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December 2019: 61:10 Pages 369–408

IN THIS ISSUE The influence of breast on breast cancer diagnosis ’s revolutionary new food guide The age of is upon us -induced and neurological effects following nitrous misuse

bcmj.org BC Medical Journal vol. 61 no. 10 | december 2019 369 December 2019 Volume 61 | No. 10 Pages 369–408

Psychedelic medications, including mushrooms, are on the verge of becoming mainstream practice. Article begins on page 390.

The BCMJ is published by Doctors of BC. The 372 Editorials Clinical journal provides peer-reviewed clinical and review articles written primarily by BC physicians, for My selfish Christmas wish, BC physicians, along with debate on medicine 376 The influence of breast density and medical politics in editorials, letters, and David R. Richardson, MD essays; BC medical news; career and CME listings; New research on and on breast cancer diagnosis: physician profiles; and regular columns. breast cancer: The headlines A study of participants in the Print: The BCMJ is distributed monthly, BC Cancer Breast Screening other than in January and August. don’t convey what women need Web: Each issue is available at www.bcmj.org. to know, Caitlin Dunne, MD, Program, Colin Mar, MD, Janette Subscribe to print: Email [email protected]. Timothy Rowe, MBBS Sam, MRT, Colleen E. McGahan, Single issue: $8.00 MSc, Kimberly DeVries, MSc, Canada per year: $60.00 375 President’s Comment Foreign (surface mail): $75.00 Andrew J. Coldman, PhD Subscribe to notifications: Strength in numbers: The power of To receive the table of contents by email, visit 385 Drug-induced psychosis and www.bcmj.org and click on “Free e-subscription.” cooperation, Kathleen Ross, MD neurological effects following Prospective authors: Consult the “Guidelines for Authors” at www.bcmj.org misuse: A case for submission requirements. report, Matthew Kin Kwok, MD, Jane de Lemos, PharmD, Mazen Sharaf, BSc Pharm

On the cover Editor Managing editor Proofreader Printing Drug-induced psychosis and David R. Richardson, MD Jay Draper Ruth Wilson Mitchell Press neurological effects following Editorial Board Associate editor Web and social media Advertising nitrous oxide misuse Jeevyn Chahal, MD Joanne Jablkowski coordinator Kashmira Suraliwalla Nitrous oxide is becoming a popular David B. Chapman, MBChB Amy Haagsma 604 638-2815 Senior editorial and recreational drug all over the world. Brian Day, MB or [email protected] production coordinator Cover concept and Caitlin Dunne, MD Users can easily obtain it by puncturing Kashmira Suraliwalla art direction, Jerry Wong, ISSN: 0007-0556 David J. Esler, MD small cannisters used in whipped Peaceful Warrior Arts Established 1959 dispensers. Our case study on Yvonne Sin, MD Copy editor Cynthia Verchere, MD Design and production drug-induced psychosis following Barbara Tomlin Laura Redmond, Scout Creative its misuse begins on page 385.

370 BC Medical Journal vol. 61 no. 10 | december 2019 n Celebrating a family medicine milestone and 1969 trailblazers n Naloxone kits encouraged for those who or snort n New international exercise guidelines for cancer survivors n Patients with , disorders share abnormalities in brain’s control circit n New DNA “clock” could help measure development in young children

399 Obituaries Dr Donald Wilson Lang Dr Pascualito Aquino Seminiano Mr James ( Jim) Edward Gilmore

401 GPSC The current role of genomics/genetics in medicine and possible future applications and implications. Article begins PSP supports for quality on page 388. improvement activities: Refreshed compensation policy, simplified 388 BCMD2B 394 BC Centre for Disease Control certification process, Alana Godin The role of genetics in medicine: Shared decision making and 402 Council on Health Promotion A future of precision medicine, breastfeeding: Supporting families’ Yue Bo Yang, BSc informed choices, Sarah Munro, Canada’s revolutionary new food PhD, Cynthia Buckett, MBA, guide, Michael Lyon, MD 390 Premise Julie Sou, MSc, Nick Bansback, 403 WorkSafeBC The age of mushrooms is upon us PhD, Henry Lau, RD in medicine, Mark Elliott, MD Workplace exposure to rabies, 395 News Geetha Raghukumar, MBBS, n 392 SSC Book review: Essential Caregiving Olivia Sampson, MD Physician engagement gains Guide: How to optimize the extended care your loved one needs 404 CME Calendar traction across BC, Sam n BC’s top family physician of 2019 Bugis, MD, Cindy Myles n Hear from patients: New GPSC 405 Classifieds Patient Tool n poisonings on the rise in BC 407 Club MD

Environmental impact Postage paid at Vancouver, BC. Canadian Publications Mail, Product Sales Agreement #40841036. Return undeliverable copies The BCMJ seeks to minimize its negative impact on the to BC Medical Journal, 115–1665 West Broadway, Vancouver, BC V6J 5A4; tel: 604 638-2815; email: [email protected]. environment by: Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. • Supporting members who wish to read online with an e-subscription to bcmj.org © Medical Journal, 2019. All rights reserved. No part of this journal may be reproduced, stored in a retrieval system, or trans- • Avoiding bag use, and using certified-compostable plant-based mitted in any form or by any other means—electronic, mechanical, photocopying, recording, or otherwise—without prior permission in bags when needed writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any form for any purpose, send an email to • Working with Mitchell Press, ranked third in North America for [email protected] or call 604 638-2815. sustainability by canopy.org Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not necessarily those of Doctors of BC or the • Printing with vegetable-based inks institutions they may be associated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omis- • Using FSC-certified paper sions, or from the use of information or advice contained in the BCMJ. • Printing locally in British Columbia The BCMJ reserves the right to refuse advertising.

BC Medical Journal vol. 61 no. 10 | december 2019 371 Editorials

My selfish Christmas wish

hristmas is a magical time for a child. reflected through a gift well chosen warms the Our journal’s circulation is roughly 14 000, Does anyone else remember the long- heart. I would rather watch a loved one’s reaction which includes practising and retired physicians, anticipated arrival of the Sears cata- to opening a gift than open one myself. Being students, and residents. I have heard that every Clogue? My brothers and I would pour over the with family, sharing food and drink during this person has at least one good novel in them. I pages circling desired toys for my parents’ later time, is about as perfect as it gets. would prefer to think that each of you has at perusal. Unable to sleep on Christmas morning, least one good essay, opinion piece, scientific we would lie in bed tortured by the slow move- “All I want for Christmas is you!” study, theme issue, letter, or back-page feature ment of time until the anointed hour arrived floating around in your . So, for and we were free to empty stockings and open As another Yuletide approaches, I find my- Christmas, that is what I want. Write them presents. My parents seldom bought any of self in an interesting position. My children are down, type them up, finish that last paragraph, the circled items, explaining they looked cheap grown and my parents have passed on. Grand- and send them in. Don’t be intimidated. Our and wouldn’t last. I am sure there was a lesson children are awesome and I love spoiling them journal is written by the physicians of BC for in there somewhere. Regardless, I was blessed on Christmas; however, I find myself restless the physicians of BC, so that means you. Please to grow up in a home that could afford all the and longing for the good old days. Therefore, I do your part to make this aging editor’s dream a trappings of the holidays. have decided that this Christmas should once reality this Christmas. You all have something Over the years Christmas has become less again be all about me and my wants (don’t valuable to share and I want to read it. about receiving and more about giving. The focus judge me). So, what does an editor desire for Happy Holidays. n shifted to shopping for my spouse and children. the year ahead? To paraphrase Mariah Carey, —David Richardson, MD This can be stressful, but the joy and “All I want for Christmas is you!”

2,300 BC pedestrians are injured in car crashes every year.

Doctors of BC has launched a safety campaign to help make the province’s roadways a safer place for pedestrians.

BE SEEN KEEP YOUR USE EYE HEAD UP CROSSWALKS CONTACT IS KEY Let British Columbians know that the province’s physicians care about their safety by hanging a

armbands for your patients.

To get posters and armbands for your practice, email: [email protected]

372 BC Medical Journal vol. 61 no. 10 | december 2019 editorials

New research on hormones and breast cancer: The headlines don’t convey what women need to know

esearchers in the UK recently - As doctors, we are continually challenged to estrogen, normally produced by the ovaries, and lished the results of a worldwide analy- interpret scientific research and then distill the the body’s struggle to re-equilibrate. Although sis on menopausal therapy relevant parts into language that our patients they are not threatening, these complaints Rand breast cancer risk in the Lancet.1 The anal- understand. Sometimes, however, we are merely should not be dismissed as trivial. ysis included 58 studies, published between a second opinion to the media. Like it or not, Dr For example, menopause in one of our pa- 1992 and 2018, of over 100 000 postmenopausal Google has become the most accessible medi- tients, a lawyer, led to unpredictable sweats that women with breast cancer. They found that cal resource in the world. So when our patients caused her to appear distracted and nervous women who had ever taken hormone therapy get bad information online before they see us, in the courtroom. She chose to take hormone had a higher incidence of breast cancer than it makes our job that much harder and, more therapy to help ease her body through the tran- those who had not. importantly, it compromises their health care. sition and credited it with keeping her fast- Now, these findings are significant and pub- A brief history of menopause and hormone paced career on track. Another professional, a lished in a reputable journal, but they are no- therapy is required to understand the impact surgeon, could not practise because sweat from where near as astonishing as the news media of these recent titles. Menopause is a normal her face would drip into patients’ open incisions. portrayed them to be. stage of life for women. A girl is born with a She also chose hormone therapy to allow her Immediately after the results, sensational finite number of eggs that decrease over her career to continue. and fear-provoking interpretations appeared lifetime until there are none left, and she enters Hormone therapy mitigates menopausal in the headlines. The Telegraph reported, “HRT menopause. On average this happens around 51 symptoms by giving back a small of estro- raises breast cancer risks by a third, major Ox- years old, but anywhere from 45 to 55 is normal. gen. Contemporary regimens most commonly ford study finds,” and read, “Breast While some women navigate this major life involve an estrogen patch, gel, or tablet. Doc- cancer risk from using HRT is ‘twice what was event without issue, 60% to 80% of women will tors individualize the amount to find the low- thought.’” The Independent conveyed, “Meno- encounter symptoms that worsen their qual- est effective dose for each woman. Unless the pausal hormone therapy linked to greater breast ity of life.5,6 Hot flushes, night sweats, trouble woman has had a hysterectomy, she would also cancer risk for more than a decade after use.”2-4 sleeping, memory problems, and depressed be prescribed to limit the growth These headlines might entice readers, but mood are some of the most common concerns. of the uterine lining, which could otherwise they certainly do not help women. These symptoms stem from the abrupt loss of cause bleeding.

