Susan Pedwell

Women with BRCA-related breast cancer can halve their risk of dying from breast cancer with a double mastectomy, according to a U of T-led study published in the British Medical Journal.

The study led by Professor Kelly Metcalfe, from U of T's Lawrence S. Bloomberg Faculty of Nursing, reported that women with BRCA-related breast cancer who have a double mastectomy are nearly 50 per cent less likely to die of breast cancer within 20 years of diagnosis compared to women who have a single mastectomy.

Many media reports on the study have noted its connection to Angelina Jolie's highly publicized and controversial decision to undergo a preventative double-mastectomy last year. (Read a U of T News interview with Professor Metcalfe about Angelina Jolie's preventative surgery)

Metcalfe explained this breakthrough research and how the study findings have the potential to change the future of breast cancer treatment.

What did your study show?
What we saw is that women with a BRCA genetic mutation who had a bilateral mastectomy – that is, had both breasts removed – had half the chance of dying from breast cancer compared to women who had just one breast removed. At 20 years, the survival rate was 88 per cent for the women who had a double mastectomy, but only 66 per cent for women having a single mastectomy.

In the study, we assessed the medical records of 390 women across North America who had been diagnosed with early-stage breast cancer, had a BRCA mutation, and had been treated with either a single or double mastectomy. We followed the women, on average, for 14 years after their initial diagnosis.

We know that women with a BRCA1 or BRCA2 mutation and who have been diagnosed with breast cancer have a high lifetime risk of developing a subsequent cancer in the same or opposite breast. However, we didn’t know what impact a diagnosis of a second breast cancer had on mortality. This study has shown that women who develop a second breast cancer have twice the risk of dying of their disease. So when we think of treating a woman with a BRCA mutation, we need to think not just about treating her first breast cancer, but preventing a second breast cancer.

Our research may change the way we think about treating women with BRCA-associated breast cancer. These women may need a different surgical treatment than those without the genetic mutation; for them, a more conservative surgery may be appropriate.

Can your research findings be put into practice?
Yes, they can immediately go into clinical practice. We need to prevent this cohort of women from getting a second breast cancer, and the way to prevent that second breast cancer is a bilateral mastectomy.

It’s important for women to be aware of these study findings because it shows that there may be a survival benefit associated with having a bilateral mastectomy. To translate this information into clinical practice, though, a woman needs to know if she has BRCA mutation.

Should BRCA testing be offered more readily?
I think so. BRCA testing is not appropriate for every woman, but it is appropriate for women with young-onset breast cancer, women with a strong family history of the disease, and women who are Jewish, as there’s a higher frequency of these mutations in the Jewish population.

This research speaks to the importance of a woman being offered genetic testing at the time of breast cancer diagnosis and receiving those results quickly. In the era of personalized medicine, it is important that a woman has this genetic information, so her breast cancer treatment can be targeted to obtain the best possible outcome.

With this information, will women elect to have a bilateral mastectomy?
That’s what we’re evaluating now. We don’t want to cause more distress to a woman at the time of breast cancer diagnosis. We want to make sure that it’s appropriate to give women this information and also that they do something with the knowledge. If the information doesn’t impact treatment decisions, it may not be necessary to do genetic testing at diagnosis.

Susan Pedwell is the editor of Pulse, U of T Nursing’s biannual magazine.

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Dr. Homer Tien: from the battlefield to the ER

sgupta — Fri, 06 Jul 2012 08:34:11 +0000

Dr. Homer Tien: from the battlefield to the ER sgupta Fri, 07/06/2012 - 04:34

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Assistant Professor Homer Tien is Director of Trauma Services at Sunnybrook Health Sciences Centre and the first Canadian Forces Chair in Military Trauma Research (photo by Tim Fraser)

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When Dr. Homer Tien is asked why he received the Order of Military Merit in December, he shrugs.

“I guess because I’ve been in the Forces for a while,” he offers modestly.

Only later does the colonel, an assistant professor at U of T and director, trauma services, at Sunnybrook Health Sciences Centre, recall his exceptional advancements.

“In ‘96, I was the first medical officer posted to the Canadian military counterterrorism team on the NATO mission in Bosnia,” says Dr. Tien. “And, oh yeah, in 2006 I was the first Canadian surgeon deployed to Kandahar.”

Since then, Tien has been deployed to Afghanistan five times, most recently last fall for a two-month tour of duty – making him also the last Canadian Forces trauma surgeon to serve in Kandahar.

At the Kandahar military base, Tien would start the day by strapping on a 9 mm Browning pistol.

“I’m so used to wearing a gun, I didn’t even think of it,” he says.

Then he’d grab a coffee at the base’s Tim Hortons and head to the military hospital. He would perform such procedures as digging shrapnel out of the bodies of British, American and Canadian coalition soldiers, and caring for civilians who had stepped on landmines.

“Amputation is common with a landmine injury,” he explains. “Sometimes we have to do a triple amputation, which is really sad, especially with a child.”

