Cancer In Ontario Research Articles

Updated breast cancer costs for women by disease stage and phase of care using population-based databases.

This study assessed health care system costs and resource utilization for adult women with breast cancer in Ontario, Canada. The goal was to update costs by stage, age, and phase of care from a health care system perspective. A retrospective analysis was conducted using linked population-based administrative data. The study included women diagnosed with breast cancer from 2017 to 2021, with follow-up data until 2022. Cases were matched with controls in a 1:5 ratio using birth year, local health integrative network, income quintile, and resource utilization band at baseline. Incremental costs were estimated using linear regression. The modified income quintile was the neighbourhood- or area-level income quintile. Among the 37,133 cases matched with 185,665 controls, the average age at diagnosis was 62 years. For the entire study duration, cases incurred an additional cost of $27,485 per year, compared with controls. Costs rose with disease severity, ranging from $15,588 for stage I to $137,319 for stage IV. The highest incremental costs occurred during the first 12 months after diagnosis (initial: $43,408), followed by the last 12 months before death (terminal: $25,940), and then interim years (continuous: $9,533 per year). Additionally, the incremental cost of breast cancer was higher when diagnosis was before age 70 ($28,415), compared with diagnosis at age 70 and older ($25,254). The findings align with previous studies on breast cancer costs for the health care system. Additionally, variations in costs based on disease severity, care phase, and age were emphasized, highlighting higher costs for metastatic breast cancer cases, women younger than 70 years, and the initial 12 months following diagnosis.

Emergency department use before cancer diagnosis in Ontario, Canada: a population-based study.

Although suspicions of cancer may be raised in patients who visit the emergency department, little is known about emergency department use before a cancer diagnosis. We sought to describe emergency department use among patients in Ontario within the 90 days before confirmed cancer diagnosis and to evaluate factors associated with this emergency department use. We conducted a retrospective, population-based study of patients aged 18 years or older who had a confirmed cancer diagnosis in Ontario from 2014 to 2021 using linked administrative databases. The primary outcome was any emergency department visit within 90 days before the cancer diagnosis date. We used multivariable logistic regression to evaluate factors associated with emergency department use, such as demographics (e.g., age, sex, rurality, Ontario Health region, indicators of marginalization), comorbidities, previous emergency department visits and hospital admissions, continuity of primary care, type of cancer, and year of cancer diagnosis. We included 651 071 patients with cancer. Of these, 229 683 (35.3%) had an emergency department visit within 90 days before diagnosis, 51.4% of whom were admitted to hospital from the emergency department. Factors associated with increased odds of emergency department use before cancer diagnosis included rurality (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.13-1.17), residence in northern Ontario (North East region OR 1.14, 95% CI 1.10-1.17 and North West region OR 1.27, 95% CI 1.21-1.32, v. Toronto region), and living in the most marginalized areas (material resources OR 1.37, 95% CI 1.35-1.40 and housing OR 1.09, 95% CI 1.06-1.11, v. least marginalized quintile). We observed significant variation in emergency department use by cancer type, with high odds of emergency department use among patients with intracranial, pancreatic, liver or gallbladder, or thoracic cancer. Emergency department use is common before cancer diagnosis, with about one-third of patients with cancer in Ontario using the emergency department before diagnosis. Understanding why patients visit the emergency department before cancer diagnosis is important, particularly for patients who live in rural or marginalized areas, or those who have specific cancer types.

Evaluating trends in radical prostatectomy approach and 30-day complication rate in Ontario from 2010-2019.

Radical prostatectomy (RP) for prostate cancer has changed over the years with the advent of minimally invasive (MIRP) approaches, which includes robotic-assisted RP (RARP). The MIRP approaches have been shown to reduce complication rate, but there remain barriers to adoption. The objective of this study was to quantitatively describe the trend in the RP approach in Ontario, and to assess the trend in complication rates. We conducted a population-based, retrospective cohort study including all men who underwent RP for prostate cancer in Ontario from 2010-2019. We used administrative data from Ontario's health databases to gather surgical outcome data. Our primary outcomes were the annualized frequency of RP by surgical approach and annualized 30-day composite complication rate. In total, 22 118 patients were included in the analysis over the study period. There was a trend away from retropubic (RRP) frequency over the study period (80.3% of cases in fiscal year [FY] 2010 to 55.6% in FY 2018) and towards RARP approach (6.8% of cases in FY 2010 and 36.7% in FY 2018). The most common complication was blood transfusion at 6.26%, which saw a downtrend over the study period (7.96% FY 2010, 3.47% FY 2018). The odds ratio for 30-day complication for open RP compared to MIRP was 1.74 (95% confidence interval 1.57-1.92, p<0.001). In Ontario, there has been a steady shift away from RRP and towards RARP. Minimally invasive approaches portend a significantly lower complication rate, likely driven by a lower blood transfusion rate.