Dr Dunne is a co-director at the Pacific Centre for Reproductive Medicine in Vancouver and a clinical assistant professor at the University of British Columbia. She serves on the BCMJ Editorial Board. Dr Rowe is an associate professor at the University of British Columbia, former Editor-in-Chief of the Journal of and Gynaecology Canada, and a former BCMJ Editorial Board member. He is a recognized expert in menopause and hormone therapy.

BC Medical Journal vol. 61 no. 10 | december 2019 373 EDITORIALS

In the 1990s hormone therapy was common. illustrate with a simple example, a headline that quote a recent statistician’s words in the New After the results of the Women’s Health Initia- reads, “double the risk of dying” (a relative risk Yorker, “How impressed should we be by very tive (WHI) study in 2002 and 2004, however, of 2.0) might actually be referring to an absolute strong evidence for a very weak effect?”12 n the number of women starting hormone therapy risk of 1% going up to 2%. —Caitlin Dunne, MD dropped from 1 in 12 to 1 in 20.7-9 Further- In this UK study, the relative risk conveys —Timothy Rowe, MBBS, FRCSC, FRCOG more, of the women already taking hormones how often the event (i.e., breast cancer) hap- when the WHI study was released, one in five pened in the hormone therapy group versus the References stopped them. Among the main reasons they group that did not take hormones. Women 50 1. Collaborative Group on Hormonal Factors in Breast 9 Cancer. Type and timing of menopausal hormone did so was media reporting. to 54 years old currently using hormones had therapy and breast cancer risk: Individual participant It is imperative that we step back and ex- a relative risk of 2.1, which can be interpreted meta-analysis of the worldwide epidemiological evi- how we explain medical research to the as being twice as likely to get breast cancer. That dence. Lancet 2019;394(10204):1159-1168. public. Framing the results of a study with the sounds pretty scary to most people. Fortunately, 2. Bodkin H. HRT raises breast cancer risk by third, major Oxford study finds. Telegraph. Accessed 8 October appropriate context and magnitude can drasti- doctors are trained to rely on the absolute risk. 2019. www.telegraph.co.uk/science/2019/08/29/hrt cally change how people read them. It is much more meaningful as it refers to the -raises-breast-cancer-risk-third-major-oxford-study When we teach medical students about re- probability of breast cancer in a population of -finds. search, one of the most important principles women exposed to hormone therapy. 3. Boseley S. Breast cancer risk from using HRT is ‘twice what was thought.’ Guardian. Accessed 8 October 2019. of critical appraisal is interpreting the real-life The authors of the Lancet study actually did www.theguardian.com/science/2019/aug/29/breast risk. In statistical terms this is referred to as the an excellent job of stating the absolute risks on -cancer-risk-from-using-hrt-is-twice-what-was-thought. absolute risk versus the relative risk. Relative the front page. Unfortunately, media headlines 4. Massey N, Crew J. Menopausal hormone therapy linked risk is usually the less useful but more dramatic did not focus on that paragraph. The conclu- to greater breast cancer risk for more than a decade statistic—the one often cited in headlines. To sion was that taking estrogen and progesterone after use. Independent. Accessed 8 October 2019. www.independent.co.uk/news/health/menopausal for 5 years was associated with one additional -hormone-therapy-breast-cancer-risk-decade-after 1 breast cancer in every 50 women. To put things -use-a9084661.html. in perspective, that is actually a smaller risk 5. Gallagher J. Breast cancer: Menopausal hormone ther- increase than drinking , not breastfeed- apy risks ‘bigger than thought.’ BBC News. Accessed 8 5 October 2019. www.bbc.com/news/health-49508671. ing, or being overweight. Furthermore, as the 6. Reid R, Abramson BL, Blake J, et al. Managing meno- North American Menopause Society empha- pause. J Obstet Gynaecol Can 2014;36:830-833. 7. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and BC Medical Journal sized, these results are observational associa- benefits of estrogen plus progestin in healthy post- @BCMedicalJrnl Follow tions rather than cause-and-effect conclusions, menopausal women: Principal results from the Wom- The BC Medical Journal provides continuing medical which are normally restricted to randomized en’s Health Initiative randomized controlled trial. JAMA 4,10 education through scientific research, review articles, controlled trial. 2002;288:321-333. and updates on contemporary clinical practice. The problem, as with our periodic “pill 8. Anderson GL, Limacher M, Assaf AR, et al. Effects of con- #MedEd scares” related to birth control pills, is that bad jugated equine estrogen in postmenopausal women with hysterectomy: The Women’s Health Initiative ran- Reducing physician #burnout: Clinic news grabs a reader’s attention but good news support for patients’ social issues can domized controlled trial. JAMA 2004;291:1701-1712. help. The @CMA_Docs Statement does not. In emphasizing an arguably small (and 9. Crawford SL, Crandall CJ, Derby CA, et al. Menopausal on Physician #Health and #Wellness previously known) risk of breast cancer when hormone therapy trends before versus after 2002: Im- identifies physician health as a #quality framing a story about hormone therapy, we are pact of the Women’s Health Initiative Study Results. indicator in the overall functioning of Menopause 2018;26:588-597. missing the big picture. Menopausal women health systems. 10. Faubion SS. NAMS Responds - Lancet article on tim- Read the article: bcmj.org/gpsc/reducing- take hormone therapy because it makes their ing of HT and breast cancer risk. Accessed 8 Octo- physician-burnout-clinic-support-patients- tolerable and their careers manageable, not ber 2019. www.menopause.org/docs/default-source/ social-issues-can-help because they really want to take it. default-document-library/2019-08-30-lancet-article The commentaries that have appeared in -on-timing-of-ht-and-breast-cancer.pdf. 11. Kauntiz AM. Menopausal hormone therapy: Let the response to this recent report all stress the im- women decide. Medscape. Accessed 8 October 2019. portance of individualized decisions for women www.medscape.com/viewarticle/919243?nlid=1319 considering hormone therapy, and that’s as it 42_904&src=WNL_mdplsfeat_191008_mscpedit_ob should be.10,11 No menopausal woman should gy&uac=212025CG&spon=16&impID=2123360&faf=1. 12. Fry H. What statistics can and can’t tell us about our- take hormone therapy without a careful assess- selves. New Yorker. Accessed 8 October 2019. www ment of her individual risk and the potential .newyorker.com/magazine/2019/09/09/what benefit, conducted with a knowledgeable care -statistics-can-and-cant-tell-us-about-ourselves. provider. Women and health care professionals Follow us on Twitter for regular updates should not be alarmed by the latest news. To

374 BC Medical Journal vol. 61 no. 10 | december 2019 president’s comment

Strength in numbers: The power of cooperation

“We must use collegiality not to level people down, but to bring together their strength and creativity.” —Andy Hargreaves

s my year as Doctors of BC President very different interpretations of the same events. patient access to quality care. I have noticed the reaches the halfway mark, I am re- Maintaining and fostering this sense of profes- positive impact on relationships with our gov- flecting on my mandate to date. In my sionalism and collegiality becomes even more erning bodies, allied health, and public not-for- inaugurationA speech, I spoke about leadership, crucial in this context. profits in improving on-the-ground resources professional culture, connectivity, change in our When I sat down to write this column, I and access to care. rapidly evolving world, and the need for cour- reflected on how I could best define collegiality. I would like to challenge you all to take age. I am committed to supporting and building The Merriam-Webster Dictionary defines the a moment, look at the work your colleagues courage in physicians across our province. This word colleague as, “an associate or co-worker do every day, and ask, “What can I do in my courage enables them to lead the changes our typically in a profession or work that will improve health care system needs to be both compre- in a civil or ecclesiastical If we can respect the day-to-day work of hensive and sustainable moving into the future. office and often of simi- each other’s work, my colleagues and foster To meet these goals I outlined back in June, I lar rank or state: a fellow a better system for all of have been traveling across the province to begin worker or professional.” viewpoints, and ideas, us?” If you see nothing, to understand how my colleagues are defining, I would suggest that the we can cooperate and then I encourage you to meeting, and resolving these challenging issues, active definition of colle- provide the support reach out and ask, as you and learning how Doctors of BC can support giality encompasses much, needed to make may in fact not have the their work. much more and includes full picture. Those of us who have traveled, volunteered, the principles of respect, necessary changes. There is no room for or worked abroad understand that traveling and commitment to moral empire building or ego in sharing changes who we are at a principles, and valuing the this type of collegial work. fundamental level that can be hard to define. work of others. Collegiality builds trust. If we No matter how you as an individual apply the We understand that listening to stories and can respect each other’s work, viewpoints, and professional skills you have acquired to date, attempting to understand the experiences of ideas, we can cooperate and provide the support we are all an invaluable part of a much greater others is transformative and goes a long way needed to make necessary changes. If we are all whole. There is power in supporting each other, toward breaking down barriers. There is much committed to the same basic moral principles and exploring new ways to deliver care that we we can glean through exposure to different and values as physicians, and we understand simply cannot achieve working in silos. We are methods of studying, coping, and ultimately the goals of our health care system, it makes truly Better Together. n addressing problems. it easier to work as a team where everyone is —Kathleen Ross, MD Being invited to attend local meetings with valued. Our shared commitment to understand- Doctors of BC President grassroots physicians and Doctors of BC staff ing each other’s perspectives gives us the power who provide local support has been transforma- to lead change. tive for me personally. I have gained an amazing I have witnessed firsthand the incredible amount of direct knowledge in my engagement collegiality of our colleagues across the prov- work, but what has been most striking to me is ince, as they truly value the professional skills the power of collegiality, particularly in smaller they each bring to the table. I have seen their communities. Our personal life experiences and devotion to solving local issues in a way that (often unconscious) biases alter our interpreta- supports, rather than tears down relationships tion of what we learn from every new encounter. across specialities, as they build processes that In fact, people will often leave meetings with improve both the individual’s working life and

BC Medical Journal vol. 61 no. 10 | december 2019 375 Clinical

Colin Mar, MD, Janette Sam, MRT, Colleen E. McGahan, MSc, Kimberly DeVries, MSc, Andrew J. Coldman, PhD The influence of breast density on breast cancer diagnosis: A study of participants in the BC Cancer Breast Screening Program

A screening participant’s risk of being diagnosed with an interval breast cancer following a normal screening mammogram was found to increase with age and density, and to be roughly similar at 1 year for women at higher-than-average risk (first degree family history of breast cancer) to that at 2 years for women at average risk.

