Initial presentation of lung cancer in the emergency department: a descriptive analysis

BACKGROUND

Guidelines aimed at improving care for lung cancer, the leading cause of cancer-related death in Canada and worldwide, require accurate knowledge of the diagnostic setting or pathway. We sought to determine how often lung cancer is initially diagnosed through the emergency department.

METHODS

We performed a descriptive study that included all cases of primary lung cancer diagnosed in residents of Nova Scotia in 2014. Cancer registry data included diagnostic data and date of death to Aug. 31, 2016. We reviewed linked hospital records, including laboratory and imaging results, to identify the first positive diagnostic study and the route of presentation (emergency department v. other). We evaluated time from diagnosis to death as a function of presentation route using Kaplan-Meier curves and Cox regression (hazard rate ratios [HRRs]).

RESULTS

Sufficient data were available for 946 of 951 cases identified, of which 336 (35.5%) were diagnosed through the emergency department. Cases diagnosed via the emergency department were more likely to be at an advanced stage (stage IV, 59.5% v. 43.4%), with patients experiencing shorter survival (1-yr survival, 28.4% v. 49.5%), including stage-specific survival. Mortality for cases diagnosed in the emergency department was 54% higher than for the non-emergency department group after adjusting for age and stage (HRR 1.54, 95% confidence interval 1.32-1.81). Few patients (7.1%, n = 24) who presented to the emergency department reported having no family physician.

INTERPRETATION

The emergency department is a common route of presentation for lung cancer and is associated with advanced stage at diagnosis and reduced survival time. Strategies are needed to encourage pre-emergent diagnosis and to ensure that emergency providers are supported in the initial care of patients with lung cancer.

Impact of Detection Method and Age on Survival Outcomes in Triple-Negative Breast Cancer: A Population-Based Cohort Analysis

BACKGROUND

Most investigations have compared triple-negative breast cancer (TNBC) to non-TNBC to elucidate clinical or epidemiologic differences between subtypes. We examined a contemporary cohort of patients with primary TNBC by detection and age at diagnosis within a population-based breast screening program to examine survival outcomes.

PATIENTS AND METHODS

All women with a diagnosis of primary TNBC between January 1, 2005, and December 31, 2012, in Nova Scotia, Canada, were included. Clinicopathologic and detection variables were abstracted from the Nova Scotia Breast Screening Program. Patient charts were abstracted for adjuvant therapies and survival outcomes, supplemented by provincial vital statistical data.

RESULTS

A total of 412 patients comprised the study population, with almost half aged over 60 years (46.3%) and 30.2% having screen-detected disease. There were no significant differences in prognostic variables between age groups. Younger patients were more likely to receive adjuvant chemotherapy (96.3% ≤ 49 years vs. 31.2% ≥ 70 years), but there were no differences in disease-free or breast cancer-specific survival between the age groups. For those with disease recurrence, median time to recurrence and death was shorter for younger patients (17 vs. 26 months, 16 vs. 33 months respectively; age 40-49 vs. 70+). Those with screen-detected disease had better disease-free, breast cancer-specific, and overall survival outcomes.

CONCLUSION

Detection method may play a role in TNBC survival outcomes, thus supporting novel screening strategies for TNBC. Shorter time to survival events in the younger patient groups suggests that TNBC is a clinically heterogeneous disease despite similarities in prognostic factors across age.

Utility of relative and absolute measures of mammographic density vs clinical risk factors in evaluating breast cancer risk at time of screening mammography

OBJECTIVE

Various clinical risk factors, including high breast density, have been shown to be associated with breast cancer. The utility of using relative and absolute area-based breast density-related measures was evaluated as an alternative to clinical risk factors in cancer risk assessment at the time of screening mammography.

METHODS

Contralateral mediolateral oblique digital mammography images from 392 females with unilateral breast cancer and 817 age-matched controls were analysed. Information on clinical risk factors was obtained from the provincial breast-imaging information system. Breast density-related measures were assessed using a fully automated breast density measurement software. Multivariable logistic regression was conducted, and area under the receiver-operating characteristic (AUROC) curve was used to evaluate the performance of three cancer risk models: the first using only clinical risk factors, the second using only density-related measures and the third using both clinical risk factors and density-related measures.

RESULTS

The risk factor-based model generated an AUROC of 0.535, while the model including only breast density-related measures generated a significantly higher AUROC of 0.622 (p < 0.001). The third combined model generated an AUROC of 0.632 and performed significantly better than the risk factor model (p < 0.001) but not the density-related measures model (p = 0.097).

CONCLUSION

Density-related measures from screening mammograms at the time of screen may be superior predictors of cancer compared with clinical risk factors.

ADVANCES IN KNOWLEDGE

Breast cancer risk models based on density-related measures alone can outperform risk models based on clinical factors. Such models may support the development of personalized breast-screening protocols.

Trends and characteristics of compensated occupational cancer in Ontario, Canada, 1937-2003

BACKGROUND

In Canada, administrative databases maintained by provincial workers' compensation boards are often the best or the only available data source for describing trends and characteristics of occupational cancer. In Ontario, approximately 75% of the labor force is covered by the Ontario Workplace Safety and Insurance Board (WSIB) and allowed cancer claims date back to 1937.

METHODS

The purpose of this study was to describe WSIB-allowed cancer claims by worker demographics, claim characteristics, year of filing, cancer type, and work exposure measures including workplace agent, occupation and industry.

RESULTS

In total, claims were filed and compensated for one or more malignant neoplasms by, or on behalf of, 3,126 workers between 1937 and 2003.

CONCLUSIONS

Results show trends in cancer compensation reflecting changes in the characteristics and prevalence of workers exposed to workplace carcinogens, as well as changes to WSIB adjudication policies over time.

