Background Thoracic aortic dissections ( TADs ) and thoracic aortic aneurysms ( TAAs ) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy. Methods and Results Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost‐of‐illness analysis was performed. From a single‐payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs ( P <0.0001) and $13 M to $18 M for TAAs ( P <0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time ( P =0.04). For TAAs , median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time ( P =0.03). Home care was the most used posthospital service ( TADs 44%, TAAs 38%), but rehabilitation had the highest median cost ( TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs. Conclusions Total yearly costs have increased for TADs and TAAs . Median hospital costs have increased for TADs yet decreased for TAAs . Women use posthospital healthcare services more often than men.

Objective:To determine whether cancer risk differs in people with and without multiple sclerosis (MS), we compared incidence rates and cancer-specific mortality rates in MS and matched cohorts using population-based data sources.Methods:We conducted a retrospective matched cohort study using population-based administrative data from Manitoba and Ontario, Canada. We applied a validated case definition to identify MS cases, then selected 5 controls without MS matched on birth year, sex and region. We linked these cohorts to cancer registries, and estimated incidence of breast, colorectal and 13 other cancers. For breast and colorectal cancers, we constructed Cox models adjusting for age at the index date, area-level socioeconomic status, region, birth cohort year and comorbidity. We pooled findings across provinces using meta-analysis.Results:We included 53,984 MS cases and 266,920 controls. Multivariable analyses showed no difference in breast cancer risk (pooled hazard ratio [HR] 0.92 [95%CI: 0.78-1.09]) or colorectal cancer risk (pooled HR 0.83 [95%CI: 0.64-1.07]) between the cohorts. Mortality rates for breast and colorectal did not differ between cohorts. Bladder cancer incidence and mortality rates were higher among the MS cohort. Although the incidence of prostate, uterine and central nervous system cancers differed between the MS and matched cohorts, mortality rates did not.Conclusion:The incidence of breast and colorectal cancers does not differ between persons with and without MS; however, the incidence of bladder cancer is increased. Reported differences in the incidence of some cancers in the MS population may reflect ascertainment differences rather than true differences.

STUDY QUESTION Do female adolescents and young adults (AYAs) with cancer have a higher risk of subsequent infertility diagnosis than AYAs without cancer? SUMMARY ANSWER Female AYAs with breast, hematological, thyroid and melanoma cancer have a higher risk of subsequent infertility diagnosis. WHAT IS KNOWN ALREADY Cancer therapies have improved substantially, leading to dramatic increases in survival. As survival improves, there is an increasing emphasis on optimizing the quality of life among cancer survivors. Many cancer therapies increase the risk of infertility, but we lack population-based studies that quantify the risk of subsequent infertility diagnosis in female AYAs with non-gynecological cancers. The literature is limited to population-based studies comparing pregnancy or birth rates after cancer against unexposed women, or smaller studies using markers of the ovarian reserve as a proxy of infertility among female survivors of cancer. STUDY DESIGN, SIZE, DURATION We conducted a population-based cohort study using universal health care databases in the province of Ontario, Canada. Using data from the Ontario Cancer Registry, we identified all women 15–39 years of age diagnosed with the most common cancers in AYAs (brain, breast, colorectal, leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, thyroid and melanoma) from 1992 to 2011 who lived at least 5 years recurrence-free (Exposed, n = 14,316). Women with a tubal ligation, bilateral oophorectomy or hysterectomy previous to their cancer diagnosis were excluded. We matched each exposed woman by age, census subdivision, and parity to five randomly selected unexposed women (n = 60,975) and followed subjects until 31 December 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS Infertility diagnosis after 1 year of cancer was identified using information on physician billing codes through the Ontario Health Insurance Plan database (ICD-9 628). Modified Poisson regression models were used to assess the risk of infertility diagnosis (relative risk, RR) adjusted for income quintile and further stratified by parity at the time of cancer diagnosis (nulliparous and parous). MAIN RESULTS AND THE ROLE OF CHANCE Mean age at cancer diagnosis was 31.4 years. Overall, the proportion of infertility diagnosis was higher in cancer survivors compared to unexposed women. Mean age of infertility diagnosis was similar among cancer survivors and unexposed women (34.8 years and 34.9 years, respectively). The overall risk of infertility diagnosis was higher in cancer survivors (RR 1.30; 95% CI 1.23–1.37). Differences in infertility risk varied by type of cancer. Survivors of breast cancer (RR 1.46; 95% CI 1.30–1.65), leukemia (RR 1.56; 95% CI 1.09–2.22), Hodgkin lymphoma (RR 1.49; 95% CI 1.28–1.74), non-Hodgkin lymphoma (RR 1.42; 95% CI 1.14, 1.76), thyroid cancer (RR 1.20; 95% CI 1.10–1.30) and melanoma (RR 1.17; 95% CI 1.01, 1.35) had a higher risk of infertility diagnosis compared to women without cancer. After stratification by parity, the association remained in nulliparous women survivors of breast cancer, leukemia, lymphoma and melanoma, whereas it was attenuated in parous women. In survivors of thyroid cancer, the association remained statistically significant in both nulliparous and parous women. In survivors of brain or colorectal cancer, the association was not significant, overall or after stratification by parity. LIMITATIONS, REASONS FOR CAUTION Non-biological factors that may influence the likelihood of seeking a fertility assessment may not be captured in administrative databases. The effects of additional risk factors, including cancer treatment, which may modify the associations, need to be assessed in future studies. WIDER IMPLICATIONS OF THE FINDINGS Reproductive health surveillance in female AYAs with cancer is a priority, especially those with breast cancer, leukemia and lymphoma. Our finding of a potential effects of thyroid cancer (subject to over-diagnosis) and, to a lesser extent, melanoma need to be further studied, and, if an effect is confirmed, possible mechanisms need to be elucidated. STUDY FUNDING/COMPETING INTEREST(S) Funding was provided by the Faculty of Health Sciences and Department of Obstetrics and Gynecology, Queen’s University. There are no competing interests to declare. TRIAL REGISTRATION NUMBER N/A

