The document discusses water-induced disasters in Nepal such as glacial lake outburst floods, monsoon floods, and landslides. It notes that Nepal experiences high temporal and spatial variation in runoff and rainfall due to its geological formation in the Himalayas. On average, disasters in Nepal cause 300 deaths, 67 injuries, and over $600 million in losses annually. The document then highlights non-structural mitigation measures used in Nepal, including disaster preparedness maps and a bamboo porcupine riverbank protection innovation. It concludes by emphasizing the importance of networking to reduce disaster risks.
Exploration and Fur Trade of Western CanadaKevin Yee
Captain James Cook was the first European explorer to set foot on what is now British Columbia. He explored the coast in 1778, meeting native peoples but missing key locations like Juan de Fuca Strait. He died in 1779 in Hawaii on his third voyage of exploration. Alexander Mackenzie worked for the North West Company and in 1793 became the first person to cross North America north of Mexico. In 1789 he explored the river that now bears his name, reaching the Arctic Ocean. In 1793 he reached the Pacific Ocean but was turned back by hostile natives. Simon Fraser worked for the Hudson's Bay Company and in 1811 was the first European to travel the entire length of the Columbia River.
James Cook conducted three major voyages of exploration and discovery: (1) To observe the transit of Venus in 1768-1771, exploring New Zealand, Australia, and Tahiti; (2) In 1772-1775 to search for the mythical southern continent of Terra Australis, disproving its existence while mapping other areas; (3) From 1776-1779 to search for the Northwest Passage, landing in Hawaii where he was killed in a fight with Hawaiians in 1778. Cook made many contributions including mapping territories, discovering the true nature of Polynesians' relations with Europeans, and identifying that citrus cures scurvy. He was a skilled navigator and leader who expanded
The document discusses water-induced disasters in Nepal such as glacial lake outburst floods, monsoon floods, and landslides. It notes that Nepal experiences high temporal and spatial variation in runoff and rainfall due to its geological formation in the Himalayas. On average, disasters in Nepal cause 300 deaths, 67 injuries, and over $600 million in losses annually. The document then highlights non-structural mitigation measures used in Nepal, including disaster preparedness maps and a bamboo porcupine riverbank protection innovation. It concludes by emphasizing the importance of networking to reduce disaster risks.
Exploration and Fur Trade of Western CanadaKevin Yee
Captain James Cook was the first European explorer to set foot on what is now British Columbia. He explored the coast in 1778, meeting native peoples but missing key locations like Juan de Fuca Strait. He died in 1779 in Hawaii on his third voyage of exploration. Alexander Mackenzie worked for the North West Company and in 1793 became the first person to cross North America north of Mexico. In 1789 he explored the river that now bears his name, reaching the Arctic Ocean. In 1793 he reached the Pacific Ocean but was turned back by hostile natives. Simon Fraser worked for the Hudson's Bay Company and in 1811 was the first European to travel the entire length of the Columbia River.
James Cook conducted three major voyages of exploration and discovery: (1) To observe the transit of Venus in 1768-1771, exploring New Zealand, Australia, and Tahiti; (2) In 1772-1775 to search for the mythical southern continent of Terra Australis, disproving its existence while mapping other areas; (3) From 1776-1779 to search for the Northwest Passage, landing in Hawaii where he was killed in a fight with Hawaiians in 1778. Cook made many contributions including mapping territories, discovering the true nature of Polynesians' relations with Europeans, and identifying that citrus cures scurvy. He was a skilled navigator and leader who expanded
Four cancer survivors accompanied a riderless bike to represent those unable to participate in the Ride to Conquer Cancer due to actively fighting or having succumbed to cancer. The author was moved by stories shared during the ride, including a father who lost his son to cancer, a mother supporting her son with brain cancer, and a man riding in memory of his father who died of cancer. The stories highlighted the suffering caused by cancer and its impact on families and friends. Despite outward cynicism, the author was moved to tears and committed to fighting cancer through fundraising for research.
