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BACKGROUND Young women with metastatic breast cancer (YWMBC) are part of a digitally connected generation yet are underserved in terms of information needs. YouTube (YT) is the most commonly used search engine following Google. The accessibility of health-related content on social media, paired with the rare and marginalized experience of YWMBC, as well as the digital media practices of younger generations, implies a considerable likelihood that YWMBC will seek information and community online. OBJECTIVE This study aims to assess the quality of MBC YT videos and to identify themes in YWMBC experiences. METHODS A systematic review of MBC YT videos was conducted in 08/2021. Understandability, actionability were assessed using the Patient Education Materials Assessment Tool (PEMAT); information reliability/quality was assessed with DISCERN. Themes, sponsorships, healthcare professionals’ and patients’ narratives were reported. RESULTS A total of 101 videos were identified. Of these, 78.2% included sponsorships. Mean PEMAT score was 78.8% (SD 15.3) and 43.1% (SD 45.2) for understandability and actionability, respectively. Mean DISCERN score was 2.44/5 (SD 0.7). Identified themes include treatment (66.3%), family relationship (45.5%), motherhood (37.6%). CONCLUSIONS YT videos about YWMBC are highly understandable but demonstrate moderate rates of actionability, with low reliability and quality scores. Many have a commercial bias. While online materials have limitations, their potential to provide patient support is not fully developed. By acknowledging their patients’ media habits, physicians can 1) further develop a trusting bond with their patients, 2) provide a space for open and honest discussions of online materials, and 3) avoid any potential instances of confusion caused by misleading, inaccurate, or false online materials.

To examine the proportion of older women with ER + HER2- breast cancer receiving non-operative management versus surgery, and to evaluate the use of axillary staging and adjuvant radiation in this population. We queried the SEER database to identify all women aged 70 years or older with stage I–III ER + HER2- invasive breast cancer diagnosed between 2010 and 2016. We evaluated trends in non-operative management, breast surgery, axillary staging, and adjuvant radiation according to age at diagnosis. We identified 57,351 older women with ER + HER2- disease. Overall, 3538 (6.2%) of the cohort underwent non-operative management, 38,452 (67.0%) underwent breast-conserving surgery (BCS), and 15,361 (26.8%) underwent mastectomy. The proportion of patients undergoing non-operative management increased from 2.8% among 70–74-year-old women to 30.1% in those ≥ 90 years old (p

e21531 Background: Inguinal lymphadenectomy (ILND) has historically been associated with significant morbidity. The advent of sentinel node biopsy and selective dissection protocols have significantly decreased the frequency with which ILND is performed, reserving it for complex, recurrent disease. The study objective is to obtain contemporary morbidity rates for this complex procedure and to identify potentially preventable risk factors. Methods: Retrospective review of medical charts for all superficial, deep, and combination groin dissections performed for melanoma, sarcoma, and other rare cancers at a single, high-volume academic center between 01/2007 and 12/2020. Data points collected: patient, disease, surgery characteristics, and cancer outcomes. Outcome of interest: any complication within 30 days of surgery. Complications: wound infection, wound necrosis/disruption, seroma, drainage procedure, hematoma, lymphedema, and other. Multivariate logistic regression performed using SAS Enterprise 9.4. Results: : 139 cases were identified; type of dissection was 89, 12, and 38 for superficial, deep, and combined respectively. Melanoma accounted for 84.9% of cases, sarcoma for 8.6%. 56.1% of patients had an adverse postoperative event within 30 days. The majority of patients did not have a history of smoking, diabetes, cardiovascular disease, hypothyroidism, or radiation therapy. 61.2% were recurrent cancer cases with 56.8%, 19.4%, and 23.7% being clinically evident, radiological-only, and sentinel node positive disease respectively. Type and frequency of complications is reported in Table. Increasing age (OR: 1.04, 95CI: 1.01-1.07, P < 0.01) and number of positive lymph nodes harvested (OR: 1.22, 95CI: 1.00-1.50, P = 0.05) were associated with more complications. Deep dissection showed lower likelihood of complications than those with superficial (OR: 0.15, 95CI: 0.03-0.84, P < 0.05). Conclusions: A number of risk factors for complications were identified opening up opportunities for preventative intervention such as prehabilitation, use of frailty score, and neo-adjuvant therapy. Deep vein thrombosis, abscess, general deterioration, neuropathic pain, numbness. Frequency by occurrence, not patient. [Table: see text]

The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain.To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery.This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization.Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge.Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle.A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled.The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery.ClinicalTrials.gov Identifier: NCT04254679.

Postoperative pain control is an important cancer care component. However, opioid consumption has resulted in a surge of adverse events, with thoracic surgery patients having the highest rate of persistent use. The effect of opioid duration post-discharge and the risk of increased acute healthcare use in this population remains unclear.A prospective cohort of non-metastatic cancer patients was assembled from an academic health center in Montreal (Canada). Clinical data linked to administrative claims from the universal healthcare program was used to determine the association between time-varying opioid patterns and emergency department (ED) visits/re-admissions/death 3 months following thoracic surgery.Of the 610 patients, 77% had at least one opioid dispensed post-discharge. Compared to non-opioid users,15 days of use was associated with a 42% decreased risk of acute healthcare events, adjusted HR 0.58, 95% CI (0.40-0.85); longer durations were not associated with an increased risk. Compared to short-term use (15 days), use of30 days was associated with a 72% increased risk of the outcome, aHR: 1.72, 95% CI (1.01-2.93).There was a variation in the risk of acute healthcare use associated with postsurgical opioid use. Findings from this study may be used to inform postoperative prescribing practices.