ABSTRACT much research, but the results are often summa- 2015. Data from this period were used to examine Background: Normal fibroglandular tissue appears rized in ways that do not facilitate understanding the influence of density on the risk of breast can- white on a mammogram and is described as dense; for referring physicians and screening participants. cer development (Objective 3) and the effect of fatty tissue appears dark and is described as non- An analysis of data from the BC Cancer Breast density on prognostic factors such as tumor size dense. Increased breast density is associated with Screening Program was proposed to assess the and lymph node involvement (Objective 4). The greater breast cancer risk. Increased breast density influence of breast density on the risk of cancer 2011 to 2015 data collection period was chosen also reduces the sensitivity of mammography to and on breast cancer prognostic factors. so that notification of any cancer cases to the BC reveal changes associated with cancer, a concern Cancer Registry was complete and 5 years of data referred to as masking. Interval breast cancers are Methods: Although density scores were not could be analyzed. The screening history of each those diagnosed between screening visits and are required prior to 2018, many BC Cancer Breast participant in Sample 2 was assessed by screening more common in women with dense breasts. The Screening Program centres assigned and recorded rounds. Screening rounds that followed an abnor- effects of breast density have been the subject of this information. Two study samples were abstract- mal result were excluded from the analysis as par- ed from the Breast Screening Program database ticipants were likely subject to further testing prior to achieve four study objectives. Sample 1 data to returning to screening, and their cases would Dr Mar is medical director of the BC included mammograms of participants age 40 to 74 not necessarily reflect the influence of density on Cancer Breast Screening Program. obtained in 2017 using digital mammography and mammography performance. A breast cancer was Ms Sam is operations director of the assigned density categories according to the Breast defined as screen-detected if it was diagnosed in BC Cancer Breast Screening Program. Imaging-Reporting and Data System (BI-RADS): the 12 months following an abnormal screening Ms McGahan is director of Cancer A (least dense), B, C, or D (most dense). Sample mammogram. All breast cancers not classified as Surveillance and Outcomes, BC Cancer. 1 data were used to describe the distribution of screen-detected were defined as interval cancers. Ms DeVries is a biostatistician in Cancer BI-RADS breast density in the screening popula- Rates of screen-detected breast cancer and interval Surveillance and Outcomes, BC Cancer. tion (Objective 1). A subset of Sample 1 data was cancer were calculated and rates were estimated Dr Coldman is an emeritus scientist in used to examine the stability of BI-RADS density for participants at average risk and higher-than- Cancer Control Research, BC Cancer. categories assigned (Objective 2). Sample 2 data average risk (i.e., having a family history of breast included mammograms performed from 2011 to cancer in a first-degree relative). This article has been peer reviewed.

376 BC Medical Journal vol. 61 no. 10 | december 2019 Mar C, Sam J, McGahan CE, DeVries K, Coldman AJ Clinical

Results: Breast density data analyzed for 208 925 to that at 2 years for women at non-elevated risk. outcomes are considerably better than would BC Cancer Breast Screening Program participants Further research is needed to elucidate the specific pertain if they were diagnosed later. were seen to vary by age, with a declining propor- benefits of the increased cancer detection afforded Screening participants diagnosed with inter- tion of mammograms assigned BI-RADS C and D by supplemental testing for screening participants val cancers have not benefited from screening scores at increasing ages. Density also varied by found to have dense breasts. since their time of diagnosis and stage of disease ethnic group, with East Asian participants hav- at diagnosis are unchanged by participation in ing denser breasts and First Nations participants Background screening. In many jurisdictions, the least dense breasts. Density did not vary by Breasts are composed of varying amounts of legislation mandates the reporting of breast risk status. When 62 887 mammogram pairs from fibroglandular and fatty tissue. Normal fibro- density to the referring health care provider 2017 and earlier were compared, concordance was glandular breast tissue appears white on a mam- and screening participant,8 and supplemental lowest for mammograms with a BI-RADS score of mogram and is described testing is offered to those D. The majority of participants did not have both as dense, while fatty breast with denser breasts (iden- mammograms read by the same radiologist and tissue appears dark and is Increased breast tified as BI-RADS C or concordance was lower when different radiolo- described as non-dense. density is associated D). Currently in British gists read the mammograms than when the same At the population level with greater breast Columbia, breast density radiologist read both mammograms. Cancer risk the average amount of is reported to screen- cancer risk. Density also was evaluated by looking at 649 393 screening dense tissue declines ing participants and their rounds for 388 576 participants. Predicted rates with increasing age and reduces the sensitivity physicians. In Canada, of interval and screen-detected cancer were cal- varies by ethnic group.1,2 of mammography the organization Dense culated for women of average risk screened on a Radiologists of the BC to demonstrate Breasts Canada advocates biennial (currently recommended) basis and for Cancer Breast Screening changes associated for increased knowledge women of higher-than-average risk screened on Program (BCCBSP) as- and awareness of the ef- an annual (currently recommended) basis. Risk of sess breast composition with breast cancer. fects of breast density.9 screen-detected cancer was seen to increase with using the Breast Imag- Although the effects age and to vary with BI-RADS density for both ing-Reporting and Data of breast density have average-risk and higher-than-average-risk women. System (BI-RADS).3 A breast density category been the subject of much research, the re- Risk of interval cancer also increased with BI-RADS of A, B, C, or D is assigned based on the amount sults are often summarized in ways that do density and with age for average-risk and higher- of fibrous and glandular tissue that appears on not facilitate understanding for referring physi- than-average-risk women. Prognostic factors were a mammogram, with A being least dense (most cians and screening participants. Consequently, tabulated separately for biennial screen-detected fatty) and D being most dense (has highest we proposed an analysis of BCCBSP data on cancers and interval cancers. Screen-detected proportion of non-fatty tissue). Quantitative density and subsequent breast cancer diagnoses cancers were smaller than interval cancers and less scales that assess the proportion of the breast with four objectives: likely to have nodal involvement. Similarly, tumor that is dense4 are also common, and automated 1. To describe the distribution of BI-RADS size increased among interval cancers with increas- systems producing volumetric density estimates density categories within the population ing density, but the likelihood of nodal involvement are available.5 The BCCBSP currently provides presenting to BCCBSP for routine breast did not. BI-RADS breast density scores with all screen- screening. ing mammography results. 2. To assess the stability of BI-RADS Conclusions: Other studies report similar findings Increased breast density is associated with density categories assigned to screening to those described here, with density declining with greater breast cancer risk.6 Density also reduces participants. age,higher density seen in screening participants of the sensitivity of mammography to demonstrate 3. To examine the influence of density on East Asian heritage, instability in density categoriza- changes associated with breast cancer, a concern the risk of breast cancer in screening tion on consecutive mammograms, and instability referred to as masking.1 participants. increasing when mammograms are interpreted There is considerable interest in the influ- 4. To examine the effect of density on breast by different radiologists. When discussing breast ence of breast density on mammography screen- cancer prognostic factors. screening, breast density alone should not be seen ing performance. Increased risk and masking as the primary determinant of breast cancer risk. act synergistically to increase rates of interval Methods Following a normal screening mammogram, a breast cancer that occur between screening The BC Cancer Breast Screening Program screening participant’s risk of being diagnosed visits after a normal screening mammogram.7 maintains records of all examinations per- with an interval breast cancer over the next screen- The primary objective of breast screening is to formed. Although density scores were not re- ing round increases with age and density, and is reduce the risk of breast cancer death in par- quired prior to 2018, many screening centres roughly similar at 1 year for women at elevated risk ticipants by diagnosing cancers when treatment assigned BI-RADS density scores and this

BC Medical Journal vol. 61 no. 10 | december 2019 377 Clinical The influence of breast density on breast cancer diagnosis information was recorded in the BCCBSP rounds commenced following a normal screen- interval cancer for participants at average risk database. This database contains details on the ing mammogram in the study period. and higher-than-average risk. mammogram performed, including the result, A breast cancer was defined as screen- The study was approved by the British Co- and information on the participant (age, self- detected if it was diagnosed in the 12 months lumbia Cancer Agency Research Ethics Board reported ethnic group, etc.). The British Colum- following an abnormal screening mammogram. approval number H19-02530. bia Cancer Registry (BCCR) records all cancers All breast cancers not classified as screen-de- diagnosed in British Columbia residents, and tected that occurred within specified rescreening Results it is routinely linked with the Breast Screening intervals (annual, biennial, or triennial) were Breast density data were analyzed for 208 925 Program database so that all breast cancers oc- designated as interval cancers. BC Cancer Breast Screening Program par- curring in screening participants are identified. Rates of screen-detected breast cancer and ticipants age 40 to 74 who had a digital mam- Two study samples were used to achieve the interval cancer were calculated and analyzed. mogram in 2017 [Figure 3]. Density was seen four study objectives. Rates were estimated for screen-detected and to vary by age, with an increasing proportion Sample 1 data included mammograms of participants age 40 to 74 obtained in 2017 us- ing digital mammography and reporting BI- RADS density [Figure 1]. Sample 1 data were Eligibility requirements: Data abstracted for Objective 1: • Digital screening mammogram was • BI-RADS density, age, ethnic group, risk used to describe the distribution of BI-RADS performed in 2017 status, mammography result, reporting breast density categories in the screening popu- • Participant was age 40 to 74 at time of radiologist on 2017 mammogram lation (Objective 1). A subset of Sample 1 data mammogram 208 925 eligible mammograms identified [Figure 1] was used to examine the stability of • BI-RADS density was reported BI-RADS density categories assigned (Objec- tive 2). The interval of 18 to 30 months between screening rounds was selected to encompass the Eligibility requirements as above, plus: Data abstracted for Objective 2: usual range of rescreening times in participants • Participant had a digital screening • BI-RADS density on each mammogram, recommended for biennial screening. mammogram performed 18–30 months age on 2017 mammogram, reporting earlier than the one in 2017 radiologist on earlier mammogram Sample 2 data included mammograms per- • BI-RADS density was reported on 62 887 eligible mammogram pairs formed from 2011 to 2015 [Figure 2]. Sample preceding mammogram identified 2 data were used to examine the influence of density on the risk of breast cancer (Objective 3) and the effect of density on prognostic fac- Figure 1. Sample 1 data used to examine BI-RADS breast density categories (Objective 1) and the stability of tors such as tumor size, whether less than or BI-RADS categories (Objective 2) in BC Cancer Breast Screening Program population. more than 15 mm, and lymph node involvement (Objective 4). The 2011 to 2015 data collection period was chosen so that notification of any cancer cases to the BCCR was complete and Eligibility requirements: Data abstracted for Objective 3: 5 years of data could be analyzed. • One or more screening mammograms • BI-RADS density, age, ethnic group, risk (digital or analog) performed from status, image type, cancer diagnosis, age The screening history of each participant 1 January 2011 to 31 December 2015 at diagnosis in Sample 2 was assessed by screening rounds. • Participant was age 40 to 74 at time of 649 393 eligible screening rounds mammogram A screening round started immediately after a identified mammographic examination and ended with • BI-RADS density was reported the next screening visit, a diagnosis of can- cer, or the end of the data collection period (31 December 2015). Each screening round Eligibility requirements as above, plus: Data abstracted for Objective 4: had factors associated with it taken from the • Participant diagnosed with an invasive • BI-RADS density on preceding breast cancer mammogram, designation of cancer preceding screening visit. Screening rounds • Participant was screened biennially identified (screen-detected or interval), that followed an abnormal result were excluded tumor size, nodal involvement from the analysis as participants were likely 1300 eligible cases of breast cancer subject to further testing prior to returning to identified screening and their cases would not necessarily reflect the influence of density on mammogra- Figure 2. Sample 2 data used to examine the influence of density on the risk of breast cancer (Objective 3) phy performance. Consequently, all screening and breast cancer prognostic factors (Objective 4) in BC Cancer Breast Screening Program population.

