This study evaluated the impact of province-wide treatment guidelines on consistency of adjuvant therapy for node-negative breast cancer. A retrospective population-based cohort study was conducted in the Canadian provinces of British Columbia, which has province-wide guidelines, and Ontario, which does not. All eligible 1991 incident cases of node-negative breast cancer in British Columbia (n = 942) and a similar number of randomly selected 1991 incident cases in Ontario (n = 938) were reviewed. Consistency of adjuvant therapy received was evaluated by stratifying cases into discrete diagnostic groups using several grouping systems, and by then comparing the distribution of treatments received within each diagnostic group in the two provinces. Recursive partitioning was also performed. We observed that patterns of pathology reporting were consistent with awareness of the factors used in the British Columbia guidelines to define indications for adjuvant therapy. Consistency of care was greater in British Columbia than in Ontario by all diagnostic grouping systems and by recursive partitioning (P
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The British Columbia (BC) Cervical Cytology Screening Programme (CCSP), implemented since 1955, has resulted in a 75% decrease in both the mortality from and incidence of invasive squamous cervical carcinoma. However, despite this effect, the Native Indian population still present an overall mortality rate four times higher than that of the non-Native population. A demonstration project was initiated in four Native Indian Band communities of BC to determine the reasons underlying these findings. The participation patterns to the CCSP were investigated and revealed that the overall percentage of participation to the CCSP among Native Indian women was 30% lower than that of the non-Native population. Reasons for the under-participation to the CCSP were explored. A total of 36 women, 9 in each of the 4 communities, including current users, ex-users and never users, were interviewed. Reasons for not participating in the CCSP were due mainly to (1) the lack of knowledge about the Pap test and about its importance; (2) feelings of embarrassment and shamefulness; (3) lack of continuity of care due to the high turnover of physicians in the Native communities. Based on the study findings, a pilot CCSP clinic will be implemented in each community. In addition to taking cervical smears, this pilot project will include education sessions, notification about the results of the test, and recall for annual check up.
We report our experiences in the first 15 months of a government-funded pilot project begun in 1988 to study the feasibility of rapid throughput, low-cost screening mammography in British Columbia. The primary goals of the project were (1) to determine the unit cost of screening mammography within the context of the program; (2) to design and put into operation a centralized system of data collection, analysis, and quality control to enable calculations of cancer detection rates, biopsy rates, biopsy yield ratios, staging, and other specific cancer characteristics; and (3) to study compliance in the community where the program was offered. A total of 11,824 women had mammography at a unit cost of U.S. $32.66. Computerized analysis revealed that (1) 11% of women had known primary risk factors; (2) findings on mammograms were interpreted as abnormal in 9% of screening examinations; (3) breast cancers were confirmed in 47 (22%) of 211 patients who had biopsies, and 87% of these were stage 0-1. The overall cancer detection rate was four per 1000, with five per 1000 for women who had not had mammography in the preceding 2 years and one per 1000 for women who had had mammography in the past 2 years. The results show that screening mammography can be conducted at low cost. Data collection and analysis and compliance were sufficiently convincing to initiate province-wide expansion.
Cervical cancer mortality remains high in Canadian Native women in British Columbia. Underutilization of the Provincial Cytology Screening Program by Canadian Native women has been documented. Another potential factor is the quality of specimens obtained. Proportions of unsatisfactory smears and smears lacking endocervical cells, which reflect the sampling technique, were compared between Canadian Native and other British Columbian women. The findings suggest that differences in the quality of cytologic smears do not explain the observed discrepancy in cervical cancer mortality between Canadian Native and non-Native populations.
To determine Pap smear screening rates among urban First Nations women in British Columbia; to identify facilitators and barriers; and to develop, implement, and evaluate specific interventions to improve Pap smear screening in Vancouver.
Computer records of band membership lists and the Cervical Cytology Screening Program registry were compared to determine screening rates; personal interviews and community meetings identified facilitators and barriers to urban screening programs. A community advisory committee and the project team collaborated on developing specific interventions.
Purposive sample of British Columbia First Nations women, focusing on women living in Vancouver.
Poster, art card, and follow-up pamphlet campaign; articles in First Nations community papers; community meetings; and Pap smear screening clinics for First Nations women.
Pap smear screening rates among BC First Nations women according to residence and reasons for not receiving Pap smears.