The neutrophil-to-lymphocyte ratio (NLR) is a measure of systemic inflammation and a prognostic factor for multiple malignancies. This study assesses the value of the NLR as an independent prognostic marker in triple-negative breast cancer (TNBC) and explores the association between dynamic NLR changes and patient outcomes. The study retrospectively analyzed a prospectively maintained database including patients 18 to 80 years old with TNBC treated at the authors’ institution between 2006 to 2016. Clinical and demographic data were collected, including blood test results and treatments received. Age at diagnosis, stage of disease, and NLR scores were tested for association with overall and disease-free survival in uni- and multivariate Cox models. The inclusion criteria were met by 329 women with a median age of 58. Most of the patients had early-stage disease (30.1% with stage 1 and 47% with stage 2 malignancy). An NLR higher than 2.84 at diagnosis was associated with decreased overall survival (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.023–3.176), whereas an NLR higher than 7.82 at any time during the follow-up period was a strong predictor of 5-year mortality (HR, 10.76; 95% CI, 4.193–26.58), independent of age or stage of disease. Patients who experienced recurrence had a higher NLR than their counterparts during the 6 months before recurrence. The NLR also significantly rose during the final 18 months of life (p

Background: Prescription opioid use and overdose has steadily increased over the past years, resulting in a dramatic increase in opioid-related emergency department (ED) visits and hospitalizations. Methods: This study used a prospective cohort of cancer patients having undergone surgery in Montreal (Quebec) to describe their post-discharge opioid use and identify potential patterns of unplanned health service use (ED visits, hospitalizations). Provincial health administrative claims were used to measure opioid dispensation as well as hospital re-admissions and ED visits. The hospital warehouse, patient chart and patient interview will be used to further describe patient’s medical profile. Marginal structural models will be used to model the association between use of opioids and risk of ED visits and hospitalizations. Inverse probability of treatment and censoring weights will be constructed to properly adjust for confounders that may be unbalanced between the opioid and non–opioid users as well as to account for competing risk due to mortality. Reasons for the re-admissions will also be presented as part of the analyses. Covariates will include patient comorbidities, medication history, and healthcare system characteristics such as nurse-to-patient and attending physician-to-patient ratios. Results (interim): A total of 821 were included in the study; of these, 73% (n=597) were admitted for a cancer procedure. At postoperative discharge, 605 (74%) of patients had at least one opioid dispensation, of which the majority (67%) were oxycodone with hydromorphone being the second most prescribed (28%). Among those who filled a prescription, mean age was 66 (13.4), 68% had no previous history of opioid use, and 10% have had 3 or more dispensing pharmacies in the year prior to admission, compared to less than 1% for the non–opioid users. Overall, 343 people refilled their opioid prescription at least once and 128 at least twice during the 1-year postoperative period. Among cancer patients who were opioid users, 214 ED visits occurred in the 1 year after surgery compared to only 40 for the non-cancer opioid users. Conclusion: This study will help to identify the risk profile of cancer patients who are most likely to continue using opioids for prolonged periods following surgical procedures as well as quantify the impact of opioid use and its associated burden on the healthcare system in order to identify areas for possible interventions.

11042 Background: Young women with metastatic breast cancer (MBC) are an underserved population, rendering them susceptible to media sources that lack in credibility and reliability. YouTube (YT) is the most commonly used search engine following Google. This study aims to assess the quality of MBC YT videos and to identify common themes in MBC experiences. Methods: A systematic review of YT videos with search terms “metastatic breast cancer young” was conducted in 08/2021. Title, date uploaded, length, poster identity, number of likes, dislikes, and comments were collected. Understandability, actionability were assessed using the Patient Education Materials Assessment Tool (PEMAT) for audiovisual (A/V) materials; information reliability/quality was assessed with DISCERN. Scoring was done by 3 reviewers. Themes, presence of sponsorships, healthcare professionals’ and patients’ narratives were also reported. Results: 101 videos were identified. Of these, 78.2% were sponsored. Average video length was 14.9 minutes (SD 22.5). Majority were posted by nonprofit groups and breast cancer advocacy organizations. Mean PEMAT A/V score was 78.8% (SD 15.3) and 43.1% (SD 45.2) for understandability and actionability, respectively. Overall, videos had moderate reliability and quality levels; mean DISCERN score was 2.44/5 (SD 0.7). Patient narratives were shared in 63.3% and healthcare professionals in 57.4%. Identified themes include treatment (66.3%), family relationship (45.5%), motherhood (37.6%), terminal status (31.6%), the path to diagnosis (28.7%), and spousal relationship (24.7%). Conclusions: YouTube videos about MBC are highly understandable but demonstrate low to moderate rates of actionability, with low reliability and quality scores. Many have a potential commercial bias. More research is needed to evaluate their impact on patient decisions and possible interventions provided by healthcare institutions. [Table: see text]

Nipple-sparing mastectomy (NSM) remains controversial in patients with high-risk breast cancer. The objective of this study was to assess surgical and oncologic outcomes of NSM and to evaluate associations of outcomes with high-risk features.A retrospective review was conducted of all NSM cases performed for breast cancer at 2 academic cancer centers between January 2013 and August 2018.Of the 175 patients who underwent NSM, 13 (7.4%) had locally advanced breast cancer (LABC), 52 (29.2%) had previous neoadjuvant chemotherapy, 21 (12.0%) had previous radiation therapy, 40 (22.8%) received postmastectomy radiation, 27 (15.4%) had de-epithelialized skin reduction, and 13 (7.4%) had free nipple grafting. The median duration of follow-up was 24 months. Nipple necrosis (4 cases; 2.2%) was associated with previous radiation (9.5%; P = .018), skin reduction (11.1%; P = .001), and nipple grafting (15.4%; P = .001). The nipple-areolar complex margin (NAC) was involved with invasive disease in 1 case. Local recurrence occurred in 8 cases (4.6%), with 1 in-NAC recurrence. Overall survival was 98.3%, and disease-free survival (DFS) was 88.6%. LABC was associated with worse DFS (hazard ratio, 4.28; P = .011), with all 4 recurrences being distant.Previous radiation, skin reduction, and nipple grafting are associated with an increased risk of NAC necrosis. None of these should be considered absolute contraindications, but patients should be counseled appropriately. Although LABC is associated with worse DFS, relapses are systemic. Longer follow-up is needed to establish oncologic safety in unselected breast cancer patients.