378 BC Medical Journal vol. 61 no. 10 | december 2019 Mar C, Sam J, McGahan CE, DeVries K, Coldman AJ Clinical of BI-RADS A and B mammograms and a BI-RADS category A (5.3%) than category designated D subsequently [Table 1]. Con- declining proportion of BI-RADS C and D B (9.4%), category C (10.5%), and category cordance overall was 68.7% (same BI-RADS mammograms at increasing ages. Density also D (10.7%). density on both mammograms) and 82.5% varied by ethnic group, with East Asian par- When 62 887 mammogram pairs from 2017 for categories C and D combined. The major- ticipants having the densest breasts and First and earlier were compared, concordance was ity of participants (73.5%) did not have both Nations participants the least dense. Density lowest for mammograms designated BI-RADS mammograms read by the same radiologist and did not vary by risk status. Mammograms category D, with only 50.9% of mammograms concordance was lower when different radi- interpreted as abnormal were less likely in designated as D on the first mammogram being ologists read the mammograms (65.5%) than

Table 1. BI-RADS breast density categories reported on 2017 mammograms compared with categories reported on earlier mammograms.

Result on earlier Result on 2017 mammogram mammogram

Category Number BI-RADS D BI-RADS C or D BI-RADS C BI-RADS D Same on both (%) on both on both or D (% of D on earlier) (% of C or D on earlier)

5872 894 4858 Age 40–49 8742 1520 5564 (67.2%) (58.8%) (87.3%)

14 729 1034 8708 Age 50–59 21 453 2119 10 587 (68.7%) (48.8%) (82.3%)

16 168 585 6531 Age 60–69 23 318 1254 8109 (69.3%) (46.7%) (80.5%)

5623 148 1795 Age 70–74 8165 340 2269 (68.9%) (43.5%) (79.1%)

Same reporting 12 913 769 6285 16 690 1241 7234 radiologist (77.4%) (62.0%) (86.9%)

Different reporting 30 297 1913 15 840 46 197 4031 19 599 radiologist (65.5%) (47.5%) (80.8%)

43 210 2682 22 125 All 62 887 5272 26 833 (68.7%) (50.9%) (82.5%)

BI-RADS density by BI-RADS density by BI-RADS density by age risk status ethnic group 60 60 60

50 50

40 40 40

30 30

% by density 20 % by density 20 % by density 20

10 10

0 0 0 40–44 45–49 50–54 55–59 60–64 65–69 70–74 No Yes East First Other Age Family history of Asian Nations breast cancer in BI-RADS A BI-RADS B BI-RADS C BI-RADS D rst-degree relative

Figure 3. Breast density of participants screened in 2017 by age, risk status, and ethnic group.

BC Medical Journal vol. 61 no. 10 | december 2019 379 Clinical The influence of breast density on breast cancer diagnosis

Table 2. Screening round factors considered, including participant risk status, age, ethnic group, BI-RADS when the same radiologist read both mam- density category, and mode of detection for invasive breast cancers identified. mograms (77.4%). Factor Number % Cancer risk was evaluated by looking at 649 393 screening rounds for 388 576 partici- No 582 337 89.7 First screening visit prior to round pants [Table 2]. The use of screening rounds Yes 67 056 10.3 resulted in the data being weighted by par- No 531 587 81.9 ticipants who attended screening more fre- Higher-than- average risk Yes 117 806 18.1 quently. Within the study period, 3117 breast cancers were identified, of which 547 were 40–44 70 532 10.9 ductal carcinoma in situ (DCIS). Most BC- 45–49 106 729 16.4 CBSP screening centres (37 of 41 or 90%) 50–54 109 482 16.9 recorded BI-RADS density for some screen- Age at beginning of screening round 55–59 112 096 17.3 ing rounds. Predicted rates of interval and screen-detected cancer were calculated for 60–64 105 262 16.2 average-risk women screened on a biennial 65–69 87 763 13.5 (currently recommended) basis [Figure 4] and 70–74 57 529 8.9 for higher-than-average-risk women screened Analog 275 044 42.3 on an annual (currently recommended) ba- Image type of preceding mammogram Digital 374 349 57.7 sis [Figure 5]. Risk of screen-detected can- cer was seen to increase with age and to vary East/Southeast Asian 90 077 13.9 with BI-RADS density for both average-risk Ethnic group First Nations 13 349 2.1 women and higher-than-average-risk women. Other 535 949 82.5 Risk of interval cancer also increased with A 170 958 26.3 BI-RADS density and with age for average- risk and higher-than-average-risk women. For B 243 738 37.5 BI-RADS density at preceding mammogram women with BI-RADS category D density, C 183 487 28.3 however, a change from biennial screening D 51 210 7.9 to annual screening was found to have only a modest effect on the predicted proportion Mode of detection for invasive breast cancer Screen-detected 1513 58.9 of interval cancer found at the next screening identified Not screen-detected 1057 41.1 visit: a change from 58% (biennial) to 54%

Interval cancer: Age 40–49 Interval cancer: Age 50–59 Interval cancer: Age 60–74 6 6 6 5 5 5 4.3 4 4 4 2.8 3 2.6 3 2.8 3 2 1.7 2 1.8 2 1.6 1.1 1.1 1 0.7 1 1 0.7 1 0 0 0

Rate per 1000 women A B C D Rate per 1000 women A B C D Rate per 1000 women A B C D BI-RADS density BI-RADS density BI-RADS density

Screen-detected cancer: Age 40–49 Screen-detected cancer: Age 50–59 Screen-detected cancer: Age 60–74 6 7 7 5 6 5.7 6.1 6 5.2 4 5 5 4 4.2 3 3 3.2 4 2.1 2.2 3 2.7 3 2 1.5 1.9 2.2 2 2 1 1 1 0 0 Rate per 1000 women 0 Rate per 1000 women A B C D A B C D Rate per 1000 women A B C D BI-RADS density BI-RADS density BI-RADS density

Figure 4. Predicted rate by age and density for average-risk women to be diagnosed with interval cancer in the next 2 years or screen-detected cancer at the next biennial screening visit following a normal mammogram.

380 BC Medical Journal vol. 61 no. 10 | december 2019 Interval cancer: Age 40–49 Interval cancer: Age 50–59 Interval cancer: Age 60–74 7 7 7 6 6 6 5 5 5 4 4 4 3.7 3 2.3 3 2.4 3 2 2 2 1.8 0.6 1.1 1.2 1 1 0.3 1 0.3 0.7 1 0.5 0 0 0 Rate per 1000 women A B C D Rate per 1000 women A B C D Rate per 1000 women A B C D BI-RADS density BI-RADS density BI-RADS density

Screen-detected cancer: Age 40–49 Screen-detected cancer: Age 50–59 Screen-detected cancer: Age 60–74 7 7 7 5.6 6 6 6 5.2 5 5 5 4.7 4 4 4 3.8 3 3 2.7 2.9 2.5 3 1.9 2 1.7 2 2 1.4 2 2 1 1 1 0 0 0 Rate per 1000 women A B C D Rate per 1000 women A B C D Rate per 1000 women A B C D BI-RADS density BI-RADS density BI-RADS density Mar C, Sam J, McGahan CE, DeVries K, Coldman AJ Clinical

(annual) for women age 40 to 49, from 51% breast cancers were found to vary with age and Other studies (biennial) to 46% (annual) for women age 50 risk status. Rates of screen-detected cancer var- Other studies report similar findings to those to 59, and from 45% (biennial) to 40% (an- ied with density, although rates did not increase demonstrated here, with density declining with nual) for women age 60 to 74. uniformly with increased density. In contrast, age10 and higher density seen in East Asians.11 Prognostic factors were tabulated separately rates of interval cancer increased progressively Similarly, other studies report instability in for biennial screen-detected cancers and interval with increasing density. Tumor size at diagnosis density categorization on consecutive mam- cancers [Table 3]. Tumors in screen-detected increased with increasing density, but the like- mograms12 and instability increasing when cancers were smaller than in interval cancers lihood of nodal involvement did not change. (P < 10-5) and less likely to have nodal involve- Table 3. Prognostic factors (tumor size and nodal involvement) for screen-detected, at 18–30 months, and ment (P < 10-5). Within the screen-detected interval, within 24 months, invasive breast cancers compared by BI-RADS density category. cancers, tumor size increased with increasing density (test for trend, P = .005), but the like- Mode of detection lihood of nodal involvement did not increase Overall rates* (P = 0.06). Similarly, among interval cancers, Screen-detected cancer Interval cancer diagnosed 18–30 months diagnosed < 24 months tumor size increased with increasing density Interval cancer: Age 40–49 Interval cancer: Age 50–59 Interval cancer: Age 60–74 (P = .0002), but the likelihood of nodal involve- % % % % % % 6 6 Density6 Number > 15 mm + node Number > 15 mm + node > 15 mm + node ment did 5not (P = .19). 5 5 4.3 4 4 (95% CI) (95% CI) (95%4 CI) (95% CI ) (95% CI) (95% CI) 2.8 3 2.6 3 2.8 3 Conclusions2 1.7 2 25.61.8 11.6 50.02 20.61.6 A 207 1.1 102 1.1 32 14 The analysis1 0.7of digital1 screening mammograms 1 0.7 (20–32) (8–17) (40–60)1 (14–29) 0 0 0 performedRate per 1000 women by theA BC BCancer CBreast ScreeningD Rate per 1000 women A B 28.4C 18.0D Rate per 1000 women 58.4 A 32.6B C D B 317 190 36 22 Program in 2017 showedBI-RADS densitythat breast density BI-RADS(24–34) density (14–23) (51–65) (26–40)BI-RADS density decreased with age, was lower in First Nations 38.4 19.5 65.7 33.3 Screen-detected cancer: Age 40–49 C Screen-detected190 cancer: Age 50–59 201 Screen-detected cancer:49 Age 60–74 25 and higher in East Asian participants, and did (32–46) (14–26) (59–72) (27–40) 6 7 7 not vary by5 risk status. Examination of consecu- 6 5.7 6.1 6 5.2 4 5 38.5 15.4 576.1 28.4 tive digital mammograms found that recorded D 4 26 67 4.2 58 22 3 3 (22–57)3.2 (6–34) (65–85)4 (19–40) 2.1 2.2 3 2.7 3 density was2 not1.5 stable and that concordance1.9 2.2 2 2 1 30.5 16.5 61.6 30.2 (the same BI-RADS density reported on both All 1 740 560 1 0 0 Rate per 1000 women (27–34) (14–19) (58–66)0 (27–34) mammograms)Rate per 1000 women A was lessB likelyC whenD different A B C D Rate per 1000 women A B C D radiologists interpretedBI-RADS the densitytwo mammograms. *Obtained by weightingBI-RADS screen-detected density and interval cancer rates per 1000 as shownBI-RADS in Figure density 4. Rates of screen-detected and interval invasive

