Download Dr. Jennifer Flemming

Research Program Overview
Jennifer A Flemming, MD FRCPC MAS
Assistant Professor
Departments of Medicine and Public Health Sciences
SEAMO Clinician Scientist
Fellow of the Institute for Clinical Evaluative Sciences (ICES)
About Me - Training
• Medical School – Dalhousie 2006
• Internal Medicine (’09) and GI (‘11) training at
Queen’s
• 2-year clinical research Hepatology Fellowship at the
University of California San Francisco (UCSF) – Dr.
Norah Terrault (mentor)
• Master’s of Advanced Studies (MAS) in Clinical
Research at UCSF
About Me – Current Position
• SEAMO Clinician Scientist – January 2014
• Clinical Hepatology 2 clinics/week
• Member of the Cancer Care and Epidemiology Division
at the Queen’s Cancer Research Institute
• Fellow of the Institute for Clinical Evaluative Sciences
(ICES)
• Cross appointment to the Department of Public Health
Sciences
• Primary mentor – Dr. Christopher Booth
Research Program
• Population-based health services research
focusing on cirrhosis and primary liver
cancer
• Understanding the epidemiology and
outcomes for patients with cirrhosis and
liver cancer in Ontario
Why is this work important?
Davis et al. Gastroenterology. 2010
Biliary Tract Cancers
Intrahepatic Cholangiocarcinoma
Age-adjusted incidence rates of Intrahepatic
cholangiocarcinoma in the United States
increased by mean 9.1% per year from 1973 –
1997.
Patel. Hepatology. 2001
Research Program Overview
• Short-term goals
– To characterize the epidemiology and outcomes for
patients with cirrhosis and biliary tract cancers in
Ontario
• Long-term goals
– Development of chronic disease management strategy
for chronic liver disease and liver cancer in Canada
Methodology
• Construction of population-based cohorts of
patients with cirrhosis and biliary tract cancer
– ICES-Queen’s
– Cancer Care and Epidemiology
• Ontario Cancer Registry
• Cancer Care Ontario: Pathology reports
Database 1: Biliary Tract Cancer
Biliary Tract Cancers
-Intrahepatic cholangiocarcinoma
-Extrahepatic cholangiocarcinoma
-Gallbladder cancer
Ontario Cancer Registry
-Demographics
-Chemotherapy
-Radiotherapy
-Surgical treatment
-Death Data
-
Cancer Care Ontario
Primary pathology reports
Surgical details
Histology
Margins
Lymph nodes
Population-based database for
Biliary Tract Cancers 1994 -2012
Biliary Tract Cancer Database
• Epidemiology
– Incidence and mortality, secular trends
• Treatment
– Chemotherapy, radiotherapy, surgical
• Treatment-related outcomes
Database 2: Cirrhosis
Primary chart abstraction for ICD
coding algorithms
Population-based cohort of patients with
Cirrhosis: 1990 - 2012
Cirrhosis Database
• Epidemiology
– Incidence, mortality, geographical disease burden
• Health care utilization
– Admissions, re-admission, outpatient visits, ER visits
• Therapy
– HCV (PHO linked data), HCC screening/treatment,
transplant, variceal screening
Key Findings – Biliary Tract Cancer
Table 1: Demographics of patients diagnosed with incident biliary tract cancer from 1994 – 2012
from the Ontario Cancer Registry
All BTC
GBC
IHCC
EHCC
P
Age at diagnosis, median
years (IQR)
Female Sex, %
(n = 9,039)
(n = 3,133)
(n = 1,569)
(n = 4,337)
Value*
72
(62 – 79)
73
(63 – 80)
71
(61 – 80)
71
(62 – 79)
<.001
53.9
67.6
49.3
45.8
<.001
<.001
Disease confirmation, %
-
Cancer Clinic notes
50.2
51.5
53.2
48.3
-
Pathology record
23.4
25.4
8.4
27.4
-
Hospital record
23.3
20.0
36.5
20.8
-
Death certificate
1.6
2.7
0
1.5
-
Not stated
1.5
0.4
1.9
2.1
77.4
78.5
71.3
78.6
Pathology confirmed, %
<.001
BTC: biliary tract cancer; GBC: gallbladder cancer; IHCC: intrahepatic cholangiocarcinoma; EHCC: extrahepatic cholangiocarcinoma
Incidence and Mortality Rates for Biliary Tract Cancer 1994-2012
a.
b.
c.
d.
Figure 1: Epidemiologic trends in biliary tract cancers in Ontario from 1994-2012. a) all biliary tract cancers (n= 9,039); b)
intrahepatic cholangiocarcinoma (n=1,569); c) extrahepatic cholangiocarcinoma (n=4,337); d) Gallbladder cancer (n=3,133).
Median Survival for Biliary Tract Cancers 1994-2012
a.
c.
b.
d.
Figure 2: Secular trends in overall survival for biliary tract cancers in Ontario from 1994-2012. a) all biliary tract cancers (n= 9,039),
legend shows the median survival by BTC subtype; b) intrahepatic cholangiocarcinoma (n=1,569); c) extrahepatic
cholangiocarcinoma (n=4,337); d) Gallbladder cancer (n=3,133).
Secular Trends in Treatment for Biliary Tract Cancer 1994-2012
Figure 3: Secular trends in treatment for biliary tract cancers in Ontario from 1994-2012. a) all biliary tract cancers (n= 9,039); b)
intrahepatic cholangiocarcinoma (n=1,569); c) extrahepatic cholangiocarcinoma (n=4,337); d) Gallbladder cancer (n=3,133).
Progress so far – Cirrhosis Database
• Currently in “the que” at ICES-Queen’s to be
worked on by ICES analyst
Opportunities for Collaboration
• CIHR-Hepatitis C Research Initiative
• Public Health Ontario Hepatitis C Database
Lessons Learned and Challenges Faced
• Using provincial administrative data involves dealing
with a significant amount of paperwork, approvals, and
“red tape”
Contribution of SEAMO
• SEAMO Clinician Scientist start-up funding has
allowed for the development of the biliary tract
cancer and cirrhosis database
• Foundation for grants to secure external funding