Implementation of an integrated cancer care network

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Background: In 1998, the province of Quebec adopted its cancer control program (CP). Its goal was to establish a hierarchical and integrated cancer network of interdisciplinary teams. In 2004, a team evaluation process was initiated by the Direction de la lutte contre le cancer (ministry of health) to help implement this program. Methods: The evaluation consisted of completion of a matrix by the requesting team, a visit by a multidisciplinary group of experts and a report card. Three levels of expertise were assessed: core (all), regional (regional hospitals), and supraregional (tumor specific/complex situations). The matrix was based on the fundamental orientations of the CP, thus setting the framework for patient centered care. The conformity indicators were mainly structural and process oriented. In order to be evaluated for the subsequent mandates, teams had to conform to the core mandate. Those who did not succeed had one year to reapply. Mandates are for 4 years. Results: Teams were able to comply with most of the elements of the evaluation matrix. Sessions for clarification and coaching about this new interdisciplinary approach were necessary and helpful. A total of 153 visits were done:70 for core, 8 for regional and 75 for supraregional mandates respectively. Major health institutions such as university hospitals applied for multiple supraregional team designation. In all, 130 teams had their designation confirmed. This process highlighted some common weaknesses such as the lack of use of data for quality control. Conclusions: Acceptance of this hierarchical cancer care model was facilitated by the fact that it was in line with the integrated health care network of Quebec. The evaluation process has had an impact on the way cancer care is delivered in Quebec. This initial phase has helped implement an interdisciplinary patient centered model of care in line with the CP. Participation of different experts has also helped foster knowledge transfer and appropriation of the process. Impact on patient care and satisfaction remains to be assessed. An initial patient's questionnaire has been completed in 2008 and will serve as a control to future surveys.

No significant financial relationships to disclose.

Characterization of autocrine inducible prostaglandin H synthase-2 (PGHS-2) in human osteosarcoma cells

The human osteosarcoma 143.98.2 cell line was found to express high levels of prostaglandin synthase-2 (PGHS-2) without detectable levels of prostaglandin synthase-1 (PGHS-1) as measured by reverse transcriptase-polymerase chain reaction (RT-PCR) and immunoblot analysis. Maximal levels of PGHS-2 induction were attained when the cells were grown beyond confluence. The osteosarcoma cells also secrete IL-1 alpha, IL-1 beta and TNF alpha in the culture medium. PGHS-2 expression was inducible by the exogenous addition of these cytokines as well as conditioned media from auto-induced cultures and inhibitable by treatment with dexamethasone. In contrast, undifferentiated U937 cells selectively express PGHS-1 as analyzed by RT-PCR and Western blotting. The effects of non-steroidal anti-inflammatory drugs (NSAIDs) on the cellular PGE2 production mediated by each isoform of human PGHS were determined using osteosarcoma and undifferentiated U937 cells. When cells were preincubated with inhibitors to allow time-dependent inhibition prior to arachidonic acid stimulation, NS-398, CGP 28238, L-745,337, SC-58125 all behaved as potent (IC50 = 1-30 nM) and selective inhibitors of PGHS-2, in contrast to indomethacin, flurbiprofen or diclofenac which are potent inhibitors of enzymes. DuP-697 and sulindac sulfide were also potent inhibitors of PGHS-2 but both compounds inhibited cellular PGHS-1 activity at higher doses (IC50 = 0.2-0.4 microM). Time-dependent inhibition of PGE2 production in osteosarcoma cells was observed for indomethacin, diclofenac and etodolac. The synthesis of PGE2 by U937 cells was strongly dependent on exogenous arachidonic acid (100-fold stimulation) whereas confluent osteosarcoma cells also produced PGE2 without exogenous stimulus (7-fold stimulation by arachidonic acid). Osteosarcoma cells grown beyond confluence released more PGE2 from endogenous substrate than arachidonic acid stimulated undifferentiated U937 cells. These results indicate that osteosarcoma cells selectively express PGHS-2 with an autocrine regulation and effective utilization of endogenous arachidonic acid for PGE2 synthesis.

