Breast reconstruction has been demonstrated to have a positive impact in many facets of a woman’s life. Specifically, improved confidence, self-image, sexual relationships, body acceptance and even success in the workplace are evident in women who have undergone reconstruction. Despite this, less than 15% of Canadian women undergo reconstruction following breast cancer; this is one of the lowest rates in developed countries. While there are many contributing factors, information about reconstruction and access to reconstruction are two areas that are clearly modifiable. As a new Regional Breast Community of Practice priority, we are striving to improve on these factors for both immediate and delayed reconstruction.
Immediate reconstruction occurs at the same time as the surgical oncologist addresses the breast cancer in the operating room. These procedures involve working as a surgical team to allow women to initiate their reconstruction right at the time of their mastectomy. Alternatively, in delayed reconstruction, women undergo surgical management of their cancer, as well as any adjuvant therapies, and then have reconstruction at a later date. Unfortunately there are significant wait times for patients seeking delayed reconstruction due to limited resources, insufficient surgeons providing reconstruction, and priority being placed on patients who have active cancer or who are at high risk.
The breast reconstruction initiative will strive to improve information about breast reconstruction to all practitioners involved in breast cancer care. Specifically we aim to educate referring physicians about the options for breast reconstruction and the availability of various reconstructive methods within our region. We also aim to improve access to reconstruction and to shorten our wait lists for this important aspect in the care of women with breast cancer.
Article written by: Dr. Kirsty Usher Boyd
With improved breast imaging and earlier detection of cancer, more than a third of breast cancers are not palpable. Before surgery, a breast specialty radiologist must use image guidance (ultrasound or mammography) to place a small wire in the breast. The wire must be inserted on the same day as the surgery and at the same hospital, which requires the patient to travel within the hospital with a wire hanging out of her breast.
A new technique to localize breast cancers for surgery called radioactive seed localization (RSL) has been developed. Instead of using a wire, the radiologist inserts a tiny seed the size of a grain of rice into the breast cancer. The seed is embedded with a minuscule dose of radioactivity, i125. Not harmful to the patient or environment, the seed allows the surgeon to identify the tumor at surgery at least as well as a wire. The benefit for the patient is that she may have the seed placed in her tumor several days before the day of surgery. It decreased her anxiety, and improves scheduling of surgery.
Dr. Jean Seely and Dr. Carolyn Nessim have led a committed team of radiologists, breast surgeons, pathologists, nuclear medicine physicians, radiation safety officers, and administrators in developing the protocols and training: Dr. Jon Aro, Dr. Denis Gravel, Dr. Hung Tan, Dr. Lionel Zuckier, Jennifer Smylie and Paula Doering. Approval by the Canadian Nuclear Safety Commission to start the program was obtained in March 2015. The Ottawa Hospital RSL program began in April 2015.
Article written by: Dr. Jean Seely and Dr. Carolyn Nessim
The Champlain Regional Primary Care Cancer Program presents its Cancer Update 2015, an annual event for family physicians and other primary care providers.
- When: Friday, December 4, 2015 from 8:30 am – 4:00 pm (breakfast and registration start at 7:30 am)
- Where: Ottawa Conference & Event Center, 200 Coventry Road, Ottawa
Meet with regional experts and learn more about a range of cancer care topics including:
- Early Detection, Diagnosis, and Management of Lung Cancer
- Is it Cancer? – Insights into Hematuria
- Is it Cancer? – Thyroid Nodules
- What’s new in Colposcopy
- Building a Quality Culture in your Practice
Plenary session: The Great Debate: Prostate Cancer Screening and Treatment
Register online at cancerupdate2015.eventbrite.ca or send a fax to 613-728-6333 with your name and contact information. Registration cost is $65 including breakfast and lunch.
This program is being reviewed by the College of Family Physicians of Canada and is awaiting final accreditation by the College’s Ontario Chapter.
Yes, according to this article which describes the effectiveness of a 2 year balance training program to prevent fall induced injuries in women at risk for falls.