Small bowel cancers: A population-based analysis of epidemiology, treatment and outcomes in Ontario, Canada from 2005-2020

IntroductionSmall bowel cancers are uncommon malignancies comprised of several histologies with variable treatments and prognoses. The current study describes the epidemiology, treatment, and outcomes of a large, population-based cohort of patients with small bowel cancers. MethodsWe performed a retrospective cohort study using linked administrative healthcare data from Ontario, Canada. Patients diagnosed with a small bowel cancer between 2005–2020 were included. Trends in incidence, treatments, and survival were explored by histology (adenocarcinoma, neuroendocrine tumors (NET), gastrointestinal stromal tumors (GIST), and lymphoma). ResultsA total of 5306 patients with small bowel cancers were identified. The most common histologies were NET (40.5 %) and adenocarcinoma (31.6 %). Over the study period the annual incidence of small bowel cancers increased from 1.54 to 2.78 per 100 000 and the likelihoods of receiving surgery and systemic therapy within one year of diagnosis both increased for all histologic subtypes except lymphoma. Median overall survival from diagnosis was 1.0 year for adenocarcinoma, 13.2 years for NET, 14.2 years for GIST, and 10.1 years for lymphoma. There was no trend towards improved median survival for adenocarcinoma by year of diagnosis; 0.94 years (2005–2010), 1.07 years (2011–2015), and 0.98 years (2016–2020). DiscussionSmall bowel cancers are increasing in incidence, with increasing use of surgery and systemic therapies. While survival is favourable for many small bowel cancers, it remains poor for adenocarcinoma. Better availability of cancer stage data and detailed histopathology within the database would facilitate future research. SynopsisThis study of small bowel cancer in Ontario from 2005 to 2020 demonstrated increasing incidence, use of surgery, and systemic treatments. The most common histologies are neuroendocrine tumors and adenocarcinoma, with median survivals of 13.2 and 1.0 years respectively.

423P Marginalization and factors associated with early mortality among patients diagnosed with de novo metastatic breast cancer in Ontario, Canada

423P Marginalization and factors associated with early mortality among patients diagnosed with de novo metastatic breast cancer in Ontario, Canada

Associations of CD4 Cell Count Measures With Infection-Related and Infection-Unrelated Cancer Risk Among People With HIV.

People with HIV are at higher risk of infection-related cancers than the general population, which could be due, in part, to immune dysfunction. Our objective was to examine associations between 4 CD4 count measures as indicators of immune function and infection-related and infection-unrelated cancer risk. We conducted a cohort study of adults with HIV who were diagnosed with cancer in Ontario, Canada. Incident cancers were identified from January 1, 1997 to December 31, 2020. We estimated adjusted hazard ratios (aHR) for the associations between CD4 measures (baseline CD4, nadir CD4, time-updated CD4, time-updated CD4:CD8) and cancer incidence rates using competing risk analyses, adjusted for socio-demographic factors, history of hepatitis B or C infection, baseline viral load, smoking, and alcohol use. Among 4771 people with HIV, contributing 59,111 person-years of observation, a total of 549 cancers were observed. Low baseline CD4 (<200 cells/µL) (aHR 2.08 [95% CI: 1.38 to 3.13], nadir (<200 cells/µL) (aHR 2.01 [95% CI: 1.49 to 2.71]), low time-updated CD4 (aHR 3.52 [95% CI: 2.36 to 5.24]) and time-updated CD4:CD8 ratio (<0.4) (aHR 2.02 [95% CI: 1.08 to 3.79]) were associated with an increased rate of infection-related cancer. No associations were observed for infection-unrelated cancers. Low CD4 counts and indices were associated with increased rates of infection-related cancers among people with HIV, irrespective of the CD4 measure used. Early diagnosis and linkage to care and high antiretroviral therapy uptake may lead to improved immune function and could add to cancer prevention strategies such as screening and vaccine uptake.