Interval cancer: Age 40–49 Interval cancer: Age 50–59 Interval cancer: Age 60–74 7 7 7 6 6 6 5 5 5 4 4 4 3.7 3 2.3 3 2.4 3 2 2 2 1.8 0.6 1.1 1.2 1 1 0.3 1 0.3 0.7 1 0.5 0 0 0 Rate per 1000 women A B C D Rate per 1000 women A B C D Rate per 1000 women A B C D BI-RADS density BI-RADS density BI-RADS density

Screen-detected cancer: Age 40–49 Screen-detected cancer: Age 50–59 Screen-detected cancer: Age 60–74 7 7 7 5.6 6 6 6 5.2 5 5 5 4.7 4 4 4 3.8 3 3 2.7 2.9 2.5 3 1.9 2 1.7 2 2 1.4 2 2 1 1 1 0 0 0 Rate per 1000 women A B C D Rate per 1000 women A B C D Rate per 1000 women A B C D BI-RADS density BI-RADS density BI-RADS density

Figure 5. Predicted rate by age and density for higher-than-average-risk women to be diagnosed with interval cancer in the next year or screen-detected cancer at the next annual screening visit following a negative mammogram.

BC Medical Journal vol. 61 no. 10 | december 2019 381 Clinical The influence of breast density on breast cancer diagnosis mammograms are interpreted by different radi- Digital mammography has been found to show results presented in Figure 4 and Figure 5 be- ologists.13-15 An increase in the rates of screen- higher sensitivity in the presence of density,21 cause the rate of screen-detected cancer is from detected and interval cancer with the length of suggesting that the relationships with interval the following screen and not the current screen. the screening interval (annual, biennial, and tri- cancers reported here could change if all screen- Nevertheless, the ratio of screen-detected to ennial) is commonly observed.16 Other studies ing for this study had been conducted using screen-detected-plus-interval cancer declines have also found that rates of screen-detected7 digital mammography. The breast cancer risk with increasing density as has been seen else- and interval17 cancer vary with reported density. portion of this study used data from 2011 to where. It must also be kept in mind that the In reporting relationships with screen-detected 2015. During this period the BI-RADS density rates presented in Figure 4 and Figure 5 do not cancers, studies7 have used density recorded on assessment system was updated to its fifth edi- include in situ breast cancers or breast cancers the mammogram leading to screen detection tion,3 a change that is reported to have resulted detected at a first screening visit; inclusion of rather than the preceding mammogram as done in differential classification of mammographic such cases would increase the ratio of screen-de- in this study. The reason for using the preceding density.22 tected to screen-detected-plus-interval cancers. mammogram here is so that reported rates of both screen-detected and interval cancers relate Study implications to the likelihood of future events in participants Breast density The relationship between higher density and who have had a normal screening mammogram. decreased with age, was future interval cancer risk is of concern because lower in First Nations it suggests that screening participants with the Risk and higher in East Asian densest breasts may benefit less from screen- Many factors other than age, family history, ing. On an absolute scale, those with the lowest participants, and did and breast density have been found to influence density likely benefit the least from screen- breast cancer risk. These include ethnicity, age not vary by risk status. ing since they have the lowest rate of breast at menarche, menopause status, history of preg- cancer detected at screening. However, those nancy, body mass index, activity level, alcohol with the highest density have elevated inter- consumption, consumption, and his- Prior to February 2014, British Columbia val cancer rates before the next screening visit tory of benign breast disease.18 Individual risk is screening policy recommended annual screening and may thus represent the greatest opportu- not indicated by a single factor alone and tools for women age 40 to 49 and biennial screening nity for potential cancer detection improve- have been developed to provide estimates using for women age 50 to 79. After 2014, biennial ment. Importantly, though, all age, risk, and some of these factors.19,20 Using single factors to screening was recommended for average-risk density subgroups are diagnosed with screen- predict risk is further complicated by negative women age 50 to 74 and 40 to 49 (if electing detected and interval cancers. There is no na- correlations between some risk factors (e.g., screening), and annual screening for women tional standard defining what risk threshold, if breast density and body mass index).When with a family history of breast cancer in a first- any, is sufficient to consider altering screening discussing breast screening, breast density alone degree relative. Consequently, many of the rates recommendations. Indeed, mammography re- should not be seen as the primary determinant presented in Figure 4 and Figure 5 represent mains the primary screening tool regardless of of breast cancer risk. screening practice not recommended for part breast density. Current Canadian breast screen- of the data collection period, and observed rates ing recommendations do not indicate further Study challenges may have been influenced by factors not cap- breast screening in addition to routine mam- Although breast density reporting was not re- tured in the analysis. mography.25 In the United States, where most quired by the screening program during the Sensitivity is commonly used to measure the screening is performed annually, it has been study, the majority of BC screening centres did accuracy of diagnostic tests. However, as usually suggested17 that an annual interval cancer risk report density voluntarily and provided these defined, this sensitivity measure cannot be as- threshold of 1 per 1000, which is exceeded for data to the program. BI-RADS density was sessed in screening participants because of the women with BI-RADS D, is an appropriate not reported to physicians or patients under- absence of an accepted gold standard for iden- threshold to consider additional screening inter- going screening and was not used for routine tifying breast cancer in asymptomatic women. ventions. However, the US Preventive Services clinical care, meaning that the results may not Consequently, alternate measures are used. The Task Force considers evidence to be insufficient be representative of density when reported for most common of these is period sensitivity,23 to recommend any adjunctive screening on the use in clinical care. which is equal to the ratio of screen-detected to basis of breast density alone.26 For the evaluation of density category sta- screen-detected-plus-interval cancer rates over In and Australia, breast screening bility, only digital mammography results were the screening period. Several studies have re- policy does not vary with breast density. In used. This was not the case for evaluation of ported period sensitivity with density and have Canada, several provinces increase the mam- breast cancer risk, where 42% of the studies found that it declines with increasing density.24 mography frequency from biennial to annual were performed using analog mammography. Period sensitivity was not calculated using the for average-risk participants with the densest

382 BC Medical Journal vol. 61 no. 10 | december 2019 Mar C, Sam J, McGahan CE, DeVries K, Coldman AJ Clinical breasts (generally those categorized BI-RADS disadvantageous. Reported false-positive rates Following a normal screening mammogram, D). However, our results for women with BI- for breast ultrasound are variable27 and can be a screening participant’s risk of being diag- RADS category D density show that a change comparable to those associated with screening nosed with an interval breast cancer over the from biennial to annual screening has only a mammography. In the J-START trial, where next screening round increases with age and modest effect on the predicted proportion of participating centres received specific train- breast density, and is roughly similar at 1 year interval cancers. In the US, despite the absence ing on the performance and interpretation of for women at elevated risk to that at 2 years for of supporting guidelines, it is common to offer screening ultrasounds, 6.6% of participants women at non-elevated risk. breast ultrasound and possibly breast magnetic had an abnormal screening mammogram re- These findings are intended to facilitate a resonance imaging to women with BI-RADS C sult. Among those with a normal screening discussion of breast density, breast cancer risk, or D breast density following a normal screen- mammogram, 5.7% had an abnormal screen- the role of mammography in screening, and the ing mammogram. Many studies have shown ing ultrasound result. The positive predictive role of supplemental testing. Breast density is that the addition of breast ultrasound results in one of multiple breast cancer risk factors to be the identification of mammographically occult considered, and its greatest impact is on the breast cancer and a recent systematic review27 Rates of interval cancer risk of interval cancer. While women age 40 concluded that it increases the screen-detection increased progressively to 74 with the densest breasts (BI-RADS D) rate by an average of 40% of that detected at with increasing but of otherwise average risk may benefit the mammography. A randomized most from additional testing, annual mam- in Japanese women aged 40 to 49 is currently density. Tumor size at mography was not found to offer a significant comparing adding ultrasound to mammogra- diagnosis increased improvement. phy and clinical breast examination.28 The first with increasing density, The benefits and limitations of supplemen- round of this study found a 55% increase in but the likelihood of tal ultrasound should always be considered. screen-detected cancer with a similar propor- Evidence indicates that ultrasound does detect 29 nodal involvement tional increase across breast , and a additional cancers but is accompanied by the 37% reduction in interval invasive breast cancer did not change. additional probability of false-positive studies in those receiving ultrasound screening. While and the need for biopsy. it is unlikely that screening can produce further Further research is needed to elucidate the reductions in breast cancer mortality among ex- value for breast cancer detection was 4.8% for specific benefits of the increased cancer de- isting participants without substantially reduc- the screening mammogram and 3.6% for the tection afforded by supplemental testing for ing interval cancer rates, reductions in interval screening ultrasound.28 screening participants found to have dense cancers alone do not guarantee a reduced risk breasts. n of death. Reductions would also be required Summary in the overall frequency of advanced cancers Based on findings reported in the literature and Competing interests (screen-detected-plus-interval). the data presented here, physicians with patients All authors are affiliated with the BC Cancer Breast The previous discussion concerns the de- enrolled in the BC Cancer Breast Screening Screening Program. Dr Coldman serves as a consul- tection of invasive breast cancer, but overall Program can expect the following: tant for the BC Cancer Breast Screening Program approximately 22% of cancers detected on • Younger patients are more likely to have and was paid for drafting this report. screening mammography are DCIS, which in denser breasts since breast density tends BC is seen to decline with age. In 2017 DCIS to decrease with age. References 1. Price ER, Hargreaves J, Lipson JA, et al. The represented 33% of cancer diagnoses in partici- • Women of East Asian heritage are more breast density information group: A collaborative re- pants aged 40 to 49 and only 15% of those 70 likely than other screening participants to sponse to the issues of breast density, breast cancer to 79.30 The proportion of DCIS detected by have denser breasts, although their risk of risk, and breast density notification legislation. Radi- breast ultrasound following a normal mammo- breast cancer is lower on average. ology 2013;269:887-892. 2. Maskarinec G, Meng L, Ursin G. Ethnic differenc- gram is lower than that for mammography. For • Screening participants with a first degree es in mammographic densities. Int J Epidemiol example, in the J-START trial, 37% of cancers family history of breast cancer are not more 2001;30:959-965. detected by mammography were DCIS versus likely to have dense breasts. 3. D’Orsi CJ, Sickles EA, Mendelson EB, et al. ACR BI-RAD 16% of cancers detected by breast ultrasound in • The breast density categorization of many Atlas, Breast Imaging Reporting and Data System. Res- 28 ton, VA: American College of Radiology; 2013. those with a normal screening mammogram. screening participants will change on 4. Boyd NF, Martin LJ, Sun L, et al. Body size, mam- Given an estimated conversion rate of DCIS consecutive mammograms. mographic density, and breast cancer risk. Cancer 31 to invasive disease of less than 1% per year a • Other factors (e.g., body mass index) will Epidemiol Biomarkers Prev 2006;15:2086-2092. lower proportion of cancers detected by breast influence both breast density and breast 5. Jeffers AM, Sieh W, Lipson JA, et al. Breast cancer risk and ultrasound than by mammography may not be cancer risk. mammographic density assessed with semiautomated