This is one of the first randomized control trials to show a decrease in injuries from falls with an intensive exercise program. The participants also had a better perception of their overall physical health than the control group.
Exercise and Falls Prevention in Champlain
Fortunately there are exercise and fall prevention programs available in our region. For Ottawa residents, take a look at the Better Strength, Better Balance program with sessions starting in September.
Information on other exercise and falls prevention classes in the region is available on Champlainhealthline.ca.
Finally, your patients may be interested in these fun falls prevention videos from Ottawa Public Health.
Motivational Interviewing can be an effective tool employed by health practitioners to help patients come to their own decisions and plans about quitting smoking
This webinar, provided by the Smoking Cessation Leadership Centre, in collaboration with the American Academy of Family Physicians, will:
- Describe how the “spirit” or underlying perspective of motivational interviewing can be applied to smokers
- Explain how to speak with smokers who may not be ready to quit
- Describe how to elicit “change talk” from tobacco users
Date and Registration
The webinar will take place on Wednesday, July 22, 2015 from 2 pm to 3:30 pm EDT.
To register or learn more, visit the Smoking Cessation Leadership Centre website.
Colonoscopy is an essential component of colorectal cancer (CRC) screening. Colonoscopy is generally a very safe procedure but growing demands for screening-related colonoscopy challenges us to provide high-quality colonoscopy at minimal risk to patients.
CRC screening has clear benefits in terms of reducing the mortality and incidence of CRC. However, every patient undergoing a screening colonoscopy is at risk of potential complications. These could be direct procedural-related complications such as perforation or bleeding. Or they could be bowel preparation- related complications, or any number of secondary complications such as cardiac ischemia, or the consequences of missed lesions. In contrast symptomatic patients undergoing the same investigation have a more balanced benefit-to-risk ratio.
Quality of Colonoscopy
Broadly speaking there are two key components of colonoscopy: 1) examining the colon to the cecum completely, safely, and comfortably; and 2) the detection of adenomas and more advanced lesions and their subsequent complete removal.
There are several validated indicators of colonoscopy quality. Cecal intubation rate (CIR) is the percentage of cases the colonoscope is advanced beyond the ileocecal valve into the cecal pole and/or the terminal ileum. The target CIR is 95%. Having a high CIR ensures adequate visualization and reduces the need for repeat procedures and additional investigations. High CIR with maintained high patient comfort rates, and low perforations rates, are auditable measures of the skill of endoscopy technique.
High levels of polyp, and more importantly adenoma detection rates (ADR), are defined as the proportion of patients that have at least one adenoma identified and removed during colonoscopy. For screening colonoscopies, the ADR should be at least 20%. High ADR’s correlate with low levels of missed and interval cancers.
Ontario has adopted a minimal number of colonoscopies per year (200) as a surrogate of the other measured outcomes.
Complications of colonoscopy
Complications of colonoscopy include bleeding, perforation, sedation-related complications, and bowel prep-induced complications (dehydration, metabolic disturbances, seizures and falls). The generally accepted rate of perforation is less than 1 in 2000 screening colonoscopies (<0.05%). Some consider this rate to be high, and aim for 1 perforation per 5000 colonoscopies. Bleeding is more common, occurring in 1 in 500 colonoscopies with polypectomy. Sedation-related complications are more commonly seen when reversal agents are given. US studies indicate that the use of propofol for colonoscopy is associated with a risk of aspiration pneumonia of as high as 1 in 500.
Quality of the patient experience
It is important to consider the patient journey through endoscopy services, including the pre-procedural interventions, the level of empathy and respect shown by all staff, and the post-procedural aspects. The care of patients following an endoscopy is critical for a good patient experience and for safety and quality reasons. This includes the immediate post- procedure recovery and discharge, with post-procedure patient education. A clear plan should exist for the follow-up of pathology, and that evidence-based guidelines are followed for recall colonoscopies that are based on the polyp size and pathology. This information also needs to be clearly communicated to the primary care physician.
