Melanie Walker

Dietary patterns and risk of prostate cancer in Ontario, Canada

Dietary patterns reflect combinations of dietary exposures, and here we examine these in relation to prostate cancer risk. In a case‐control study, 80 incident primary prostate cancer cases and 334 urology clinic controls were enrolled from 1997 through 1999 in Kingston, Ontario, Canada. Food‐frequency questionnaires were completed prior to diagnosis and assessed intake in the 1‐year period 2–3 years prior to enrollment. Among controls, dietary intake was used in principal components analyses to identify patterns that were then evaluated with all subjects in relation to prostate cancer risk using unconditional logistic regression, controlling for age. Four dietary patterns were identified: Healthy Living, Traditional Western, Processed and Beverages. Increased prostate cancer risk is apparent in relation to the Processed pattern, composed of processed meats, red meats, organ meats, refined grains, white bread, onions and tomatoes, vegetable oil and juice, soft drinks and bottled water. The OR for the highest tertile compared to baseline is 2.75 (95% CI 1.40–5.39), with a dose–response pattern (trend test p < 0.0035). Our results suggest that a dietary pattern including refined grain products, processed meats and red and organ meats contributes to increased prostate cancer risk. Since dietary information was collected before subjects knew their diagnosis, recall bias was avoided.

Comparison of toxicity associated with early morning versus late afternoon radiotherapy in patients with head-and-neck cancer: a prospective randomized trial of the National Cancer Institute of Canada Clinical Trials Group (HN3).

PURPOSE Based on our demonstration of a circadian rhythm in the human oral mucosa cell cycle, with most cells in the G(1) phase in the morning and M phase at night, we hypothesized that morning radiotherapy (RT) would lead to less oral mucositis than afternoon RT. METHODS AND MATERIALS A total of 216 patients were randomized to morning (8-10 AM) vs. afternoon (4-6 PM) RT and stratified by radiation dose, smoking status, and center. Patients receiving primary or postoperative RT alone were eligible. Oral mucositis was scored using the Radiation Therapy Oncology Group (RTOG) criteria and a validated scoring system. RESULTS Of 205 evaluable patients, 52.9% vs. 62.4% developed RTOG Grade 3 or greater mucositis after morning vs. afternoon RT, respectively (p = 0.17). Morning RT was also associated with significantly less weight loss after 5 months (p = 0.024). In a subgroup of 111 patients treated to a dose of 66-70 Gy in 33-35 fractions, exploratory analyses revealed a significant reduction in Grade 3 or greater mucositis with morning RT (44.6% vs. 67.3%, p = 0.022) and a longer interval to the development of Grade 3 or greater mucositis (median, >7.9 vs. 5.6 weeks, p = 0.033). In 53 patients, who smoked during therapy, a significant reduction was found in Grade 3 or greater mucositis with morning RT (42.9% vs. 76%, p = 0.025). CONCLUSION In this proof of principle study, morning RT was associated with significantly less weight loss after 5 months and an apparent reduction in oral mucositis in a subset of patients receiving >/=66 Gy and in patients who smoked during therapy.

Association Between a Dietary Inflammatory Index and Prostate Cancer Risk in Ontario, Canada

ABSTRACT Background: Evidence exists showing that various aspects of diet are implicated in the etiology of prostate cancer, although results across studies remain inconsistent. Methods: We examined the ability of the dietary inflammatory index (DII) to predict prostate cancer in a case-control study conducted in Kingston, Ontario, Canada, between 1997 and 1999. The study included 72 cases of incident primary prostate cancer patients and 302 controls of urology clinic patients who had prostate conditions other than prostate cancer. The DII was computed based on intake of 18 nutrients assessed using a 67-item food frequency questionnaire. Univariate and multivariate logistic regression models were used to estimate odds ratios (ORs). Results: Men with higher DII scores were at increased risk of prostate cancer using DII score fit both as a continuous [OR = 1.58, 95% confidence interval (CI) 1.05–2.38] and categorical variable [compared to men in the lowest DII quartile, men in the highest quartile were at elevated risk (OR = 3.50, 95% CI 1.25–9.80; ptrend = 0.02)]. There was no significant heterogeneity by weight status, but stronger association was observed in men with body mass index >25 kg/m2 versus <25 kg/m2. Conclusion: These findings suggest that a proinflammatory diet, as indicated by increasing DII score, is a risk factor for prostate cancer.