BC Medical Journal vol. 61 no. 10 | december 2019 383 Clinical The influence of breast density on breast cancer diagnosis

and fully automated methods and BI-RADS. Radiology 15. Sprague BL, Conant EF, Onega T, et al. Variation in mam- 24. Euler-Chelpin MV, Lillholm M, Napolitano G, et al. Screen- 2016;282:348-355. mographic breast density assessments among radiol- ing mammography: Benefit of double reading by breast 6. Boyd NF, Martin LJ, Yaffe MJ, Minkin S. Mammographic ogists in clinical practice: A multicenter observational density. Breast Cancer Res Treat 2018;171:767-776. density and breast cancer risk: Current understanding study. Ann Intern Med 2016;165:457-464. 25. Klarenbach S, Sims-Jones N, Lewin G, et al. Recom- and future prospects. Breast Cancer Res 2011;13:223. 16. Canadian Partnership Against Cancer. Breast cancer mendations on screening for breast cancer in wom- 7. Boyd NF, Guo H, Martin LJ, et al. Mammographic den- screening in Canada: Monitoring and evaluation of en aged 40-74 years who are not at increased risk for sity and the risk and detection of breast cancer. N Engl quality indicators – results report 2011 to 2012. Toronto: breast cancer. CMAJ 2018;190:E1441-E1451. J Med 2007;356:227-236. Canadian Partnership Against Cancer; 2017. Accessed 26. Siu AL; U.S. Preventive Services Task Force. Screen- 8. Nayak L, Miyake KK, Leung JW, et al. Impact of breast 7 October 2019. www.partnershipagainstcancer.ca/ ing for breast cancer: U.S. Preventive Services Task density legislation on breast cancer risk assessment topics/breast-cancer-screening-quality-indicators-2017. Force recommendation statement. Ann Intern Med and supplemental screening: A survey of 110 radiol- 17. Kerlikowske K, Zhu W, Tosteson AN, et al. Identifying 2016;164:279-296. ogy facilities. Breast J 2016;22:493-500. women with dense breasts at high risk for interval can- 27. Rebolj M, Assi V, Brentnall A, et al. Addition of ultra- 9. Dense Breasts Canada. Breast density matters. Accessed cer: A cohort study. Ann Intern Med 2015;162:673-681. sound to mammography in the case of dense breast 26 July 2018. www.densebreastscanada.ca. 18. International Agency for Research on Cancer (IARC) tissue: Systematic review and meta-analysis. Br J Can- 10. Sprague BL, Gangnon RE, Burt V, et al. Prevalence of Working Group. Breast cancer screening: IARC hand- cer 2018:1. mammographically dense breasts in the United States. books of cancer prevention. Vol 15. Lyon, France: IARC; 28. Ohuchi N, Suzuki A, Sobue T, et al. Sensitivity and speci- J Natl Cancer Inst 2014;106:dju255. 2016. ficity of mammography and adjunctive ultrasonogra- 11. del Carmen MG, Halpern EF, Kopans DB, et al. Mam- 19. National Cancer Institute. The breast cancer risk assess- phy to screen for breast cancer in the Japan Strategic mographic breast density and race. Am J Roentgenol ment tool. Accessed 5 February 2019. https://bcrisktool Anti-cancer Randomized Trial (J-START): A randomised 2007;188:1147-1150. .cancer.gov. controlled trial. Lancet 2016;387(10016):341-348. 12. Holland K, van Zelst J, den Heeten GJ, et al. Consis- 20. Wolfson Institute of Preventive Medicine. Online Tyrer- 29. Ohuchi N, Suzuki A, Harada Y, et al. Balance of mam- tency of breast density categories in serial screening Cuzick Model Breast Cancer Risk Evaluation Tool. 2015; mography in conjunction with ultrasonography for mammograms: A comparison between automated Accessed 5 February 2019. https://ibis.ikonopedia.com. breast cancer screening according to breast density: and human assessment. Breast 2016;29:49-54. 21. Pisano ED, Hendrick RE, Yaffe MJ, et al. Diagnostic accu- Japan Strategic Anti-cancer Randomized Trial, J-Start. 13. Spayne MC, Gard CC, Skelly J, et al. Reproducibility racy of digital versus film mammography: Exploratory International Cancer Screening Network Meeting, Rot- of BI–RADS breast density measures among com- analysis of selected population subgroups in DMIST. terdam, the Netherlands, June 2019. munity radiologists: A . Breast Radiology 2008;246:376-383. 30. BC Cancer. BC Cancer Breast Screening: 2017 Program J 2012;18:326-333. 22. Irshad A, Leddy R, Ackerman S, et al. Effects of changes Results. November 2018. Accessed 22 August 2019. 14. Gard CC, Aiello Bowles EJ, Miglioretti DL, et al. Mis- in BI-RADS density assessment guidelines (fourth ver- www.bccancer.bc.ca/screening/Documents/Breast classification of Breast Imaging Reporting and Data sus fifth edition) on breast density assessment: Intra- _AnnualReport2018.pdf. System (BI–RADS) mammographic density and and interreader agreements and density distribution. 31. Groen EJ, Elshof LE, Visser LL, et al. Finding the balance implications for breast density reporting legislation. AJR Am J Roentgenol 2016;207:1366-1371. between over- and under-treatment of ductal carci- Breast J 2015;21:481-489. 23. Hakama M, Auvinen A, Day NE, Miller AB. Sensitivity in noma in situ (DCIS). Breast 2017;31:274-283. cancer screening. J Med Screen 2007;14:174-177.

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Matthew Mo Kin Kwok, MD, CCFP(EM), FCFP, Jane de Lemos, PharmD, MSc Epid, Mazen Sharaf, BSc Pharm, ACPR Drug-induced psychosis and neurological effects following nitrous oxide misuse: A case report

The case of a 20-year-old female who experienced auditory and visual after inhaling nitrous oxide she obtained legally in “whippits”—canisters used in whipped cream dispensers—highlights the need to report such adverse events to appropriate authorities so that data can be collected about the dangers associated with commercially available products and the number of misuse cases in Canada.

ABSTRACT: Nitrous oxide (N O) is an increasingly of N O as a consumer good contributes to misuse, 2 2 An increasing number of publications and popular recreational drug globally. Users com- as seen in the case of a 20-year-old female who the Global Drug Survey (GDS), a self-report monly inhale the from punctured canisters presented to the emergency department com- survey of , suggest N2O is known as “whippits” that are designed for use in plaining of visual and auditory hallucinations. The being misused by those seeking the whipped cream dispensers. A surge in N O use patient had no history of psychiatric or medical 2 state produced by puncturing whippits and in- has been reported in the UK, with a self-report illness before experiencing symptoms, and results haling the gas or “nanging.” The GDS found recreational drug survey finding an increase in from laboratory investigations and physical exami- that when , alcohol, and were use from 20% in 2014 to 31% in 2017. The survey nations revealed no abnormalities. The patient excluded, N2O was the seventh most common found that when nicotine, alcohol, and caffeine reported inhaling nitrous oxide on a daily basis, drug used by 130 000 respondents.3 were excluded, N O was the seventh most com- however, and had recently increased her use of 2 Whippits are readily available through mon drug used by respondents. The accessibility legally obtained whippits. A psychiatrist, a neu- storefront and online suppliers with no re- rologist, and an medicine specialist striction on age of purchaser, medical history, assessed the patient in consultation and agreed quantity desired, or intended use. As long as that her psychosis was the result of N O misuse. Dr Kwok is an emergency physician 2 the purchaser can pay for the product there is This case illustrates the need to increase awareness at Richmond Hospital and a clinical no barrier to obtaining whippits. regarding the possible sequalae of nitrous oxide assistant professor in the Department Each whippit contains 8 g of 100% N2O, on misuse and address current reporting limitations of Emergency Medicine at the University average. The duration of action is short-lived and the ease of access consumers have to nitrous 4 of BC. Dr de Lemos is a clinical (1 to 2 minutes) after the canister is punctured oxide products. pharmacist at Richmond Hospital and and the gas is released into an or an 1 a clinical professor in the Department enclosed object for . of Pharmaceutical Sciences at UBC. At itrous oxide (N2O), commonly known N2O that is chemically identical to the N2O 1 the time of writing, Mr Sharaf was a as “laughing gas,” has historically in whippits is also sold with a drug identifica- pharmacy practice resident at Lower been used for medicinal purposes tion number (DIN) for medicinal purposes. such as , analgesia, and .2 It is Mainland Pharmacy Services. Currently, N When used as an inhalational , N2O he is a clinical pharmacist at Children’s also available as a consumer product in canisters has and effects. In accor- and Women’s Health Centre of BC. known as “whippits” that are used in whipped dance with federal legislation, N2O is classified cream dispensers. by Health Canada as an “ethical” product that This article has been peer reviewed. BC Medical Journal vol. 61 no. 10 | december 2019 385 Clinical Drug-induced psychosis and neurological effects following nitrous oxide misuse

“does not require a prescription, but that is gen- Discussion determine which authority should receive the 5 erally prescribed by a medical practitioner. Ethi- This case illustrates the need to consider the report. When N2O with a DIN is used for a cal products are unscheduled non-prescription possible sequalae of nitrous oxide misuse medicinal purpose, the appropriate authority is professional use products.”5 (whether acute or chronic), the current report- the Canada Vigilance Program, which operates

ing limitations, and N2O accessibility issues. the adverse reaction online database. When