Quality is a critical component of the CRC screening pathway. While there is often a concentration on scoping procedural quality, the pre and post- procedural components also need to be of high quality. Lastly, effective communication of post-procedural care and follow-up to primary care physicians is critical for the appropriate re-entry of patients into the screening or surveillance cycles.
Article written by: Dr. Alaa Rostom, Regional Colorectal Screening GI and Endoscopy Lead
A Screening Activity Report (SAR) is now available from Cancer Care Ontario (CCO) as a tool to support CCM, FHG, FHO and FHN family physicians.
The SAR provides a comprehensive summary of patients’ breast, cervical, and colorectal cancer screening history. It can help you to improve cancer-screening rates and to organize appropriate follow-up of patients. It can also help you to calculate preventive care service payments.
A series of videos demonstrating the new SAR enhancements are available at www.cancercare.on.ca/SAR.
In our region, Champlain, ONE ID registration is on the rise with 440 family physicians (56% of family physicians in patient enrollment models) registered to access their SAR.
Note that the Ontario Breast Screening Program’s client report that you have been receiving in the past is no longer available. However, you can obtain this information from the SAR.
If you are not yet registered for, or would like more information on the SAR, please visit www.cancercare.on.ca/SAR. You can also contact Julie de Loë at 613-728-6508 ext. 238 to obtain more information about your registration with ONE ID.
The MyQuit program is designed to support anyone interested in quitting smoking or cutting back their tobacco use. The program is free of charge and is delivered by coaches who are trained in the latest techniques to help people successfully stop smoking.
MyQuit offers a few different types of coaching: one on one at a clinic or by telephone, group coaching and an online program.
Services are offered in locations across the Champlain region from 7 am – 9 pm. Many clients will choose to use one of the available quit smoking medications and may be eligible to access these medications at a reduced cost (e.g. nicotine replacement therapy).
The MyQuit program is the result of a partnership between eight local health care partners including the University of Ottawa Heart Institute, the Champlain Regional Cancer Program, Ottawa Public Health, Eastern Ontario Health Unit, Renfrew County and District Health Unit, Leeds, Grenville & Lanark District Health Unit, Smokers’ Helpline and Mackay Manor Renfrew County Addiction Treatment.
Colorectal cancer (CRC) is the second most common cancer in men and the third most common cancer in women.
Ontario has a colorectal cancer screening program called ColonCancerCheck (CCC). The program recommends that those between the ages of 50 and 74 with no personal or family history of CRC be screened using the fecal occult blood test (FOBT) every two years. For individuals at increased risk due to one or more first degree relative(s) with CRC, it recommends colonoscopy starting at the age of 50, or 10 years earlier than the age at which their relative was diagnosed, whichever comes first.
The overall participation to CRC screening in Ontario remains low. In 2012, 57.8% of at-risk Ontarians were up-to-date with CRC screening (FOBT, colonoscopy and flexible sigmoidoscopy) – 58.7% in the Champlain LHIN.
Different screening modalities
There is strong evidence (level one) that screening with FOBT every 1-2 years reduces CRC mortality by 16%. In 2011-2012, 29.9% of eligible Ontarians completed at least one FOBT during the two-year period; the Champlain LHIN had the highest rate of FOBT screening (35.5%).
The FOBT is relatively simple, cheap and accessible. However, the FOBT has been criticized for its low sensitivity. This limitation has prompted many CRC screening programs in Canada and in Europe to use the fecal immunochemical test (FIT) as entry-level CRC screening test instead of the FOBT.
The FIT is an immunoassay that detects the presence of human blood in stools. It can detect much lower amounts of blood than the FOBT does, it is not affected by dietary changes, and it is more specific for colonic sources of blood.
In 2010, Cancer Care Ontario (CCO) and Program in Evidence-Based Care (PEBC) formed the FIT Guidelines Expert Panel to review and evaluate the evidence for FIT CRC screening. The panel concluded that FIT has a greater sensitivity for detecting cancer, a much greater sensitivity for detecting advanced adenoma, and that it achieves higher screening participation rates.
CCO is working with the Ministry of Health and Long-Term Care to develop a plan to fund and implement FIT in the CCC program as the recommended screening test for those at average-risk of developing CRC.
