Monitoring and reporting on cancer survival provides a mechanism for understanding the effectiveness of Canada's cancer care system. Although 5-year relative survival for colorectal cancer and lung cancer has been previously reported, only recently has pan-Canadian relative survival by stage been analyzed using comprehensive registry data. This article presents a first look at 2-year relative survival by stage for colorectal and lung cancer across 9 provinces.As expected, 2-year age-standardized relative survival ratios (ARSRS) for colorectal cancer and lung cancer were higher when the cancer was diagnosed at an earlier stage. The ARSRS for stage I colorectal cancer ranged from 92.2% in Nova Scotia [95% confidence interval (CI): 88.6% to 95.1%] to 98.4% in British Columbia (95% CI: 96.2% to 99.3%); for stage IV, they ranged from 24.3% in Prince Edward Island (95% CI: 15.2% to 34.4%) to 38.8% in New Brunswick (95% CI: 33.3% to 44.2%). The ARSRS for stage I lung cancer ranged from 66.5% in Prince Edward Island (95% CI: 54.5% to 76.5%) to 84.8% in Ontario (95% CI: 83.5% to 86.0%). By contrast, ARSRS for stage IV lung cancer ranged from 7.6% in Manitoba (95% CI: 5.8% to 9.7%) to 13.2% in British Columbia (95% CI: 11.8% to 14.6%).The available stage data are too recent to allow for meaningful comparisons between provinces, but over time, analyzing relative survival by stage can provide further insight into the known differences in 5-year relative survival. As the data mature, they will enable an assessment of the extent to which interprovincial differences in relative survival are influenced by differences in stage distribution or treatment effectiveness (or both), permitting targeted measures to improve population health outcomes to be implemented.

Introduction: Large cell neuroendocrine carcinoma (LCNEC) is a rare type of high-grade pulmonary neuroendocrine tumor. The study objective is to investigate its survival outcomes, incidence of brain metastases, and patterns of recurrence. Methods: This is a single center study of patients with pathologic diagnosis of pulmonary LCNEC. Patient data were collected retrospectively and analyzed, including survival, incidence of brain metastases, and patterns of recurrence. Results: Of 87 patients (stages I: 24, II: 14, Ill: 23, IV: 26), 52 were managed curatively and 35 palliatively. The median follow-up time was 17.3 months (range 0.6-89.5) for those treated with curative intent and 7.0 months (range 0.1-28.6) for those treated palliatively. The 2- and 5-year overall survival (OS) rates are 48.4% and 25.5% for the curative group, with a median OS of 13.5 months. In the palliative group, the OS are 30.8% at 1 year and 6.8% at 2 years, with a median OS of 7.0 months. Thirty-eight of 52 (73%) patients treated with curative intent had disease relapse, with the common sites being regional lymph nodes (20), brain (18), bones (11), and liver (9). The incidence of brain recurrence among those managed curatively are 21.4% and 41.3%, respectively at 1 and 2 years. Of 18 patients experiencing brain metastases, 14 developed them as part of a first relapse. Conclusions: LCNEC's survival outcomes are poor. The incidence of brain metastases is higher than what is observed for other types of nonsmall cell lung cancers. Prophylactic cranial irradiation should be investigated as a means of improving outcomes. (C) 2018 Published by Elsevier Inc.

Occupational exposure to strong inorganic acid mists containing sulfuric acid has been recognized as a carcinogen (Group 1) since 1992. An augmented, secondary data analysis of a population-based case-control study of lung cancer was conducted to assess lung cancer-specific risks using 772 lung cancer cases diagnosed between 1981 and 1985. Individually matched controls--on age, gender, and borough of residence--were identified. Lifetime exposure to 10 acidic agents, including strong inorganic acids and some gases, was assessed from complete lifetime occupational histories in terms of concentration, frequency, and reliability of the various exposure assessments. Smoking-adjusted odds ratios and 95% confidence intervals were determined for overall and histology-categorized lung cancers using conditional logistic regression. No excess risk for overall lung cancer was associated with any of the acids, and effect modification by gender could not be identified. The absence of an acid lung cancer effect reinforces more recent toxicological data that suggest specificity to the larynx.

