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Introduction: Delayed diagnosis and treatment of NETs may result in increased health care utilization, medical costs and patient distress. Patients may be treated by different specialists and modalities. Aim(s): To analyze health care utilization of NETs patients in Ontario and variations in treatments. Materials and methods: Using the Ontario Cancer Registry (cross-linked with the Registered Persons Database and the Canadian Institute of Health Information Discharge Abstract Database), all cases of NETs were identified in Ontario (> 13 million persons) from 1994 to 2009. Baseline demographic, clinical and outcomes data were abstracted. Results: A total of N=5,619 cases were identified. Two years, one year and 60 days prior to diagnosis, 60.3%, 52.3% and 35.3% of patients, respectively, visited a hospital emergency room and 83.1%, 78.0% and 65.4%, respectively, had a radiological investigation. Within 60 days pre-diagnosis 98% of patients visited a physician with family practice (83%), general surgeon (44%), cardiologist (25%) and gastroenterologist (22%) being the most common. Only 4% of patients visited an endocrinologist. Post-diagnosis 26% of patients had chemotherapy and 8% had radiotherapy while 64% of patients had a major surgical procedure and 12% an embolization at some point. Conclusion: NET patients have large health care utilization prior to diagnosis likely due to diagnosis delays. Treatment varies significantly with most patients receiving surgery. Further follow-up on patient outcomes in relation to the treatments is warranted. [ABSTRACT FROM AUTHOR]

Introduction: A recent study of the SEER database in the United States showed a 5-fold increase in neuroendocrine tumors (NETs) over the last 30 years. Conflicting reports of incidence trends have been reported worldwide. Aim(s): To describe the incidence and anatomical distribution of NETs in Ontario, Canada. Materials and methods: A population-based study was initiated using the Ontario Cancer Registry, cross-linked with the Registered Persons Database and the Canadian Institute of Health Information Discharge Abstract Database. All cases of NETs were identified in Ontario (> 13 million persons) from 1994 to 2009. Baseline demographic, clinical and outcomes data were abstracted. Results: A total of N=5,619 cases were identified. The incidence rate increased from 2.46/100,000 (95% CI, 2.13-2.83) in 1994 to 5.86/100,000 (95% CI, 5.40 - 6.35) in 2009. The median age was 62 with 50.5% female cases. Bronchopulmonary NETs were the most common (22%), then jejunum/ileum (17%) and rectal (16%). The absolute increase was most pronounced for pNETs (6-fold), rectal (5-fold) and gastric (5-fold) NETs. Metastatic disease was documented in 45% of cases. Conclusion: There appears to be a significant increase of reported cases of NETs in Ontario, Canada, particularly pancreas, rectum and gastric NETs. This supports much of the population-based reports worldwide. Further research is required to understand the impact of this cancer previously perceived to be rare but clearly increasing. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether tumour enhancement on preoperative delayed-phase gadoxetate-enhanced MRI can predict long-term survival in patients with colorectal liver metastases (CRCLM) post-hepatectomy., Materials and Methods: Sixty-five patients who received a preoperative gadoxetate-enhanced MRI prior to liver resection for CRCLM from January 1, 2010, to December 31, 2012, were included in this retrospective study. Target tumour enhancement (TuEn) was calculated as the mean percentage increase in SNR from precontrast to 10-min or 20-min delayed phase for up to two target lesions. Per-patient TuEn was stratified into weak and strong enhancement based on the cut-off determined by the Youden Index for 3-year survival. Kaplan-Meier and Cox regression analyses were used to determine whether tumour enhancement could predict overall survival independent of potential confounders (clinical risk score)., Results: The proportion surviving at 3 years was 85.1% in patients with strong TuEn at 10 min vs. 56.5% in those with weak TuEn at 10 min (p = 0.001). The proportion surviving at 3 years was 79.4% in patients with strong TuEn at 20 min vs. 58.7% in those with weak TuEn at 20 min (p = 0.011). After adjusting for potential confounders, the hazard ratio of death was 0.24 (p = 0.009) in patients who had weak TuEn at 10 min and 0.32 (p = 0.018) in patients who had weak TuEn at 20 min., Conclusions: Strong delayed tumour enhancement seen on gadoxetate-enhanced MRI is associated with overall survival in patients with CRCLM post-hepatectomy and may be useful for preoperative risk stratification., Key Points: • Delayed tumour enhancement of colorectal liver metastases on gadoxetate-enhanced MRI is associated with survival post-hepatectomy • Delayed tumour enhancement of colorectal liver metastases on gadoxetate-enhanced MRI can be measured at both 10 min and 20 min post-contrast injection.