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
This document summarizes kidney, pancreas, and pancreatic islet transplantation. It discusses how kidney transplantation has become the treatment of choice for many with kidney failure due to improved outcomes. However, there remains a shortage of donor organs. The document outlines efforts in BC to increase living donors and use of expanded criteria deceased donors. Individualized immunosuppression also improves outcomes while reducing side effects. Pancreas transplantation requires strict criteria due to limited donors and aims to restore normoglycemia without insulin.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Four cancer survivors accompanied a riderless bike to represent those unable to participate in the Ride to Conquer Cancer due to actively fighting or having succumbed to cancer. The author was moved by stories shared during the ride, including a father who lost his son to cancer, a mother supporting her son with brain cancer, and a man riding in memory of his father who died of cancer. The stories highlighted the suffering caused by cancer and its impact on families and friends. Despite outward cynicism, the author was moved to tears and committed to fighting cancer through fundraising for research.
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
British Columbia Medical Journal, January/February 2010 issue
Please download or visit this entire issue online at http://bcmj.org/january-february-2010
This document summarizes kidney, pancreas, and pancreatic islet transplantation. It discusses how kidney transplantation has become the treatment of choice for many with kidney failure due to improved outcomes. However, there remains a shortage of donor organs. The document outlines efforts in BC to increase living donors and use of expanded criteria deceased donors. Individualized immunosuppression also improves outcomes while reducing side effects. Pancreas transplantation requires strict criteria due to limited donors and aims to restore normoglycemia without insulin.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Know the difference between Endodontics and Orthodontics.
British Columbia Medical Journal, December 2010 - Revisiting rectal cancer management in British Columbia
1. P. Terry Phang, MD, R. Cheifetz, MD, C.J. Brown, MD, C.E. McGahan, MSc,
Manoj Raval, MD
Revisiting rectal cancer
management in British
Columbia
A high local recurrence rate for rectal cancer has been reduced with
the help of new clinical practice guidelines.
n 1996 a high local recurrence rate awareness among family doctors, out-
I
ABSTRACT: An audit of data from
1996 found a high rate of local recur- for rectal cancer was identified in comes analysis using data from pa-
rence in patients treated for rectal an audit of outcomes for patients tient follow-up, and provision of feed-
cancer in British Columbia. The Col- treated for rectal cancer in BC.1 Pelvic back to participating specialists and
orectal Surgical Tumour Group of the recurrence at 4 years occurred in 16% family physicians.
Surgical Oncology Network of the BC of rectal cancer patients for all stages
Cancer Agency addressed the high and in 27% of Stage 3 patients. In con- Step 1: Outcomes review
rate of local recurrence with treat- trast, local recurrence from colon can- Our review of 1996 rectal cancer man-
ment strategies of short-course pre- cer is estimated at 5% to 10%. agement in BC1 determined that only
operative radiation and total meso- Factors contributing to a higher about 10% of operative reports includ-
rectal excision. Education sessions rate of local recurrence after surgical ed statements that the rectal cancer
were given for surgeons, oncologists, resection of rectal cancer than after was resected with clear gross radial
and pathologists. Initial outcomes resection of colon cancer include more margins and that all mesorectal lymph
following implementation of this difficult surgical anatomy in the pelvis nodes were removed in keeping with
management plan indicate a reduc- compared with the abdomen, nonstan- the tenants of oncological surgical
tion in local recurrence in BC. Issues dardized technique for resection of the resection. Only about 50% of pathol-
identified that require further im- rectum, and poor adherence to inter- ogy reports assessed whether radial
provement include facilitation of pre- national standards in the provision of margins were histologically free of
operative MRI staging and strategies adjuvant radiotherapy. cancer. The mean number of lymph
to decrease high positive resection nodes identified at pathology evalua-
margin rates for distal third rectal Management plan tion was 6 instead of 12, the minimum
cancer location. This communica- Having recognized this significant recommended for accurate staging.