Patterns of Survivorship Follow-Up Care Among Patients With Breast Cancer: A Retrospective Population-Based Cohort Study in Ontario, Canada, Between 2006 and 2016.

Many cancer survivors have ongoing follow-up with their oncologist(s), despite evidence that this care can be competently managed by primary care and transitioning well survivors could relieve growing pressure on cancer care systems. We analyzed population-based administrative data from Ontario, Canada, to examine rates of transition to primary care-led follow-up care during the survivorship phase, including clinical and demographic predictors associated with being transitioned. We conducted a retrospective cohort study to describe the patterns of survivorship follow-up care among all patients with breast cancer in Ontario from 2006 to 2016. Data were derived from the Ontario Cancer Registry and other linked data sets. We defined the survivorship phase of care beginning at 2 years after initial diagnosis. Logistic regression was used to explore factors potentially prognostic of no oncology visits in each of the years after survivorship. Our survivorship cohort was composed of 71,719 patients with breast cancer, 42% of whom were considered to have transitioned from oncology to primary care 2 years after diagnosis. Although the number of patients having oncology visits diminished over time, a quarter of the cohort continued being seen in year 5 of survivorship. Regression analysis found older age, early cancer stage, living farther from a cancer center, not receiving radiation or chemotherapy, and high well-being to be associated with transitioning to primary care. Our findings contribute to the development of low-risk profiles among survivors to inform optimal transition from oncology to primary care. Further research examining qualitative perspectives from oncologists, cancer survivors, and primary care is also required to illuminate other sentinel factors to be considered when transitioning during follow-up.

Residential exposure to ambient fine particulate matter (PM2.5) and nitrogen dioxide (NO2) and incident breast cancer among young women in Ontario, Canada

BackgroundAir pollution has been classified as a human carcinogen based largely on findings for respiratory cancers. Emerging, but limited, evidence suggests that it increases the risk of breast cancer, particularly among younger women. We characterized associations between residential exposure to ambient fine particulate matter (PM2.5) and nitrogen dioxide (NO2) and breast cancer. Analyses were performed using data collected in the Ontario Environmental Health Study (OEHS). MethodsThe OEHS, a population-based case-control study, identified incident cases of breast cancer in Ontario, Canada among women aged 18–45 between 2013 and 2015. A total of 465 pathologically confirmed primary breast cancer cases were identified from the Ontario Cancer Registry, while 242 population-based controls were recruited using random-digit dialing. Self-reported questionnaires were used to collect risk factor data and residential histories. Land-use regression and remote-sensing estimates of NO2 and PM2.5, respectively, were assigned to the residential addresses at interview, five years earlier, and at menarche. Logistic regression was used to estimate odds ratios (OR) and their 95 % confidence intervals (CI) in relation to an interquartile range (IQR) increase in air pollution, adjusting for possible confounders. ResultsPM2.5 and NO2 were positively correlated with each other (r = 0.57). An IQR increase of PM2.5 (1.9 µg/m3) and NO2 (6.6 ppb) at interview residence were associated with higher odds of breast cancer and the adjusted ORs and 95 % CIs were 1.37 (95 % CI = 0.98–1.91) and 2.33 (95 % CI = 1.53–3.53), respectively. An increased odds of breast cancer was observed with an IQR increase in NO2 at residence five years earlier (OR = 2.16, 95 % CI: 1.41–3.31), while no association was observed with PM2.5 (OR = 0.96, 95 % CI 0.64–1.42). ConclusionsOur findings support the hypothesis that exposure to ambient air pollution, especially those from traffic sources (i.e., NO2), increases the risk of breast cancer in young women.