Background: Gastrectomy with negative resection margins and adequate lymph node dissection is the cornerstone of curative treatment for gastric cancer (gc). However, gastrectomy is a complex and invasive operation with significant morbidity and mortality. Little is known about surgical practice patterns or short- and long-term outcomes in early-stage gc in Canada., Methods: We undertook a population-based retrospective cohort study of patients with gc diagnosed between 1 April 2005 and 31 March 2008. Chart review provided clinical and operative details such as disease stage, primary tumour location, surgical approach, operation, lymph nodes, and resection margins. Administrative data provided patient demographics, geography, and vital status. Variations in treatment and outcomes were compared for 14 local health integration networks. Descriptive statistics and log-rank tests were used to examine geographic variation., Results: We identified 722 patients with nonmetastatic resected gc. We documented significant provincial variation in case mix, including primary tumour location, stage at diagnosis, and tumour grade. Short-term surgical outcomes varied across the province. The percentage of patients with 15 or fewer lymph nodes removed and examined varied from 41.8% to 73.8% ( p = 0.02), and the rate of positive surgical margins ranged from 15.2% to 50.0% ( p = 0.002). The 30-day surgical mortality rates did not vary statistically significantly across the province ( p = 0.13); however, rates ranged from 0% to 16.7%. Overall 5-year survival was 44% and ranged from 31% to 55% across the province., Conclusions: This cohort of patients with resected stages i-iii gc is the largest analyzed in Canada, providing important historical information about treatment outcomes. Understanding the causes of regional variation will support interventions aiming to improve gc operative outcomes in the cancer system., Competing Interests: CONFLICT OF INTEREST DISCLOSURES We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none.

Objectives: TNM stage is the preeminent cancer staging system and a fundamental determinant of disease prognosis. Our goal was to evaluate the predictive power of TNM stage for gastric adenocarcinoma (GAC), in a low-incidence country., Methods: A province-wide chart review of GAC patients diagnosed from April 1, 2005 to March 31, 2008 was conducted in Ontario and linked to routinely collected vital status data with a follow-up on March 31, 2012. TNM staging was classified using the sixth and seventh Union International for Cancer Control/American Joint Committee on Cancer editions. Kaplan-Meier and log-rank tests compared stage-stratified survival estimates. Discrimination was evaluated using Harrell's C statistic., Results: The cohort included 2366 patients. One- and 5-year survival was 43% and 17%. Using the sixth edition, 9% of patients had stage I disease, 5.4% stage II, 7.3% stage III, and 64% stage IV; 15% were not staged. Using the seventh edition, 9% were stage I, 7.7% stage II, 16% stage III, and 54% stage IV; 14% were not staged. Stage-stratified 5-year survival ranged from 68% to 7% with the sixth edition and from 70% to 4% with the seventh edition. Harrell's C statistic was 0.64 (0.63-0.65) for the broad sixth edition staging categories and 0.68 (0.67-0.69) for the broad seventh edition. Discriminative power was similar for the refined stage categories and across multiple subgroup analyses; it was best in non-metastatic patients., Conclusion: Existing staging systems for GAC used in North America predict individualized prognosis poorly. The creation of a more complex prediction tool is necessary to provide accurate and precise prognostication information to oncologists, patients, and their families.