tion to the BC medical community problem for rectal cancer patients, the
completes the feedback loop for this Colorectal Surgical Tumour Group All authors are members of the Colorectal
quality improvement project using a of the Surgical Oncology Network Surgical Tumour Group of the Surgical
multidisciplinary approach. (SON) of the BC Cancer Agency de- Oncology Network of the BC Cancer
signed a management plan aimed at Agency. Additionally, Dr Phang is an asso-
standardizing care across the province ciate professor of surgery at the University
and reducing local recurrence. The of British Columbia; Dr Cheifetz is an assis-
plan included an outcomes review tant professor of surgery at UBC; Dr Brown
to define the problem, strategy devel- is a clinical assistant professor of surgery at
opment to address the problem, an UBC; Dr Raval is chair of the Colorectal Sur-
education program for specialists, gical Tumour Group of the Surgical Oncolo-
implementation of the strategy includ- gy Network and clinical assistant professor
This article has been peer reviewed. ing an information campaign to raise of surgery at UBC.
510 BC MEDICAL JOURNAL VOL. 52 NO. 10, DECEMBER 2010 www.bcmj.org
2. Revisiting rectal cancer management in British Columbia
Adjuvant radiation was given to about
50% of eligible patients with Stages 2
1. Diagnosis is made on biopsy obtained during sigmoidos-
and 3 disease.
copy or colonoscopy.
Step 2: Strategy development 2. Preoperative clinical stage is determined by CT (abdomen,
After recognizing these management pelvis) to assess distant spread (clinical stage M) and by
deficiencies, we recommended a new MRI (pelvis) or endorectal ultrasound to assess local
surgical technique, total mesorectal
invasion (clinical Stage T and N, and predicted radial
excision (TME), for excision of the
resection margin).
rectal cancer and all mesorectal lymph
nodes within an intact mesorectal fas- 3. Preoperative radiation is indicated for clinical Stages 2
cial envelope.2 Local recurrence rates and 3 (T3-4, N1-2).
at 10 years for curative resections using a. Short-course preoperative radiation over 5 days is
TME were reported to be as low as recommended for mobile lesions with clear predicted
4%. A new protocol for preoperative
radial resection margins.
short-course radiation recommended
b.Long-course preoperative radiation (with concurrent
by Pahlman and colleagues in Sweden
reduced local recurrence to 11% from chemotherapy) over 5 weeks is recommended for
27% after follow-up for a minimum clinically fixed lesions or for close/involved predicted
of 5 years.3 The combination of short- radial resection margins in order to maximize tumor
course preoperative radiation and TME shrinkage prior to surgery.
resulted in a 2-year local recurrence
4. Postoperative adjuvant chemotherapy over 4 to 6 months
of 2.4% in a Dutch national trial.4 On
is given for clinical Stages 2 and 3 lesions.
the basis of this and other studies, the
clinical guidelines for rectal cancer a. Postoperative adjuvant radiation is given for clinical
management in BC (see Figure ) were Stages 2 and 3 lesions if radiation is not given
changed to recommend short-course preoperatively.
preoperative radiation for Stages 2 and 5. Surveillance is recommended in Stages 2 and 3 patients
3 rectal cancers followed by surgical
for 5 years: office visits for rectal examination and
resection using TME. The guidelines
carcinogenic embryonic antigen testing every 3 to 4
also include preoperative clinical stag-
ing using CT, MRI, and endorectal months for 3 years, then every 6 months for years 4 and 5;
ultrasound in order to recommend pre- liver imaging (ultrasound or CT) every 6 to 12 months in
operative radiation where appropri- the first 3 years, then annually for years 4 and 5; chest
ate. Guidelines for pathology report- X-ray every 6 to 12 months; colonoscopy at year 1 and
ing include assessment of the radial year 4, then every 5 years thereafter. Flexible sigmoidos-
resection margin and examination of copy every 6 to 12 months should also be considered.
at least 12 lymph nodes. The recom-
mendations were not changed for long-
course preoperative chemoradiation Figure. Clinical guidelines for rectal cancer management in BC.
