CONTEXTE : Pour limiter la propagation de la maladie a coronavirus 2019 (COVID19), de nombreux pays ont decide de reduire le nombre d'interventions chirurgicales non urgentes, ce qui a cree des ...retards en chirurgie partout dans le monde. Notre objectif etait d'evaluer l'ampleur du retard pour ce type d'interventions en Ontario, au Canada, ainsi que le temps et les ressources necessaires pour y remedier. METHODES : Nous avons consulte 6 bases de donnees administratives decrivant la population ontarienne et canadienne pour degager la distribution du volume chirurgical et de la cadence des salles d'operation pour chaque type d'interventions et chaque region, et con naitre la duree d'occupation d'un lit d'hopital et d'un lit de soins intensifs. Les donnees utilisees concernent l'ensemble ou une partie de la periode du 1er janvier 2017 au 13 juin 2020. Nous avons estime l'ampleur du retard accumule et predit le temps necessaire pour le reprendre dans un scenario avec capacite d'appoint de + 10% (ajout d'un jour a 50% de la capacite par semaine) a l'aide de modeles de series chronologiques, de modeles de files d'attente et d'une analyse de sensibilite probabiliste. RESULTATS : Entre le 15 mars et le 13 juin 2020, le retard en chirurgie a l'echelle de l'Ontario s'est accru de 148 364 operations (intervalle de prevision a 95% 124 508-174 589) au total, et en moyenne de 11 413 operations par semaine. Pour reprendre le retard accumule, il faudra environ 84 semaines (intervalle de confiance IC a 95% 46-145) et une cadence hebdomadaire de 717 patients (IC a 95% 326-1367), qui elle demande 719 heures passees au bloc operatoire (IC a 95% 431-1038), 265 lits d'hopital (IC a 95% 87-678) et 9 lits de soins intensifs (IC a 95% 4-20) par semaine. INTERPRETATION : L'ampleur du retard en chirurgie du a la COVID-19 laisse entrevoir de graves consequences pour la phase de reprise en Ontario. Le cadre qui nous a servi a modeliser la reprise du retard peut etre adapte ailleurs, avec des donnees locales, pour faciliter la planification.
An increasing proportion of patients (> 30%) with node-positive breast cancer will obtain an axillary pathologic complete response after neoadjuvant chemotherapy (NAC). If sentinel node (SN) biopsy ...(SNB) is accurate in this setting, completion node dissection (CND) morbidity could be avoided.
In the prospective multicentric SN FNAC study, patients with biopsy-proven node-positive breast cancer (T0-3, N1-2) underwent both SNB and CND. Immunohistochemistry (IHC) use was mandatory, and SN metastases of any size, including isolated tumor cells (ypN0i+, ≤ 0.2 mm), were considered positive. The optimal SNB identification rate (IR) ≥ 90% and false-negative rate (FNR) ≤ 10% were predetermined.
From March 2009 to December 2012, 153 patients were accrued to the study. The SNB IR was 87.6% (127 of 145; 95% CI, 82.2% to 93.0%), and the FNR was 8.4% (seven of 83; 95% CI, 2.4% to 14.4%). If SN ypN0(i+)s had been considered negative, the FNR would have increased to 13.3% (11 of 83; 95% CI, 6.0% to 20.6%). There was no correlation between size of SN metastases and rate of positive non-SNs. Using this method, 30.3% of patients could potentially avoid CND.
In biopsy-proven node-positive breast cancer after NAC, a low SNB FNR (8.4%) can be achieved with mandatory use of IHC. SN metastases of any size should be considered positive. The SNB IR was 87.6%, and in the presence of a technical failure, axillary node dissection should be performed. We recommend that SN evaluation with IHC be further evaluated before being included in future guidelines on the use of SNB after NAC in this setting.
To mitigate the effects of coronavirus disease 2019 (COVID-19), jurisdictions worldwide ramped down nonemergent surgeries, creating a global surgical backlog. We sought to estimate the size of the ...nonemergent surgical backlog during COVID-19 in Ontario, Canada, and the time and resources required to clear the backlog.
We used 6 Ontario or Canadian population administrative sources to obtain data covering part or all of the period between Jan. 1, 2017, and June 13, 2020, on historical volumes and operating room throughput distributions by surgery type and region, and lengths of stay in ward and intensive care unit (ICU) beds. We used time series forecasting, queuing models and probabilistic sensitivity analysis to estimate the size of the backlog and clearance time for a +10% (+1 day per week at 50% capacity) surge scenario.
Between Mar. 15 and June 13, 2020, the estimated backlog in Ontario was 148 364 surgeries (95% prediction interval 124 508-174 589), an average weekly increase of 11 413 surgeries. Estimated backlog clearance time is 84 weeks (95% confidence interval CI 46-145), with an estimated weekly throughput of 717 patients (95% CI 326-1367) requiring 719 operating room hours (95% CI 431-1038), 265 ward beds (95% CI 87-678) and 9 ICU beds (95% CI 4-20) per week.
The magnitude of the surgical backlog from COVID-19 raises serious implications for the recovery phase in Ontario. Our framework for modelling surgical backlog recovery can be adapted to other jurisdictions, using local data to assist with planning.
The consolidation of surgical practices has been suggested to improve patient outcomes for complex surgeries. In 2005, Ontario Health-Cancer Care Ontario released the Thoracic Surgical Oncology ...Standards to facilitate the regionalization process at thoracic centers in Ontario, Canada. This work describes the quality-improvement process involved in updating the minimum surgical volume and supporting requirement recommendations for thoracic centers to further optimize patient care for esophageal cancer.
