Canadian Cancer Society Research Articles

Comprehension of Internet-based numeric cancer information by older adults

Competency in health numeracy is essential in understanding risk about disease susceptibility and the consequences of disease treatment. Both health literacy and skill in using the Internet to obtain health information are lower among older compared with younger adults. Presentation format of health information has been shown to influence comprehension. The objective of this study was to determine the influence of information formatting (text and graphic) on older adults' comprehension of Internet-based numeric cancer risk information. This cross-sectional study involved a convenience sample of adults, aged 50 years and older from diverse ethnic and educational backgrounds. Cancer risk information, obtained from a Canadian Cancer Society web page, was presented as text, graphics or as a combination of text and graphics formats. Comprehension of the information was assessed by six questions focused on basic numeracy skill and ability to perform simple calculations and operations. A three-item general context numeracy and an eight-item health context numeracy instrument were used to describe health numeracy skills of participants. The six-item Newest Vital Sign (NVS) test was used to assess prose and numeric health literacy. There was no statistically significant effect of presentation format on participants' comprehension of the cancer information. Participants' comprehension of basic health numeracy information was positively correlated with education (p ≤ 0.05) and income (p ≤ 0.01) whereas comprehension of information that assessed calculation and operations numeracy skill was positively correlated only with income (p ≤ 0.05). Health literacy skill and income explained a significant proportion of the variance in overall comprehension of Internet-based cancer risk information (R2 = 0.414, p ≤ 0.01) in this sample of older adults. Format of numeric risk information was not a significant factor in the comprehension of cancer risk information in this group of ethnically diverse, older adults. However, comprehension of the information was related to health literacy skill and income.

Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial

Results from phase II studies in patients with stage IIIA non-small-cell lung cancer with ipsilateral mediastinal nodal metastases (N2) have shown the feasibility of resection after concurrent chemotherapy and radiotherapy with promising rates of survival. We therefore did this phase III trial to compare concurrent chemotherapy and radiotherapy followed by resection with standard concurrent chemotherapy and definitive radiotherapy without resection. Patients with stage T1-3pN2M0 non-small-cell lung cancer were randomly assigned in a 1:1 ratio to concurrent induction chemotherapy (two cycles of cisplatin [50 mg/m(2) on days 1, 8, 29, and 36] and etoposide [50 mg/m(2) on days 1-5 and 29-33]) plus radiotherapy (45 Gy) in multiple academic and community hospitals. If no progression, patients in group 1 underwent resection and those in group 2 continued radiotherapy uninterrupted up to 61 Gy. Two additional cycles of cisplatin and etoposide were given in both groups. The primary endpoint was overall survival (OS). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00002550. 202 patients (median age 59 years, range 31-77) were assigned to group 1 and 194 (61 years, 32-78) to group 2. Median OS was 23.6 months (IQR 9.0-not reached) in group 1 versus 22.2 months (9.4-52.7) in group 2 (hazard ratio [HR] 0.87 [0.70-1.10]; p=0.24). Number of patients alive at 5 years was 37 (point estimate 27%) in group 1 and 24 (point estimate 20%) in group 2 (odds ratio 0.63 [0.36-1.10]; p=0.10). With N0 status at thoracotomy, the median OS was 34.4 months (IQR 15.7-not reached; 19 [point estimate 41%] patients alive at 5 years). Progression-free survival (PFS) was better in group 1 than in group 2, median 12.8 months (5.3-42.2) vs 10.5 months (4.8-20.6), HR 0.77 [0.62-0.96]; p=0.017); the number of patients without disease progression at 5 years was 32 (point estimate 22%) versus 13 (point estimate 11%), respectively. Neutropenia and oesophagitis were the main grade 3 or 4 toxicities associated with chemotherapy plus radiotherapy in group 1 (77 [38%] and 20 [10%], respectively) and group 2 (80 [41%] and 44 [23%], respectively). In group 1, 16 (8%) deaths were treatment related versus four (2%) in group 2. In an exploratory analysis, OS was improved for patients who underwent lobectomy, but not pneumonectomy, versus chemotherapy plus radiotherapy. Chemotherapy plus radiotherapy with or without resection (preferably lobectomy) are options for patients with stage IIIA(N2) non-small-cell lung cancer. National Cancer Institute, Canadian Cancer Society, and National Cancer Institute of Canada.