90 Background: Treatment-related infertility is an important cause of distress in young women with breast cancer (YWBC) that is preventable by fertility preservation (FP) prior to initiating therapy. This study assesses FP service use by YWBC in Quebec (Canada). Methods: Administrative claims for women ≤ 40 diagnosed between 01-04-2012 and 31-03-2018 were identified using Quebec’s universal health services database (RAMQ). Access to and use of FP services were ascertained by identifying claims for a visit with an obstetrician/gynecologist (OB/GYN) ≤ 90 days of diagnosis, followed by claims for ovarian stimulation, ovule harvesting or artificial insemination. Patient, disease and treatment-related predictors were estimated using logistic regression. Results: 1 616 YWBC were treated. Mean age was 36 (SD 4.1), 72.1% had a CCI = 0, 84.5% were urban residents, and 72.2% experienced some form of socioeconomical disadvantages. Stage distribution was: 0.93%, 68.8, and 30.3% for stages 0, 1-2, and 3 respectively. 53.0% had a mastectomy, 40.8% received chemotherapy (CT), 70.7% received radiotherapy, 20.9% initiated anti-estrogen therapy. 387 YWBC consulted an OB/GYN within 90 days of diagnosis and 155 subsequently received FP services. Predictors associated with FP use included: decreased age (OR= 0.82, 95CI = 0.79-0.86), type of surgery (OR = 0.46, CI = 0.22-0.97), social isolation (OR =1.39, 95CI = 0.99-1.96) and receipt of chemotherapy (OR = 1.74, 95CI = 1.10-2.76). Conclusions: Only 23.9% of eligible YWBC in Quebec accessed FP specialists. Of these, 40.1% chose to move forward with FP. These findings raise important questions on how to optimize access to FP expertise. [Table: see text]

Background and Objective Many countries require hospitals to implement medication reconciliation for accreditation, but the process is resource-intensive, thus adherence is poor. We report on the impact of prepopulating and aligning community and hospital drug lists with data from population-based and hospital-based drug information systems to reduce workload and enhance adoption and use of an e-medication reconciliation application, RightRx. Methods The prototype e-medical reconciliation web-based software was developed for a cluster-randomized trial at the McGill University Health Centre. User-centered design and agile development processes were used to develop features intended to enhance adoption, safety, and efficiency. RightRx was implemented in medical and surgical wards, with support and training provided by unit champions and field staff. The time spent per professional using RightRx was measured, as well as the medication reconciliation completion rates in the intervention and control units during the first 20 months of the trial. Results Users identified required modifications to the application, including the need for dose-based prescribing, the role of the discharge physician in prescribing community-based medication, and access to the rationale for medication decisions made during hospitalization. In the intervention units, both physicians and pharmacists were involved in discharge reconciliation, for 96.1% and 71.9% of patients, respectively. Medication reconciliation was completed for 80.7% (surgery) to 96.0% (medicine) of patients in the intervention units, and 0.7% (surgery) to 82.7% of patients in the control units. The odds of completing medication reconciliation were 9 times greater in the intervention compared to control units (odds ratio: 9.0, 95% confidence interval, 7.4-10.9, P Conclusion High rates of medication reconciliation completion were achieved with automated prepopulation and alignment of community and hospital medication lists.

e18656 Background: Medical oncology (MEDONC) requires a combination of skills in collaboration, communication, and professionalism, ultimately delivering technical and clinical knowledge in practice. Standard assessment tools (e.g. written examination, OSCE) are not effective in evaluating competencies beyond technical skills and fail to define the cancer care experience holistically. This explorative, descriptive study aims to identify the potential of unstructured, unsolicited, open access online patient reviews (OPRs) as a tool to assess physician competency. Methods: University-affiliated MEDONCs in Ontario (Canada) were selected. All OPRs were identified on RateMD using every name permutation; physician names and institutional affiliations were removed from comments. A descriptive analysis of the cohort was completed. The CanMEDS Framework, defining physician standards, was used with its hierarchy of roles, concepts, and competencies. Two reviewers, a communication studies researcher and a healthcare professional, independently assessed comments and identified common themes. Competency-level assessments were evaluated using kappa with linear weights. Results: 473 OPRs were identified for 49 MEDONCs (71% male, 29% female). Of these, 23% were written by care providers. Competencies defining roles of Medical Expert, Communicator, and Professional were most prevalent (64%, 38%, and 27% respectively). Agreement levels were high in all roles (wK = 0.71 - 1.00). Themes identified were similar in positive and negative evaluations. Most commonly discussed positive themes were knowledge translation and compassionate interpersonal skills. Most common negative themes centered on lack of humility, compassion, and communication skills. 38% of comments were marked helpful, indicating engagement with other OPRs as a key characteristic of rating tools. In addition to the physician in question, 21% of OPRs reported on healthcare delivery by staff. Conclusions: OPRs emphasize experiential competencies related to interpersonal skills and suggest an alternative format to evaluating such aspects of MEDONC competencies.[Table: see text]

Background Older patients with breast cancer represent a vulnerable population at higher risk of experiencing distress and pain, as well as medication-related adverse events from pharmacological treatment of these symptoms. The purpose of this study is to estimate the prevalence of psychotropic (anxiolytic, antidepressant, and antipsychotic) and opioid medication use by older women diagnosed with breast cancer. Methods This population-based cohort study followed 19,353 women older than 65 years diagnosed with incident, nonmetastatic breast cancer in Quebec, Canada. Data were obtained from provincial, universal health and drug insurance plans covering all medical and pharmaceutical care. Descriptive statistics were calculated for demographic information, breast cancer characteristics, and treatments. Psychotropic and opioid medication use was assessed across the care trajectory: precancer baseline, active care, and first-year survivorship. Results There was a marked increase in the prevalence of medication use from precancer baseline to active care, followed by a decrease into first-year survivorship. Anxiolytics were used most often across the care trajectory (36.3%, 50.6%, and 44.4% at baseline, active care, and survivorship, respectively). In contrast, antipsychotic and opioid medications were sought primarily during active care (4.5- and 7-fold increases from baseline, respectively), with opioid use during active care increasing dramatically over the study period (9.0% to 40.9% from 1998 to 2010). Unlike other drugs, antidepressant use peaked in active care but persisted into survivorship (14.7%, 22.4%, and 22.3% at baseline, active care, and survivorship, respectively). Conclusions A substantial proportion of older patients with breast cancer use psychotropic and opioid medications. The different patterns of medication use represent distress and pain experienced by patients across the care trajectory. Given that medication use in this vulnerable population is associated with an increased risk of adverse events, a multidimensional approach integrating psychological interventions in cancer care may better address psychosocial needs of older patients with breast cancer.

