Commentary on the Downside of Breast Screening
by Anthony B. Miller, MD, FRCP. Professor Emeritus, Dalla Lana School of Public Health, University of Toronto
When the 25-year report of the Canadian National Breast Screening Study (CNBSS) was published , showing no benefit from mammography screening, there was much dissension, and attempts to show that what we reported could not be true [2,3], to which we responded . The belief that “early” detection of a cancer is bound to be beneficial is entrenched in our society, people do not understand that the mere early detection of a cancer does not automatically result in benefit, the cancer may not have been destined to be fatal with modern therapy even when detected later by the woman herself, the cancer might never have progressed to become detectable by the woman if it had not been revealed by the mammogram, or, the cancer was destined to kill whatever stage it was detected because of its innate biology. Even if we accept that mammography screening reduces breast cancer mortality by 15-20% , and I do not, that means that 80% or more of the deaths from breast cancer destined to occur will still do so.
“Fertility Studies in Young Women with Breast Cancer”
by Dr. Ellen Warner, MD, M.Sc., FRCPC, FACP
For many years there has been a gap in research focusing on breast cancer patients who are aged 40 and younger. Since these women represent just over 5% of all breast cancer cases, they have generally constituted a very small subset of the patients enrolled in clinical trials, which has made it difficult to make progress in addressing the very unique medical and psychosocial issues of this population. A recent Canadian study called RUBY (Reducing the bUrden of Breast cancer in Young women), http://www.womensresearch.ca/ruby-study, jointly funded by the Canadian Breast Cancer Foundation and Canadian Institutes of Health Research, is attempting to change this situation. Over 4 years, 1200 women aged 40 and younger newly diagnosed with breast cancer at 32 cancer centres and hospitals across Canada will be enrolling in RUBY. Almost 200 women have enrolled to date and recruitment is well on target to be completed in 2019. The overall goal of this study is to improve the cure rate and quality of life of young women with breast cancer. RUBY has several sub-studies, two of which, SPOKE and GYPSY, relate to fertility issues.
by Sara E. McEwen, PT, PhD
What is cancer rehabilitation? Cancer rehabilitation enables people living with cancer or the effects of cancer treatments to maximize physical, social and psychological function within the limits imposed by the disease, and subsequently to engage in personally valued activities in their home, community, and work environments. One could say that cancer rehabilitation is concerned about mitigating the consequences of the disease and restoring function. Cancer rehabilitation services are as diverse as the disease itself – they could include a swallowing exercise program administered by a speech-language pathologist for a patient with head and neck cancer, lymphedema treatment by a physiotherapist for a patient with breast cancer, or perhaps a driving assessment by an occupational therapist for a patient with a brain tumour, to name just a few of the many professional disciplines involved and the profuse potential clinical scenarios.
What is the current state of cancer rehabilitation in Canada? Despite the need for these services, they are fragmented and inconsistently available in Canada. To move the agenda forward, the Partners in Cancer Rehabilitation Research (PCRR) group held a 3-day invitational working meeting last spring aimed at defining the state of the science and identifying key areas for development of research and education. Twenty-nine clinicians, patients, and researchers gathered and the results included consensus statements on research and education priorities that were published in Current Oncology, Volume 20, No. 1, February 2013. The group concluded that a main research priority is to develop and test personalized rehabilitation interventions and short form instruments to detect the presence and severity of disabling symptoms specific to different types of cancer and different times in the trajectory, and to mesh with the personal characteristics of individual patients, such as age, comorbidities, and personal preferences. We established two main education priorities: 1. Develop and disseminate a clear, interdisciplinary description of the nature of cancer rehabilitation and its mandate; 2. Increase awareness among health care providers and patients of the need for and general effectiveness of cancer rehabilitation.
What is the evidence supporting the efficacy of cancer rehabilitation? Also stemming from last spring’s meeting was a best evidence synthesis to summarize current evidence regarding rehabilitation interventions to address problems during survivorship.[i] We identified post-cancer treatment needs that could be addressed by rehabilitation and summarized the strongest evidence from systematic reviews and randomized controlled trials. Evidence regarding the effectiveness of rehabilitation interventions was reviewed for physical functioning, fatigue, pain, sexual functioning, cognitive functioning, depression, employment, nutrition and participation. We concluded that:
- Good evidence exists for the use of exercise/physical rehabilitation in reducing fatigue after treatment for most cancers, and improving upper extremity functioning following treatment for breast cancer. Of particular interest is the extensive literature regarding rehabilitation interventions for breast cancer which has resulted in a comprehensive guideline for prevention and intervention for mobility, pain, swelling and function.[ii]
- There is preliminary evidence that pain, sexual functioning, cognitive functioning and return to work may be improved by rehabilitation interventions, but further research is needed.
What cancer rehabilitation services exist in your clinical setting? Are there gaps? Are there innovations? This is a small but growing field, so please share your successes and challenges so that we can work together to improve the functional health for survivors of cancer.
[i] Egan MY, McEwen SE, Sikora L, Chasen M, Fitch M, Eldred S. Rehabilitation following cancer treatment. Disability and Rehabilitation. Published early online, March 15, 2013.
[ii] Harris SR, Schmitz KH, Campbell KL, McNeely ML. Clinical practice guidelines for breast cancer rehabilitation: syntheses of guideline recommendations and qualitative appraisals. Cancer 2012; 118:2312–24.
Dr. Sara McEwen is a physiotherapist and a scientist at the Sunnybrook Research Institute, St. John’s Rehab Research Program. She also holds appointments as Assistant Professor, Department of Physical Therapy, University of Toronto, Associate Member, Graduate Department of Rehabilitation Science, University of Toronto, and Research Associate with the Cognitive Rehabilitation Research Group, Washington University, St. Louis, MO. Broadly. She is interested in investigating long-term meaningful outcomes in people living with chronic conditions. Her specific interests include exploring the links among cognition, motivation, and motor skill acquisition, and facilitating knowledge exchange between front-line health professionals and researchers. Her current projects include two randomized controlled trials investigating cognitive strategy based interventions in people living with stroke, as well as foundational work to develop new oncology rehabilitation interventions. She obtained her B.Sc. in Physical Therapy and M.Sc. in Rehabilitation Science from McGill University, and PhD in Rehabilitation Science from the University of Toronto. In addition to her role as a researcher, Dr. McEwen has worked as a clinical physiotherapist, educator, and project coordinator. She is an avid skier, cyclist, and runner, and lives near Orillia, Ontario, with her husband and children.
Interview by Jonathan Klein, MD
Current Oncology: This is an interview with Dr. Barbara-Ann Millar, staff oncologist at Princess Margaret Hospital and the Hospital for Sick Children in Toronto and the current Program Director of the University of Toronto Radiation Oncology residency program. She has agreed to sit down with Current Oncology to discuss issues relating to radiation oncology in Toronto and elsewhere. First of all thank you for agreeing to speak with me today.
First off, I’m going to ask you a question that you will be asking all prospective radiation oncology residents which is: why radiation oncology?
Interview by Jonathan Klein, MD
Meredith Giuliani is the current Chief Resident of the Radiation Oncology residency training program at the University of Toronto. She graciously agreed to sit down with Current Oncology to discuss her experiences in the field and answer questions about applying to radiation oncology residency programs.
Current Oncology: To start, I’m going to ask you the question that you will be asking all prospective radiation oncology residents: why radiation oncology?