Cancer Connections

Cancer Connections is a joint venture between Photosensitive—a not-for-profit Canadian collective of photographers with the stated ethos of combining “artistic excellence with social justice”—and the Canadian Cancer Society (CCS). When it launched in May, 2008, the show comprised 300 stills, real-life images captured by amateur and professional photographers and centred on the theme of cancer.

Interplay between Np95 and Eme1 in the DNA damage response

Methyl methansulfonate UV sensitive clone 81 (Mus81) and essential meiotic endonuclease 1 (Eme1) form a heterodimeric endonuclease that preserves genomic integrity through the repair of DNA replication‐associated damage. Despite its role as genome guardian and tumour suppressor, our understanding of how this endonuclease is coordinated during the DNA damage response is poor. In order to identify other proteins that interact with Mus81‐Eme1, our laboratory conducted a protein interaction screen to identify and characterize proteins that interact with Eme1. One candidate identified in this screen was found to encode the carboxy‐terminal domain of Np95, a chromatin‐associated ubiquitin ligase. Np95 and Eme1 co‐localize on nuclear chromatin following exposure of cells to camptothecin, an agent that promotes the collapse of replication forks. The observed co‐localization following DNA damage was found to be dependent on an intact RING finger, the structural motif that encodes the E3 ubiquitin ligase activity of Np95. These findings for the first time, link the tumour‐suppressor Mus81‐Eme1 with the replication‐associated chromatin modifier functions of Np95 in the DNA damage response. Supported by grants from the Canadian Cancer Society through the National Cancer Institute of Canada and the Cancer Research Society.

In the face of cancer

Cancer Connections Photography exhibition Photosensitive, in partnership with the Canadian Cancer Society Online gallery and travelling exhibition [www.photosensitive.com/][1] May 2008–December 2009 Everyday we are saturated with images, most of which we tune out before we even tune in. In most

Cancer survivorship: Creating a national agenda

The cadre of individuals who are living after a diagnosis of cancer is growing steadily. In developed countries, as many as 78% of pediatric patients are alive five years following diagnosis, as are 60% of adult patients (Curtiss & Haylock, 2006). At present in Canada, about one million individuals are living as cancer survivors (Canadian Cancer Society, 2008). With the anticipated increase in the incidence of cancer around the world and the success of treatment approaches, it is anticipated this cadre will continue to grow. Unfortunately, cancer survivorship does not come without cost. It is becoming increasingly evident there are late and long-term effects cancer survivors experience, both physical and psychosocial, that can compromise quality of life and increase the burden of suffering. Compared to matched population controls, cancer survivors have significantly lower outcomes on many burden of illness measures and experience difficulties accessing appropriate health care for a broad range of chronic medical conditions (Yabroff, Lawrence, Clauser, Davis, & Brown, 2004; Earle & Neville, 2004). A history of cancer may shift attention from important health problems unrelated to cancer and the roles of primary care providers and specialists in cancer care of survivors are not yet clear. As well, quality of life issues are different for survivors than for individuals at the point of diagnosis and treatment. Cancer survivors face a range of physical and psychosocial challenges. Up to 75% of survivors have health deficits related to their treatments (Aziz & Rowland, 2003), more than 50% live with chronic pain (Lance Armstrong Foundation, 2004), 70% have experienced depression (Lance Armstrong Foundation, 2004), and between 18% and 43% have reported emotional distress (Vachon, 2006). Regardless of tumour type, there are commonly reported challenges: living with fear and uncertainty; changes in family roles; alterations in self image and self esteem; changes in comfort, physiological functioning and mobility; alterations in cognitive functioning; changes in employment and recreation; altered fertility and sexuality (Aziz & Rowland, 2003; Denmark-Wahnefried, Aziz, Rowland, & Pinto, 2005; Ganz, 2001; Lance Armstrong Foundation, 2005). Clearly, cancer survivors are a vulnerable population. New approaches are needed to overcome the barriers cancer survivors experience and ensure they receive appropriate care.