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Objective:We tested the hypotheses that overall survival and cancer-specific survival after breast cancer diagnosis would be lower in persons with multiple sclerosis (MS) as compared to persons without MS using a retrospective matched cohort design.Methods:We applied a validated case definition to population-based administrative data in Manitoba and Ontario, Canada to identify female MS cases. We linked the MS cohorts to cancer registries to identify women with breast cancer. Then we selected 4 breast cancer controls without MS matched on birth year, cancer diagnosis year and region. We compared all-cause survival between cohorts using Cox proportional hazards regression adjusting for age at cancer diagnosis, cancer diagnosis period, income quintile, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a multivariable cause-specific hazards model. We pooled findings between provinces using meta-analysis.Results:We included 779 MS cases and 3116 controls with breast cancer. Most subjects with stage data (1976/2822, 70.0%) were diagnosed with stage I or II breast cancer, and the mean (SD) age at diagnosis was 57.8 (10.7) years. After adjustment for covariates, MS was associated with a 28% increased hazard for all-cause mortality (hazard ratio [HR] 1.28; 95%CI: 1.08-1.53), but was not associated with altered cancer-specific survival (HR 0.98; 95%CI: 0.65-1.46).Conclusion:Women with MS have lower all-cause survival after breast cancer diagnosis than women without MS. Future studies should confirm these findings in other populations and identify MS-specific factors associated with worse prognosis.

Background and Objectives:We tested the hypothesis that overall and cancer-specific survival following colorectal cancer diagnosis is lower in persons with multiple sclerosis (MS) than without MS, using a retrospective matched cohort design.Methods:Using population-based administrative data in Manitoba and Ontario we identified persons with MS using a validated case definition, and linked these cohorts to cancer registries to identify those with colorectal cancer. We selected persons with colorectal cancer and without MS matching 4:1 on birth year, sex, cancer diagnosis year and region. We used Cox proportional hazards regression to compare all-cause survival between cohorts adjusting for age at cancer diagnosis, cancer diagnosis year, income, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a cause-specific hazards model. We pooled findings across provinces using random-effects meta-analysis. Complementary analyses using a subcohort from Ontario adjusted for cancer stage and disability status, as measured based on the use of home care or long-term care services.Results:We included 338 MS cases and 1352 controls with colorectal cancer. The mean (SD) age at cancer diagnosis was 64.7 (11.1) years. After adjustment, MS was associated with an increased hazard for all-cause death which was highest six months post-diagnosis (hazard ratio [HR] 1.45; 95%CI: 1.19-1.76), then declined over time (HR [95%CI] 1 year: 1.34 [1.09-1.63], 2 years: 1.24 [0.99-1.56]; 5 years: 1.10 [0.80-1.50]). MS was associated with increased cancer-specific death at 6 months post-diagnosis only (HR 1.29; 95%CI: 1.04-1.61). After adjusting for cancer stage, MS was associated with an increased hazard of death due to any cause (1.60; 95%CI: 1.16, 2.21) and with cancer-specific death (HR 1.47; 95%CI: 1.02, 2.12). The association of MS and all cause death was partially attenuated after adjustment for disability status (HR 1.37; 95%CI: 0.97, 1.92), as was the association with cancer-specific death (HR 1.34; 95%CI: 0.91, 1.97).Discussion:Overall and cancer-specific survival was lower in persons with than without MS in the early period following colorectal cancer diagnosis. Further study is warranted to determine what factors underlie these worse outcomes.