Background: Postoperative surveillance following curative-intent resection of colorectal cancer (CRC) is variably performed due to existing guideline differences and to the limited data supporting different strategies., Objectives: To examine population-based rates of surveillance imaging and endoscopy in patients in Ontario following curative-intent resection of CRC with no evidence of recurrence, as well as patient or disease factors that may predispose certain groups to more frequent versus less frequent surveillance; to provide insight to the care patients receive in the presence of conflicting guidelines, in efforts to help improve care of CRC survivors by identifying any potential underuse or overuse of particular surveillance modalities, or inequalities in access to surveillance., Method: A retrospective cohort study was conducted using data from the Ontario Cancer Registry and several linked databases. Ontario patients undergoing curative-intent CRC resection from 2003 to 2007 were identified, excluding patients with probable disease relapse. In the five-year period following surgery, the number of imaging and endoscopic examinations was determined., Results: There were 4960 patients included in the study. Over the five-year postoperative period, the highest proportion of patients who underwent postoperative surveillance received the following number of tests for each modality examined: one to three abdominopelvic computed tomography (CT) scans (n=2073 [41.8%]); one to three abdominal ultrasounds (n=2443 [49.3%]); no chest CTs, one to three chest x-rays (n=2385 [48.1%]); and two endoscopies (n=1845 [37.2%]). Odds of not receiving any abdominopelvic imaging (CT or abdominal ultrasound) were higher in those who did not receive adjuvant chemotherapy (OR 6.99 [95% CI 5.26 to 9.35]) or those living in certain geographical areas, but were independent of age, sex and income. Nearly all patients (n=4473 [90.2%]) underwent ≥1 endoscopy at some point during the follow-up period., Conclusion: In contrast to findings from similar studies in other jurisdictions, most Ontario CRC survivors receive postoperative surveillance with imaging and endoscopy, and care is equitable across sociodemographic groups, although unexplained geographical variation in practice exists and warrants further investigation.

Background: Administrative wait times reflect the time from the decision to treat until surgery; however, this does not reflect the total time a patient actually waits for treatment. Several factors may prolong the wait for colon cancer surgery. We sought to analyze the time from the date of surgical consultation to the date of surgery and any events within this time frame that may extend wait times., Methods: We retrospectively reviewed the cases of all adult patients in Ontario aged 18-80 years with diagnosed colon cancer who did not receive neoadjuvant therapy and underwent resection electively between Jan. 1, 2002, and Dec. 31, 2009. Wait times were measured from the date of surgical consultation to the date of surgery. We chose a wait time of 28 days, reflecting local administrative targets, as a comparative benchmark. We performed univariate and multivariate analyses to identify variables contributing to a waits longer than 28 days. Variables were analyzed in continuous linear and logistic regression models., Results: We included 10 223 patients in our study. The median wait time from initial surgical consultation to resection was 31 (range 0-182) days. Age older than 65 years had a negative impact on wait time. Preoperative services, including computed tomography, cardiac consultation, echocardiography, multigated acquisition scan, magnetic resonance imaging, colonoscopy and cardiac catheterization also significantly increased wait times. Wait times were longer in rural hospitals., Conclusion: Preoperative services significantly increased wait times between initial surgical consultation and surgery.

Background and Objectives: Limited qualitative studies exist regarding the patient experience of having a rare cancer. We sought to understand the patient experience of having a rare malignancy by interviewing patients diagnosed with neuroendocrine tumours (NET)., Methods: Semi-structured qualitative interviews were used to examine the cancer journey experience of NET patients. Purposive sampling was utilized and 18 telephone interviews were completed by a single interviewer. Eight interviewees were female, median age was 63 (age range 45-77). Median interview time was 31 min (range 9 min - 2 h 8 min). Patient interviews were transcribed verbatim and analysed using qualitative research methodology. Grounded theory guided the generation of the interview guide and analysis., Results: The dominant theme identified was that of 'no clear pathway' of care for the patient with NETs. Four subthemes that influenced this theory included: (1) difficulty with obtaining a diagnosis; (2) difficulty finding appropriate information about NETs from physicians; (3) difficulty finding treatment centres with knowledge of NETs and (4) difficulty finding disease specific support. Two global modifiers were also identified; satisfaction with a specialized clinic and long term physical and psychological side effects of treatment. These modifiers did not affect the overall theme but do potentially offer a solution for some of the difficulties the patients experienced., Conclusions: Patients with NETs had 'no clear pathway' of care in their cancer journey. A multidisciplinary specialized clinic for NETs is recommended as well as a strong role for nursing in providing support and building patient and family resilience., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Recent trials have shown that cytoreductive surgery and heated intraperitoneal chemotherapy (S+HIPEC) for colorectal cancer carcinomatosis (CRC-C) leads to 5-year, disease-free survival rates of more than 30%. Since these data represent a substantial change in the management of CRC-C, the objectives of this study were to determine physicians' awareness of S+HIPEC for CRC-C and physician characteristics predictive of awareness of S+HIPEC for CRC-C., Methods: This study was a mailed, cross-sectional survey of general surgeons and medical oncologists in Ontario., Results: The response rate was 44.0% (214 of 487). Most respondents were men and younger than 50 years. There was an even split between those at academic and community hospitals. Overall, 46% of respondents were aware of S+HIPEC for CRC-C, and multivariate analysis showed that there were no physician characteristics predictive of awareness of S+HIPEC for CRC-C., Conclusion: Physician awareness of S+HIPEC for CRC-C is low. Therefore, strategies to improve patient and physician knowledge about S+HIPEC for CRC-C are important to ensure appropriate treatment for patients.