The Imperative of Strategic Alignment Across Organizations: The Experience of the Canadian Cancer Society’s Centre for Behavioural Research and Program Evaluation

The Canadian Cancer Society’s Centre for Behavioural Research and Program Evaluation (CBRPE) is a national asset for building pan-Canadian capacity to support intervention studies that guide population-level policies and programs. This paper briefly describes CBRPE’s experience in advancing this work in the field of prevention. The aim is to illuminate issues of central importance for advancing the goals of the Population Health Intervention Research Initiative for Canada. According to our experience, success in building the population intervention field will depend heavily on purposeful alignment across organizations to enable integration of research, evaluation, surveillance, policy and practice. CBRPE’s capacity development roles include a) a catalytic role in shaping this aligned inter-organizational milieu and b) investing our resources in building tangible assets (teams, indicators, data systems) that contribute relevant capacities within this emerging milieu. Challenges in building capacity in this field are described.

Helene Hudson Memorial Lectureship CANO 2008

One in nine women will develop breast cancer in her lifetime (Canadian Cancer Society, 2007). Hereditary breast cancer accounts for only five to 10 per cent of all breast cancers. However, women carrying a single high-penetrance gene mutation have a 40% to 80% chance of developing breast cancer (Fackenthal & Olopade, 2007). Most of these breast cancers occur in women under the age of 50. The BRCA 1 gene mutation was first reported in 1994, and the BRCA 2 gene mutation in 1995. The BRCA 2 gene mutation is often carried in males, and accounts for approximately six per cent of male breast cancer. Women with this gene mutation have a lifetime risk of developing breast cancer of between 50% and 85%, a second breast cancer of between 30% and 50%, and ovarian cancer between 10% and 20%. Each parent with the BRCA 2 gene mutation has a 50% chance of passing this gene mutation to their children (National Cancer Institute, 2006). The emotional impact of receiving cancer risk information such as this is difficult to predict. When presented with information about risk-reduction surgery, chemoprevention, risk avoidance and increased screening, how does one make decisions? Walk with me, as I share how my family discovered we carry the Icelandic founder gene mutation, the steps we took together during the testing process, and the decision-making by the family members who tested positive. We'll focus on my sister Rita--ordinary days, an extraordinary woman.

The imperative of strategic alignment across organizations: The experience of the Canadian Cancer Society's Centre for Behavioural Research and Program Evaluation

The Canadian Cancer Society's Centre for Behavioural Research and Program Evaluation (CBRPE) is a national asset for building pan-Canadian capacity to support intervention studies that guide population-level policies and programs. This paper briefly describes CBRPE's experience in advancing this work in the field of prevention. The aim is to illuminate issues of central importance for advancing the goals of the Population Health Intervention Research Initiative for Canada. According to our experience, success in building the population intervention field will depend heavily on purposeful alignment across organizations to enable integration of research, evaluation, surveillance, policy and practice. CBRPE's capacity development roles include a) a catalytic role in shaping this aligned inter-organizational milieu and b) investing our resources in building tangible assets (teams, indicators, data systems) that contribute relevant capacities within this emerging milieu. Challenges in building capacity in this field are described.

Canadian Colorectal Cancer Screening Initiatives and Barriers

Colorectal cancer (CRC) remains an important health concern in North America. It is the third most common cancer diagnosed in both men and women and the second leading cause of total cancer-related deaths. The lifetime risk for developing CRC in men is 6.7%, compared with 6.1% in women [1]. According to the Canadian Cancer Society's annual statistics, more than 21,500 Canadians are expected to be diagnosed with CRC this year and approximately one-third, or 8,900, will ultimately die of the disease [2,3].

Vitamin D: Cancer Prevention's Sunny Future?