Background: Opioid use is associated with greater health resource utilization, namely unplanned emergency department (ED) visits. The purpose of this study was to characterize ED visit patterns by patients hospitalized for cancer based on their use of prescription opioids in the community. Design & Methods: A prospective cohort study of cancer patients discharged from medical and surgical units at an academic health center in Montreal (Canada) between October 2014 and November 2016 was assembled. The main outcome was frequent ED use (≥4 ED visits) in the year following hospital discharge. Clinical information linked to health administrative claims from the provincial universal health care program (RAMQ) was used in multivariable logistic regression to model patient and opioid prescription characteristics, comparing frequent ED users to non-frequent ED users. Potential predictors included history of chronic pain condition, mental health diagnoses, type of cancer, receipt of radiotherapy/chemotherapy, medication history (previous use of opioids, history of antidepressant use, benzodiazepines), receipt of surgery during the hospitalization as well as characteristics of the discharge prescription (e.g: receipt of an opioid, presence of a multi-modal pain regimen). Results: A cohort of 1253 cancer patients discharged from the medical and surgical units was assembled. The mean age for these patients was 70.9 (11.8) and the most frequent cancers included 488 (38.9%) respiratory and 309 (24.6%) upper digestive cancer. Overall, 54% of cancer patients (n =654) had at least one ED visit in the year post-discharge. Of these, all had filled at least one opioid prescription during the follow-up period. Of patients with at least one ED visit in the one year post-discharge, 29% (n = 188) became frequent ED users. In adjusted multivariable logistic model, the strongest associations of frequent ED use were receipt of chemotherapy one year before their index hospitalization (odds ratio (OR) 1.67; 95% CI: 1.08 - 2.61) and respiratory cancer diagnoses (OR 1.69; 95% CI: 1.07 - 2.67). With respect to opioid prescribing, most the dispensations were for oxycodone (51.4%) and hydromorphone (33.6%). Patients receiving a daily dose >90 MME (morphine milligram equivalents) had an odds ratio of 2.24 (95% CI: 1.14- 4.40) of becoming frequent ED users. Those who filled more than one type of opioid during the follow-up were 1.81 times more likely to become repeated ED users (95% CI: 1.23 - 2.70). Conclusions: Cancer patients with higher opioid use after hospital discharge and active use of more than two different type of opioids within one year time of discharge are at higher risk of encoring unplanned health visits in the ER. A new approach to care planning and coordination is recommended to better monitor opioid prescribing practices and improve outcomes. Citation Format: Siyana Kurteva, Robyn Tamblyn, Ari Meguerditchian. Opioid prescription characteristics associated with frequent emergency department use among hospitalized cancer patients: a comparative cohort study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5769.

Purpose Older Breast Cancer (BC) survivors are an increased risk of osteoporosis due to natural aging and long-term cancer treatment-related toxicity. It is well known that anti-estrogen therapy (AET), especially aromatase inhibitors (AI), is associated with rapid bone loss and thus increases the risk of osteoporosis. This study characterizes patterns and predictors of receiving guideline-recommended bone densitometry (BD) screening at AET initiation. Methods A retrospective cohort study (1998–2012) of all women ≥65 years of age initiating AET was designed using claims data from Quebec's universal health care. Associations with BD screening were estimated using a generalized estimating equations regression model, adjusting for clustering of patients within physicians. Results Among 16,480 women initiating AET, 36.1% received a baseline BD. Among AI users, the rate was 58.4%. In the multivariate analysis, age, lower socioeconomic status, tamoxifen use, lack of periodic health exam and having a general practitioner as the AET prescriber were associated with lower odds of BD screening. In terms of quality of care-related variables, lack of guideline-appropriate radiotherapy (OR: 0.69 (95% CI, 0.57–0.83), or chemotherapy consideration (0.82 (95% CI, 0.71–0.94)) and non-adherence to AET (0.76 (95% CI, 0.68–0.84)) were associated with lower odds of receiving BD screening. Women diagnosed with BC after 2003 had significantly better odds of being screened. Conclusion Despite an increase in rates since 2003, BD screening remains suboptimal, especially for women at higher risk of osteoporosis. Coordination of health care and service-delivery monitoring can potentially optimize long-term management of treatment-related toxicity in older BC survivors.

Objectives: The primary objective of this study was to identify the predictors of new-onset psychological distress available in routinely collected administrative health databases for women diagnosed with breast cancer. The secondary objective was to explore whether the predictors vary based on the period of cancer care. Methods: A population-based cohort study followed 16,495 female patients with newly diagnosed breast cancer who did not experience psychological distress during the 14 months before breast cancer surgery. The incidence of psychological distress was reported overall and by type of mental health problem. Time-varying Cox proportional hazards models were developed to identify predictors of new-onset psychological distress during 2 key periods of cancer care: (1) hospital-based treatment during which women undergo treatment with breast surgery, chemotherapy, and/or radiation, and (2) 1-year transitional survivorship when women begin follow-up care. Results: The incidence of psychological distress was 16% within each period. Anxiety was present in 85.1% and 65.5% of new cases during hospital-based treatment and transitional survivorship, respectively. Predictors during both periods were younger age, receipt of axillary lymph node dissection, rheumatologic disease, and baseline menopausal symptoms, as well as new opioid dispensations, emergency department visits, and hospital contacts that occurred during follow-up. Other predictors varied based on the period of cancer care. More advanced breast cancer and type of treatment were associated with onset of psychological distress during hospital-based treatment. Psychological distress during transitional survivorship was predicted by diagnosis of localized breast disease, shorter duration of hospital-based treatment, receipt of additional hospital-based treatment in survivorship, and newly diagnosed comorbidities or symptoms. Conclusions: This study identified the predictors of new-onset psychological distress available in routinely collected administrative health databases, and showed how predictors change between hospital-based treatment and transitional survivorship periods. The results highlight the importance of developing predictive models tailored to the period of cancer care.

Purpose Unmanaged distress has been shown to adversely affect survival and quality of life in breast cancer survivors. Fortunately, distress can be managed and even prevented with appropriate evidence-based interventions. Therefore, the objective of this systematic review was to synthesize the published literature around predictors of distress in female breast cancer survivors to help guide targeted intervention to prevent distress. Methods Relevant studies were located by searching MEDLINE, Embase, PsycINFO, and CINAHL databases. Significance and directionality of associations for commonly assessed candidate predictors (n ≥ 5) and predictors shown to be significant (p ≤ 0.05) by at least two studies were summarized descriptively. Predictors were evaluated based on the proportion of studies that showed a significant and positive association with the presence of distress. Results Forty-two studies met the target criteria and were included in the review. Breast cancer and treatment-related predictors were more advanced cancer at diagnosis, treatment with chemotherapy, longer primary treatment duration, more recent transition into survivorship, and breast cancer recurrence. Manageable treatment-related symptoms associated with distress included menopausal/vasomotor symptoms, pain, fatigue, and sleep disturbance. Sociodemographic characteristics that increased the risk of distress were younger age, non-Caucasian ethnicity, being unmarried, and lower socioeconomic status. Comorbidities, history of mental health problems, and perceived functioning limitations were also associated. Modifiable predictors of distress were lower physical activity, lower social support, and cigarette smoking. Conclusions This review established a set of evidence-based predictors that can be used to help identify women at higher risk of experiencing distress following completion of primary breast cancer treatment. Electronic supplementary material The online version of this article (doi:10.1007/s10549-017-4290-9) contains supplementary material, which is available to authorized users.