Trends and outcomes in patients receiving neoadjuvant chemotherapy for breast cancer in Ontario: A population-based study.

e12664 Background: Modern neoadjuvant chemotherapy (NAC) regimens in breast cancer offer higher rates of pathologic complete response, an ability to guide further adjuvant treatment, and may de-escalate surgery. However, the utilization of NAC has been heterogeneous in Ontario. This study aimed to describe trends in NAC use in Ontario, report survival outcomes, and explore factors associated with overall survival in these patients. Methods: This was a population-based cohort study using linked health administrative data in Ontario, Canada. From the Ontario Cancer Registry, we identified women ≥18 years who underwent neoadjuvant chemotherapy followed by surgery for operable (cT1N1, cT2-3N0, or cT2-3N1) breast cancer between 2012 and 2020. Patients were divided by receptor subtype (triple negative breast cancer [TNBC], ER+/HER2-, ER+/HER2+, ER-/HER2+) and characteristics were compared using standardized mean differences (SMDs). Five-year overall survival (OS) and breast cancer-specific survival (BCSS) were determined and reported for each subtype. Associations with OS and BCSS were calculated for patient and disease characteristics using univariate and multivariable Cox proportional hazards models and Fine and Gray models, respectively. Results: 3,804 women underwent NAC for cT1N1, cT2-3N0, or cT2-3N1 breast cancer in Ontario between 2012 and 2020. The largest contributing subtype was ER+/HER2- patients (39.3%) followed by those with HER2+ disease (ER-/HER2+ 13.8%, ER+/HER2+ 23.4%), and TNBC (23.5%). The median age was 50 years (IQR 42-59 years). Most patients were clinically node-positive (2,736; 71.9%), and underwent mastectomy (2,397; 63.0%). There was a significant increase in the number of patients receiving NAC in Ontario, from 217 in 2012 to 667 in 2019 ( p&lt;0.001), with a greater increase among patients with TNBC or HER2+ disease. Compared to those with ER+/HER2- disease, TNBC patients were treated for smaller tumours (28.6% T3 vs. 39.8%; SMD = 0.24), and were more likely to be node-negative (39.1% N0 vs. 22.1%; SMD = 0.38). Similar trends for nodal status were found for patients with ER-/HER2+ (26.7% N0) and ER+/HER2+ cancer (27.9% N0). 5-year OS for the entire cohort was 88.1% (95% CI 87.1 – 89.2%). Survival was highest for ER+/HER2+ patients (94.2%, 95% CI 92.6 – 95.8%) and lowest for TNBC patients (80.1%, 95% CI 77.5 – 82.8%). Similar patterns were seen for BCSS. Factors associated with OS in a multivariable model included older age (increase in 5 years HR 1.1, 95% CI 1.07 – 1.14), N1 status (HR 1.99, 95% CI 1.61 – 2.47), larger tumour size (T3 HR 1.83, 95% CI 1.34 – 2.5), mastectomy (HR 1.45, 95% CI 1.2 – 1.75), and TNBC (versus ER+/HER2- HR 1.9, 95% CI 1.56 – 2.32). Conclusions: The use of NAC has increased in Ontario, particularly among TNBC and HER2+ patients. Women with TNBC have worse outcomes compared to those with ER+/HER2- disease, despite being treated for less advanced disease.

The impact of the Ontario quality-based procedures funding model on radical prostatectomy outcomes.

In 2015, radical prostatectomy (RP) in Ontario transitioned to the quality-based procedures (QBP) funding model, which assigns disbursement from surgical quality indicator (QI) outcome performance. The objective of this study was to assess the QBP QI outcomes before and after implementation of the QBP funding model for RP, and to determine whether changes seen were attributable to the QBP model. We conducted a population-based, retrospective cohort study including all men who underwent RP for prostate cancer in Ontario from 2010-2019. We used administrative data from Ontario's health databases to gather surgical and QI outcome data. Our primary outcomes were the five measurable QBP QIs outlined by the province. We performed a pre- and post-intervention comparison, in addition to an interrupted-time series (ITS) analysis. Two of the five QIs improved after implementation of the QBP model (complication rate: 11.89% vs. 9.96%, p<0.001; proportion meeting length of stay target: 78.11% vs. 86.84%, p<0.001). ITS analysis revealed that there was no difference in trend in either outcome between pre- and post-implementation periods (p=0.913 and p=0.249, respectively). Two QIs were worse in the post-implementation period (unplanned visit rate: 23.45% vs. 25%, p=0.015; proportion meeting Wait 2 target: 94.39% vs. 92.88%, p<0.001). ITS revealed no significant trend changes post-implementation (p=0.260 and p=0.272, respectively). There was no difference in re-operation rate (2.84% vs. 2.45%, p=0.107). The QBP model for RP corresponds with mixed QI changes, but further analysis suggests that these changes were pre-existing trends and not attributable to the model.