for clinically fixed tumors and lesions Adapted from BC Cancer Agency web site (www.bccancer.bc.ca).5
having predicted close resection mar-
gins or for adjuvant postoperative care of patients with rectal cancer. (neoadjuvant) and postoperative (ad-
chemotherapy for Stage 3 cancers.5 Held in 2002 and 2003, the education juvant) setting, pelvic anatomy, the
sessions consisted of lectures, live sur- surgical technique of total mesorectal
Step 3: Education program gery with a video link to the audience, excision,6 gross pathology of the resect-
To implement the new treatment strat- and hands-on dissection of the pelvis ed TME specimen, and standardized
egies, we designed an education pro- in cadaver labs. Session topics includ- operative reporting. A parallel course
gram for surgeons, pathologists, and ed preoperative imaging, radiation, of lectures and live demonstration was
radiation oncologists involved in the and chemotherapy in the preoperative held for pathologists, including TME
www.bcmj.org VOL. 52 NO. 10, DECEMBER 2010 BC MEDICAL JOURNAL 511
3. Revisiting rectal cancer management in British Columbia
Use of preoperative imaging mo-
Use of preoperative imaging modalities dalities of MRI and endorectal ultra-
sound continue to be limited because
of MRI and endorectal ultrasound of resource limitations in BC and
continue to be limited because of because radiologists have not yet
adopted a standardized report form for
resource limitations in BC and rectal cancer. BC Cancer Agency cen-
because radiologists have not yet tres in Victoria, Vancouver, Surrey,
Kelowna, and Abbotsford, and soon
adopted a standardized report in Prince George, offer potential for
form for rectal cancer. creating rectal cancer care pathways
to improve accessibility of MR scan-
ning and radiation. The Colorectal
Surgical Tumour Group of the Surgi-
cal Oncology Network has preopera-
tive MR imaging on its working agen-
specimen processing, gross and mi- for Stage 3 rectal cancers and from da and invites radiologists to join the
crosopic findings, and standardized 9.6% to 6.9% overall.14 Use of adju- community of family physicians, sur-
pathology reporting.7,8 World experts vant radiation increased to 65%, most- geons, oncologists, and pathologists
from the UK, Sweden, the Nether- ly given preoperatively. Negative as integral contributors to the care of
lands, and the US were invited to teach radial margins were achieved in 87% rectal cancer patients.
at the sessions. Favorable feedback of cases. Pathology reporting showed Technical problems with surgical
from course participants regarding the increased assessment of the radial resection of rectal cancer persist in
educational value of the sessions and margin to 97% of cases and an aver- BC. Positive radial margins for rectal
tests of knowledge retention suggest- age of 12 lymph nodes per case. These cancer location in proximity to the
ed good knowledge transfer.9 improvements were statistically and anal sphincter were recorded in 35%
clinically significant. of specimens with cancers in the
Step 4: Implementation with distal-third of the rectum (located less
information campaign Step 6: Feedback than 5 cm from the anus).15 Also, the
Our next step was to implement the The final step of the quality improve- rate of permanent colostomy for distal-
treatment plan and to inform family ment process involved providing feed- third rectal cancer location was not
doctors in BC of the new rectal cancer back to participants. Ongoing reports decreased after the education courses.
management strategy. This informa- were provided to BC surgeons at their It seems reasonable to recommend
tion was transmitted via the BC Med- annual spring meeting (BC Surgical that surgeons who operate for rectal
ical Journal in a two-part theme issue Society) and to oncologists at their cancer less frequently should consid-
in July-August and September of annual fall meeting (BC Cancer Agen- er referral of difficult distal-third rec-
2003.10-13 cy), as well as through the SON news- tal cancers to subspecialist surgeons
letter. A rectal cancer education course in higher-volume centres.16
Step 5: Outcomes analysis update was held in 2008 that reported
Data on patient outcomes were col- on the final outcomes. Conclusions
lected and analyzed by the Colorectal Feedback to family doctors in BC Quality improvement in rectal cancer
Surgical Tumour Group of the SON. will continue to be provided through treatment will ideally continue in cy-
We audited patients treated with cura- the BC Medical Journal. cles of assessment, strategy, and execu-
tive-intent major resection of their tion. We have identified improvements
rectal cancer in the year after the edu- Further improvements needed in the care of rectal cancer
cation courses. This group of patients needed patients and hope to use the recently
was compared with patients treated in As with many quality improvement developed cancer surgeon network to
our initial study. The main finding of projects, important aspects of care promote these. With a multidisciplinary
this audit was a decrease in 2-year requiring further attention have been approach to care, physicians and sur-
pelvic recurrence from 18.2% to 9.2% identified. geons continue seeking to improve
512 BC MEDICAL JOURNAL VOL. 52 NO. 10, DECEMBER 2010 www.bcmj.org
4. Revisiting rectal cancer management in British Columbia
patient outcomes. However, limita-
tions in resources and geography pose
challenges for quality improvement in
our large province. Patient awareness, Surgeons who operate for rectal
education, and advocacy will be im-
cancer less frequently should
portant drivers in the quest to beat col-
orectal cancer in British Columbia. consider referral of difficult distal-
third rectal cancers to subspecialist
Competing interests
None declared. surgeons in higher-volume centres.