A third of breast cancers (BC) occur in women ≥65 years (seniors). Anti-estrogen therapy (AET) significantly reduces BC recurrence and death. This study characterizes determinants of adherence to AET in seniors with BC. Provincial cancer registry and administrative claims data were accessed for all non-metastatic BC diagnosed in Quebec (1998-2005) to identify seniors treated for 5 years with AET. Multivariate linear regression was used to assess the association with patient, disease, and physician characteristics and the 5-year medication possession ratio (MPR) for each patient. 4,715 women were included (mean age: 72.9). Mean MPR was 83.5%, 79% of patients reached a 5-year MPR of ≥80%, and 34% discontinued AET at some point during treatment. The cumulative probability of discontinuation was 33.8% (mean time to discontinuation 2.3 years). The MPR decreased with increasing age and non-BC related hospitalizations, p < 0.05. Each new medication added during the 5-years decreased the MPR by 0.3% (p < 0.05). Women with in situ disease, on antidepressants at baseline, or treated with Tamoxifen had a lower MPR by 6.5% (p = 0.0002), 4.7% (p = 0.003) and 6% (p = 0.001), respectively. Switching AET type was associated with a lower MPR by 5.3% (p = 0.002) if the switch occurred during the first year. Optimal 5-year adherence to AET in seniors with BC remained a challenge and medication discontinuation rates were high. Advanced age, increasing number of hospitalizations, in situ disease, baseline use of antidepressants, Tamoxifen (versus aromatase inhibitors), early switches of AET type, and newly added medications significantly reduced the MPR.

Aim A prospective phase II study to investigate the feasibility and the rate of complete pathological response (ypT0) after short-course radiotherapy (SCRT) followed by surgery at 8 weeks. Method Operable patients with localized rectal cancer staged T3-4N0/+ or T2N+ were eligible and received 25 Gy (in one-third of patients, the gross tumor volume received a simultaneous integrated boost up to a total of 30 Gy) in five consecutive fractions to the posterior pelvis followed by surgery 8 weeks later. Pathological response and surgical toxicity were assessed in all patients. Results Fifty-two patients (median age 68 years) completed the study. The median distance of the tumour from the anal verge was 6.5 cm. The median interval to surgery was 52 days. Three-quarters of patients underwent a low anterior resection. All underwent complete surgical resection and 100% had pathological negative margins. Ten per cent had stage ypT0 after radiotherapy. The median length of hospital stay was 8 days. Toxicity was comparable with the rates reported in the literature. Conclusion In this study, SCRT followed by delayed surgery was feasible and had acceptable toxicity. All patients underwent complete surgical resection and 100% had negative pathological margins. The rate of ypT0 was 10%.

Importance Adverse drug events (ADEs) account for up to 16% of emergency department (ED) visits and 7% of hospital admissions. Medication reconciliation is required for hospital accreditation because it can reduce medication discrepancies, but there is no evidence that reducing discrepancies reduces ADEs or other adverse outcomes. Objective To evaluate whether electronic medication reconciliation reduces ADEs, medication discrepancies, and other adverse outcomes compared with usual care. Design, Setting, and Participants This cluster randomized trial involved 3491 patients who were discharged from 2 medical units and 2 surgical units at the McGill University Health Centre, Montreal, Quebec, Canada, between October 2014 and November 2016. Data analysis took place from July 2017 to July 2019. Intervention The RightRx intervention electronically retrieved community drugs from the provincial insurer and aligned them with in-hospital drugs to facilitate reconciliation and communication at care transitions. Main Outcomes and Measures The primary outcome was ADEs in 30 days after discharge. Secondary outcomes included medication discrepancies, ED visits, hospital readmissions, and a composite outcome of ED visits, readmissions, and death up to 90 days after discharge. Results Of 4656 eligible patients, 3567 (76.6%) consented to participate (2060 [57.8%] men; mean [SD] age, 69.8 [14.9] years). Overall, 76 patients died during the hospital stay, so 3491 patients were included in the analysis. There was no significant difference in the risk of ADEs between intervention and control groups (76 [4.6%] vs 73 [4.0%]; OR, 0.97; 95% CI, 0.33-1.48), ED visits (433 [26.2%] vs 488 [26.6%]; OR, 0.83; 95% CI, 0.36-1.42), hospital readmission (170 [10.3%] vs 261 [14.2%]; OR, 0.22; 95% CI, 0.06-1.14), or the composite outcome (447 [27.0%] vs 506 [27.6%]; OR, 0.75; 95% CI, 0.34-1.27) at 30 days. Medication discrepancies were significantly reduced in the intervention group compared with the control group (437 [26.4%] vs 1029 [56.0%]; OR, 0.24; 95% CI, 0.12-0.57). Changes made to community medications (OR, 1.05; 95% CI, 1.01-1.10) and new medications (OR, 1.09; 95% CI, 1.01-1.18) were significant risk factors for ADEs. Conclusions and Relevance Electronic medication reconciliation reduced medication discrepancies but did not reduce ADEs or other adverse outcomes. Hospital accreditation should focus on interventions that reduce the risk of adverse events for patients with multiple changes to community medications. Trial Registration ClinicalTrials.gov identifier:NCT01179867