C ould preventing cancer be as easy as taking a vitamin supplement? For decades, studies have suggested that sunlight and vitamin D decrease the risk of some nonskin cancers. In the past few years, there has been a crescendo in the research, including results from the first randomized, controlled trial to show that vitamin D can lower cancer risk. The Canadian Cancer Society thinks that vitamins might be one way to prevent some cancers. In June 2007, the national organization recommended that adults living in Canada consider taking vitamin D supplements of 1,000 international units (IU) a day in the fall and winter. Those at high risk of low vitamin D levels should take it year round. The move was a break from the Canadian government’s daily intake recommendation of 200 – 600 IU, which is aligned with the U.S. Institute of Medicine’s adequate intakes. Then, in October, the Canadian Cancer Society wrote a letter to North American research granting agencies, including the National Institutes of Health, lobbying for a large-scale clinical trial that tests at least 1,000 IU of vitamin D. The goal: to fi gure out what dose prevents cancer. Although making a recommendation and asking for more research at the same time may seem contradictory, Heather Chappell, senior manager of cancer control policy for the Canadian Cancer Society, said that this approach struck a balance between two health issues. One is geographic location — 90% of vitamin D comes from the sun when ultraviolet rays convert a precursor in the skin to vitamin D, but during fall and winter at higher latitudes, no vitamin D synthesis occurs. Findings from a conference on vitamin D and health, sponsored by the cancer society and the National Cancer Institute of Canada, concluded that overall vitamin D levels may be low in the general population and that “vitamin D may have benefi cial effects on some types of cancer.” The other issue is reminding Canadians to protect themselves from the sun. Tanning salons in Canada were advertising indoor tanning as a venue to get your vitamin D, which most scientists consider dangerous because of the skin cancer risk. “Taking a supplement is a safer alternative for Canadians than indoor tanning,” Chappell said. “That recommendation is only based on what we know to date.” What the society does know is based on a combination of the conference fi ndings (which brought together 14 national health organizations) and a review of about 60 studies, mostly o b s e r v a t i o n a l , Chappell said. But making recommendations before there have been many randomized, controlled trials concerns some researchers. Several research conferences and organizations have looked at the many questions that still need to be answered about vitamin D and cancer risk. “When you fi nd something in observational studies, the interventions are rarely, rarely as positive or as powerful as the observations,” said Wake Forest University professor Gary Schwartz , Ph.D., who has been examining the vitamin D link to prostate cancer for two decades. “It is an open question whether vitamin D supplementation will reduce the risk of cancer. The questions are how much vitamin D, when, and what cancer.” Ecologic, epidemiologic, and laboratory studies have provided evidence linking higher vitamin D exposures to lower risk of colon, breast, and prostate cancers. But a U.S. National Cancer Institute conference in May 2007 determined that there are many gaps in the research. The conference was spurred by the “sunshine vitamin” getting a lot of attention in the lay press, for which pace picked up after results from a randomized trial were published.

News and Notes

News and Notes

Venous Thromboembolism and Non-Small Cell Lung Cancer: A Pooled Analysis of National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) Trials.

Purpose: To determine the incidence of venous thromboembolism (VTE) in patients with early and advanced non-small cell lung cancer (NSCLC); to explore predictive factors for VTE occurrence during trials in these populations, and to investigate the effect of VTE on overall survival in patients with NSCLC.Patients and Methods: Data from three National Cancer Institute of Canada Clinical Trials Group trials were included in the analyses (n=1987). JBR.10 was a randomized study of post-resection adjuvant vinorelbine/cisplatin versus observation in stage IB/II NSCLC. BR.18 was a randomized study of paclitaxel/carboplatin ± the metalloproteinase inhibitor BMS-275291 in advanced NSCLC (1st line). BR.21 was a randomized study of erlotinib versus placebo in previously treated (2nd or 3rd line) NSCLC. The relationship between VTE, cancer treatment, concomitant medications, and baseline patient characteristics was explored with univariate and multivariate analysis. Cox regression analysis was performed to determine whether VTE was independently associated with survival. Each trial was analyzed separately; in addition a pooled analysis was performed with the advanced disease trials (BR.18 and BR.21).Results: The incidence of VTE was 0% in the observation arm of JBR.10 and ranged from 3% in the adjuvant chemotherapy arm of JBR.10 to 8% in BR.18. In JBR.10, VTE was independently associated with the administration of adjuvant chemotherapy (p=0.015), baseline obesity (p=.001), and low platelet count (p=.007). For patients with advanced NSCLC, VTE was significantly more common in patients receiving chemotherapy (BR.18) compared to patients receiving erlotinib or placebo (BR.21) (8% vs 2%, p< 0.0001). In BR.18, but not BR.21, VTE was associated with a prior history of VTE (p=0.001). When BR.18 and BR.21 were pooled, prior VTE remained significant. In BR.18 and BR.21, VTE was associated with shorter survival in multivariate analysis (HR=1.69, 95%CI 1.32–2.17, p<.0001); further analyses, including JBR.10, are planned to explore this finding.Conclusion: VTE is a frequent event in patients with advanced NSCLC and is associated with the administration of chemotherapy. Treatment with metalloproteinase or epidermal growth factor inhibitors does not appear to increase the risk of VTE. In early NSCLC, adjuvant chemotherapy, morbid obesity and a prior history of VTE are associated with increased risk. VTE is associated with shortened survival in patients with advanced NSCLC. Funding for this study was provided by the Canadian Cancer Society.