Interventions to improve care coordination between primary healthcare and oncology care providers: a systematic review.

Coordination of patient care between primary care and oncology care providers is vital to care quality and outcomes across the cancer continuum, yet it is known to be challenging. We conducted a systematic review to evaluate current or new models of care and/or interventions aimed at improving coordination between primary care and oncology care providers for patients with adult breast and/or colorectal cancer. MEDLINE, EMBASE, CINAHL, Cochrane Library Database of Systematic Reviews, and the Centre for Reviews and Dissemination were searched for existing English language studies published between January 2000 and 15 May 2015. Systematic reviews, meta-analyses, randomised controlled trials (RCTs) and non-randomised studies were included if they evaluated a specific model/intervention that was designed to improve care coordination between primary care and oncology care providers, for any stage of the cancer continuum, for patients with adult breast and/or colorectal cancer. Two reviewers extracted data and assessed risk of bias. Twenty-two studies (5 systematic reviews, 6 RCTs and 11 non-randomised studies) were included and varied with respect to the targeted phase of the cancer continuum, type of model or intervention tested, and outcome measures. The majority of studies showed no statistically significant changes in any patient, provider or system outcomes. Owing to conceptual and methodological limitations in this field, the review is unable to provide specific conclusions about the most effective or preferred model/intervention to improve care coordination. Imprecise results that lack generalisability and definitiveness provide limited evidence to base the development of future interventions and policies. Trial registration number CRD42015025006.

Challenges and insights in implementing coordinated care between oncology and primary care providers: a Canadian perspective

We report here on the current state of cancer care coordination in Canada and discuss challenges and insights with respect to the implementation of collaborative models of care. We also make recommendations for future research. This work is based on the findings of the Canadian Team to Improve Community-Based Cancer Care Along the Continuum (canimpact) casebook project. The casebook project identified models of collaborative cancer care by systematically documenting and analyzing Canadian initiatives that aim to improve or enhance care coordination between primary care providers and oncology specialists. The casebook profiles 24 initiatives, most of which focus on breast or colorectal cancer and target survivorship or follow-up care. Current key challenges in cancer care coordination are associated with establishing program support, engaging primary care providers in the provision of care, clearly defining provider roles and responsibilities, and establishing effective project or program planning and evaluation. Researchers studying coordinated models of cancer care should focus on designing knowledge translation strategies with updated and refined governance and on establishing appropriate protocols for both implementation and evaluation.

A call for theory-informed approaches to knowledge translation studies: an example of chemotherapy for bladder cancer.

There is a clear evidence-to-practice gap in bladder cancer care. International guidelines recommend that patients with muscle-invasive bladder cancer (mibc) receive some form of perioperative chemotherapy, with stronger evidence for the use of neoadjuvant (nact) than of adjuvant (act) chemotherapy1. Delivery of perioperative chemotherapy involves close collaboration and communication between at least two physician subspecialties: the urologist who makes the initial diagnosis of bladder cancer and undertakes surgery, and the medical oncologist who delivers the chemotherapy. Urologists are the “gatekeepers” to nact or act because they make the upstream decision about whether to refer the patient to a medical oncologist. We recently described very low concordance with the guideline recommendations for patients with mibc in Ontario: 4% and 18% of patients in Ontario received nact or act respectively2. We also found that only 18% of patients were referred to a medical oncologist for consideration of nact, with 25% of that group subsequently receiving treatment. Of the 39% of patients who were referred to a medical oncologist after surgery, 51% received act3. Those findings suggest the presence of barriers to treatment at both the upstream level of the urologist and the downstream level of the medical oncologist, and yet there is a critical lack of information about why urologists and medical oncologists do not recommend the use of chemotherapy. Similarly, the literature concerning why patients might decline referral to medical oncology or recommended nact or act is sparse.