Pap smear screening rates were substantially lower among First Nations women than among other British Columbia women; older women had even lower rates. No clear differences were found among First Nations women residing on reserves, residing in Vancouver, or residing off reserves elsewhere in British Columbia. Facilitators and barriers to screening were similar among women residing on reserves and in Vancouver. Many First Nations women are greatly affected by health care providers' attitudes, abilities to provide clear information, and abilities to establish trusting relationships.
Family physicians are an important source of information and motivation for Pap smear screening among First Nations women.
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The relationship between cigarette smoking and risk of prostate cancer was examined in a case-control study conducted in Ontario and British Columbia, Canada. In each centre, cases were men with a histologically confirmed diagnosis of adenocarcinoma of the prostate notified to the provincial cancer registry. In Ontario, controls were selected randomly from assessment lists maintained by the Ontario Ministry of Revenue and were frequency matched to the cases on age. In British Columbia, controls were also frequency matched to the cases on age and were selected randomly from a roster maintained by the Medical Services Plan of British Columbia. The study in Ontario was conducted between April 1990 and April 1992, and that in British Columbia was conducted between January 1989 and December 1991. In all, the study included 408 cases (207 in Ontario and 201 in British Columbia) and 407 controls (207 in Toronto and 200 in British Columbia (one case was unmatched). Overall, there was little variation in risk of prostate cancer with pack-years of cigarette consumption (filter and non-filter cigarettes combined), and there was no evidence for an effect confined to filter or non-filter cigarettes. There was some evidence for a positive association with non-filter cigarettes in British Columbia, but on formal testing for heterogeneity, this finding was not inconsistent with the absence of an association in Ontario. There was also little variation in risk by years since first smoked or (for ex-smokers) by years since quitting. These data provide little support for an association between cigarette smoking and prostate cancer risk.
The association between cigarette smoking and cervical cancer has been demonstrated in numerous prior studies. As part of population-based case-control studies of cancers of the vulva, vagina, cervix, anus, and penis in relation to infection with human papillomavirus, conducted in western Washington State and the province of British Columbia from the mid 1980s until the present time, the authors have collected detailed information on smoking history. The proportion of subjects who were current smokers of cigarettes ranged from slightly over 40% among incident cases of vaginal and cervical cancer to 60% among cases of vulvar and anal cancer. In contrast, only about 25% of controls were current smokers. The adjusted odds ratios (OR) associated with current smoking were substantially elevated (OR = 1.9-14.6) for all cancer sites except cancer of the vagina (OR = 1.3). The risks tended to increase in proportion to the number of cigarettes smoked. For most cancer sites, the odds ratios associated with former smoking were substantially less than those associated with current smoking and diminished with increasing time since cessation of smoking. The authors' data and those of other investigators suggest that cigarette smoking plays a role in the etiology of anogenital cancers and that smoking has a late-stage or promotional effect.
Practice guidelines for cancer management have been in use in the province of British Columbia (BC), Canada, since the mid 1970s. To evaluate practice guideline compliance, treatment received was compared with treatment recommended in a population-based cohort of women with breast cancer.
All incident cases (n = 939) of invasive, pathologically node-negative breast cancer diagnosed in 1991 were identified from the BC Cancer Registry. Treatment details were abstracted from cancer clinic records for cases referred to the BC Cancer Agency (BCCA) (n = 661) and original source documents for nonreferred cases. Management decisions were considered compliant if the patient received the recommended treatment or was entered onto a randomized trial of the modality being assessed.
Overall compliance with adjuvant therapy guidelines was 97% for radiotherapy, 96% for chemotherapy, and 89% for tamoxifen. An oncology specialist was consulted by 94% of patients with an indication for adjuvant treatment and by 58% of those without an indication (odds ratio [OR] = 10.7; 95% confidence interval, 7.0 to 16.4). Compliance with a guideline to deliver radiotherapy was 95%; with chemotherapy, 77%; and with tamoxifen, 68%. Compliance with a guideline that stated no adjuvant treatment was indicated was 99% for radiotherapy, 98% for chemotherapy, and 92% for tamoxifen. Noncompliance among patients with an indication for treatment was related to nonreferral to an oncology specialist and less complete implementation of guideline changes in the community as compared with cancer center practices.
Compliance was high, but scheduled updating and more effective community implementation could further improve consistency of care.