Wait times and breast cancer survival: a population-based retrospective cohort study using CanIMPACT data.

The time from breast cancer surgery to chemotherapy has been shown to affect survival outcomes; however, the effect of time from first breast cancer-related healthcare contact to first cancer specialist consultation, or the time from first breast cancer-related healthcare contact to adjuvant chemotherapy on survival has not been well explored. We aimed to determine whether various wait times along the breast cancer treatment pathway (contact-to-consultation, contact-to-chemotherapy, surgery-to-chemotherapy) were associated with overall survival in women within the Canadian province of Ontario. We performed a population-based retrospective cohort study of women diagnosed with stage I-III breast cancer in Ontario between 2007 and 2011 who received surgery and adjuvant chemotherapy. This was the Ontario cohort of a larger, nationwide study (the Canadian Team to improve Community-Based Cancer Care along the Continuum - CanIMPACT). We used Cox-proportional hazards regression to determine the association between the contact-to-consultation, contact-to-chemotherapy, and surgery-to-chemotherapy intervals and overall survival while adjusting for cancer stage, age, comorbidity, neighborhood income, immigration status, surgery type, and method of cancer detection. Among 12,782 breast cancer patients, longer surgery-to-chemotherapy intervals (HR 1.13, 95% CI 1.03-1.18 per 30-day increase), but not the contact-to-consultation (HR 0.979, 95% CI 0.95-1.01 per 30-day increase), nor the more comprehensive contact-to-chemotherapy intervals (HR 1.00, 95% CI 0.98-1.02 per 30-day increase) were associated with decreased survival in our adjusted analyses. Our findings emphasize the prognostic importance of a shorter surgery-to-chemotherapy interval, whereas the contact-to-consultation and contact-to-chemotherapy intervals have less impact on survival outcomes.

Stage of diagnosis and survival for prostate cancer among immigrant men in Ontario, Canada

IntroductionWe previously identified specific immigrant groups (West African and Caribbean) with increased incidence of prostate cancer in Ontario, Canada. In this population-level retrospective cohort study, we used administrative databases to compare stage of diagnosis, 5-year overall survival and prostate cancer-specific survival for immigrants versus long-term residents of Ontario. MethodsWe linked several provincial-level databases available at ICES, an independent, non-profit research institute. We included all male Ontario residents 20–105 years of age who had an incident prostate cancer diagnosis date between March 31, 2008 and March 31, 2017, stratified into immigrants vs. long-term residents. We used multivariable logistic regression to determine the odds of early (stage I-II) vs. late (III-IV) stage of diagnosis, adjusting for age, co-morbidities, neighbourhood income and continuity of care. We produced Kaplan-Meier curves for 5-year overall survival and for 5-year prostate cancer-specific survival. ResultsCompared to long-term residents, men from West Africa (adjusted odds ratio 1.66 [95% CI 1.16–2.38], East Africa (AOR 1.54 [95% CI 1.02–2.33]) and the Caribbean (AOR 1.22 [95% CI 1.01–1.47]) had a diagnostic stage advantage, and men from South Asia were most likely to be diagnosed at a late stage. In both unadjusted and adjusted analyses, overall and prostate cancer-specific survival were higher for immigrants than long-term residents. The highest five-year overall survival was seen for men from Sub-Saharan Africa and the Caribbean, and the lowest was seen for South Asian men, where 11.7% died within five years of diagnosis. ConclusionImmigrant men in Ontario with prostate cancer are more likely to be diagnosed at an early stage and to survive for 5 years than long-term residents. Among immigrant men, men from the Caribbean and Sub-Saharan Africa have the greatest stage and survival advantage and South Asian men the least. Differences in awareness, diagnostic suspicion, genetic predisposition, and social factors may play a role in these findings.

Longitudinal adherence to surveillance for late effects of cancer treatment: a population-based study of adult survivors of childhood cancer.