O-96 Accelerated E-CMF (accE-CMF) chemotherapy with pegfilgrastim support in early stage breast cancer is associated with low incidence of severe lymphopenia

Prediction of response to anthracycline-based therapy for breast cancer is challenging. We aimed to assess the value of HER2 and TOP2A as predictive markers of response to anthracycline-based adjuvant therapy in patients with early breast cancer.We did a meta-analysis of individual patient data from five randomised adjuvant trials that compared anthracycline-based regimens with cyclophosphamide, methotrexate, and fluorouracil (CMF) regimens. We assessed the status of HER2 and TOP2A genes with fluorescent in-situ hybridisation. Tumour samples were submitted to an external laboratory for validation. We calculated hazard ratios (HR) to compare event-free survival (EFS) and overall survival in patients receiving anthracycline-based treatment with those receiving CMF in two HER2 cohorts (HER2 amplified and non-amplified tumours) and in three TOP2A cohorts (normal, amplified, and deleted tumours).We analysed data for 3452 patients for HER2 and 3102 patients for TOP2A. For EFS, HRs were 0·89 (95% CI 0·79–1·01) for HER2 non-amplified patients and 0·71 (0·58–0·86) for HER2-amplified patients (pinteraction=0·0485); for overall survival, HRs were 0·91 (95% CI 0·79–1·05) for HER2 non-amplified patients and 0·73 (0·59–0·89) for HER2-amplified patients (pinteraction=0·0718). In analysis of TOP2A status, HRs for EFS were 0·88 (0·78–1·00) for normal, 0·63 (0·46–0·87) for deleted, and 0·62 (0·43–0·90) for amplified (pinteraction=0·0513); HRs for overall survival were 0·89 (0·78–1·03) for normal, 0·68 (0·49–0·95) for deleted, and 0·67 (0·46–0·98) for amplified (pinteraction=0·1608). When patients with TOP2A-deleted and TOP2A-amplified tumours were grouped together (altered cohort) and compared with data from patients with normal TOP2A tumours, HRs for EFS were 0·64 (0·50–0·81) for altered and 0·88 (0·78–1·00) for normal (pinteraction=0·0183); HRs for overall survival were 0·67 (0·52–0·86) for altered and 0·89 (0·78–1·03) for normal (pinteraction=0·0455).Although HER2 amplification and combined TOP2A amplification and deletion may have some value in the prediction of responsiveness to anthracycline-based chemotherapy, our findings do not support the use of anthracyclines only in patients with HER2-amplified or TOP2A-aberrated tumours.Associazione Italiana Ricerca Cancro, Academy of Finland, Belgian Federation Against Cancer, Cancer Research UK, Les Amis de l'Institut Bordet, Scottish Breast Cancer Trials Group, NCIC Clinical Trials Group, Canadian Cancer Society Research Institute, Danish Council for Strategic Research, Pharmacia-Upjohn (now Pfizer), and Abbott Laboratories.

Effectiveness of a self-administered, home-based exercise rehabilitation program for women following a modified radical mastectomy and axillary node dissection: a preliminary study

This pilot study examined the effects of a self-administered, home-based exercise (HBE) rehabilitation programme designed to help women regain shoulder mobility immediately following surgery for a modified radical mastectomy and axillary node dissection. Twenty-seven women who were scheduled for surgery were randomly assigned to either a post-surgical experimental HBE rehabilitation group (n = 16) or a usual care group (UC; n = 11). Women assigned to the HBE group followed an 11 day (days 3-14 post-surgery), home-based rehabilitation programme consisting of shoulder flexibility and stretching exercises that were described on videotape. The videotape programme was modelled after the exercises and guidelines described in a brochure produced by the Canadian Cancer Society. As a result of the exercise programme intervention, there was a time x group interaction indicating that the HBE group demonstrated a significantly greater increase in shoulder flexion range of motion (ROM) (p = 0.003) and abduction ROM (p = 0.036) when compared to the UC. There were no statistical differences in shoulder strength between groups over time. External rotation (p = 0.036) and grip strength (p = 0.001) significantly increased in both groups during the intervention period but there were no interaction effects. With respect to the forearm circumferences, there was a significant decrease over time (p < 0.001) but no interaction between groups. This HBE rehabilitation programme is an effective way to improve shoulder mobility and ROM during the immediate 2-week recovery period following surgery.