Case data the N2O comes from a product marketed for A 20-year-old female presented to the emer- Possible sequalae making whipped cream, the appropriate author- gency department with visual and auditory hal- Beyond symptoms of psychosis, N2O misuse ity is Health Canada Consumer Products and lucinations, agitation, and gait disturbance. She has been associated with myeloneuropathy and Cosmetics. A member of our health care team voiced concerns about a “transmitting” device neurological effects, which are mentioned in submitted a report to both authorities to ensure in her throat. She believed that this device was a growing number of reports.1,2,6-8 These ad- appropriate actions could be taken. making her legs weak and affecting her walking. verse effects can result from both acute and In response to our report, a Health Canada She also heard voices from the device telling chronic exposure. A systematic review from representative explained that Consumer Prod- her to kill herself. She had come to the emer- 2016 that focused exclusively on N2O misuse ucts and Cosmetics would document the misuse gency department because she was worried for revealed that the users in 72 of 91 cases experi- but only take further action if the N2O canister her safety. enced some sort of neurological adverse effect, had faults or hazards regarding its intended use, The patient had no history of psychiatric or which is making whipped cream. medical illness. She reported inhaling nitrous To our surprise, no cases of N2O misuse oxide on a daily basis. She had increased her Nitrous oxide can be have been reported to Health Canada Consum- use recently and was inhaling gas from approxi- readily obtained as a er Products and Cosmetics, and only one case mately 100 whippits per day. The patient stated of of N O had been reported commercial product 2 that she bought the canisters legally with a shop- to the Canada Vigilance Program. ping app and showed the physician the website without any restrictions. We also contacted the BC Drug and Poi- she used to make her purchases. She reported son Information Centre (DPIC) and learned no other recreational or use. that the provincial toxicology call centre re-

The patient was a slim and slightly built predominantly , myeloneuropathy, ceived 14 calls regarding N2O from Asian female. She appeared anxious but not and subacute combined degeneration.2 Less misuse of whippits or similar commercial distressed. She was cooperative and her vital common presentations included psychiatric products between 2015 and 2019. Since our signs at triage were stable. On examination symptoms as seen in our case. Additionally, investigation determined that Health Canada she showed no sign of head trauma. Her 29 cases of nitrous-oxide-related death were received only one report of N2O misuse in were equal and reactive to light. Her speech and reported.2 Although the systematic review was this period, many incidents appear to have her gait were normal. Her neck was supple and unable to establish a dose-related toxicity be- gone unreported. her thyroid examination revealed no abnor- cause of unreliable data, the majority of cases The number of 2N O cases described in the malities. Respiratory, cardiac, and abdominal involved the daily use of whippits. literature, the calls made to BC DPIC, and findings were unremarkable. Her neurologi- The mechanism of these adverse effects is news stories of misuse9 all suggest that current cal examination results were normal with no not well understood. N2O is thought to be as- reporting does not reflect the magnitude of the lateralizing sign, and her mental status exam sociated with low vitamin B12 levels. N2O- toxicity problem. revealed normal . induced oxidation converts vitamin B12 from

Laboratory investigations included an ECG a reduced to an oxidized form, which inhibits N2O accessibility issues that revealed normal sinus rhythm and a QTC the activity of methionine synthase, leading to Nitrous oxide can be readily obtained as a of 399. CBC, , blood urea , impairment of reactions and DNA commercial product without any restrictions. and creatinine levels were all within normal synthesis. This in turn leads to the accumula- In the case described here, the patient pur- limits. ASA, acetaminophen, and lev- tion of homocysteine.2,6 Clinical syndromes chased canisters from a reputable online shop- els were normal. Her vitamin B12 level was have been reported with both acute and chronic ping website and had them shipped directly also normal. nitrous oxide use. to her. A psychiatrist, a neurologist, and an addic- Whippits come in different sizes and can tion medicine physician assessed the patient in Reporting limitations be purchased in bulk. At the time of writing, consultation and agreed that she was psychotic Health care providers play an important role a package of 100 canisters could be purchased as a result of N2O misuse. The patient was kept in reporting adverse events from nitrous oxide online for less than $100.00 ($1.00 per can- in hospital until her symptoms resolved and she misuse to the appropriate authorities. In the ister).10 Because the canisters are not sold for was discharged without incident. case described here it was initially difficult to inhalation, there is no regulation that mandates

386 BC Medical Journal vol. 61 no. 10 | december 2019 Kwok M, de Lemos J, Sharaf M Clinical

providing information on the risks or possible being collected about the dangers associated References sequelae of N2O misuse, nor are sellers qualified with commercially available products or the 1. Cousaert C, Heylens G, Audenaert K. Laughing to provide this information. number of misuse cases in Canada. gas abuse is no joke. An overview of the implica- tions for psychiatric practice. Clin Neurol Neurosurg Medicinal products with a drug identifica- Increased awareness is needed regarding 2013;115:859 -862. tion number are classified by Health Canada N2O toxicity and the more serious adverse drug 2. Garakani A, Jaffe RJ, Savla D, et al. Neurologic, psychi- according to different schedules that determine effects that are possible. Solutions to misuse atric, and other medical manifestations of nitrous ox- how accessible the product is to the public and might include restricting access, adding safe- ide abuse: A systematic review of the case literature. the circumstances that require a health care Am J Addict 2016;25:358-369. 3. Global Drug Survey. The Global Drug Survey 2016 find- provider (e.g., physician or pharmacist) to be ings. Accessed 7 April 2019. www.globaldrugsurvey 11 Health Canada considers involved in acquiring the product. The safety .com/past-findingsthe-global-drug-survey-2016 and the complexity of the product and the harm nitrous oxide to be -findings. the product may cause patients when used are an “unscheduled 4. Zacny JP, Lichtor JL, Coalson DW, et al. Time course of effects of brief of nitrous oxide in normal all considered. Health Canada will reassess ac- non-prescription volunteers. 1994;89:831-839. cess to a medicinal product if new information professional use” 5. Government of Canada. Drug product database (DPD). arises, such as reports of adverse reactions, and Accessed 7 April 2019. www.canada.ca/en/health-can may choose to further restrict or to ease access product. This raises an ada/services/-health-products/drug-products/ important question: drug-product-database/terminology.html. to the public. 6. Hathout L, El-Saden S. Nitrous oxide-induced B12 de- Health Canada considers nitrous oxide to ficiency myelopathy: Perspectives on the clinical bio- if N2O used medicinally be an “unscheduled non-prescription profes- is deemed to require chemistry of vitamin B12. J Neurol Sci 2011;301:1-8. sional use” product.5 This raises an important 7. Weimann J. Toxicity of nitrous oxide. Best Pract Res health care provider Clin Anaesthesiol 2003;17:47-61. question: if N2O used medicinally is deemed to 8. Pema PJ, Horak HA, Wyatt RH. Myelopathy caused by require health care provider involvement, why involvement, why is nitrous oxide toxicity. AJNR Am J Neuroradiol 1998; is the purchase of N O used commercially not 19:894-896. 2 the purchase of N2O restricted in any way given the potential impact 9. Xiong D. Richmond man almost paralyzed after “laugh- used commercially not ing gas” abuse. Richmond News. 14 December 2017. on consumers? restricted in any way Accessed 9 April 2019. www.richmond-news.com/ news/richmond-man-almost-paralyzed-after-laughing Summary given the potential -gas-abuse-1.23123235. A case of nitrous oxide misuse by a 20-year-old impact on consumers? 10. Amazon.ca. Whipped cream canisters/chargers. Ac- female that resulted in drug-induced psychosis cessed 18 October 2019. www.amazon.ca/Whip -Brand-Original-Whipped-Chargers/dp/B0747XWTNT/ and neurological effects illustrates the need ref=sr_1_7?keywords=whip+it&qid=1571417184 for clinicians to recognize N2O as a potential &sr=8-7. substance of abuse and a possible cause of un- guards to minimize harm, and encouraging 11. National Association of Pharmacy Regulatory Authori- explained psychiatric or neurological symptoms. intervention from authorities to prevent product ties (NAPRA). Drug scheduling in Canada. Accessed 28 June 2019. https://napra.ca/drug-scheduling-canada. In addition, this case highlights the need to misuse. n report N2O-related adverse events to appropri- Competing interests ate authorities. The lack of N2O misuse reports going to Health Canada means data are not None declared.

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The role of genetics in medicine: A future of precision medicine

Detailing the current role of genomics/genetics in medicine and expanding on its future applications and implications.

Yue Bo Yang, BSc

lexis and Noah Beery were misdiagnosed and mistreated for cancer by 11.3% from the prior standard of treatment.5 Let us not forget cerebral palsy for 14 years, until genetic sequencing led to a that the sequencing of factors VIII, IX, and insulin were the foundation proper diagnosis of dopa-responsive dystonia in 2010 and of pharmacologic management of hemophilia and diabetes respectively. Acured them of the symptoms that had plagued their childhood.1 How- Pharmacogenomics, the optimization of drug response in relation ever, despite the power of genetic sequencing in to genetics, is another promising emerging field medicine, it is still emerging in translation and is and is a cornerstone of current genetic medicine. reserved for certain subsets of patients. Sequencing Cancer therapy has Ivacaftor is a potentiator of the CFTR channel the first human genome was a 13‑year interna- focused on using and is the most effective cystic fibrosis medication 2 tional collaborative effort costing US$3 billion. tumor-specific antigens on the market; however, it is only applicable to the Today, it can be completed for US$1000 in under 4% to 5% of the patient population who are ho- 24 hours3 due to advancements in biotechnolo- elucidated by sequencing mozygous for the F508del mutation.6 In Canada, gies. This opens the door to the exciting prospect as the targets of genetic testing is offered to patients only under of routine whole-genome sequencing (genomic biologic therapies. specific circumstances, such as having a lineage of sequencing) for the standard patient, bringing Huntington disease or a high index of suspicion forth an era of precision medicine, which tailors for BRCA1/2 mutations. Otherwise, patients may the prevention and management of illness to an access fee-based genotyping through private bio- individual patient using their detailed genomic data in combination technology companies such as 23andMe7 that profile patients’ genomes with their environment, lifestyle, and background. for specific genes of interest. Whole-genomic sequencing is currently not widely available for typical consumers outside of specific research Current uses of genetics in medicine circumstances. Nevertheless, genomics has its place in current medicine Prenatal screening tests are the most widely offered genetic tests across and is poised to expand vastly in the next decade. North America, whereby fragments of placental DNA fragments drawn from maternal blood are sequenced for genetic abnormalities. In recent The future of genomics in medicine years, cancer therapy has focused on using tumor-specific antigens4 elu- Clinician leaders visualize two primary future roles for preventive whole- cidated by sequencing as the targets of biologic therapies. For example, genome sequencing: ado-trastuzumab is a monoclonal chemotherapy combination drug that 1. As a noninvasive screening test for preventive medicine. has reduced the 3-year disease-free remission rate of HER2-positive breast 2. As a test to improve diagnostic capabilities.8 In effect, similar to how the identification of BRCA1/2 mutation carriers led to prophylactic mastectomy and oophorectomies, early de- Mr Yang is a medical student in the tailed genomic data would lead to valuable insight into future disease class of 2021 at the University of British risks spanning diverse specialties from oncology9 to psychiatry10 and Columbia Faculty of Medicine. In his would aid in their prevention. In order to accomplish this feat, there is spare time he enjoys playing badminton a worldwide push for “big data” in genomic medicine, where millions and eating at buffets. of reference sequences, individualized patient factors, and phenotypic expression are collected and coalesced into a multifactorial database and This article has been peer reviewed.