285 Background: Adjuvant endocrine therapy (AET) improves survival in hormone receptor positive breast cancer (HR+BC). Challenges with adherence to AET in seniors are well documented; however, there is limited knowledge on primary non-adherence (PNAD). PNAD is defined as non-initiation of a prescribed medication. Our aim is to characterize PNAD rates in women aged ≥ 65 with HR+BC and identify potential predictors, using real-time treatment information. Methods: Optimum is an e-health platform integrating real-time analysis of administrative claims data combined to patient-level clinical information on breast cancer. Optimum tracks care trajectories to identify deviations from best practice, using data from Quebec’s universal health insurance plan that covers all medical and pharmaceutical care. In this single-center feasibility study, we characterized PNAD as a non-initiation of AET within 10 days from the first prescription. Descriptive analyses were used to assess potential predictors. Results: Of the 57 patients enrolled, 9 were excluded due to lack of > 30 day follow up. In the remaining 48 patients, PNAD was 21 %. Baseline Charlson comorbidity index (0 vs 13 %), psychotropic drug use (20 % vs 26 %) and polypharmacy rate (10 % vs 11 %) were lower in PNAD patients, compared to primary-adherent patients. PNAD patients had larger average tumor size (1.8 cm vs 1.6 cm), more often overexpressing HER2NEU (10 % vs 3 %), more negative progesterone receptor (10 % vs 5 %). They also more often had lumpectomy (70 % vs 65 %), SLNB (70 % vs 58 %) and more frequent margin revisions (30 % vs 16 %). They more often received chemotherapy (30 % vs 0 %). At 30-day follow-up, 40 % of PNAD patients had not yet initiated AET. Conclusions: This study confirms the feasibility of combining real-time administrative data and patient-level clinical information to assess breast cancer quality care. PNAD in women with HR+BC was higher than expected. PNAD patients had less comorbidities and drug use, but more aggressive cancers and more often also had quality challenges with surgical care (margin revision). PNAD predictors can potentially be used to identify patients that may require additional support to optimize disease management.

We report a case of 43-year-old man who presented with an enlarging, painless, palpable mass in the left breast for one year associated with surface blue discoloration of the skin. Mammogram showed a well-defined 2.3-cm mass with microcalcifications. Ultrasound revealed a well-defined, subcutaneous hypoechoic mass adherent to the skin with multiple bright foci. Ultrasound-guided needle biopsy produced a dark-colored sample corresponding to pilomatricoma on final pathology. Bilateral breast magnetic resonance imaging showed heterogeneously hyperintense in T1- and T2-weighted images with heterogeneous enhancement toward the delayed phase. Surgical resection was carried out with wide margins.

A comprehensive geriatric assessment (CGA) provides clinicians with detailed information on a patient's physiological age and may aid in the treatment decision-making process. Conducting a CGA, however, is time-consuming, requiring extensive data collection and, in some cases, the involvement of multiple healthcare professionals. The CGA is also not specifically targeted towards assessing patients presenting with neoplastic pathologies. These limitations have precluded this tool's inclusion in routine oncologic practice involving seniors. In order to identify CGA domains most predictive of important cancer-specific outcomes, we conducted a systematic review (PROSPERO registration number CRD42012002476) using MEDLINE, CINAHL, EMBASE and CANCERLIT databases. Studies published in English or French between May 1997 and May 2012, in which a CGA was conducted in patients over the age of 65 initiating cancer treatment, were assessed for eligibility, of which 9 studies were selected for this review. As part of the inclusion criteria, all studies must have assessed, at minimum, the following domains: nutritional, cognitive and functional status, polypharmacy, comorbidities and the presence of geriatric syndromes. In predicting mortality, in at least one study or another, all of the aforementioned CGA domains were found to be significant. Most frequently, however, the following domains were reported for predicting mortality: nutritional status (HR=1.84-2.54), the presence of geriatric syndromes such as depression (HR=1.51-1.81), and functional status (HR=1.04-1.33). With regards to chemotherapy-related toxicity, similar findings were obtained where functional status (OR=1.71-2.47) and the presence of geriatric syndromes, such as impaired hearing (OR=1.67, 95% CI 1.04-2.69), had the most significant predictive value. Only one study reported on the incidence of post-operative complications for which severe comorbidity was found to be highly associated with experiencing severe complications (OR=5.62, 95% CI 2.18-14.50), while functional status was found to be significantly associated with experiencing any complication (OR=4.02, 95% CI 1.24-13.09).

Objective We tested the hypothesis that the anabolic effect of hypocaloric, isonitrogenous nutrition in patients undergoing colorectal surgery depends on the patient's preoperative catabolic state. Background Although there is evidence to suggest that total parenteral nutrition more effectively spares protein in depleted than in nondepleted cancer patients, the influence of preoperative catabolism on the anabolic effects of hypocaloric nutrition in patients undergoing elective surgery is unknown. Methods Seventeen patients undergoing colorectal surgery received intravenous infusion of glucose with amino acids. Feeding was administered over 72 hours, from 24 hours before until 48 hours after surgery. Glucose provided 50% of the patient's measured resting energy expenditure. Amino acids provided 20% of the resting energy expenditure. Whole-body leucine balance (difference between the incorporation of leucine into protein = protein synthesis and endogenous leucine release = proteolysis) was determined using L-[1-(13)C]leucine kinetics before and 2 days after surgery. We analyzed the association between the postoperative increase in leucine balance and the following factors: preoperative leucine balance, protein breakdown, weight loss, oxygen consumption, circulating concentrations of glucose, free fatty acids, insulin, glucagon, cortisol, albumin, age, duration of surgery, and blood loss. Results Of 6 potentially relevant variables, 4 (weight loss, protein breakdown, albumin, and cortisol) were removed because they were not significant during the stepwise linear regression procedure. Leucine balance and age were the remaining 2 factors that remained with the final regression model: Δleucine balance = 19.1 - (0.20 × age [years]) - (0.58) × leucine balance(preOP)). Conclusions We demonstrate a significant association between the degree of preoperative catabolism, the patient's age, and the anabolic effect of hypocaloric nutrition (ClinicalTrials.gov registration ID: NCT01414946).

Objectives To characterize rates, reasons for, and associated predictors for emergency department (ED) visits after breast cancer (BC) surgery. Methods All women over 65 years undergoing curative surgery for non-metastatic incident BC (1998–2012) were identified using Quebec's universal healthcare administrative databases. Reasons for ED visits within 45 days of operation were reported. Associated factors were estimated using Cox regression. Results Of 24,463 patients, 12.8% had postoperative ED visits. Most frequent reasons were: superficial infection, noninfectious gastrointestinal, trauma or wound (other than breast), noninfectious respiratory, and breast wound disruption. Significant predictors included localized (aHR, 1.24, CI 1.04–1.49) or regional disease (aHR 1.64, CI 1.41–1.92), mastectomy (aHR 1.22, CI 1.10–1.34), each operation before definitive oncologic control (aHR 1.12, CI 1.03–1.21), lower institutional volume (aHR 1.23, CI 1.09–1.38), having 6–10 prescriptions (aHR 1.23, CI 1.15–1.31) or > 10 (aHR 1.53, CI 1.33–1.77), benzodiazepine use (aHR 1.09, CI 1.01–1.18), anticoagulant use (aHR 1.29, CI 1.13–1.46), cardiovascular disease (aHR 1.15, CI 1.05–1.26), diabetes (aHR 1.11, CI 1.00–1.24), past hospitalization (aHR 1.25, CI 1.17–1.34), and lower income (aHR 1.12, CI 1.04–1.20). Conclusion Identification of risk factors in older patients before BC surgery could help prevent postoperative ED visits.