Objective: To describe the processes of care for gastric cancer in Ontario and identify areas in which care and possibly survival can be improved., Summary Background Data: Survival in North America is poor for patients with gastric cancer, with stage-matched survival markedly worse than is seen in Asian and European series. Few Western studies have examined processes of care associated with gastric cancer., Methods: We identified all cases of gastric cancer in Ontario, Canada from April 1, 2000 to March 31, 2005, and describe the demographics of patients, staging of the cancer, treatment, and survival., Results: In this series of 3,666 patients, 81% of cases had a CT scan performed prior to resection and 90% of cases received an upper endoscopy. We found that 55% of patients were treated palliatively and only 1,645 patients underwent a curative-intent resection. Among patients who did not receive a resection over 50% of the cases appeared to have had a diagnostic laparoscopy rather than a laparotomy. Survival was related to the type of resection performed, likely reflecting the extent of disease. Higher institution volume and age were related to improved survival for curative-intent cases., Conclusion: In this population-based analysis, we found evidence of under-utilization of pre-operative radiology and endoscopy. Many patients were treated palliatively, reflecting presentation of the cancer at an advanced stage. For curative patients, survival was associated with age, surgical type, and resection in a higher volume institution., ((c) 2010 Wiley-Liss, Inc.)

Objective: To assess the quality of the operative reports from cases of ovarian cancer surgery in Ontario., Methods: We undertook a population cohort study including all newly diagnosed ovarian cancer patients treated initially with surgery from January 1996 to December 1998 in Ontario (n = 1341). We abstracted charts from hospitals and cancer centres. All surgical and pathology notes were abstracted into an ACCESS database., Results: A total of 1,341 women had surgery as the first step in management of ovarian cancer. A vertical abdominal incision was used in 87.6% of these cases. Peritoneal cytology was obtained in 87.8% of cases overall, but in only 69.5% of stage 1 cases. A description of the ovaries was provided in 85% of reports, of the uterus in 70%, the diaphragm in 53%, the liver in 69%, the pelvic lymph nodes in 10%, and the para-aortic lymph nodes in 41%. In stage 1 cases, the ovaries were assessed histologically in 89% of cases, the uterus in 80%, the omentum in 69%, the peritoneum in 20%, the appendix in 9%, the pelvic lymph nodes in 10%, and the para-aortic lymph nodes in 7%. Frozen section was obtained in half of the stage 1 cases, and the false negative rate for identifying malignancy was 6%. In all, 23% of women received adequate surgical staging for stage 1 disease, and 12% of women with advanced disease had optimal debulking (to less than 1 cm residual disease). There are clear differences between centres with a gynaecologic oncologist on staff and other centres in the adequacy of surgical staging in women with stage 1 disease (chi2 = 60.6, P < 0.0001) and in optimal debulking for advanced disease (chi2 = 39.1, P < 0.0001). In 40% of cases with advanced disease, the amount of residual disease following surgery is not reported., Conclusion: The current approach of dictating operative notes does not provide sufficient detail in a large number of cases; this affects treatment decisions and limits our ability to assess quality indicators for operative care in ovarian cancer. This problem is pervasive but is more significant in centres without a gynaecologic oncologist.