6125 Background: Within a 5-year population-based cohort of colorectal cancer (CRC) patients with Collaborative Stage in Nova Scotia (NS), Canada, survival curves showed that stage IIIA patients had better 1-year overall survival (OS) than stage I patients and better 5-year OS than stage II patients. We hypothesize that the Collaborative Staging system, which uses clinical data in the absence of pathology data, may be partially responsible for this finding. Thus, the objective of this study is to further explore the relationship between lymph node (LN) assessment and OS in CRC patients. Methods: All CRC patients diagnosed between 2001-2005 were identified through the NS Cancer Registry (n = 3501). Linkage with vital statistics data allowed for determination of survival to March 31, 2008. The Kaplan-Meier method was used to estimate stage-specific 1- year and 5-year OS. Cox Regression was used to examine the relationship between LN assessment and OS for stage I and II patients. Results: Controlling for age and comorbidity, compared with stage III patients, the adjusted OS for stage I patients with assessed LN (HR = 0.36, p < 0.0001) and without assessed LN (HR = 0.626, p < 0.0001) were higher. Compared with stage III patients, the adjusted OS for stage II patients with assessed LN (HR = 0.6, p < 0.0001) was higher and without assessed LN (HR = 2.3, p < 0.0001) was lower. Conclusions: The lower OS for stage II patients appears to be related to LN assessment. Reasons for not pathologically assessing LN in CRC patients include not undergoing a resection or undergoing a resection for rectal cancer that does not involve LN removal. Further analyses are warranted to explore the impact of pathologically unassessed LN on stage misclassification and ultimately survival, particularly in the setting of Collaborative Staging where patients with pathologically unassessed LN may be classified as stage I or II patients. No significant financial relationships to disclose.

Male breast carcinoma (Male BC) is a distinct biological subtype of breast cancer. We previously reported an association between 5-year overall survival and strong intratumoral aromatase (ITA) expression in Male BC. In this study, we investigate survivin and COX-2 expression and their relationship to ITA. Clinical data were abstracted for all Male BC patients diagnosed between 1985 and 2005 in Nova Scotia, Canada. Archival tissues were retrieved for tissue microarray (TMA) and immunohistochemistry (IHC). Of 54 Male BCs identified, 39 cases had tissue available for IHC. Survivin expression was noted in 27 cases (69%); 12 nuclear and 26 cytoplasmic while strong COX-2 expression was observed in 14 cases (36%). Cytoplasmic survivin and COX-2 expressions were positively associated with ITA expression. However, survivin and COX-2 expression were not predictive of survival. Additional studies are needed to further elucidate the correlation between cytoplasmic survivin, COX-2 and ITA expression in Male BC considering their potential therapeutic implications.

BACKGROUND:Adjuvant Anastrozole (ANA) for 5 years and Tamoxifen followed by Exemestane (TAM-EXE) for 2.5 years each have become acceptable alternatives to 5 years of Tamoxifen (TAM) for post-menopausal women with breast cancer. As these newer options are associated with higher drug costs as well as improved outcomes, an economic evaluation was undertaken to compare the cost-utility of ANA and TAM-EXE relative to TAM alone and to each other in terms of cost per quality-adjusted life year (QALY) gained.METHODS:A Markov model was developed to calculate monthly costs and outcomes in a hypothetical cohort of post-menopausal women with early-stage breast cancer. Baseline rates of cancer recurrence and adverse effects with TAM, and hazard ratios associated with ANA and EXE, were derived from the ATAC and IES trials. Patients received hormonal therapy for 5 years and benefit was modeled to persist 5 years beyond treatment. The analysis took a direct payer perspective with a 20-year time horizon. Costs and outcomes were discounted by 3%. Costs are in 2005 Canadian dollars.RESULTS:ANA and TAM-EXE were associated with increased costs and QALYs, though the cost-utility of both relative to TAM alone was strongly favourable (<$50,000/QALY). Based on an indirect comparison of ANA and TAM-EXE, using TAM alone as a common comparator, the cost-utility of ANA relative to TAM-EXE appears unfavourable.CONCLUSIONS:Both upfront and sequential AI options were cost-effective alternatives to TAM alone, but TAM-EXE appears to be the economically preferred AI option based on its more favourable cost-utility versus ANA.

Measurement of care time intervals is complex, being influenced by many factors. The definition of the care interval monitored can also bias the detection of changes in waits. The implications of using different care interval definitions to report wait times and identify delays in care provision were examined using a retrospective chart review of 637 women with surgically treated breast cancer who were referred to a cancer centre between September 1999 and 2000 or September 2003 and 2004. Overall waits between detection and adjuvant treatment increased by 12 days over the two periods, but their exact location and cause(s) could not be determined at such a low-resolution interval. At higher resolutions of care intervals, reporting the comprehensive sequence of care events, the prolongation was mainly associated with delayed access to surgery (4 days) and delivery of adjuvant chemotherapy (4 days). The latter went unnoticed when waits were reported at intermediate (referral to adjuvant treatment) and low (detection to adjuvant treatment) resolutions. Disease stage and type of first adjuvant treatment consistently and significantly influenced the length of waits. Comprehensive monitoring of the entire care path is essential to effectively prioritize interventions, assess their outcomes and optimise access to cancer care.