The utility of axillary lymph node dissection after sentinel lymph node biopsy has been called into question. We sought to determine the sensitivity, specificity, and accuracy of axillary ultrasound and fine-needle aspiration biopsy (FNAB) in the identification of axillary nodal metastasis in early breast cancer patients. Data of patients with stage I and II breast cancer who underwent surgery and staging were reviewed. Axillary ultrasound findings were assessed and lymph node status recorded after axillary dissection. The data were cross-tabulated, and test characteristics were calculated. Of 235 patients, none demonstrated more than 2 positive sentinel lymph nodes. Ductal carcinoma was present in 68 %, estrogen and progesterone receptors were positive in 81 and 64 %, respectively, Her-2/neu was positive in 10 %, and 36 % were axillary node positive. The sensitivity and specificity of ultrasound alone were 55 and 88 %, respectively. Predictors of abnormal ultrasound included size of metastasis, estrogen receptor and Her-2 status, tumor grade, and presence of lymphovascular invasion. Addition of FNAB increased the sensitivity and specificity to 69 and 100 %. In conjunction with FNAB, the positive and negative predictive values were 100 and 54 %, respectively. Ten percent of patients with nodal metastases demonstrated a positive FNAB. Patients with a positive FNAB did not harbor more nodal metastases or a greater proportion of gross extranodal disease compared to patients not subjected to FNAB. Axillary ultrasound with FNAB has an accuracy of >70% in this series. It is easily performed and may avoid unnecessary sentinel lymph node biopsy in a significant number of patients.

Objective: Sentinel lymph node frozen section is used to obviate the need for a second operation in breast cancer patients with involved nodes. However, the overall sensitivity, specificity and accuracy of sentinel lymph node frozen section are debated, and the impact of sentinel lymph node frozen section positivity on the risk of additional nodal metastases is not known and was the focus of this investigation. Methods: We used our hospital record system to identify 176 sentinel lymph node biopsies done out of 354 cases of Stage T1-3N0 breast cancers managed from 2005 to 2007 and evaluated the sentinel lymph node frozen section results against the predictions of additional nodal metastases based on the Memorial Sloan-Kettering Breast Cancer Nomogram which is a validated tool for this purpose. Results: Sentinel lymph node metastases size was an independent predictor of sentinel lymph node frozen section sensitivity and those with macrometastases had 15 times the odds (odds ratio, 15.4; 95% confidence interval, 3.4-69.1) of having a true-positive frozen section when compared with those with micrometastases. The breast cancer nomogram predicted that the latter patients have a very low probability of additional nodal metastases with a median probability at 10% (inter-quartile range, 7-14%). Conclusions: A negative sentinel lymph node frozen section is also associated with a low probability of additional nodal metastases. Additional prognostic factors in the breast cancer nomogram are of little clinical impact because the most predictive factor in the nomogram is the method of detection.

Background Effective medication reconciliation is critical in reducing the risk of preventable adverse drug events. Medical trainees are often responsible for medication reconciliation on admission, transfer and discharge of the most vulnerable patients; therefore, it is important that trainees are educated on this aspect of quality care. Methods We conducted a systematic review using MEDLINE and EMBASE databases to identify education initiatives targeted at improving trainee skill and knowledge in carrying out medication reconciliation. Studies published in English or French between July 1980 and July 2013, where the primary focus of the article was the role of medical trainees in conducting medication reconciliation, and where trainee-specific data was reported, were included. Included articles must have reported trainee-specific data. Given the anticipated heterogeneity and array of outcomes, we were unable to employ a specific tool in assessing the risk of bias across studies. Results Seven studies met pre-specified eligibility criteria, indicating the lack of published education initiatives targeted towards improving trainee knowledge and experience. Four described an education intervention targeted towards students completing internal medicine clerkship, while the remaining 3 were implemented among residents. Although no two interventions were the same, 5 out of 7 included an experiential component. Conclusions Varying success was achieved with medication reconciliation education interventions. While some noted improved competence and/or confidence amongst trainees, namely undergraduate medical students, others noted little effect resulting from the intervention.

Background Treatment with bisphosphonates in women with breast cancer and established bone metastasis delays further skeletal-related events. Evidence is emerging that bisphosphonates are beneficial for secondary prevention of bone metastasis. The study aimed to estimate the effect of oral bisphosphonates for treatment or prevention of osteoporosis on development of bone metastasis in a population of women with breast cancer. Methods A historical cohort of 21664 women diagnosed with breast cancer was created from health administrative data in Quebec, Canada. The primary outcome was time to develop bone metastasis; exposure was bisphosphonate use prediagnosis, postdiagnosis, both, or neither and a cumulative index of drug exposure. The sample was stratified according to stage (0-II or III) at time of diagnosis. Cox proportional hazards tested the effect of bisphosphonate use on time to develop bone metastases. Results Taking bisphosphonates postdiagnosis of breast cancer only or continuing bisphosphonates started prior to diagnosis after diagnosis was associated with a reduction in risk of bone metastasis from 45% to 28% in women with local disease at diagnosis. In women with regional disease, postdiagnosis bisphosphonate use, with or without prediagnosis use, reduced risk by almost 50%. A statistically significant dose-response trend was observed relating increased use to lower risk (slope = 0.94, 95% confidence interval = 0.90 to 0.99). Bisphosphonates were also associated with a decreased risk of all-cause mortality similar to that of the development of bone metastasis. Conclusion Low-dose oral bisphosphonates administered for prevention or treatment of postmenopausal osteoporosis were associated with lower risk of skeletal metastasis in patients with early- or more advanced-stage breast cancer.

The development of colorectal cancer is characterized by a multitude of molecular events that can occur through the pathways of loss of heterozygosity, microsatellite instability, and CpG-island methylation. The accumulation of these molecular events ultimately results in polyps formed from previously normal mucosa to develop the fundamental characteristics of cancerization: uncontrolled proliferation, growth, and invasion. Advances in the understanding of molecular events leading to colorectal cancer have led to the development of biomarkers, patient-specific and tumor-specific molecular signatures that have potential as tools for accurate risk assessment, personalized treatment planning, development of targeted agents, and evaluation of treatment response.

