Women's College Hospital Research Articles

The lived experiences of transgender and gender-diverse people in accessing publicly funded penile-inversion vaginoplasty in Canada.

Canada's health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system. We used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women's College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen's framework of lived body, lived time, lived space, and lived human relations. We interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women (n = 13) and White (n = 14). Participants lived in rural (n = 4), suburban (n = 5), or urban (n = 6) locations. Their median age was 32 (range 27-67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples' lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants' intersecting identities and emotional pain (lived body); participants' experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants' understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants' experiences of loss of trust and connection (lived human relations). Our findings reveal TGD patients' lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences.

Headache Education in Canadian Medical Schools.

This study aims to gain a better understanding of the current scope of headache education received in Canadian medical schools. The Women's College Hospital Centre for Headache at the University of Toronto, Canada, distributed a questionnaire to administrators and physicians involved in medical student education at Canadian medical schools and gathered information surrounding headache education. Overall, the degree of headache education varied between schools in regard to the hours of training that occurred and year the training took place. This survey provides an initial insight into the current standards of headache-specific education in Canadian medical schools.

Features of paradoxical psoriasis and risk factors in inflammatory bowel disease: A systematic review and meta-analysis.

Features of paradoxical psoriasis and risk factors in inflammatory bowel disease: A systematic review and meta-analysis.

A89 EXPLORING THE ENDOSCOPY SEDATION EXPERIENCES OF INDIVIDUALS WITH PEDIATRIC-ONSET INFLAMMATORY BOWEL DISEASE (IBD) AFTER THE TRANSITION TO ADULT CARE: A PILOT STUDY

Abstract Background Different sedation practices are utilized in pediatric and adult endoscopy settings. While pediatric endoscopies are performed under deep sedation, adult endoscopies are often performed under conscious sedation. Purpose This study sought to explore the experiences of patients with pediatric-onset IBD that have undergone transfer to adult care and to identify gaps in endoscopy sedation practices that may inform a larger and more comprehensive evaluation of this topic. Method A pilot study was performed at Women's College Hospital involving patients aged 18 to 25 years old with a diagnosis of pediatric-onset IBD that received endoscopies in both the pediatric and adult setting. Patients were recruited between June 1 and October 1, 2022. A 36-item questionnaire was distributed assessing sedation methods used in pediatric and adult settings, anxiety, pain, satisfaction during endoscopy and perceptions of transition of care preparation as it pertained to endoscopy. This study was reviewed by institutional authorities at WCH and was deemed not to require REB approval. Result(s) Twelve patients participated in the pilot survey study (7 Ulcerative colitis, 5 Crohn’s disease) with a mean age of 22. Of those, 100% were female and 66% did not have any comorbid conditions. The mean age of diagnosis was 12.8 years, with respondents spending an average of 67.3 months in pediatric care prior to transition. In pediatric care, the mean number of endoscopies received was 2.3 with a majority performed under deep sedation (83%). Respondents reported being very satisfied with their sedation experience (58%) and experiencing no pain (67%), however mild to severe anxiety was reported (58%). In adult care, mean endoscopies received was 2.1, with conscious sedation (50%) performed more often than deep (42%) or no sedation (8%). More respondents reported satisfaction with deep sedation (100%) than conscious sedation (67%). During conscious sedation, respondents experienced more pain (50% vs. 20%), moderate discomfort (33% vs. 0%), and were more anxious (83% vs. 60%) than in deep sedation. Factors that contributed to anxiety included fear of endoscopy and insufficient sedation. Of those who received deep sedation in the adult setting, 60% reported that the sedation method utilized impacted their future willingness for endoscopy. Lack of communication regarding sedation method, poor experiences with conscious sedation, and the desire to choose the sedation method appropriate for them were areas for improvement. Conclusion(s) This pilot study demonstrated that IBD patients transferred to adult care receive varying endoscopy sedation methods and experience differential levels of satisfaction favouring deep sedation. This is an important signal that requires larger study. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Cardiac Investigation Trends Among Primary Care Physicians: A Paradigm Shift.

