95% CI 0.12-0.48, RR 0.29 95% CI 0.20-0.42, respectively), a hospital with a gynecologic oncologist (RR 0.29 95% CI 0.15-0.56), by a gynecologic oncologist (RR 0.04 95% CI 0.01-0.12) or gynecologist (RR 0.37 95% CI 0.21-0.66), or by a high-volume surgeon (RR 0.09 95% CI 0.03-0.23). The adjusted survival was improved if the initial surgery was done by a gynecologic oncologist (HR 0.70 95% CI 0.57-0.85) or gynecologist (HR 0.65 95% CI 0.53-0.79). CONCLUSIONS: There is a relationship between hospital volume and reoperation rate. Institution type only influenced reoperation rate. Statistically significant associations were found between surgical specialty and all three outcome variables. The volume of surgery performed by an individual surgeon only influenced reoperation rate. Our results are preliminary but support the need for further studies examining factors such as stage.     

A population-based study of the use and outcome of radical radiotherapy for invasive bladder cancer

Purpose: The objective of this study is to describe the use and outcome of radical radiotherapy for bladder cancer in the province of Ontario, Canada, between 1982 and 1994.

Methods: Electronic records of invasive bladder cancer (ICD code 188) from the Ontario Cancer Registry were linked to surgical records from all Ontario hospitals and radiotherapy (RT) records from all Ontario cancer centers. We identified cases receiving radical RT by selecting RT records containing “bladder” or “pelvis” anatomic region codes and a radical or curative intent code (or dose > 39.5 Gy if intent missing). We identified cases receiving salvage total cystectomy by selecting total cystectomy procedure codes occurring at any time beyond 4 months from the start of radical RT. We used life table methods to compute the following: the time from diagnosis to radical RT, the time from radical RT to salvage cystectomy, overall and cause-specific survival from radical radiotherapy to death, and overall and cause-specific survival from salvage cystectomy to death. We modeled the factors associated with time to death, time to cystectomy conditional on survival, and time to cystectomy or death, whichever came first, using Cox proportional hazards regression.

Results: From the 20,906 new cases of bladder cancer diagnosed in Ontario from 1982 to 1994, we identified 1,372 cases treated by radical radiotherapy (78% male, 22% female; mean age 69.8 years). The median interval to start of radical RT from diagnosis was 13.4 weeks. Ninety-three percent of patients were treated on high-energy linacs, and the most common dose/fractionation scheme was 60 Gy/30 (31% of cases). Five-year survival rates were as follows: bladder cancer cause-specific, 41%; overall, 28%; cystectomy-free, 25%; bladder cancer cause-specific following salvage cystectomy, 36%; overall following salvage cystectomy, 28%. Factors associated with a higher risk of death and a poorer cystectomy-free survival were histology (squamous or nonpapillary transitional cell carcinoma [TCC]) and advanced age.

Conclusion: This population-based study confirms previous institutional studies and clinical trials and shows that radical RT has a curative role in the management of invasive bladder cancer and allows about one-quarter of patients receiving radiotherapy to survive 5 years while retaining the bladder. Salvage cystectomy following RT provides a chance of cure at the time of bladder relapse.     

A population-based study of rectal cancer: permanent colostomy as an outcome

Purpose: The objectives of this study are to describe the utilization of surgery and of radiotherapy in the treatment of newly diagnosed rectal cancer in Ontario between 1982 and 1994, and to describe the probability of permanent colostomy at any time after the diagnosis of rectal cancer, as an outcome of the treatment of newly diagnosed rectal cancer.

Methods and Materials: Electronic records of rectal cancer (International Classification of Diseases code 154) from the Ontario Cancer Registry (n = 18,695, excluding squamous, basaloid, cloacogenic, and carcinoid histology) were linked to surgical records from all Ontario hospitals, and radiotherapy (RT) records from Ontario cancer centers. Procedures occurring within 4 months of diagnosis, or within 4 months of another procedure for rectal cancer, were considered part of initial treatment. Multivariate analyses controlled for age, sex, and year of diagnosis.

Results: Resection plus permanent colostomy was performed in 33.1% of cases, whereas local excision or resection without permanent colostomy was performed in 38.2%. Multivariate logistic regression demonstrated higher odds ratios (OR) for resection plus permanent colostomy in all regions of Ontario relative to Toronto. The OR for postoperative RT following local excision or resection without permanent colostomy varied among the regions relative to Toronto (e.g., OR Ottawa = 0.59, OR Hamilton = 0.76, OR London = 1.25). The relative risk (RR) of colostomy conditional upon survival within 5 years from diagnosis varied among regions relative to Toronto (e.g., RR Ottawa = 1.21, RR Hamilton = 1.20).