Background Medication reconciliation at admission, transfer and discharge has been designated as a required hospital practice to reduce adverse drug events. However, implementation challenges have resulted in poor hospital adherence. The aim of this study was to assess the processes required to carry out medication reconciliation: the health professionals involved, the tasks and time devoted to medication reconciliation in general hospital settings. Methods A time-and-motion study design was used. Using a systematic sample of patients admitted and discharged from geriatric, medical and surgical units in two academic centers, health professionals involved in medication reconciliation were observed and timed. Descriptive statistics were used to summarize the number of professionals involved, tasks performed, and mean time devoted. Results Up to 3 professionals from 2 disciplines (medicine and pharmacy) were involved in the medication reconciliation process. Geriatric reconciliations took the most time to complete at admission (mean: 92.2 minutes (SD = 44.3)) and discharge (mean: 29.0 minutes (SD = 23.8)), followed by internal medicine at admission (mean: 46.2 minutes (SD = 21.1)) and 19.4 (SD = 11.7) minutes at discharge) and general surgery minutes at discharge (mean: 9.9 minutes (SD = 18.2)). Considerable differences in order, type and number of tasks performed were noted between and within units. Tasks independent of direct patient interaction took more than twice the time required to complete than tasks requiring patient interaction. Conclusion Lack of coordination, specialized training and agreement on the roles and responsibilities of professionals are among the most probable reasons for work-flow inefficiencies, possibly variability in quality, and time required for the current medication reconciliation process. A better understanding of the admission processes in general surgery is required. Standardization and use of electronic tools could improve efficiency and hospital adherence.

Background: In women with hormone receptor positive breast cancer, adjuvant endocrine therapy (AET) is associated with a significant survival advantage. Nonadherence is a particular challenge in older women, even though they stand to benefit the most from AET. Therefore, a novel eHealth tool (OPTIMUM) that integrates real-time analysis of health administrative claims data was developed to provide point-of-care decision support for clinicians. Objectives: The objectives of the study are to determine the effectiveness of a patient-specific, real-time eHealth alert delivered at point-of-care in reducing rates of AET discontinuation and to understand patient-level factors related to AET discontinuation as well as to assess integration of eHealth alerts regarding deviations from best practices in administration of AET by cancer care teams. Methods: A prospective, 2-group controlled comparison pilot study will be conducted at 2 urban, McGill University–affiliated hospitals, the Royal Victoria Hospital and St. Mary’s Hospital. A minimum of 43 patients per study arm will be enrolled through site-level allocation. Follow-up is 1.5 years. Health care professionals at the intervention site will have access to the eHealth tool, which will report to them in real-time medical events with known associations to AET discontinuation, an AET adherence monitor, and a discontinuation alert. Cox proportional hazard ratios with 95% confidence intervals will estimate risks of AET discontinuation. Tests for significance will be 2-sided with a significance level of P

72 Background: Aromatase inhibitors (AI) improve recurrence and survival rates in women ≥ 65 with hormone-receptor positive (HR+) breast cancer (BC). However, AI’s are associated to increased bone demineralization in a population already at risk for osteoporosis. Bone mineral densitometry (BMD) is therefore recommended at treatment start, to minimize treatment-related toxicity. This study assesses compliance to BMD recommendations in older BC survivors treated with an AI and identifies predictors of non-adherence to guidelines. Methods: A population-based historical prospective cohort study was conducted in Quebec (Canada), where universal health insurance provides medical and pharmaceutical services. All women ≥ 65 with incident stage I, II or III BC (1998-2012) were identified from the provincial cancer registry. Administrative claims were accessed to track receipt of BMD (±12 months from treatment start) and potential predictors: age, economic status, Charlson comorbidity index, breast and axillary surgery, chemotherapy, radiotherapy, bisphosphonate use, adherence to anti-estrogen therapy (AET), physician specialty and having a primary care physician (PCP). Multivariate logistic regression was performed using generalized estimating equations to identify predictors of BMD, adjusting for clustering within physicians. Results: Of 16,480 patients, 36.1% had a BMD at AET start. This increased to 58.4% for women on AI. Factors predicting baseline BMD non-use in AI patients were: older age (OR 0.42; 95% CI, 0.36 – 0.49), lower annual income (OR 0.57; 95%CI, 0.47 – 0.70), not having a PCP (OR 0.77; 95%CI, 0.68 – 0.86), chemotherapy and radiotherapy outside of guidelines (OR 0.80; 95%CI, 0.66 – 0.96 and 0.69; 95%CI, 0.54 – 0.87, respectively), non-surgical specialist managing AET (OR 0.81; 95%CI, 0.67 – 0.98), older physicians (OR 0.61; 95% CI, 0.46 – 0.81), and non-adherence to AET (OR 0.69; 95%CI 0.60-0.79). The same predictors persisted in patients on any AET. Conclusions: Bone health management in seniors receiving AET is suboptimal. Factors related to underutilization of BMD can be easily identified and used to optimize chronic care of older BC survivors.

Radiotherapy (RT) after breast conserving surgery (BCS) represents the standard for local control of breast cancer (BC). However, variations in practice persist. We aimed to characterize the rate of RT consideration (or referral) after BCS and identify predictors in Quebec, Canada, where universal health insurance is in place. A historical prospective cohort study using the provincial hospital discharge and medical services databases was conducted. All women with incident, non-metastatic BC (stages I–III) undergoing BCS (1998–2005) were identified. Odds ratios (ORs) and 95 % confidence intervals (CIs) for RT consideration were estimated with a generalized estimating equations regression model, adjusting for clustering of patients within physicians. Of the 27,483 women selected, 90 % were considered for RT and 84 % subsequently received it. Relative to women 50–69 years old, younger and older women were less likely to be considered: ORs of 0.82 (95 % CI 0.73–0.93) and 0.10 (0.09–0.12), respectively. Emergency room visits and hospitalizations unrelated to BC were associated with decreased odds of RT consideration: 0.85 (0.76–0.94) and 0.83 (0.71–0.97). Women with regional BC considered for chemotherapy were more likely to be considered for RT: 3.41 (2.83–4.11). RT consideration odds increased by 7 % (OR of 1.07, 95 % CI 1.03–1.10) for every ten additional BCSs performed by the surgeon in the prior year. Social isolation, comorbidities, and greater distance to a referral center lowered the odds. Demographic and clinical patient-related risk factors, health service use, gaps in other aspects of BC management, and surgeon’s experience predicted RT consideration.

Background Adverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem. Methods/Design Participants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units. Discussion The goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors. Trial registration NCT01179867