Adult survivors of childhood cancer are at elevated risk of morbidity and mortality compared to the general population, but their adherence to lifelong periodic surveillance is suboptimal. We aimed to examine adherence to surveillance guidelines for high-yield tests and identify risk factors for nonadherence in adult survivors of childhood cancer. In this retrospective, population-based cohort study, we used health care administrative data from Ontario, Canada, to identify adult survivors of childhood cancer diagnosed between 1986 and 2014 who were at elevated risk of therapy-related colorectal cancer, breast cancer, or cardiomyopathy. Using a Poisson regression framework, we assessed longitudinal adherence and predictors of adherence to the Children's Oncology Group surveillance guideline. Among 3241 survivors, 327 (10%), 234 (7%), and 3205 (99%) were at elevated risk for colorectal cancer, breast cancer, and cardiomyopathy, respectively. Within these cohorts, only 13%, 6%, and 53% were adherent to recommended surveillance as of February 2020. During a median follow-up of 7.8 years, the proportion of time spent adherent was 14% among survivors at elevated risk for colorectal cancer, 10% for breast cancer, and 43% for cardiomyopathy. Significant predictors of adherence varied across the risk groups, but higher comorbidity was associated with adherence to recommended surveillance. Survivors of childhood cancer in Ontario are rarely up to date for recommended surveillance tests. Tailored interventions beyond specialized clinics are needed to improve surveillance adherence.

Protocol for the ONLOOP trial: pragmatic randomized trial evaluating a province-wide system of personalized reminders for evidence-based surveillance tests in adult survivors of childhood cancer in Ontario

BackgroundChildhood cancer treatment while often curative, leads to elevated risks of morbidity and mortality. Survivors require lifelong periodic surveillance for late effects of treatment, yet adherence to guideline-recommended tests is suboptimal. We created ONLOOP to provide adult survivors of childhood cancer with detailed health information, including summaries of their childhood cancer treatment and recommended surveillance tests for early detection of cardiomyopathy, breast cancer, and/or colorectal cancer, with personalized reminders over time.MethodsThis is an individually randomized, registry-based pragmatic trial with an embedded process and economic evaluation to understand ONLOOP’s impact and whether it can be readily implemented at scale. All adult survivors of childhood cancer in Ontario overdue for guideline-recommended tests will be randomly assigned to one of two arms: (1) intervention or (2) delayed intervention. A letter of information and invitation will detail the ONLOOP program. Those who sign up will receive a personalized toolkit and a screening reminder 6 months later. With the participants’ consent, ONLOOP will also send their primary care clinician a letter detailing the recommended tests and a reminder 6 months later.The primary outcome will be the proportion of survivors who complete one or more of the guideline-recommended cardiac, breast, or colon surveillance tests during the 12 months after randomization. Data will be obtained from administrative databases. The intent-to-treat principle will be followed. Based on our analyses of administrative data, we anticipate allocating at least 862 individuals to each trial arm, providing 90% power to detect an absolute increase of 6% in targeted surveillance tests completed. We will interview childhood cancer survivors and family physicians in an embedded process evaluation to examine why and how ONLOOP achieved success or failed. A cost-effectiveness evaluation will be performed.DiscussionThe results of this study will determine if ONLOOP is effective at helping adult survivors of childhood cancer complete their recommended surveillance tests. This study will also inform ongoing provincial programs for this high-risk population.Trial registrationClinicalTrials.gov NCT05832138.

Factors Associated With Adolescent and Young Adult Females Attending a Fertility Consultation Within 30 Days of a Cancer Diagnosis in Ontario, Canada.

