For people with cancer, a visit to the emergency department can be an ordeal. Waits for care can be long 1 and uncomfortable. 2 In particular, for patients who are dying of cancer and their families, such visits can be disruptive, distressing and exhausting. Visits to the emergency department made near the end of life have been used as an indicator of poor-quality care for patients with cancer at the end of life. 3,4 In Ontario, the proportion of patients who visit the emergency department during the final two weeks of life is about 40%.5 Such a visit often represents a transition in a patient's care. 6 Even for those whose care is based on an established palliative approach, the visit may be precipitated by the distress of family members at end-of-life symptoms. 7 Ideally, the symptoms of a patient near death would be adequately controlled and the patient would be cared for in the setting of his or her choice, rather than on an emergency basis. While some patients have unexpected urgent medical problems that result in an unavoidable emergency department visit, other such visits are likely avoidable. Understanding why this group of patients visits the emergency department is crucial for determining how best to attempt to minimize the number of patients who go to the emergency department. We describe the most common reasons for visits made to the emergency department during the final six months and the final two weeks of life among patients who die of cancer. MethodsWe performed a descriptive, retrospective study using administrative sources of health care data. We examined how often and why patients dying of cancer visited the emergency department near the end of life. Sources of dataThe Ontario Cancer Registry is a comprehensive, populationbased registry that captures 95% of all incident cases of cancer in the province. 8,9 The National Ambulatory Care Reporting System captures all visits to the emergency department. The Registered Persons Database contains demographic information on all residents of Ontario who are eligible for the Ontario Health Insurance Plan. 10 Inclusion criteriaWe used the Ontario Cancer Registry to identify all patients who died of cancer between 2002 and 2005, as indicated by death certificates. If more than one record existed, we chose the cause of death as the record that matched the diagnosis of registration. We excluded patients for whom a diagnosis of cancer had not been made before death, whose deaths occurred within 30 days of a major cancer-related operative procedure, whose health insurance numbers were invalid during the final six months of life, who died outside of Ontario, or who were younger than 20 years of age. We linked cases using a common unique identifier. Background: For patients dying of cancer, a visit to the emergency department can be disruptive, distressing and exhausting. Such visits made near the end of life are considered an indicator of poor-quality cancer care. We describe the most common reasons for visits made to the emergency department during the final ...

Individual patient data were available for all four of the randomized trials that began before 1995, and that compared adjuvant radiotherapy vs no radiotherapy following breast-conserving surgery for ductal carcinoma in situ (DCIS). A total of 3729 women were eligible for analysis. Radiotherapy reduced the absolute 10-year risk of any ipsilateral breast event (ie, either recurrent DCIS or invasive cancer) by 15.2% (SE 1.6%, 12.9% vs 28.1% 2 P <.00001), and it was effective regardless of the age at diagnosis, extent of breast-conserving surgery, use of tamoxifen, method of DCIS detection, margin status, focality, grade, comedonecrosis, architecture, or tumor size. The proportional reduction in ipsilateral breast events was greater in older than in younger women (2P < .0004 for difference between proportional reductions; 10-year absolute risks: 18.5% vs 29.1% at ages <50 years, 10.8% vs 27.8% at ages ≥ 50 years) but did not differ significantly according to any other available factor. Even for women with negative margins and small low-grade tumors, the absolute reduction in the 10-year risk of ipsilateral breast events was 18.0% (SE 5.5, 12.1% vs 30.1%, 2P = .002). After 10 years of follow-up, there was, however, no significant effect on breast cancer mortality, mortality from causes other than breast cancer, or all-cause mortality.

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Background:Ductal carcinoma in situ (DCIS) is a non-invasive form of breast cancer that may progress to invasive cancer. Identification of factors that predict recurrence and distinguish DCIS from invasive recurrence would facilitate treatment recommendations. We examined the prognostic value of nine molecular markers on the risks of local recurrence (DCIS and invasive) among women treated with breast-conserving therapy.Methods:A total of 213 women who were treated with breast-conserving therapy between 1982 and 2000 were included; 141 received breast-conserving surgery alone and 72 cases received radiotherapy. We performed immunohistochemical staining on the DCIS specimen for nine markers: oestrogen receptor, progesterone receptor, Ki-67, p53, p21, cyclinD1, HER2/neu, calgranulin and psoriasin. We performed univariable and multivariable survival analyses to identify markers associated with the recurrence.Results:The rate of recurrence at 10 years was 36% for patients treated with breast-conserving surgery alone and 18% for women who received breast-conserving surgery and radiotherapy. HER2/neu+/Ki-67+ expression was associated with an increased risk of DCIS recurrence, independent of grade and age (HR=3.22; 95% CI: 1.47–7.03; P=0.003). None of the nine markers were predictive of invasive recurrence.Conclusion:Women with a HER2/neu/neu+/Ki67+ DCIS have a higher risk of developing DCIS local recurrence after breast-conserving surgery.