6066 Background: Defining, measuring and monitoring quality of care is a facet of health services research that is growing in importance. Breast cancer offers a disease model to examine quality end-of-life (EOL) care provided to women. Administrative data have the unique potential to provide population-based measures of quality of care. The objective of this study was to assess the feasibility of using routinely-collected administrative data to measure quality EOL care for breast cancer patients. Methods: A cohort of all women in Nova Scotia who died of breast cancer between 01/01/1998 and 31/12/2002 was assembled from the Cancer Registry and Vital Statistics data. The EOL study period was defined as the last 6 months of life. A total of 864 women met the eligibility criteria. After a literature review, an expert panel identified 19 indicators that were potentially measurable through administrative data. Physician billings, hospital discharge abstracts and seniors pharmacare data, supplemented by clinical datasets, were utilized to calculate the statistics with which to represent the indicators. Results: Benchmark measures of care across the cohort show 63.4% died in a hospital, a mean continuity of care index of 0.786, and the mean number of inpatient days in the last 30 was 9.9. Indicators of aggressive care include 9.3% had chemotherapy in the last 14 days, 5.6% had more than 1 emergency room visit in the last 30 days, and 29.1% had more than 14 inpatient days in the last 30 days. Conclusions: Weaknesses of using these data include: 1) fixed variables with an administrative rather than a clinical objective; 2) lack of comprehensiveness of various datasets; and 3) the use of billings data where increasingly physicians are paid through methods other than fee-for-service. Strengths of this approach are: 1) population-based cohort; 2) comprehensiveness of cohort selection through the provincial Vital Statistics file; and 3) accessibility of data. No significant financial relationships to disclose.

Background: To determine cost-effective (CE) strategies comparing adjuvant upfront aromatase inhibitor (AI) with sequential tamoxifen (TAM) AI in postmenopausal (PM) women with breast cancer (BC).Design: A Markov model was constructed to calculate cumulative costs and quality-adjusted life year (QALY) gains for upfront AI and TAM-AI in a hypothetical cohort of 60-year-old PM women with BC. Costs, utilities and probabilities were derived from the literature. The hazard ratios (HRs) of AI strategies were applied to a baseline cancer recurrence risk (RR) to determine CE strategies at the $50,000/QALY gain threshold. A direct payer perspective is utilized, and costs and benefits were discounted at 3%.Results: Two-way sensitivity analyses are presented to determine CE strategies across a wide range of HRs and in different clinical scenarios including varying RRs (low, average, high and very high). TAM-AI is the preferred CE strategy at low and average RR, while upfront AI is CE at very high RR. The CE strategy in patients with high RR was dependent on the scenario examined.Conclusions: This model may help health care providers select CE-adjuvant AI strategies in PM women with BC, until further direct evidence is available from randomized clinical trials.

9636 Background: This study was conducted to evaluate the incidence and survival rates for mesothelioma in the province of Nova Scotia (NS), Canada using population-based data. Methods: A retrospective chart review was performed, using NS cancer registry data and cancer centre patient charts of all documented cases of mesothelioma in the province of NS between 1990 and 2002. Results: Between 1990 and 2002, 101 cases of mesothelioma were recorded. The overall incidence of mesothelioma was 1.3 per 100,000. The incidence rate by gender showed a higher rate in men than women with 1.47 per 100,000 versus 0.2 per 100,000, respectively. Incidence rates were highest in the area of Halifax County. The median age at the time of diagnosis was 70 in men and 64 in women. The distribution of mesothelioma per anatomical site was 87% pleural, 12% peritoneal and 1% unspecified. The most common presenting symptoms were shortness of breath (61%), chest pain (43%), and cough (27%). 69% of patients had documented asbestos exposure and 78% had a positive smoking history. The two year overall survival rate was 10% (10% for men and 15% for women). Conclusions: In Nova Scotia, Canada, the highest incidence of mesothelioma occurred in geographic areas where shipyards were common (Halifax County). Pleural disease was the most common anatomical site of origin for both genders. Men were at higher risk compared to women for the development of pleural mesothelioma over the time interval studied. Variable rates of mesothelioma were observed during the period examined. No significant financial relationships to disclose.