While numerous recent guidelines support coronary computed tomography angiography (CTA) as a first-line test for stable chest pain, it remains underutilized by primary care physicians (PCPs). We aimed to evaluate cardiac investigation ordering practices following education sessions, as well as the total number of downstream tests and time to diagnosis for patients presenting with stable chest pain. A retrospective chart review was completed for eligible patients assessed at the Women's College Hospital Family Practice Health Centre between 2017 and 2019 following the education sessions. The outcome measures were first-choice cardiac investigation, additional downstream testing, time from presentation to first investigation, and time to final diagnosis. 419 patients were included in the final analysis (74.70% female; mean age 61 ± 11years). Coronary CTA requests by PCPs increased between 2017 and 2019 (18 vs 72 tests; P < .0001). When coronary CTA was the first-line test, patients were less likely to receive additional downstream testing when compared to those receiving other first-line investigations (P < .0001). Coronary CTA was associated with longer time to diagnosis than stress echocardiography (47 ± 45 vs 27 ± 36days; P = .0068) due to limited availability of coronary CTA appointment times. There was no significant difference in time to final diagnosis among the cardiac imaging modalities observed in the cohort (P = .0623). Utilization of coronary CTA as the first-line test for stable chest pain increased following our education sessions targeting PCPs. Coronary CTA was associated with less downstream testing compared to other non-invasive cardiac investigations.

An examination of depression, anxiety, and fear of recurrence among cancer survivors who participated in a virtual cognitive behavioral therapy (CBT)-based telephone coaching program.

Depression, anxiety, and fear of recurrence (FOR) are prevalent among cancer survivors, and it is recommended that they have access to supportive services and resources to address psychosocial needs during follow-up care. This study examined the impact of a virtual cognitive behavioral therapy (CBT)-based telephone coaching program (BounceBack®) on depression, anxiety, and FOR. Through the After Cancer Treatment Transition (ACTT) clinic at the Women's College Hospital (Toronto, Canada), eligible participants were identified, consented, and referred to the BounceBack® program. Program participation involved completion of self-selected online workbooks and support from trained telephone coaches. Measures of depression (PHQ-9), anxiety (GAD-7), and FOR (fear of cancer recurrence inventory, FCRI) were collected at pre-intervention (baseline) and post-intervention (6-month and 12-month time points). For each psychosocial measure, paired t-tests compared mean scores between study time points. Participant experiences and perceptions were collected through a survey. Measures of depression and anxiety significantly improved among participants from pre-intervention to post-intervention. Scores for PHQ-9 and GAD-7 decreased from moderate to mild levels. Measure of FOR also significantly improved, while FCRI sub-scale scores significantly improved for 5 of the 7 factors that characterize FOR (triggers, severity, psychological distress, functional impairment, insight). Participants rated the intervention a mean score of 7 (out of 10), indicating a moderate level of satisfaction and usefulness. This study suggested that a virtual CBT-based telephone coaching program can be an effective approach to managing depression, anxiety, and fear of recurrence in cancer survivors.

Clinician acceptability of self-collected human papillomavirus swabs as a primary cervical cancer screening method.

To determine knowledge and acceptability of and opinions about human papillomavirus (HPV) self-screening as an alternative to Papanicolaou testing among Canadian primary care providers (PCPs: family physicians and nurse practitioners) and obstetrician-gynecologists (OB-GYNs). Descriptive, cross-sectional, anonymous, online pilot survey. Two academic teaching hospitals in downtown Toronto, Ont. Staff physicians and nurse practitioners in the Department of Family and Community Medicine and the Department of Obstetrics and Gynecology at Women's College Hospital and St Michael's Hospital. Recommended patient groups for, potential advantages and disadvantages of, and likelihood of recommending HPV self-sampling for cervical cancer screening. The overall response rate was 30.9%. More than three-quarters of survey respondents were female PCPs. Slightly more than half of clinicians had poor knowledge of HPV self-sampling. However, more than three-quarters would recommend it if there were adequate collection of cervical samples, high patient acceptability, and high sensitivity (almost 100% of respondents), followed by high specificity and cost-effectiveness (more than 80% of respondents). Primary care practitioners were more likely than OB-GYNs to agree that HPV self-sampling made screening easier and less embarrassing for patients. Although not statistically significant, OB-GYNs tended to be more concerned than PCPs were about patients failing to follow up on abnormal HPV results and missed opportunities to address other health issues. Although knowledge of HPV self-sampling for cervical screening was poor, it was generally acceptable to clinicians if certain screening test conditions were met. However, the potential for missed opportunities to visualize pathology and address other health concerns were raised. These and other clinical practice and health systems issues must be addressed before broad implementation of HPV self-sampling in Canada.

Factors affecting surgical decision-making in carriers of BRCA1/2 pathogenic variants undergoing risk-reducing surgery at a dedicated hereditary ovarian cancer clinic.