50 Wikipedia culture and usage: a survey of first year medical students to determine barriers and facilitators

Objectives Wikipedia is the sixth most trafficked website globally and used heavily by individuals seeking health information. For example, Wikipedia’s pneumonia entry is, on average, viewed daily over 10 000 times. Unsurprisingly, researchers have identified medical students among Wikipedia users. Medical students are trained to practice evidence-based medicine (EBM) that requires accessing and critically appraising information from a variety of sources. While researchers have investigated use of information resources (e.g., MEDLINE, UpToDate, BMJ Best Practice) as evidence dissemination tools, there is limited information in relation to Wikipedia. This project examined medical student perceptions of Wikipedia use by medical practitioners and the public, and in ongoing student training. Method In Fall 2017, 101 first-year medical students at Queen’s University, Canada participated in a longitudinal project to learn how to contribute to a medical page in Wikipedia. This was part of their critical appraisal, research and lifelong learning course which is a mandatory component of the students’ EBM training. Based on their engagement with Wikipedia pages and the Wikipedia community, the students were required to complete a survey at project end that sought their feedback on: (1) whether and how the project changed their opinion of Wikipedia as a medical resource for the public; (2) their views on Wikipedia as a resource for medical practitioners, and (3) their prediction on future Wikipedia usage going forward in medical school or as a resident. Two members of the research team who were not involved in marking student assessments reviewed survey responses and, using thematic analysis, identified salient themes. Results Students recognised Wikipedia as a useful health information resource for the public. Students also described an increased appreciation of the Wikipedia editing and citation process and assurance with the oversight and engagement provided by the Wikipedia community. Conversely, perceived barriers to recommending Wikipedia to the public included concerns about Wikipedia editors’ lack of content expertise, unreliability of information and outdated information compared with other evidence-based resources. With respect to their opinion of Wikipedia as a resource for medical practitioners, student opinions were more divided with concerns raised regarding the depth, comprehensiveness and reliability/accuracy of information provided compared to other resources. However, despite these reservations, the large majority of respondents indicated they will use Wikipedia going forward in medical school and as a resident. Students attributed Wikipedia’s utility to its’ ease of access, usefulness as a ‘refresher’ on background information and its use as a springboard to more evidence-based resources. Conclusions Medical students reported appreciation for Wikipedia as a useful health information resource given their enhanced understanding of the editing and oversight processes. Students cited Wikipedia as a resource they would recommend to the public and that they will continue to use owing to its ease and speed of access to background information on health topics. Concerns about reliability, accuracy and currency of information were barriers identified in recommending Wikipedia to medical practitioners. There is an opportunity for medical schools and educators to develop a health advocacy partnership with the Wikipedia community to improve evidence-based content.

24 Wikipedia medical page editing as a platform to teach evidence-based medicine

Objectives Medical articles on Wikipedia are viewed over 10 million times a day and Wikipedia is arguably the most-read medical information platform on the internet. The quality and evidence-base of Wikipedia medical articles are improving but there is an ongoing need for refinement and updating. Editing and improving these articles represents a ‘whole task’ application of the steps in Evidence-Based Medicine (EBM) while simultaneously contributing to an altruistic mission of knowledge sharing and health advocacy. Involving medical students in Wikipedia-editing initiatives provides an opportunity for application of EBM skills while also improving medical articles on Wikipedia. We developed an embedded longitudinal Wikipedia editing project as part of a first year critical appraisal course in the School of Medicine at Queen’s University, Canada. Our goal was to evaluate the design and implementation of this project using student feedback in a structured survey. Method Students completed online training modules provided by Wikipedia and chose a medical article to improve. Students worked in small groups to assess their articles, made suggestions for improvement, and searched the literature for high-quality secondary sources containing suitable evidence. They posted suggested changes to the Wikipedia community for feedback and consulted with a faculty expert prior to making final page edits. All students completed a Wikipedia project evaluation form. Feedback was sought on the perceived strengths, weaknesses, struggles in project completion, and suggestions for improvement going forward. Using the Five-Dimensional Framework for Authentic Assessment (Gulikers, JTM et al., 2004), student feedback data was reviewed by two investigators (MW and LM) who independently identified barriers to/facilitators in project completion and assigned them into one of five dimensions relating to (1) the task (2) the physical/virtual context (3) the social context; (4) the result and (5) the criteria for evaluation. Results One hundred and one students made over 1000 edits to 16 articles, adding over 10 000 words to the pages, all with appropriate secondary source citations. Based on a preliminary review of the feedback data, students enjoyed applying the critical appraisal skills taught within the broader scope of the course (task), they liked making an improvement to a highly accessed public resource (result), they reported positive collaboration within their teams (social context), and they enjoyed learning about the process involved in forming and editing a Wikipedia medical page (task). Barriers to the project identified by the students included a lack of clarity regarding assignment expectations (task), frustration with Wikipedia coding (task), difficulty engaging with the Wikipedia editors/community (social context), distrust of Wikipedia editors as content experts (social context), and a perceived mismatch in efforts dedicated to the assignment and the resulting change/impact on their Wikipedia medical page (result). Conclusions Initial results highlight important barriers and facilitators identified by medical students in engaging with and completing the longitudinal Wikipedia assignment as part of their first-year critical appraisal, research and life long learning course. These results will inform the future delivery and assessment of this assignment in an effort to increase engagement among first-year medical students in improving one of the leading sources of online health information worldwide.