Introduction: Our objective was to compare the short-term outcomes by type of surgical management of endometriosis in Ontario, Canada and to characterize the population of women undergoing surgical management of endometriosis. Material and methods:We conducted a population-based cohort study including women aged 18-50 years undergoing same-day or inpatient surgery for endometriosis from 1 April 2002 through 31 March 2018. Surgery was classified as minimally invasive hysterectomy (MIH), total abdominal hysterectomy (TAH) or minor or major conservative (uterus-preserving) surgery. Outcomes examined included length of stay, intraoperative complications, postoperative complications, emergency department visits, ambulatory care visits, and readmission. We estimated the relative risk of these outcomes in minor, major conservative surgery and TAH vs MIH adjusted for age, income quintile, parity, and comorbidities.Results: A total of 85 605 patients underwent surgery, 12.9% MIH, 22.1% TAH, 36.3% major conservative, and 28.6% minor conservative. The mean age at index surgery was 37.6 ± 7.7 years. Before surgery, 70.6% of patients had visited a physician for pain at least once (64.7% MIH, 69.5% TAH, 71.1% major conservative and 73.4% minor conservative) and 23.5% of patients had sought infertility consultation (5.7% MIH, 6.6% TAH, 29.3% major conservative and 37.1% minor conservative). The overall risk of intraoperative and postoperative complications was 1.5% and 4.7%, respectively.In adjusted models, compared with those undergoing minor conservative surgery, those having major conservative surgery were 1.77 (95% CI 1.49-2.11) times as likely to experience an intraoperative complication, those having MIH and TAH were 2.55 (95% CI 2.08-3.13) and 2.34 (95% CI 1.93-2.82) times as likely to do so, respectively.Similarly, compared with those undergoing minor conservative surgery, those having major conservative surgery were 2.60 (95% CI 2.30, 2.93) times as likely to experience any postoperative complication, and those having MIH and TAH were 4.69 (95% CI 4.11-5.36) and 5.38 (95% CI 4.76-6.09) times as likely to do so, respectively. | 1141 BOUGIE Et al.

Background The risk of premature ovarian insufficiency (POI) is increased in adolescent and young adult (AYA) cancer survivors, with the prevalence depending on cancer diagnosis, treatment, and patient factors. Prior studies are limited by sample size and type of cancer included. The objective of this study was to assess the risk of POI in female AYA survivors of non-gynecologic cancers, using a population-based approach. Methods This population-based retrospective cohort study comprises 21,666 females, 15–39 years old, diagnosed with a single non-gynecologic cancer in Ontario, Canada from 1995 to 2015. Through health administrative data linkage, participants were followed until their 40th birthday, December 31, 2018, bilateral oophorectomy, loss of health insurance eligibility or death. Each cancer survivor was matched to 5 females who were not diagnosed with cancer (unexposed, n = 108,330). Women with bilateral oophorectomy or a prior menopause diagnosis were excluded. POI was identified through use of the ICD-9 code for menopause (ICD9-627). Modified Poisson regression models were used to calculate the adjusted relative risk (aRR) of POI for AYA cancer survivors compared to unexposed individuals, adjusted for income, parity, age, and immigration status. Results The occurrence of POI was higher in survivors of AYA cancer versus unexposed patients (5.4% vs. 2.2%). Survivors of AYA cancer had an increased risk of POI relative to unexposed patients (aRR 2.49; 95% CI 2.32–2.67). Risk varied by type of cancer: breast (4.32; 3.84–4.86), non-Hodgkin’s lymphoma (3.77; 2.88–4.94), Hodgkin’s lymphoma (2.37; 1.91–2.96), leukemia (14.64; 10.50–20.42), thyroid (1.26; 1.09–1.46) and melanoma (1.04; 0.82–1.32). Risk varied by age at time of cancer diagnosis, with a higher risk among females diagnosed at age 30–39 years (3.07; 2.80–3.35) than aged 15–29 years (1.75; 1.55–1.98). Conclusions AYA survivors of non-gynecologic cancers are at an increased risk of POI, particularly survivors of lymphomas, leukemia, breast, and thyroid cancer. The risk of POI is increased for those diagnosed with cancer at an older age. These results should inform reproductive counseling of female AYAs diagnosed with cancer.