Women with germline BRCA1/2 pathogenic variants have a significantly elevated lifetime risk of ovarian and fallopian tube cancer. Bilateral salpingo-oophorectomy (RRSO) is associated with a 90% reduction in the development of tubal and ovarian cancer. At our tertiary hospital, we have a dedicated clinic where women predisposed to hereditary ovarian/tubal cancer receive counseling on reproduction, risk reduction, surgical prophylaxis, and menopausal aftercare. The objective of this study was to evaluate the choices that Canadian women with BRCA1/2 pathogenic variants make regarding ovarian cancer risk reduction within this highly specialized multidisciplinary clinic. This retrospective chart review included all women with confirmed BRCA1/2 mutations referred to the Familial Ovarian Cancer Clinic at Women's College Hospital, Toronto, Canada over a 45-month time period. Patient demographics, preoperative consultation notes and investigations, intraoperative findings, and pathology were recorded. A total of 191 women were included in our cohort; 140 (73.3%) underwent risk-reducing surgery and 51 (26.7%) deferred or declined surgery. In women who underwent surgical prevention (median age 45 [30-72] y), 123 (87.9%) underwent RRSO and 17 (12.1%) chose a risk-reducing bilateral salpingectomy with deferred oophorectomy. Of the women undergoing RRSO, 11 (8.9%) women chose concurrent hysterectomy. Prevalent themes affecting decision-making included fears around premature surgical menopause, family planning, and concerns around development of endometrial cancer related to tamoxifen. Women with BRCA1/2 pathogenic variants face challenging decisions regarding risk reduction and care providers must be knowledgeable and supportive in helping women make informed and individualized choices about their care.

Gaps in Referral to Bariatric Surgery for Eligible Patients With Type 2 Diabetes and Obesity Seen in Ambulatory Diabetes Clinics at Women's College Hospital, Toronto

One in three Canadian adults have obesity. Bariatric surgery reduces weight and obesity-related complications, but remains under-utilized. Our objective was to determine whether a gap exists in bariatric surgery referral among patients with type 2 diabetes (T2D) at Women's College Hospital.

A descriptive evaluation of resident prescription writing errors and self‐perceived learning needs in dermatology

Prescribing errors in medical practice are common and may be preventable in a significant proportion of cases. Literature on dermatologic prescription errors is scarce. We sought to determine the rate and causes of resident prescribing errors in an outpatient dermatology practice and surveyed residents' self-perceived prescription writing learning needs. All prescription errors were tabulated at Women College Hospital's Ricky Kanee Schachter Dermatology Clinic from November 2019 to January 2020. There was an overall prescribing error rate of 1.58% (23/1457), with no significant difference between topical and systemic drugs (1.85% and 0.86%, respectively; p=0.20) or written prescriptions and electronic-medical record created prescriptions (1.66% and 1.29%, respectively; p=0.84). 26.2% (22/82) of residents responded to the survey reporting overall confidence in dermatology prescription writing as 7.14±1.75 out of 10. While the resident prescribing error rate was relatively low, multiple errors were avoidable, and residents agree targeted dermatology-specific training in prescription writing is needed.

Weight-based thyroid dosing vs fixed dosing during pregnancy for subclinical hypothyroidism: A retrospective cohort study.

Thyroid hormones play a crucial role in foetal growth and neurocognitive development. Our aim was to compare a weight-based dosing method of starting thyroxine to a fixed-dose method in newly diagnosed women with subclinical hypothyroidism during pregnancy. We performed a retrospective cohort study of consecutive women with newly diagnosed subclinical hypothyroidism during pregnancy seen at Mount Sinai Hospital and Women's College Hospital, Toronto, Canada 2015-2018. We identified women that were treated based on pre-pregnancy weight and those that were given a fixed dose of 50 mcg/day. The percent of women who reached the target TSH of <2.5mIU/L within 4-8weeks was compared using a chi-squared test and a logistic regression model, adjusting for age, initial TSH and gestational age treatment was started. 393 women were included: 252 treated using a fixed-dose approach; 141 treated based on pre-pregnancy weight. In the unadjusted analysis, there was no difference between the groups in the percentage of women in the target range within 4-8weeks (89.6% in the fixed-dose group vs 88.8% in the weight-based group (p=.954)). However, after adjustment for between-group differences in age, initial TSH and gestational age treatment was started, there was a significantly greater odds of achieving the target range using the weight-based dosing (OR 4.26 (1.60-11.7), p=.004). Treating women with newly diagnosed subclinical hypothyroidism during pregnancy with a weight-based strategy increased the odds of reaching the target TSH range within 4-8weeks. Clinicians caring for these women should consider this approach when starting treatment during pregnancy.