The fatty acid amide hydrolase C385A (P129T) missense variant in cannabis users: studies of drug use and dependence in Caucasians

A genetic variation in fatty acid amide hydrolase (FAAH), C385A (P129T), has been previously associated with risk for problem street drug use. FAAH is a mammalian enzyme that inactivates neuromodulatory-signaling lipids including the endogenous cannabinoid 1 receptor agonist anandamide. We investigated in adult Caucasians (N = 749) whether this FAAH variant altered the risk for trying, regular use of or dependence on cannabis, alcohol or nicotine, traditional "gateway" drugs. Consistent with our knowledge that the A/A genotype results in reduced FAAH expression and activity in humans, subjects with the A/A genotype were less likely to be THC dependent than subjects with either a C/C or C/A genotype (11% vs. 26%, P < 0.05). No association was observed between the A/A genotype and risk for alcohol or tobacco regular use, or DSM IV dependence. Controlling for regular use of nicotine and sedatives, both identified as confounders, those with the A/A genotype were at significantly reduced risk for being THC dependent (OR 0.25, 95% CI: 0.07-0.88) as compared with those with the C/A or C/C genotype, supporting a link between alterations in the endocannabinoid system and THC dependence. Unexpectedly, we found an increased risk for regular use of sedatives among the A/A genotype group. The relationship between the FAAH A/A genotype and risk for drug dependence in this study was drug class specific, suggesting it is not part of a more general drug abuse effect. These results, particularly the observation of altered risk for sedative drug use, should be investigated further in multiple ethnic populations.

Methods for estimating the labour force insured by the Ontario Workplace Safety and Insurance Board: 1990-2000

This paper presents a methodology for estimating the size and composition of the Ontario labour force eligible for coverage under the Ontario Workplace Safety & Insurance Act (WSIA). Using customized tabulations from Statistics Canada's Labour Force Survey (LFS), we made adjustments for self-employment, unemployment, part-time employment and employment in specific industrial sectors excluded from insurance coverage under the WSIA. Each adjustment to the LFS reduced the estimates of the insured labour force relative to the total Ontario labour force. These estimates were then developed for major occupational and industrial groups stratified by gender. Additional estimates created to test assumptions used in the methodology produced similar results. The methods described in this paper advance those previously used to estimate the insured labour force, providing researchers with a useful tool to describe trends in the rate of injury across differing occupational, industrial and gender groups in Ontario.

Work-related population health indicators

OBJECTIVE

To provide evidence-based recommendations for work-related population health indicators.

METHODS

Drawing on a framework of work-related experiences, we systematically reviewed studies that assess the association between these experiences and health and reviewed related measures at the population level that could be used as indicators.

RESULTS

We recommend (and grade the strength of evidence supporting our recommendation for) the following indicators for which data are already routinely collected: unemployment rate (strong), long-term unemployment rate (limited), and permanent lay-off rate (limited). As well, we recommend and grade our support for the following new indicators: insecurity associated with pending job loss (limited), with possible major organizational change (limited), and with actual major organizational change (limited); and job strain (medium).

CONCLUSION

These evidence-based indicators can be used to monitor work-related determinants of health and thus to inform the conceptualization, development, and evaluation of policies and programs related to these determinants.

Work-related population health indicators

OBJECTIVE

To provide evidence-based recommendations for work-related population health indicators.

METHODS

Drawing on a framework of work-related experiences, we systematically reviewed studies that assess the association between these experiences and health and reviewed related measures at the population level that could be used as indicators.

RESULTS

We recommend (and grade the strength of evidence supporting our recommendation for) the following indicators for which data are already routinely collected: unemployment rate (strong), long-term unemployment rate (limited), and permanent lay-off rate (limited). As well, we recommend and grade our support for the following new indicators: insecurity associated with pending job loss (limited), with possible major organizational change (limited), and with actual major organizational change (limited); and job strain (medium).

CONCLUSION

These evidence-based indicators can be used to monitor work-related determinants of health and thus to inform the conceptualization, development, and evaluation of policies and programs related to these determinants.

Iron-induced pigment formation and ionizing radiation resistance in three strains of Micrococcus violagabriellae

Three strains of Micrococcus violagabriellae-Littlepig, Pig (Parental), and Superpig--were studied. The pulcherrimin pigment (which imparts a violet-red color to the colonies of the Parental and Superpig strains) is produced only when the cells are grown in the presence of excess iron and provides a unique system for the study of the radioprotection conferred by a pigment. Cell suspensions of each of the three strains (initially grown in the presence and in the absence of excess iron) were exposed to gamma rays and plated on media containing an excess of iron and on media without iron. The survival curves of the treated strains indicate a correlation between the color intensity of the pigment (pulcherrimin), and the ability of the organisms to survive moderate doses of ionizing radiation. Studies using radioactive iron (59Fe) showed that a correlation also exists between the intensity of the pigment and the amount of iron that the cells of each strain can remove from the medium. The effect of gamma irradiation on postirradiation cell growth is discussed for each strain irradiated during logarithmic growth and during a stationary state.

Selenite reduction by Salmonella heidelberg

When Salmonella Heidelberg is grown in 0.1% w/v Na2SeO3and examined microscopically during growth, two morphological changes can be seen. Red intracellular granules are seen in most of the population within 10 to 12 hours, and organisms containing granules elongate without cell division. The intracellular granules produced by S. heidelberg in selenite broth have been identified by X-ray analysis as amorphous red selenium. The intermediate in the conversion of selenite to elemental selenium has been trapped and identified as divalent selenium ion. Growth studies have shown that selenite toxicity is primarily associated with the lag phase of growth, and also that the divalent intermediate is more toxic than the tetravalent precursor.