There is also strong evidence to support the use of flexible sigmoidoscopy (FS) in persons at average risk for CRC.
FS every 5 years or once in a lifetime has been shown to decrease CRC incidence by about 20% and CRC mortality by 25%. The anticipated harms associated with FS (including follow-up colonoscopy for those with positive tests) are small and are outweighed by the benefits. CCO has piloted the Registered Nurse Flexible Sigmoidoscopy (RNFS) program, with sites in several regions, including the Montfort Hospital and The Ottawa Hospital.
Colonoscopy remains the gold standard intervention for follow- up of individuals with abnormal screening tests. However, there are no randomized controlled trials of the effectiveness and safety of colonoscopy for average risk screening.
CT colonography use for population-based screening has not been studied, although a Canadian economic evaluation revealed its use, for population-based screening, would be more resource intensive than an endoscopy-based or FOBT- based screening program. By comparison with colonoscopy, it is as good at detecting polyps that are greater than 1 cm in size, but less sensitive for smaller polyps.
Serologic blood tests for CRC screening, such as the Cologic test, are being promoted by some laboratories. The scientific evidence is insufficient to recommend or endorse their use, and as such, CCO is not able to offer a recommendation on follow-up of abnormal results.
In summary, CRC is one of the leading causes of cancer- related morbidity and mortality in Ontario. Screening can effectively reduce the risk of these harms. Although there are multiple tests available for CRC screening, there is strong evidence in support of only a few such tests in the context of an organized, population-based, screening program. CCC currently recommends that average-risk individuals aged 50 to74 be screened with FOBT every 2 years.
Article written by: Dr. Catherine Dubé, Provincial Clinical Lead, ColonCancerCheck
Meet Drs. Catherine Dubé and Alaa Rostom, your new regional resources for cancer services in the Champlain LHIN.
Dr. Catherine Dubé is currently the Clinical Lead for ColonCancerCheck, Ontario’s colorectal cancer screening program. She is a gastroenterologist who obtained her medical degree from the University of Montréal in 1989, where she also completed a master’s degree in pharmacology (1990). She completed her fellowships in Internal Medicine (1993) and Gastroenterology (1995) as well as a master’s degree in Clinical Epidemiology (1999) at the University of Ottawa. She was Associate Clinical Professor of Medicine at the University of Calgary from 2006-2013 and is currently a Staff Physician at The Ottawa Hospital and an Associate Professor of Medicine at the University of Ottawa.
Dr. Dubé was Medical Lead for the Alberta Colorectal Cancer (CRC) Screening Program from 2011-2013, where she led the implementation of the fecal immunochemical test (FIT). She also participated in the work of the Canadian Partnership Against Cancer (CPAC) to define pan-Canadian quality determinants for CRC screening programs, and steered a Canadian Consensus on endoscopy safety and quality indicators for the Canadian Association of Gastroenterology.
She currently leads the Canadian Association of Gastroenterology’s initiative to implement a patient-centered quality improvement program in endoscopy based on the use of the UK’s Endoscopy Global Rating Scale (GRS).
Dr. Alaa Rostom returns to Ottawa from the University of Calgary where he spent the last 7 years in the planning and implementation of the Calgary zone colorectal cancer screening program. He held several positions in Calgary including deputy chief division of gastroenterology, zone medical director of the Alberta colorectal screening program and medical director of the Colon Cancer Screening Centre. Dr Rostom was also the chair of the RCPSC Exam Board for Gastroenterology and the chair of education for the Canadian Association of Gastroenterology (CAG).
Dr. Rostom is Chair and Chief of the Division of Gastroenterology, and also Regional Lead for colorectal screening and endoscopy. He is actively involved in measuring and evaluating endoscopy quality and technology. He developed the first validated clinical instrument for the evaluation of comfort/safety during colonoscopy. He helped initiate the CAG’s endoscopy train-the-trainers program as well as the endoscopy master’s program. He currently co-chairs the CAG’s endoscopy maintenance of competency and upskilling program.