Conclusions: There is regional variation in the utilization of resection with permanent colostomy, and in the utilization of postoperative RT among cases not undergoing permanent colostomy. Regions with higher initial rates of resection plus permanent colostomy continue to experience higher probability of permanent colostomy 5 years after diagnosis of rectal cancer. Higher initial rates of permanent colostomy may be malleable to interventions aimed at improving overall outcomes.     

Factors associated with colonoscopy performed in nonhospital settings

BACKGROUND:

Colonoscopy is being increasingly performed in facilities outside of hospitals. Regulation of these facilities is variable, and concerns regarding the quality of procedures in nonhospital (NH) settings have been raised. Further study is needed to better understand endoscopic practice in these facilities.

OBJECTIVES:

To describe NH-based colonoscopy practice in Ontario from 1993 to 2005, and to identify patient (age, sex, income quintile and comorbidity) and physician (specialty and colonoscopy volume) factors associated with this practice.

METHODS:

The present study was a population-based, cross-sectional analysis using health administrative data from Ontario adults who underwent at least one outpatient colonoscopy between 1993 and 2005. A total of 1,240,781 patients underwent 1,917,714 colonoscopies. The main outcome measure was the receipt of colonoscopy in an NH facility.

RESULTS:

An increase in NH-based colonoscopy from 10.0% in 1993 to 15.1% in 2005 (P<0.0001) was found. In the multivariate model, younger, healthier men living in higher income areas were significantly more likely to undergo NH-based colonoscopy. Surgeons and other practitioners (eg, nongastroenterologists and noninternists) were significantly more likely to practice in NH settings. Physicians in the highest colonoscopy volume quintile were 25 times more likely to practice in NH settings than those in the lowest volume quintile (P<0.0001).

CONCLUSION:

Rates of NH-based colonoscopy are rising in Ontario. High-volume endoscopists and surgeons are most likely to practice in NH settings. Given its increasing use, further study of the practice and the regulation of NH colonoscopy is warranted.     

Comparing patient and endoscopist perceptions of the colonoscopy indication

BACKGROUND

Determining whether a colonoscopy is performed for screening or nonscreening purposes can facilitate clinical practice and research. However, there is no simple method to determine the colonoscopy indication using patient medical files or health administrative databases.

OBJECTIVE

To determine patient-endoscopist agreement on the colonoscopy indication.

METHODS

A cross-sectional study was conducted among staff endoscopists and their patients at seven university-affiliated hospitals in Montreal, Quebec. The study participants were 50 to 75 years of age, they were able to understand English or French, and were about to undergo colonoscopy. Self- (endoscopist) and interviewer-administered (patient) questionnaires ascertained information that permitted classification of the colonoscopy indication. Patient colonoscopy indication was defined as the following: perceived screening (routine screening, family history, age); perceived nonscreening (follow-up); medical history that implied nonscreening; and a combination of the three preceding indications. Agreement between patient and endoscopist indications was measured using concordance and Kappa statistic.

RESULTS

In total, 702 patients and 38 endoscopists participated. The three most common reasons for undergoing colonoscopy were routine screening/regular check-up (33.8%), follow-up to a previous problem (30.2%) and other problem (24.6%). Concordance (range 0.79 to 0.85) and Kappa (range 0.58 to 0.70) were highest for perceived nonscreening colonoscopy. Recent large bowel symptoms accounted for 120 occurrences of disagreement in which the patient perceived a nonscreening colonoscopy while the endoscopist perceived a screening colonoscopy.

CONCLUSIONS

Patient self-report may be an acceptable means for rapidly assessing whether a colonoscopy is performed for screening or nonscreening purposes. Delivery of patient-centred care may help patients and endoscopists reach a shared understanding of the reason for colonoscopy.     