Factors affecting surgical decision making in BRCA carriers undergoing risk reducing surgery

Objectives Women with germline BRCA1/2 mutations have a significantly elevated lifetime risk of ovarian cancer. Risk-reducing bilateral salpingo-oopherectomy (RRSO) is associated with an 80% reduction in the development of ovarian cancer. In January 2014 the Familial Ovarian Cancer Clinic (FOCC) was created as a centralized clinic to manage referrals of women with documented BRCA1/2 mutations. The objective of this study was to evaluate the choices that Canadian women with BRCA1/2 mutations made regarding ovarian cancer risk reduction within this highly specialized multidisciplinary clinic. Methods A retrospective chart review was performed on all women with confirmed BRCA1/2 mutations referred to the FOCC at Women's College Hospital, Toronto, Canada over a 45-month time period. Patient demographics, preoperative investigations, intraoperative findings and pathology were recorded. Results A total of 191 women were included in our cohort; 140(73.3%) underwent RRS and 51 (26.7%) deferred or declined surgery. In women who underwent RRS (median age 45 [30-72] years), 123 (87.9%) underwent RRSO and 17 (12.1%) chose a two-step risk-reducing bilateral salpingectomy with delayed oophorectomy (RRSDO). Of the women undergoing RRSO, 11 (8.9%) women chose concurrent hysterectomy. Prevalent themes affecting decision making included fears around premature surgical menopause, family planning, and concerns around development of endometrial cancer related to tamoxifen. Conclusions Women with BRCA1/2 mutations referred to our FOCC clinic face challenging decisions regarding risk reduction.

The impact of gender discrimination on a Woman's Mental Health

The impact of gender discrimination on a Woman's Mental Health

Scalp ulcers - differential diagnoses that should be sought!

Ulceration of the scalp is an uncommon clinical presentation, and it may be caused by myriads of cutaneous etiologies such as infections, inflammatory disorders, and malignancies. We sought to reveal the underlying etiology of scalp ulcers referred to our tertiary wound healing clinic; we would also like to propose a classification for scalp ulcerations. A retrospective study was conducted in an academic tertiary wound healing clinic between January 2015 and June 2018. The study was approved by the Women's College Hospital Institutional Research Ethics Board. We have also conducted a review of the literature to recognize the major causes of scalp ulceration reported in the literature. We have identified a total number of 15 patients with scalp ulceration. Twelve patients with atypical scalp ulcers underwent a skin biopsy. A malignancy rate of 73% (11/15) was diagnosed histologically. The review of the literature showed 237 articles. After screening the title and the abstracts, we have selected 41 case reports for the full text review. Scalp ulcers are uncommon but important. Our sample study indicates the high frequency of malignant etiologies presenting as scalp ulcers. These results emphasize not only the need for clinicians to be on the watch for the possibility of this option but rather highlights the need for early biopsy to prevent further complications. We hope that our paper helps to shed some light on this topic and guide clinicians on how to approach scalp ulceration.

Proceeding report of the third symposium on Hidradenitis Suppurativa advances (SHSA) 2018.

The 3rd Annual Symposium on Hidradenitis Suppurativa Advances (SHSA) took place on 12-14 October 2018 at the Women's College Hospital in Toronto, Ontario, Canada. This symposium was a joint meeting of the Hidradenitis Suppurativa Foundation (HSF) founded in the USA and the Canadian Hidradenitis Suppurativa Foundation (CHSF). This cross-disciplinary meeting with experts from around the world was an opportunity to discuss the most recent advances in the study of hidradenitis suppurativa pathogenesis, epidemiology, classification, scoring systems, radiologic diagnosis, treatment approaches and psychologic assessment. Two special sessions this year were HS as a systemic disease and HS management guidelines. There were focused workshops on wound healing and ultrasound. There were two sessions primarily for patients and their families in the HS School programme: One workshop focused on mindfulness, and the second involved discussion among clinicians and patients about various disease aspects and the latest management. To facilitate networking between clinical and research experts and those early in their career, a mentoring breakfast was held.

Predictors of time to death after distant recurrence in breast cancer patients.