8 Knowledge translation in the digital world: using wikipedia as an EBM teaching platform

Objectives Learning outcomes for participants: Understand structure of Wikipedia pages and process for editing and adding citations. Examine Wikipedia–based assignments used in two different medical schools for different learner populations (pre–clerkship and clerkship students). Identify barriers and supports that would enhance feasibility for adoption in participant environments and for targeted groups of learners. Plan student assessment that evaluates both EBM whole task capability and critical thinking for a variety of learner types and level. Method Background With more than 220M page views per day, Wikipedia is the ultimate knowledge translation platform, providing unbiased, structured and rigorously-sourced medical information free to the world. Based on the instructors’ experience teaching Wikipedia editing courses to medical students at Queen’s University and the University of California, San Francisco (UCSF), editing Wikipedia pages allows learners to improve Wikipedia, improve communication skills, and build critical appraisal skills while practicing Evidence-Based Medicine (EBM). Participants in this workshop will learn how to design and implement Wikipedia-based EBM exercises for a broad range of learner types and training levels. Results Resources Participants will need to bring laptops or tablets for hands-on activities within Wikipedia. Instructors will distribute assignment and assessment materials from the Wikipedia-based longitudinal EBM exercises at Queen’s University and at UCSF. We will actively collaborate to scale these resources to ensure suitability for learners across the continuum of medical education. Finally, we will troubleshoot potential challenges and brainstorm solutions for regional implementation of these exercises. Conclusions N/A.

Abstract B46: The influence of exemestane on breast density in postmenopausal women: A cohort study nested within the NCIC CTG MAP.3 chemoprevention trial

Background: Endogenous estradiol blood levels and high breast density are both associated with an increased risk for breast cancer (BC), but, there is conflicting evidence about whether or not they influence breast cancer risk through a shared pathway. Exemestane is an aromatase inhibitor that blocks the synthesis of estrogen and has been demonstrated to reduce the incidence of breast cancer in postmenopausal women by 65%. However the effects of exemestane on breast density remain unclear. Objectives: The primary objective of this research was to prospectively examine the relationship between exemestane versus placebo and changes in mammographic breast density (BD) in postmenopausal women during 3 or more years of treatment. Methods: The NCIC Clinical Trials Group conducted a phase III randomized controlled trial (RCT) comparing exemestane (E), with placebo (P) in postmenopausal women at higher than average risk for BC (MAP.3). This study was nested within the MAP.3 RCT using data from 568 participants across Canada and Buffalo, New York. Information on treatment allocation and established risk factors for BC was previously collected and data on the outcome measures was obtained from mammograms. Baseline and follow-up mammograms were collected from participating centres and were measured (percent density) using Cumulus software by our team radiologist (DJ). Multivariable linear regression was used to estimate the effect of exemestane treatment on >=3 year change in percent BD from randomization controlling for potential confounding variables. Results: Percent BD was measured for 386 participants (E=200, P=186) with a baseline and >=3 year follow-up mammogram that was matching in format (i.e. film or digital). The average age of women at study entry was 63 years and the average Gail score was 2.8%. The mean BD was similar in both arms at baseline (P: 12.9% (SD: 14.5) and E: 13.7% (SD: 14.4)). Similarly, the annual mean change in percent BD was not significantly different between the two treatment arms (P: 0.63% (SD: 1.82) vs E: .077% (SD: 1.80); p=0.90). After controlling for potential confounders (age, body mass index, first degree family history of BC and prior use of HRT), exemestane was not predictive of change in percent BD (p-value=0.641). Neither age ( =60 yrs) nor BMI modified the exemestane-breast density relationship significantly. Conclusion: We found no association between >=3 years of exemestane use and change in percent BD among a subset of postmenopausal women participating in MAP.3. These results suggest that estrogen and breast density may have independent pathways in breast cancer etiology. Citation Format: Harriet Richardson, Paul E. Goss, Melanie Walker, Doris Jabs, Will King. The influence of exemestane on breast density in postmenopausal women: A cohort study nested within the NCIC CTG MAP.3 chemoprevention trial. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B46.