Altered sensitivity of aspirin-acetylated prostaglandin G/H synthase-2 to inhibition by nonsteroidal anti-inflammatory drugs

Aspirin (ASA) acetylates Ser516 of prostaglandin G/H synthase-2 (PGHS-2) resulting in a modified enzyme that converts arachidonic acid to 15(R)-hydroxy-eicosatetraeroic acid [15(R)-HETE]. ASA has pharmacological benefits that may not all be limited to inhibition of prostaglandin synthesis, and this study was initiated to further investigate the properties of ASA-acetylated PGHS-2 and of the mutation of Ser516 to methionine, which mimics ASA acetylation. Both the S516M mutant and ASA-acetylated form of PGHS-2 (ASA-PGHS-2) synthesize 15(R)-HETE and have apparent K(m) values for arachidonic acid within 10-fold of the apparent K(m) value for untreated PGHS-2. The time courses of turnover-dependent inactivation were similar for reactions catalyzed by PGHS-2 and ASA-PGHS-2, whereas the PGHS-2(S516M) showed a decrease in both the initial rate of 15-HETE production and rate of enzyme inactivation. The production of 15-HETE by modified PGHS-2 was sensitive to inhibition by most nonsteroidal anti-inflammatory drugs (NSAIDs), including selective PGHS-2 inhibitors. As observed for the cyclooxygenase activity of PGHS-2, the inhibition of 15-HETE production by indomethacin was time-dependent for both ASA-PGHS-2 and PGHS-2(S516M). However, two potent, structurally related NSAIDs, diclofenac and meclofenamic acid, do not inhibit either ASA-PGHS-2 or the PGHS-2(S516M) mutant. These results demonstrate that the sensitivity to inhibition by NSAIDs of the 15-HETE production by ASA-treated PGHS-2 is different than that of prostaglandin production by PGHS-2 and that Ser516 plays an important role in the interaction with fenamate inhibitors. The results also indicate that the conversion of arachidonic acid to 15-HETE by ASA-PGHS-2 is an efficient process providing a unique mechanism among NSAIDs that will not lead to arachidonic acid accumulation or shunting to other biosynthetic pathways.

Alzheimer's disease: preliminary study of spatial distribution at birth place

Alzheimer's disease (AD) is a neurodegenerative disorder which is characterized by a progressive loss of memory and the alteration of cognitive functions. At least three chromosomal segments have been associated with early-onset AD in genetic linkage studies. These results argue for a certain degree of heterogeneity in the genetic origin of some forms of AD, although environmental risk factors cannot be ruled out in late-onset AD. In this preliminary study, we analyzed the geographical distribution of the birth places of a sample of 235 AD cases born in a defined region of Quebec (Canada), between 1895 and 1935. We wished to test the hypothesis that risk factors acting at, or around birth place and time play a role in the etiology of AD. The field of study was divided into rural and urban areas. A reference population of live births was used to compute a measure of odds ratio (OR). The OR results showed a statistically significant excess of AD cases in the rural area as compared to the reference population. When stratified for sex, the OR results showed a global excess of female AD cases in both the rural and the urban areas. For men, only the urban area presented a statistically significant deficit. We also analyzed the structures of the genealogical kinships of the rural and urban sub-groups. Although AD cases from the rural sub-group were more closely related to each other than those from the urban one, removal of the kin pairs from the OR analysis seemed to have little effect on the rural/urban distribution of cases. Therefore, the OR results would not appear to be due primarily to a difference in the kinship structures of the two sub-groups. This could mean that some risk factors for AD afflict women more strongly than men, the effect being different depending on the urban or rural origin. However, potential biases such as a higher rate of report for women, differential migration between birth places or a differential mortality ratio between sexes could produce spurious results in the direction of what we have observed in this preliminary study.