On occasion, Tien would work 36 hours straight – without complaining.

“The only thing I have to do on the base is work,” he explains. At home, he’s busy helping his wife drive their three daughters to music lessons and sporting events.

Tien enlisted in the Canadian Forces in 1990 to pay for medical school at McMaster. Later, his military service funded surgical training at U of T and a two-year fellowship with Sunnybrook’s trauma team. Tien also earned a master’s degree in clinical epidemiology at U of T, graduating in 2007.

Today, he excels in teaching the intricacies of treating blast injuries and gunshot wounds.

Perhaps Tien’s greatest teaching, though, is leadership.

“In medical school there is very little formal teaching of leadership training but in the military you receive a lot. You learn to be decisive in an emergency situation and assertively pass on your decisions. You learn you absolutely must not waffle.”

Tien also has a teaching role in the Forces. In 2007, for example, he trained military medical technicians to perform on the battlefield an emergency cricothyrotomy, which involves making a cut in the neck and inserting a breathing tube through the slit.

“Medical technicians had never done it before, and they do a very good job in a very difficult environment,” says Tien, whose research focuses on military medicine, including war surgery.

On July 3, the Parliamentary Secretary to the Minister of National Defence presented Tien with the Canadian Forces Major Sir Frederick Banting Term Chair in Military Trauma Research.

“I am very proud that Colonel Tien's continuing work is being recognized, and that he is being extended this important opportunity as the first Canadian Forces Chair in Military Trauma Research,” says Chris Alexander. “I look forward to following the progress of his work over the years to come.”

Barry McLellan, President and Chief Executive Officer, Sunnybrook Health Sciences Centre, says: “We are excited to continue our work with Dr. Tien and the Canadian Forces in a research capacity to share experiences in trauma medicine that will better serve the CF and civilian populations.”

At Sunnybrook, Tien cares for Ontario’s most seriously injured. They come by helicopter or ambulance after falling from the high beam of a construction site or being cut out of a mangled car on the 401.

About 50 per cent die before they get to Sunnybrook’s Tory Regional Trauma Centre where Tien is the medical director, but a remarkable 90 per cent survive if only they can arrive with a beating heart.

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U of T helps province evaluate child welfare system

sgupta — Tue, 04 Oct 2011 04:08:01 +0000

U of T helps province evaluate child welfare system sgupta Tue, 10/04/2011 - 00:08

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Social work professor Aaron Shlonsky discusses the provincial child welfare database with Deborah Goodman. (Edge photo)

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Partnership will result in tool for assessing likelihood of ongoing victimization

Between 1993 and 2003, the number of confirmed cases of child maltreatment in Ontario nearly tripled. "The province, however, doesn't have a viable information system," said Aron Shlonsky, Factor-Inwentash Chair in Child Welfare at U of T's Factor-Inwentash Faculty of Social Work. "We're unable to tell the story of how children and families make their way through the foster care system, making it difficult to improve services."

To address this need, Shlonsky is helping develop the Ontario Child Abuse and Neglect Data System (OCANDS). "The database will enable agencies to more effectively manage and deliver services for our most vulnerable children," said Shlonsky, who also co-chairs the Social Welfare Group of the Campbell Collaboration, an international organization developing a world library of systematic reviews.

The Factor-Inwentash Faculty of Social Work is about to boost its international reputation as a hub of child welfare research. When Shlonsky and his team complete the data system in 2014, it will be Canada's first longitudinal research database of child maltreatment services. "We are also building a laboratory that will house this and other key child welfare databases. Once it is built, the lab and databases will generate timely and relevant evidence used to inform and guide policy makers and practitioners from across Ontario as they contend with the multiple complex challenges faced by maltreated children."

Shlonsky believes partnership is key to creating effective social work research that can be applied to practice. That's why he is collaborating with several top child welfare scholars and Ontario's children's aid societies. "The partnership approach to research is necessary for the field of social work. While scholarship for its own sake has its merits, social work research should generate the type of information that can be readily used to improve lives."

His research partners agree and praise Shlonsky for his collaborative approach.

"Aron builds sustainable research bridges between academia and the field, funders and community partners," said Deborah Goodman (pictured above), manager of research and program evaluation at the Toronto Children's Aid Society.

Shlonsky worked with Goodman and others to evaluate the Ontario Risk Assessment Model (ORAM) that the province's social workers were using. Such tools are intended to pinpoint elements in a family's story that alert social workers to the likelihood that a child will continue to be victimized. "Our analysis found the tool to be neither reliable nor valid in predicting which children will be re-abused," said Goodman, who is also an adjunct assistant U of T social work professor. "The Ministry of Children and Youth Services ceased using ORAM based on our research, as well as field experience."

Now Shlonsky and his partners are using that knowledge to build a better tool. "It's a complex project," he said. "And that's how partnership plays a valuable role. The more expertise on an initiative like this, the more likely we are to design a database that will have a truly positive impact on the children and families we serve."

This story first appeared in Edge Magazine.

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