Purpose: To examine the factors associated with females attending a fertility consultation within 30 days of cancer diagnosis. Methods: This is a retrospective cohort study, including females, 15 to 39 years of age, diagnosed with cancer in Ontario, Canada. Administrative data were used from the Institute of Clinical and Evaluative Sciences for the period 2006 to 2019. A backward selection multivariate logistic regression was performed, with a primary outcome of fertility consultation within 30 days of diagnosis. Results: A total of 20,556 females were included in the study, with 7% having attended a fertility visit within 30 days of diagnosis. Factors associated with being more likely to attend included: not currently having children (odds ratio [OR] = 4.3; confidence interval [95% CI 3.6-5.1]), later years of diagnosis (OR = 3.2; 95% CI [2.8-3.8]), having undergone chemotherapy (OR = 3.6; 95% CI [3.0-4.3]) or radiation therapy (OR = 1.9; 95% CI [1.6-2.2]), and less marginalization within dependency quintiles (OR 1.4; 95% CI [1.1-1.7]). Having a cancer with lower risk to fertility (OR = 0.3; 95% CI [0.2-0.3]), death within a year of diagnosis (OR = 0.4; 95% CI [0.3-0.6]), and residing in a northern region of Ontario (OR = 0.3; 95% CI [0.2-0.4]) were associated with being less likely to attend. For sociodemographic factors, lower levels of income (OR = 0.5; 95% CI [0.4-0.6]) and marginalization with residential instability (OR = 0.6; 95% CI [0.5-0.8]) were associated with being less likely to attend a fertility consultation. Conclusions: Rates for attendance of female fertility consultations after a cancer diagnosis remain low, with disparities by both clinical and demographic factors.

First-line Palliative Chemotherapy for Colorectal Cancer: a Population-based Analysis of Delivery and Outcomes in a Single-payer Health System

AimsClinical practice guidelines recommend palliative chemotherapy for most patients with metastatic colorectal cancer. However, outcomes observed in the real world compared with patients enrolled in clinical trials have not been sufficiently described. The objective of this study was to evaluate the delivery and outcomes of first-line palliative chemotherapy administered to patients with colorectal cancer in routine clinical practice compared with clinical trials. Materials and methodsUsing linked health administrative data, we carried out a retrospective population-level cohort study on patients diagnosed with colorectal cancer in Ontario, Canada from 2010 to 2019. Patient, disease and treatment characteristics were summarised. The primary outcome was median overall survival, stratified by treatment prescribed and age. Demographics and outcomes in this real-world population were compared with those from pivotal clinical trials. A multivariable Cox regression model reporting hazard ratios and 95% confidence intervals was used to determine factors associated with survival in patients receiving systemic treatment. ResultsWe identified 70 987 patients with a new diagnosis of colorectal cancer, of which 4613 received first-line chemotherapy for unresectable locally advanced or metastatic disease and formed the study cohort. Fifty-eight per cent were male and the mean age was 63 years. Most had colon cancer (69%), at least one comorbidity (73%) and lived in an urban location (79%). Less than half (47%) had surgery after diagnosis. The most common regimen prescribed was folinic acid, 5-fluorouracil and irinotecan (FOLFIRI) with bevacizumab or epidermal growth factor receptor inhibitors (EGFRi; n = 2784, 60%). Among all treated patients, the median overall survival was 17.1 months, with survival difference by regimen [median overall survival 18.3 for FOLFIRI with bevacizumab or EGFRi, 19.6 for folinic acid, 5-fluorouracil and oxaliplatin (FOLFOX)/capecitabine, oxaliplatin (XELOX) with bevacizumab or EGFRi, 13.6 for FOLFIRI alone and 7.8 for 5-fluorouracil or capecitabine]. Patients aged >80 years were most likely to have received single-agent 5-fluorouracil or capecitabine, and had inferior overall survival compared with their younger counterparts. Compared with pivotal clinical trials, patients in the real world had inferior overall survival outcomes despite similar demographic characteristics (including age and sex). ConclusionsIn this real-world population-based analysis of patients receiving first-line chemotherapy for unresectable locally advanced or metastatic colorectal cancer, survival outcomes were inferior to those reported in randomised trials despite similarities in age and sex. This information can be used when counselling patients in routine practice about expected outcomes.

A Population-Based Analysis of the Management of Symptoms of Depression among Patients with Stage IV Non-Small Cell Lung Cancer in Ontario, Canada

A Population-Based Analysis of the Management of Symptoms of Depression among Patients with Stage IV Non-Small Cell Lung Cancer in Ontario, Canada

Palliative Care Among Lung Cancer Patients With and Without COPD: A Population-Based Cohort Study.