After experiencing a distant recurrence, breast cancer patients have a poor prognosis; fewer than 5% survive for ten or more years. However, the time to death is highly variable, ranging from a few months to many years. The purpose of this study is to identify, in a large hospital-based series of patients with early-stage breast cancer, factors which predict survival after distant recurrence. We studied a cohort of 2312 women diagnosed with invasive breast cancer at Women's College Hospital between 1987 and 2000 (stages I-III). For each patient, we abstracted information on age at diagnosis, the initial presentation of the cancer (tumour size, lymph node status, tumour grade, ER status, PR status, HER2 status), treatment (surgery, radiotherapy, chemotherapy, hormone therapy), the dates of all tumour recurrences (local, regional, distant) and the dates and causes of death. The Cox proportional hazards model was used to estimate the univariate and multivariate hazard ratios for death from breast cancer following distant recurrence associated with the various tumour features. After a mean follow-up of 12.8years from diagnosis, 523 distant recurrences were recorded among women in the cohort (23% of 2312) and 604 women (26%) died of breast cancer. For the 484 women who had a distant recurrence on record and died of breast cancer, the mean time from distant recurrence to death was 2.0years (range 0-11.9years). In a multivariate analysis, only two factors were significantly associated with time to death after distant recurrence: ER status (positive vs. negative, HR 0.56; 95% CI 0.43-0.71; p < 0.0001) and tumour grade (high vs. low, HR 1.87; 95% CI 1.16-3.01; p = 0.01). Among ER-negative patients (N = 175), high tumour grade and a short time from diagnosis to distant recurrence were associated with a rapid time to death. Among ER-positive patients (N = 336), there was no significant independent predictor of time from recurrence to death. Among ER-negative breast cancer patients, the time to death after distant recurrence was predictable to some extent; women with a short time from diagnosis to recurrence and/or with high-grade tumours were more likely to succumb to breast cancer within 3years. Among ER-positive breast cancer patients who experience a distant recurrence, the time to death varies substantially and between patients could not be predicted by tumour factors or treatment. This suggests that for ER-positive patients, the factors that determine the time from diagnosis to distant recurrence do not predict the course of the cancer post-recurrence.

Thyroid hormone receptor beta-1 expression in early breast cancer: a validation study.

Preliminary data suggest that high expression of the TRβ1 tumor suppressor is associated with longer survival among women with early breast cancer. We undertook this study to validate these findings. In this prospective cohort study, we analyzed the prognostic significance of TRβ1 protein expression in the breast tumors of 796 women who had undergone breast surgery in the Henrietta Banting Breast Cancer database. All women were recruited after undergoing primary surgical therapy at Women's College Hospital (Toronto, ON, Canada) between January 1987 and December 2000. Details regarding patient age at diagnosis, systemic, and local therapies, as well as pathological features of their tumor have been systematically recorded. Clinical outcomes including breast cancer recurrence and death have been updated at least once each year with a median follow-up of 9.6years (range 0.1-21years). High TRβ1 expression (> 4 on the Allred score) was associated with a longer breast cancer-specific survival with a HR 0.45 (95% CI 0.33-0.61), p < 0.0001 in a univariable Cox regression model. This was maintained in a multivariable model adjusted for age, tumor size, nodal status, chemotherapy, hormone therapy, radiotherapy, surgery, and ER status with a HR of 0.61 (95% CI 0.44-0.85), p = 0.004. High expression of TRβ1 is associated with longer breast cancer-specific survival independent of other prognostic factors. Given that low TRβ expression is associated with chemotherapy resistance in-vitro, TRβ1 may also serve as a predictive biomarker or even a therapeutic target given the availability of TRβ agonists.

Pectoralis and Serratus Fascial Plane Blocks Each Provide Early Analgesic Benefits Following Ambulatory Breast Cancer Surgery: A Retrospective Propensity-Matched Cohort Study.

Pectoralis and serratus blocks have been described recently for use in breast surgery, but evidence supporting their analgesic benefits is limited. This cohort study evaluates the benefits of adding a pectoralis or serratus block to conventional opioid-based analgesia (control) in patients who underwent ambulatory breast cancer surgery at Women's College Hospital between July 2013 and May 2015. We tested the joint hypothesis that adding a pectoralis or serratus block reduced postoperative in-hospital (predischarge) opioid consumption and nausea and vomiting (PONV). We also examined the 2 block types for noninferiority. A total of 225 patients were propensity matched on 5 potential confounders among 3 study groups (75 per group): (1) pectoralis; (2) serratus; and (3) control. The propensity-matched cohort was used to evaluate the effect of the study group on postoperative in-hospital oral morphine equivalent consumption and PONV. We considered pectoralis noninferior to serratus block if it was noninferior for both outcomes, within 10 mg morphine and 17.5% in PONV incidence margins. Other outcomes included intraoperative fentanyl requirements, pain scores, time to first analgesic request, and duration of recovery room stay. Both pectoralis and serratus blocks were each associated with reduced postoperative in-hospital opioid consumption and PONV compared with control. Pectoralis was noninferior to serratus block for these 2 outcomes. Pectoralis and serratus blocks were each associated with reduced intraoperative fentanyl requirements, prolonged time to first analgesic request, and expedited recovery room discharge compared with control; there were no differences for the remaining outcomes. Pectoralis and serratus blocks were each associated with a reduction in postoperative in-hospital opioid consumption and PONV compared with conventional opioid-based analgesia after ambulatory breast cancer surgery.