Randomized phase II study of maintenance vandetanib (ZD6474) in small cell lung cancer (SCLC) patients who have a complete or partial response to induction therapy: NCIC CTG BR.20

7522 Background: Vandetanib (V) is an inhibitor of vascular endothelial and epidermal growth factor receptors. This trial sought to determine whether maintenance V, given after standard chemotherapy (CT) and radiation (RT), prolonged progression-free survival (PFS) in responding patients with SCLC. Secondary endpoints: overall survival (OS) and toxicity. Methods: Phase II randomized, study of V 300 mg PO daily or placebo (P). Eligibility: complete (CR) or partial response (PR) to platinum-based CT, ECOG PS 0–2 and completion of RT (thoracic or prophylactic cranial). Statistics: 80% power to detect a 2.5 months improvement in median PFS (estimate for P of 4 months) using a 1-sided 10% level test (100 eligible patients; 77 events). Results: Between May 2003 and March 2006, 107 patients were accrued from 17 centres. Median follow up: 13.5 months. 46 had limited disease (LD); 61 extensive disease (ED). There were fewer PS 0 patients (11 vs. 20), and fewer had CR to initial CT (4 vs. 8) in the V arm. V patients were more likely to experience toxicity and require dose modification. The most frequent toxicities leading to dose modifications were gastrointestinal and rash. Clinically asymptomatic QTc prolongation was observed in 8 V patients. 83 of 107 patients developed progressive disease (43 on V; 40 on P). The median PFS for V was 2.7 months (80% C.I.: 1.1 –4.5) and 2.8 months for P (80% C.I.: 1.9 –5.6); estimated hazard ratio (HR) was 1.01 for V vs P (80% C.I.: 0.75 –1.36, 1-sided P-value = 0.51). Median OS for V was 10.6 months vs. 11.9 months for P; HR was 1.43 for V vs. P (80% C.I.: 1.00 –2.05, 1-sided P-value = 0.90). In a planned subgroup analysis, a significant interaction was noted (P-value = 0.01); with LD patients randomized to V having a longer OS (HR: 0.45, 1-sided P-value = 0.07), whereas ED patients randomized to V had a shorter OS compared to P (HR: 2.27, 1-sided P-value = 0.996). Conclusion: V failed to demonstrate efficacy as maintenance therapy for SCLC. Future targeted therapies should probably be explored concurrently with chemotherapy. This study was supported by the Canadian Cancer Society and AstraZeneca. [Table: see text]

A phase III adjuvant trial of sequenced EC + filgrastim + epoetin-alpha followed by paclitaxel compared to sequenced AC followed by paclitaxel compared to CEF in women with node-positive or high-risk node-negative breast cancer (NCIC CTG MA.21)

550 Background: CEF and AC followed by paclitaxel (AC/T) are commonly used adjuvant regimens in women with early breast cancer. In a trial conducted by the EORTC, NCIC CTG, and SAKK three months of dose-dense EC was equivalent to six months of CEF in women with locally advanced breast cancer. We hypothesized that three months of a taxane following dose-dense EC would be superior to CEF alone or AC/T. The results of a planned interim analysis were presented in San Antonio 2006 (Abstract #53). We now present more detailed results on efficacy and toxicity. Methods: Women 60 years of age or younger, with axillary node positive or high risk node negative breast cancer were randomized to CEF, EC/T or AC/T for six months. Results: Between December 2000 and April 2005, 2104 patients were enrolled. The median follow-up is 30.4 months. Hazard ratios for recurrence are: AC/T vs. CEF, 1.49 (95% CI, 1.12–1.99), p=0.005; AC/T vs. EC/T, 1.68 (95% CI, 1.25–2.27), p=0.0006; and EC/T vs. CEF, 0.89 (95% CI, 0.64–1.22), p=0.46. Three year recurrence-free survival rates for CEF, EC/T, and AC/T are 90.1, 89.5 and 85.0%, respectively. There was no significant interaction between ER status and treatment. Multivariate analysis of predictive factors will be presented. The numbers of deaths are 50 (CEF), 47 (EC/T) and 65 (AC/T). There was more toxicity in CEF and EC/T compared to AC/T. Conclusion: AC/T given every three weeks, although less toxic is significantly inferior to CEF or EC/T in terms of relapse-free survival. It is too early to detect any difference between CEF and dose-dense EC/T. Our results indicate that there is still room to explore anthracycline and taxane adjuvant chemotherapy regimens. Supported by: NCI Canada and Canadian Cancer Society, Pfizer, Bristol-Myers Squibb, Amgen, Janssen Ortho, Ortho Biotech, and NCI US. [Table: see text] No significant financial relationships to disclose.