References
1. Phang PT, MacFarlane J, Taylor RH, et al.
Effects of positive resection margin and
tumour distance from anus on rectal can-
cer treatment outcomes. Am J Surg
2002;183:504-508. 7. Quirke P, Durdey P, Dixon MF, et al. Local operative rectal cancer imaging. BCMJ
2. Heald RJ, Moran BJ, Ryall RDH, et al. recurrence of rectal adenocarcinoma due 2003;45:259-261.
Rectal cancer: The Basingstoke experi- to inadequate surgical resection. Histo- 12. Phang PT, Law J, Toy E, et al. Pathology
ence of total mesorectal excision, 1978- pathological study of lateral tumour audit of 1996 and 2000 reporting for rec-
1997. Arch Surg 1998;133:894-899. spread and surgical excision. Lancet tal cancer in BC. BCMJ 2003;45:319-323.
3. Pahlman L, Glimelius B, and the Swedish 1986;2(8514):996-999. 13. Phang PT, Strack T, Poole B. Proposal to
Rectal Cancer Trial investigators. Improv- 8. Nagtegaal ID, van de Velde CJ, van der improve rectal cancer outcomes in BC.
ed survival with preoperative radiothera- Worp E, et al.; Cooperative Clinical Inves- BCMJ 2003;45:330-335.
py in resectable rectal cancer. N Engl J tigators of the Dutch Colorectal Cancer 14. Phang PT, McGahan CE, McGregor G, et
Med 1997;336:980-987. Group. Macroscopic evaluation of rectal al. Effects of change in rectal cancer man-
4. Kapiteijn E, Marijnen CA, Nagtegaal ID, cancer resection specimen: Clinical sig- agement on outcomes in British Colum-
et al.; Dutch Colorectal Cancer Group. nificance of the pathologist in quality con- bia. Can J Surg 2010;53:225-231.
Preoperative radiotherapy combined with trol. J Clin Oncol 2002;20:1729-1734. 15. Phang PT, Kennecke H, McGahan CE, et
total mesorectal excision for respectable 9. Cheifetz R, Phang PT. Evaluating learning al. Predictors of positive radial margin sta-
rectal cancer. N Engl J Med 2001;234: and knowledge retention after a continu- tus in a population-based cohort of pa-
638-646. ing medical education course on total tients with rectal cancer. Curr Oncol
5. BC Cancer Agency. Management guide- mesorectal excision for surgeons. Am J 2008;15:1-6.
lines for rectal cancer. www.bccancer.bc Surg 2006;191:687-690. 16. Martling AL, Holm T, Rutqvist LE, et al.
.ca/HPI/CancerManagementGuidelines/ 10. Phang PT, MacFarlane J, Taylor RH, et al. Effect of a surgical training programme
Gastrointestinal/06.Rectum/Manage Practice patterns and appropriateness of on outcome of rectal cancer in the Coun-
ment (accessed 8 October 2010). care for rectal cancer management in BC. ty of Stockholm. Lancet 2000;356(9224):
6. Phang PT. Total mesorectal excision: Tech- BCMJ 2003;45:324-329. 93-96.
nical aspects. Can J Surg 2004;47:130-137. 11. Malfair D, Brown JA, Phang PT. Pre-
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