Myotonic dystrophy: clinical assessment of muscular disability in an isolated population with presumed homogeneous mutation

We evaluated the muscular disability of 295 patients affected by the adult form of myotonic dystrophy (DM) and living in the Saguenay-Lac-Saint-Jean region (Quebec, Canada). The patients are known to have a common ancestral couple, and a homogeneous DM mutation is presumed. Using a five-point muscular disability rating scale (MDRS), we confirmed, in each age group, the wide expressivity of the muscular involvement usually observed in DM. Based on the duration of the disease and the MDRS, we also found a great variation in the rate of disease progression. There were no significant relationships between the rate of disease progression and the sex of the patient, the sex of the affected parent, or the age at onset of the disease. Furthermore, there was an absence of association between the age at onset and the sex of the patient or the sex of the affected parent. The variable severity of the muscular involvement, and the absence of relationship between age at onset and rate of disease progression, suggest a multiallelic influence at the DM locus or at other loci.

[Preliminary results on the residence distribution at birth of patients with Alzheimer's disease in the Saguenay-Lac-Saint-Jean/Quebec (the IMAGE project)]

The IMAGE Project is pursuing the establishment of a population-based registry of Alzheimer's disease (AD) cases in the Saguenay-Lac-Saint-Jean (SLSJ) (Quebec). The authors report on the spatial distribution at birth of 221 possible, probable and definite cases. A large network of key-informants for screening AD cases has been established over SLSJ. The spatial distribution of cases at birth and at the onset of disease has been computed by calculating the Alzheimer birth rate (ABR) on the basis of three scales: six specific geographical spheres of screening, all municipalities, and the public health departments. The statistical significance of results was determined using the theoretical Poisson and the Chi square distributions. ABR for each of the geographical spheres of screening showed no statistically significant differences considering either residence at the onset of the disease or residence at birth. Furthermore, differences were observed between rural and urban areas with an interesting trend for a higher number of cases than expected in one area of SLSJ. The spatial distribution of cases considered on the basis of residence at birth appears to show a different pattern, but no significant, from that measured on the basis of residence at the onset of disease. Screening of cases is actively being pursued all across SLSJ by the IMAGE network. There is a clear trend towards rural residence at birth of cases. It remains to see whether or not this observation is due to a geographical concentration of familial cases.

Partial syndrome of myotonic dystrophy: clinical presentation and follow-up

The neurological and ophthalmological investigation of 602 members of 88 Saguenay kindreds affected by myotonic dystrophy (MyD) revealed 130 persons with a partial syndrome. These patients, whose average age was 34.1 years, showed different abnormalities such as particular ophthalmic and/or neuro-muscular signs, suggesting MyD in the absence of myotonia or typical lens abnormalities. After an average period of 2.4 years, 44 of these 130 patients were reassessed by the same neurologists and ophthalmologists. Thirty still had a partial syndrome, 8 showed a typical form of MyD and 6 no longer presented any identifiable anomaly. This preliminary follow-up study of the partial MyD syndrome did not allow us to identify any clinical anomaly from which the presence of the MyD gene could be predicted in a significant way. It furthermore suggested that the identification of equivocal or unspecific signs among these patients can sometimes lead to misdiagnosis. This must be taken into account when providing genetic counselling. It furthermore indicates that the use of DNA probes is essential for a reliable identification of asymptomatic MyD gene carriers.

Familial factors in Alzheimer's disease (IMAGE project). A case-control study in the Saguenay-Lac-St-Jean region (Quebec, Canada)

Alzheimer's disease is now recognized as a major public health problem. Many hypotheses have tried to explain the etiology of Alzheimer's disease and, among them, genetic factors are considered one of the most plausible. A case-control study of familial factors, including sex distribution, age at onset, birth order, parental age, fertility, mortality, inbreeding and kindship, was conducted on 130 clinically diagnosed patients born in the Saguenay-Lac-St-Jean region (Quebec, Canada). The cases were screened by the IMAGE project. Our results showed that most factors studied are not associated with Alzheimer's disease. Inbreeding was found to be slightly increased in the Alzheimer group. Kindship was higher in the Alzheimer group than in the control groups, therefore confirming that familial predisposition is a very important risk factor.