Factors associated with incomplete colonoscopy: a population-based study

BACKGROUND & AIMS: The U.S. Multi-Society Task Force on Colorectal Cancer sets a target of cecal intubation in at least 90% of colonoscopies. We conducted a population-based study to determine the colonoscopy completion rate and to identify factors associated with incomplete procedures. METHODS: Men and women 50 to 74 years of age who underwent a colonoscopy in Ontario between January 1, 1999, and December 31, 2003, were identified. The first (index) colonoscopy was classified as complete or incomplete. A generalized estimating equations model was used to evaluate the association between patient, endoscopist (specialty, colonoscopy volume), and setting (academic hospital, community hospital, private office) factors and incomplete colonoscopy. RESULTS: A total of 331,608 individuals had an index colonoscopy, of which 43,483 (13.1%) were incomplete. Patients with an incomplete colonoscopy were older (odds ratio [OR] 1.20 per 10-year increment; 95% confidence interval [CI]=1.18-1.22), more likely to be female (OR 1.35; 95% CI: 1.30-1.39), have a history of prior abdominal surgery (OR 1.07; 95% CI: 1.05-1.09) or prior pelvic surgery (OR 1.04; 95% CI: 1.01-1.06). For colonoscopies done in a private office, the odds of an incomplete procedure were more than 3-fold greater than for procedures done in an academic hospital (OR 3.57; 95% CI: 2.55-4.98). CONCLUSIONS: In usual clinical practice in Ontario, 13.1% of colonoscopies are incomplete. The factors most strongly associated with incomplete colonoscopy were increased patient age, female sex, and having the procedure in a private office. Quality improvement programs are needed to improve colonoscopy completion rates.     

Colorectal cancer screening with nurse-performed flexible sigmoidoscopy: results from a Canadian community-based program

BACKGROUND: Despite highest-quality evidence that early detection of colorectal cancer (CRC) can lead to reduced mortality, no organized CRC screening programs exist in Canada. OBJECTIVE: To report the safety, the feasibility, and the detection rate for the first Canadian community-based nurse-performed flexible sigmoidoscopy (FS) screening program for CRC, established in 1999. DESIGN: Cross-sectional analysis of data collected from a prospective study of FS done by nurses from March 1999 to November 2002. Estimate of differences between men and women in FS findings, with relative risks. Logistic regression used to calculate odds ratios for advanced neoplasia. SETTING: Endoscopy suite of a community hospital. PATIENTS: Asymptomatic men and women > or =50 years, with no previous history of CRC. INTERVENTION: FS done by a nurses, and colonoscopy for persons with abnormalities done by an experienced gastroenterologist. MAIN OUTCOME MEASUREMENTS: Mean depth of insertion of endoscope; duration of FS procedure; number and location of polyps found during FS; number, location, and type of polyps found during colonoscopy. RESULTS: A total of 1818 individuals (mean age, 62 years) underwent nurse-performed FS (mean duration, 7.3 minutes; mean depth of insertion of the endoscope, 53.5 cm), without complications. Results of the FS were abnormal for 240 (13.2%) of the 1818 participants; 231 (12.7%) underwent colonoscopy. Distal neoplasms (adenomas or cancer) were detected in 8.7% (158/1818). After adjustment for age and family history of CRC, the risk of advanced neoplasm in the distal colon for men was about twice that for women (odds ratio 1.95, 95% confidence interval 1.21-3.14). Cancer was detected in 5 of the 1818 participants screened (0.28%), and high-grade dysplasia was detected in an additional 5 (0.28%). One of the cancers and all the lesions with high-grade dysplasia were treated endoscopically. CONCLUSIONS: Our community-based nurse-performed FS screening program was feasible and safe. The referral rate for colonoscopy was 13%, and the cancer detection rate was 2.8 per 1000 persons screened.     

Surgical outcomes in women with ovarian cancer

Objective

We sought to assess whether the specialty of the surgeon or the hospital involved in the initial management of women with ovarian cancer determined the likelihood of unnecessary repeated abdominal surgery and long-term patient survival.

Methods

We conducted a population-based study involving women in Ontario, Canada, who had epithelial ovarian cancer treated initially with abdominal surgery between January 1996 and December 1998. We documented incident surgical cases using hospital contact data and the Ontario Cancer Registry. We obtained data on patient characteristics, clinical findings, surgical techniques and perioperative care from electronic administrative data records and patient charts. We performed regression analyses to assess the influence of surgeon and hospital specialization and of case volumes on the likelihood of repeat surgery and survival. We controlled for stage of disease and other factors associated with these outcomes. We also examined the relation between the adequacy of surgery and adjuvant chemotherapy with survival.

Results

A total of 1341 women met our inclusion criteria. Our analysis showed that repeat surgery was associated with the surgeon''s discipline, younger patient age, well-differentiated tumours and early stage of disease. However, survival was not associated with the surgeon''s discipline; rather, it was associated with advanced patient age, increasing comorbidities, advanced stage of disease, poorly differentiated tumours, urgent surgery and adjuvant chemotherapy. We observed a trend between inadequate surgery and a decreased likelihood of survival.

Conclusion

Further study is needed to understand patterns of repeat surgery for ovarian cancer. Improved quality of operative reporting is required to classify surgical adequacy.