Integrating Public Health Policy, Practice, Evaluation, Surveillance, and Research: The School Health Action Planning and Evaluation System

The Canadian Cancer Society and the National Cancer Institute of Canada have charged their Centre for Behavioral Research and Program Evaluation with contributing to the development of the country's systemic capacity to link research, policy, and practice related to population-level interventions. Local data collection and feedback systems are integral to this capacity. Canada's School Health Action Planning and Evaluation System (SHAPES) allows data to be collected from all of a school's students, and these data are used to produce computer-generated school "health profiles." SHAPES is being used for intervention planning, evaluation, surveillance, and research across Canada. Strong demand and multipartner investment suggest that SHAPES is adding value in all of these domains. Such systems can contribute substantially to evidence-informed public health practice, public engagement, participatory action research, and relevant, timely population intervention research.

The Canadian Study of Diet, Lifestyle, and Health: Design and characteristics of a new cohort study of cancer risk

Background: We have established a new cohort study, the Canadian Study of Diet, Lifestyle, and Health, to investigate the relationship between diet, lifestyle factors, molecular markers, and cancer incidence in Canada. Methods: The cohort was established predominantly by recruiting alumni from the Universities of Alberta, Toronto, and Western Ontario between 1995 and 1998, but also includes a small contingent recruited mostly in 1992 through the Canadian Cancer Society. Participants completed baseline lifestyle and food frequency questionnaires, measured waist and hip circumferences, and provided hair and toenail specimens. Results: Seventy-three thousand nine hundred and nine individuals (34,291 males and 39,618 females) were recruited, with representation from all Canadian provinces and territories; 97% provided biological specimens. The mean (S.D.) ages of the male and female participants at recruitment were 51.6 (15.6) and 46.1 (15.2) years, respectively. Data from a random sample of the study subjects at baseline show that approximately one-half of the males and one-third of the females were overweight (BMI ≥ 25 kg/m 2), and approximately one-quarter of all participants reported that they walked at least 4 h/week. Mean (S.D.) daily caloric intake was 2341 (697) kcal for males and 2091 (612) kcal for females. Conclusions: Given the rich repository of questionnaire and biological data, and an average follow-up time for cohort members of 10.4 years, the study is poised to make a major Canadian contribution towards understanding the roles of diet, lifestyle factors, and molecular markers in influencing cancer risk.

Effect of the Women's Health Initiative Study Publication on Hormone Replacement Therapy Use among Women Who Have Undergone BRCA1/2 Testing

Since the publication, in July 2002, of the Women's Health Initiative (WHI) study, use of hormone replacement therapy (HRT) has decreased substantially in the general population. However, little is known about the effect of WHI study results on HRT use among women at high risk of breast cancer. The purpose of this study is to compare HRT use, prepublication versus postpublication of the WHI study, among women tested for BRCA1/2 mutations. Participants were >35 years of age and had received their result of genetic testing (delivered within the interdisciplinary research program Interdisciplinary Health Research International Team on Breast Cancer Susceptibility), no later than February 28, 2005. HRT use was reported in self-administered questionnaires, 1 year after result disclosure. Women returning their questionnaire before July 17, 2002 were classified as pre-WHI, whereas those returning it after October 15, 2002 comprised the post-WHI group. Four hundred fifty-seven women (199 and 258 in the pre-WIH and post-WHI groups, respectively) were included in this analysis. Globally, there was no difference in HRT use between prepublication and postpublication of the WHI study (8% and 11%, respectively; prevalence ratio, 0.74; 95% confidence interval, 0.43-1.28). However, noncarriers of the familial mutation were less likely to use HRT after publication of the WHI study results (9%) than before (21%; P = 0.03). Overall, HRT use among women tested for BRCA1/2 mutations is relatively low and apparently uninfluenced by the WHI study findings. However, the HRT use reduction among noncarriers is similar to that of women in the general population and consistent with the Canadian Cancer Society's recent HRT use recommendations.