6040 Background: Adjuvant anastrazole (ANA) for 5 years or tamoxifen followed by exemestane (TAM-EX) for 2.5 years each have become acceptable alternatives to tamoxifen (TAM) for 5 years in postmenopausal women with breast cancer. An economic evaluation was undertaken to compare the cost-effectiveness (CE) of ANA and TAM-EX relative to TAM alone. Methods: A Markov model was developed to calculate cumulative costs and disease free survival years (DFSY) for each alternative over 5- and 20-year time horizons. The analysis took a direct payer perspective. Drug costs were based on average wholesale prices in Canada in 2004. Costs of adverse events and relapses were not included in the primary analysis. The baseline TAM DFS rate and hazard ratios associated with ANA and TAM-EX were taken from the published ATAC and IES trials. Beyond the 5-year treatment period, hazard ratios for ANA and TAM-EX were set to 1.0, reflecting conservative estimates of benefit. Both costs and benefits were discounted at 3%. Results: Both ANA and TAM-EX were associated with gains in DFS. Per 1,000 patients treated, ANA resulted in an incremental gain of 56.4 DFSY after 5 years and 162.3 DFSY after 20 years relative to TAM alone. TAM-EX had an incremental gain of 31.6 and 164.9 DFSY per 1,000 treated relative to TAM alone after 5 and 20 years, respectively. Incremental costs were $6.35 million per 1,000 treated with ANA and $2.90 million per 1,000 treated with TAM-EX. The CE of ANA relative to TAM alone was $112,510 per DFSY after 5 years and $39,124 per DFSY after 20 years. The CE of TAM-EX relative to TAM alone was $91,604 and $17,570 per DFSY after 5 and 20 years. Comparing TAM-EX and ANA directly, ANA had an incremental cost of $139,174 per DFSY gained at 5 years and was dominated by TAM-EX at 20 years. Conclusions: Although the short-term CE of ANA and TAM-EX is unfavourable, projecting the benefits over a longer horizon results in CE ratios well below $50,000 per DFSY gained. Both alternatives appear to be cost-effective options for postmenopausal women with breast cancer. These results will be updated based on the recently reported DFS and adverse events rates of the ATAC and IES trials. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration AstraZeneca Pfizer

6005 Background: Wait times for cancer treatment are of significant concern to the Canadian public. Previous studies of time to breast cancer care have examined single care events such as time to surgery. The spectrum of care however extends from disease detection to completion of adjuvant therapies. Our objective was to compare elapsed times from breast cancer detection to start of first adjuvant therapy in a Canadian province over 2 time periods; 1999–2000 and 2003–2004. Methods: A retrospective chart review was performed. All eligible women had pathologic confirmation of invasive disease and were referred to a provincial cancer center between Sept 1, 1999-Sept 1, 2000 (cohort 1) and Sept 1, 2003-Sept 1, 2004 (cohort 2). All dates were abstracted from patient charts and electronic records. The log-rank test was used to assess differences in time to events between cohorts. Results: Care intervals assessed (cohort 1 vs 2, median days); (I) detection to pathologic confirmation; 13d vs 14d (p=.12) (II) pathologic confirmation to definitive surgery; 21d vs 24d (p=.002) (III) definitive surgery to referral receipt at cancer center; 16d vs 19d (p=.005) (IV) referral receipt to patient contact; 10.5d vs 6d (p=.04) (V) patient contact to first med/rad onc appt; 5d vs 6d (p=.48) (VI) first appt to start of first adjuvant therapy 11d vs 18.5d (p=.03). Summary elapsed times are presented below with interquartile ranges (IQR). Conclusions: The majority of women experience long elapsed times for breast cancer care. Elapsed times have lengthened over the cohorts studied, although the overall difference did not reach statistical significance. Intervals prior to referral receipt at cancer centers account for prolongation in elapsed times between cohorts. Our data, spanning a sequence of care events, more fully elucidates waiting time burden and may provide a framework for the design and evaluation of programs aimed at reducing elapsed care times. No significant financial relationships to disclose.

F Burge Associate Professor, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, G Johnston Associate Professor, School of Health Services Administration, Dalhousie University, Halifax, Nova Scotia and Senior Epidemiologist, Nova Scotia Cancer Registry, B Lawson Research Associate, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, R Dewar Biostatistician, Nova Scotia Cancer Registry and I Cummings Associate Professor, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia and Director, Palliative Care Program, QEII Health Sciences Centre