We conducted a literature review to identify and synthesize evidence informing the volume–outcome relationship related to esophagectomy. The results of this review and esophageal cancer surgery common indicators (reoperation rate, unplanned visit rate, 30-day and 90-day mortality) from Ontario's Surgical Quality Indicator Report were presented and reviewed by a Thoracic Esophageal Standards Expert Panel and Surgical Oncology Program Leads at Ontario Health-Cancer Care Ontario. Hospital outliers were identified, and a subgroup analysis was conducted to determine the most appropriate minimum surgical volume threshold based on 30- and 90-day mortality rates data from the last 3 fiscal years.
Based on the finding that a significant decrease in mortality occurred at 12 to 15 esophagectomies per year, the Thoracic Esophageal Standards Expert Panel reached a consensus that thoracic centers should perform a minimum of 15 esophagectomies per year. The panel also recommended that any center performing esophagectomies have at least 3 thoracic surgeons to ensure continuity in clinical care.
We have described the process involved in updating the provincial minimum volume threshold and the appropriate support services for esophageal cancer surgery in Ontario.
Display omitted
Pathological response of breast cancer to chemotherapy is a prognostic indicator for long-term disease free and overall survival. Responses of locally advanced breast cancer in the neoadjuvant ...chemotherapy (NAC) settings are often variable, and the prediction of response is imperfect. The purpose of this study was to detect primary tumor responses early after the start of neoadjuvant chemotherapy using quantitative ultrasound (QUS), textural analysis and molecular features in patients with locally advanced breast cancer.
The study included ninety six patients treated with neoadjuvant chemotherapy. Breast tumors were scanned with a clinical ultrasound system prior to chemotherapy treatment, during the first, fourth and eighth week of treatment, and prior to surgery. Quantitative ultrasound parameters and scatterer-based features were calculated from ultrasound radio frequency (RF) data within tumor regions of interest. Additionally, texture features were extracted from QUS parametric maps. Prior to therapy, all patients underwent a core needle biopsy and histological subtypes and biomarker ER, PR, and HER2 status were determined. Patients were classified into three treatment response groups based on combination of clinical and pathological analyses: complete responders (CR), partial responders (PR), and non-responders (NR). Response classifications from QUS parameters, receptors status and pathological were compared. Discriminant analysis was performed on extracted parameters using a support vector machine classifier to categorize subjects into CR, PR, and NR groups at all scan times.
Of the 96 patients, the number of CR, PR and NR patients were 21, 52, and 23, respectively. The best prediction of treatment response was achieved with the combination mean QUS values, texture and molecular features with accuracies of 78%, 86% and 83% at weeks 1, 4, and 8, after treatment respectively. Mean QUS parameters or clinical receptors status alone predicted the three response groups with accuracies less than 60% at all scan time points. Recurrence free survival (RFS) of response groups determined based on combined features followed similar trend as determined based on clinical and pathology.
This work demonstrates the potential of using QUS, texture and molecular features for predicting the response of primary breast tumors to chemotherapy early, and guiding the treatment planning of refractory patients.
Purpose
Phyllodes tumors are rare breast neoplasms with limited prospective data to guide treatment, leading to heterogeneous management of this disease. We developed National consensus statements ...using modified Delphi methodology including patients and practitioners across Canada.
Methods
Statements were developed based on a literature review. Two iterations of surveys were distributed with a planned virtual consensus meeting. Panelists were invited from surgery, radiation oncology, medical oncology, pathology, radiology, and plastic surgery.
Results
Twenty-three participants attended the virtual conference. One hundred statements regarding diagnostics, pathology, surgical planning, adjuvant therapies, recurrence, surveillance, and patient support were approved with an a priori defined consensus of ≥ 80%. Two tables on locoregional management were developed and approved. The management of borderline phyllodes tumors was a source of uncertainty, and recommendations reflect the lack of evidence in this rare presentation.
Conclusion
A consensus document containing all approved statements for the care and management of phyllodes tumors was developed to help guide practice and future research.
To evaluate whether the early identification of patients who may benefit from palliative care impacts on the use of palliative, community and acute-based care services.
Between 2014 and 2017, ...physicians from eight sites were encouraged to systematically identify patients who were likely to die within one year and would were thought to benefit from early palliative care. Patients in the INTEGRATE Intervention Group were 1:1 matched to controls selected from provincial healthcare administrative data using propensity score-matching. The use of palliative care, community-based care services (home care, physician home visit, and outpatient opioid use) and acute care (emergency department, hospitalization) was each evaluated within one year after the date of identification. The hazard ratio (HR) in the Intervention Group was calculated for each outcome.
Of the 1,185 patients in the Intervention Group, 951 (80.3%) used palliative care services during follow-up, compared to 739 (62.4%) among 1,185 patients in the Control Group HR of 1.69 (95% CI 1.56 to 1.82). The Intervention Group also had higher proportions of patients who used home care 81.4% vs. 55.2%; HR 2.07 (95% CI 1.89 to 2.27), had physician home visits 35.5% vs. 23.7%; HR 1.63 (95% CI 1.46 to 1.92) or had increased outpatient opioid use 64.3% vs. 52.1%); HR 1.43 (95% CI 1.30 to 1.57. The Intervention Group was also more likely to have a hospitalization that was not primarily focused on palliative care (1.42 (95% CI 1.28 to 1.58)) and an unplanned emergency department visit for non-palliative care purpose (1.47 (95% CI 1.32 to 1.64)).
Physicians actively identifying patients who would benefit from palliative care resulted in increased use of palliative and community-based care services, but also increased use of acute care services.
PDF