Lung cancer patients with chronic obstructive pulmonary disease (COPD) may have greater palliative care needs due to poor prognosis and symptom burden. We sought to compare the provision of timely palliative care and symptom burden by COPD status. We performed a retrospective, population-based cohort study of individuals diagnosed with lung cancer in Ontario, Canada (2009-2019) using health administrative databases and cancer registries. The impact of COPD on the probability of receiving palliative care was determined accounting for dying as a competing event, overall and stratified by stage. The provision of palliative care for patients with severe symptoms (Edmonton Symptom Assessment Scale score ≥ 7), location of the first palliative care visit and symptom severity were compared by COPD status. A total of 74,993 patients were included in the study (48% of patients had available symptom data). At the time of lung cancer diagnosis, 50% of patients had COPD. Stage I-III patients with COPD were more likely to receive palliative care (adjusted Hazard Ratio (HR)s: 1.05-1.31) with no difference for stage IV (1.02, 95% CI: 1.00-1.04). Despite having severe symptoms, very few patients with early-stage disease received palliative care (Stage I: COPD-23% vs. no COPD-18%, SMD=0.12). Most patients (84%) reported severe symptoms and COPD worsened symptom burden, especially among early-stage patients. COPD impacts the receipt of palliative care and symptom burden for patients with early-stage lung cancer. Many patients with severe symptoms did not receive palliative care, suggesting unmet needs among this vulnerable population.

QOL-24. FINANCIAL AID REQUESTS BY BRAIN TUMOR PATIENTS IN ONTARIO THROUGH GOFUNDME

Abstract Brain tumors affect individuals globally including Ontario residents. Numerous Ontario brain tumor patients suffer the unequal burden of responsibility to pay for treatments like oral chemotherapy. In addition to chemotherapy, patients and their families have other costs associated with their diagnosis. However, less is known about other direct and indirect financial costs due to their diagnosis. GoFundMe, an online fundraising platform, provides worldwide brain tumor patients the opportunity to raise money for financial assistance with costs associated with their diagnosis The purpose of this study was to analyze publicly-available data from GoFundMe, an online fundraising platform, to explore the financial needs of brain tumor patients across Ontario, unaware and/or unable to get assistance elsewhere. A qualitative descriptive design drawing on thematic analysis was used to analyze GoFundMe requests to support individuals diagnosed with brain cancer in Ontario between 2014 and 2021. A coding framework was created to determine emerging themes using qualitative data analysis software NVivo 10. A final sample of 154 requests described financial strain from the loss of income experienced by the patient and their caregivers to afford cancer treatments. Requests highlighted 1) an overall lack of awareness of how and where access financial aid and affordable psychosocial support; 2) concerns over the long-term financial well-being of bereaving family members; 3) A call for more public awareness of the financial burden and emotional distress experienced by of those impacted by brain cancer. These GoFundMe requests highlight a connection between financial burden and emotional distress and an overall lack of awareness of where/how to seek financial and emotional support. These results will serve as the foundation to advocate for and raise awareness of the financial assistance needed by brain tumor patients and their families.

Evaluating equity of access andpredictors of minimally invasive hysterectomy for endometrial and cervical cancer from 2000 to 2017 in Ontario, Canada: A population-based cohort study.

We sought to assess the uptake of minimally invasive hysterectomy among patients with endometrial and cervical cancer in Ontario, Canada, and assess the equity of access to minimally invasive surgery (MIS) by evaluating associations with patient, disease, institutional, and provider factors. This is a retrospective population-based cohort study of hysterectomy for endometrial and cervical cancer in Ontario (2000-2017). Surgical approach, clinicopathologic, sociodemographic, institutional, and provider factors were identified through administrative databases. Fisher's exact, χ2 , Wilcoxon rank sum, logistic regression, and Cox proportional hazards modeling were used to explore factors associated with MIS. A total of 27 652 patients were included. In total, 6199/24 264 (26%) endometrial and 842/3388 (25%) cervical cancer patients received MIS. The proportion of MIS to open surgeries increased from <0.1% in 2000 to over 55% in 2017 (odds ratio [OR] = 1.31, confidence interval [CI] = 1.28-1.34). Low-income quintile, rurality, low hospital volume, nonacademic hospital, nongynecologic oncology surgeon, and earlier year of surgeon graduation were associated with reduced odds of MIS (OR < 1). The uptake of MIS hysterectomy increased steadily over the time period. Receipt of MIS is dependent upon multiple social determinants, provider variables, and systems factors. These disparities raise concern for health equity in Ontario and have significant implications for health systems planning and resource allocation.