The prognostic effect of estrogen receptor status differs for younger versus older breast cancer patients.

To estimate the prognostic impact of estrogen receptor (ER)-status among women with primary invasive breast cancer, according to age at diagnosis. We studied 1910 women with primary invasive breast cancer (stages I-III) who were treated at Women's College Hospital between 1987 and 2000. For each patient, we obtained information on age at diagnosis, tumour size, lymph node status, ER-status, treatments received (radiotherapy, chemotherapy and tamoxifen) and dates and causes of death. Patients were followed from the date of diagnosis until the date of death from breast cancer or the date of last follow-up. We used the Kaplan-Meier method to estimate the 15-year actuarial rates of breast cancer-specific survival for women with ER-positive and ER-negative breast cancer, according to age at diagnosis (categories). We used the Cox proportional hazards model to estimate the adjusted hazard ratios for death from breast cancer associated with positive ER-status (compared to negative ER-status), stratified by age at diagnosis. We identified 1347 women with ER-positive breast cancer (70.5%) and 563 women with ER-negative breast cancer (29.5%). Among all 1910 women in the cohort, the actuarial rate of breast cancer-specific survival at 15years was 77% for those with ER-positive breast cancer compared to 70% for those with ER-negative breast cancer (adjusted HR=0.69; 95% CI0.56-0.85; p=0.0006). The prognostic impact of ER-status differed according to age at diagnosis. Among 213 women diagnosed before age 40, breast cancer-specific survival at 15years was worse for those with ER-positive breast cancer than for those with ER-negative breast cancer (55 vs. 61%; adjusted HR=0.90; 95% CI0.57-1.41; p=0.64). In contrast, among 1697 women diagnosed between ages 40 and 75, breast cancer-specific survival at 15years was better for those with ER-positive breast cancer than for those with ER-negative breast cancer (78 vs. 72%; adjusted HR=0.60; 95% CI0.47-0.76; p<0.0001). Positive ER-status is a favourable prognostic factor among women diagnosed with breast cancer at or above age 40, but not among women diagnosed before age 40.

Which women decide to take tamoxifen?

To identify factors which predict, among estrogen receptor (ER)-positive breast cancer patients, who chooses to take adjuvant tamoxifen. We studied 1347 women with ER-positive breast cancer who were treated at Women's College Hospital between 1987 and 2000. For each patient, we obtained information on age at diagnosis, tumour size, lymph node status, ER status, treatments received and dates of local recurrence and of death. We compared women who did and who did not take tamoxifen for a range of factors. We used the Kaplan-Meier method to estimate 15-year local recurrence-free and breast cancer-specific survival rates for women who did and who did not take tamoxifen. Overall, 50.4% of women who had a mastectomy took tamoxifen and 61.0% of women who had a lumpectomy took tamoxifen (p=0.002). Tamoxifen use did not correlate with any of the factors that were predictive of a high risk of death from breast cancer, such as young age, large tumour size and positive lymph node status. Young women (<40years) experienced much higher mortality (41.1%) than older (>60years) women (14.1%, p<0.01), but were much less likely to have taken tamoxifen (35.0 vs. 74.6%, p<0.01). Approximately one-half of women with ER-positive breast cancer who are candidates for tamoxifen did not take tamoxifen. Women with lumpectomy were more likely to take tamoxifen than women with mastectomy. Paradoxically, women at high risk of death from breast cancer (less than 40 at diagnosis and/or lymph node positive) and who are expected to receive the greatest benefit from tamoxifen in terms of mortality reduction were less likely to take it than were low-risk women (older women, lymph node negative). These findings suggest that women consider the reduction in risk from local recurrence to be more important than the reduction in risk of death from breast cancer when they consider taking tamoxifen.