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Perhaps purely clinical diagnoses such as trigeminal neuralgia, major depressive disorder, or atopic dermatitis will reform in light of underlying genetic origins.

algorithm where individually sequenced genomes can be compared. To Acknowledgments reach this goal, President Barack Obama launched the National Institutes I would like to acknowledge Mr Shanning Yang, Ms LanLan Meng, and Dr Meng- of Health’s All of Us campaign in 2015, mandating the collection of lin Yang for their discussions, which helped formulate the idea for this article. 1 million sequenced genomes, complementing environmental factors, and 11 demographic information from US citizens. Currently, over 600 000 Competing interests 12 have been collected. This is a multinational effort; countries such as None declared. the and China have launched similar initiatives. The Global Alliance for Genomics and Health (GA4GH) predicts 60 mil- References lion genomes will be sequenced worldwide by 2025. Just as radiological 1. Check Hayden E. Genome study solves twins’ mystery condition. Nature Publishing imaging has increased the positive predictive value of suspected diag- Group, 2011. Accessed 31 October 2019. www.nature.com/news/2011/110615/full/ news.2011.368.html. noses based on clinical signs and symptoms, and has decreased the rates 2. Venter JC, Adams MD, Myers EW, et al. The sequence of the human genome. Science of exploratory surgical procedures, genomics in medicine is poised to 2001;291:1304-1351. augment this further and add another layer of confidence to diagnostic 3. Davies K. The $1,000 genome: The revolution in DNA sequencing and the new era of approaches. personalized medicine: New York, NY: Simon and Schuster; 2015. 4. Bettegowda C, Sausen M, Leary RJ, et al. Detection of circulating tumor DNA in early- and late-stage human malignancies. Sci transl med 2014;6:224ra24. Conclusion 5. Lambert JM, Chari RV. Ado-trastuzumab Emtansine (T-DM1): An -drug con- It is exciting to hypothesize how the expanding role of genomics in jugate (ADC) for HER2-positive breast cancer. J Med Chem 2014;57:6949-6964. medicine will impact our understanding and classification of disease. 6. Wainwright CE, Elborn JS, Ramsey BW, et al. Lumacaftor-ivacaftor in patients with cys- Perhaps purely clinical diagnoses such as trigeminal neuralgia, major tic fibrosis homozygous for Phe508del CFTR. N Engl J Med 2015;373:220-231. 7. 23andMe. Accessed 31 October 2019. www.23andme.com. depressive disorder, or atopic dermatitis will reform in light of underlying 8. Ashley EA. Towards precision medicine. Nat Rev Genet 2016;17:507-522. genetic origins. Ultimately, this will better classify our understanding of 9. Friedman AA, Letai A, Fisher DE, Flaherty KT. Precision medicine for cancer with next- illnesses and improve treatment strategies and research. generation functional diagnostics. Nat Rev Cancer. 2015;15:747-756. Lastly, we cannot turn a blind eye to the barriers to precision medi- 10. Insel TR. The NIMH Research Domain Criteria (RDoC) Project: Precision medicine for psychiatry. Am J Psychiatry 2014;171:395-397. cine. With much of the world’s population still deplete of basic resources 11. Collins FS, Varmus H. A new initiative on precision medicine. N Engl J Med 2015; and health care, genomics and precision medicine would primarily be a 372:793-795. resource for developed countries in the next decade. The ethics of storing 12. Collins F. Presidential plenary: Whole genome approaches to unravelling diseases. identifiable genetic information, the rights of patients to knowledge of ENDO 2019. 23 March 2019. New Orleans, LA. such data, and the potential effects on stakeholders at all levels of health care are additional complex issues. However, given the current funding status and international attention garnered by precision medicine and genomics, it will certainly have its place in the future of medicine. n

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The age of mushrooms is upon us in medicine

Psychedelic medications, including mushrooms, are on the verge of becoming mainstream practice.

Mark Elliott, MD

ome of us will remember turn-on-tune-in-drop-out Timothy The reason that antifungal agents in medicine are so toxic in humans is Leary, the psychologist whose work on then-legal psychedelics in that fungi are much closer to humans than . the 1960s got him fired from Harvard University. His subsequent Sarrest and the government’s attempt to stamp out the counterculture review anti-Vietnam movement led to the US federal government banning the Psychedelics—whether one is referring to (found in more manufacture and sale of all psychedelic drugs. than 200 species of mushrooms), (from the ), But the tide has turned, and psychedelic drugs are currently having LSD (a refined form of lysergic extracted from the ergot ), or a huge resurgence. (a brewed mixture of substances from vines traditionally found in the Amazon basin)—seem to Indications This year US affect and/or (MAO) Psychedelics will soon be routine for treating opi- congresswoman receptors in the brain. As research ramps up there un- 1 2 3 oid addiction, PTSD, and refractory , Alexandria Ocasio- doubtedly will be other receptors with cool-sounding 4 as well for use in palliative care settings. Cortez filed legislation acronyms. These drugs cause the brain to light up on an fMRI. As this “neuronal crosstalk” increases, so review to remove the legal does the patient’s “ego dissolution,” usually with ac- Fungi is the generic term for the group of eu- restrictions surrounding companying feelings of bliss and a sense of oneness. karyotic organisms that include molds, yeast, and clinical research of The uses that seem to be generating the most press mushrooms. Mushrooms are -bearing fruit psilocybin in the are for and addiction, end-of-life care of the fungus and the roots are called . issues, refractory depression, and PTSD. In October Mycelium are thread-like branchings that can name of assisting 2018, the US Food and Drug Administration granted become enormous. A mycelium mat in veterans with PTSD. “breakthrough therapy” designation to psilocybin for was found to be 2500 acres in size.5 What is so depression. In May 2019, Denver, Colorado, voters fascinating about mycelium is that fungi branched passed a ballot to decriminalize psychedelic mush- off from the human evolutionary tree perhaps 600 million years ago. At rooms. This year US congresswoman Alexandria Ocasio-Cortez filed this point, animals internalized their digestive systems but fungi left theirs legislation to remove the legal restrictions surrounding clinical research externalized. These mycelium threads in the ground are separated from of these compounds in the name of assisting veterans with PTSD. the external world, teeming with bacteria and viruses, by a skin only one The guru of mycology, Paul Stamets,6 who lives nearby on the Olympic cell thick (animal skin, in contrast, is many cell layers thick). There is a Peninsula in Washington, has a very interesting evolutionary take on this constant war between the mycelia who need to eat the subject, which is basically a promotion of the older Stone Age hypoth- and the microorganisms who want to eat the mycelia—so that fungi have esis of Terence McKenna.7 In essence, it says that something amazing extensive antiviral and antibacterial properties that are now beginning happened to the homo sapiens brain about 200 000 years ago; a massive to be investigated. Mycelia are the decomposters of the world’s forests. increase in cognitive ability allowed humans to conquer the planet by cooperating. This theory goes on to say that early hominids coming out of the trees and onto the savannah came across large amounts of mush- Dr Elliott is a staff anesthesiologist at rooms growing like weeds from animal dung. Over many millennia these Providence Healthcare in Vancouver. early humans got to know which mushrooms were for calories, which ones were poisonous, and which ones were “magic”—that is, contained This article has been peer reviewed. psilocybin. As McKenna writes, “Homo sapiens ate its way to a higher

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psychedelics.8 The Multidisciplinary Associa- tion for Psychedelic Studies run by researcher Fungi have extensive antiviral and TED Talks speaker Rick Doblin is a not- for-profit research organization dedicated to and antibacterial properties psychedelics also getting a lot of attention.9,10 that are now beginning to be The age of mushrooms is upon us!n References investigated. 1. Argento E, Tupper KW, Socias ME. The tripping point: The potential role of psychedelic-assisted therapy in the response to the opioid crisis. Int J 2019;66:80-81. 2. Sartori SB, Singewald N. Novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders. Pharmacol Ther 2019 Aug 27:107402. doi: 10.1016/j.pharmthera.2019.107402. 3. Carhart-Harris RL, Bolstridge M, Day CMJ, et al. Psilocy- bin with psychological support for treatment-resistant depression: Six-month follow-up. Psychopharmacol- ogy (Berl) 2018;235:399-408. 4. Dyck E. Psychedelics and dying care: A historical look at the relationship between psychedelics and pallia- tive care. J Psychoactive Drugs 2019;51:102-107. 5. Morris L. The world’s largest living organism. National Geographic. 16 May 2017. Accessed 8 October 2019. www.nationalgeographic.com.au/nature/the-worlds -largest-living-organism.aspx. 6. Stamets P. Mycelium running: How mushrooms can help save the world. Berkeley, CA: Ten Speed Press; 2005. 7. McKenna T. Food of the : The search for the original tree of knowledge—A radical history of plants, drugs, and human evolution. New York, NY: Bantam; 1992. 8. Pollan M. How to change your mind: What the new science of psychedelics teaches us about conscious- ness, dying, addiction, depression, and transcendence. Toronto, ON: Penguin Books; 2018. 9. Elton C. The interview: MDMA-therapy expert Dr Rick Doblin. Magazine. 9 October 2019. Ac- cessed 1 November 2019. www.bostonmagazine.com/ health/2019/09/10/rick-doblin. 10. McBride S, Brown KV. When you need money for prescription psychedelics, Burning Man is your des- tination. Bloomberg Businessweek. 22 July 2019. Ac- cessed 1 November 2019. www.bloomberg.com/news/ features/2019-07-22/the-mdma-advocate-s-biggest -fundraising-week-is-burning-man.

consciousness,” and, “It was at this time that things change faster now. German millionaire religious , calendar making, and natural Christian Angermayer has started a company magic came into their own.”7 called Compass Pathways that is buying the intellectual property rights for the manufacture The future of psychedelics with the backing of Silicon Val- The trend to acceptance of these drugs is now ley billionaire Peter Thiel. Food guru Michael about where was 10 years ago, but Pollan has a recent book on the virtues of the

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Physician engagement gains traction across BC

eaningful physician engagement Facility Engagement in action issues during the opening of new hospital is essential to a health care orga- As a first step to creating a foundation for col- campuses. nization’s ability to deliver high- laboration, many MSAs have improved physi- • At Providence Health Care in Vancouver, quality, cost-effective patient care. But for the cian-to-physician relationships. This is the most six physician leads were selected to repre- M notable change associated with Facility Engage- past 2 decades—as BC’s health authorities were sent the voice of medical staff and work regionalized and doctors in hospitals became ment to date, as reported in the 2019 evaluation alongside senior health authority executives even busier with capacity and wait-list pres- of the initiative (www.facilityengagement.ca/ to carry out the organization’s new 7-year sures—doctors and administrators have been evaluation). Two examples of the 160-plus ac- strategic priorities and clinical/master plan- challenged to build effec- tivities with this goal are: ning. More than 120 physicians were en- tive collaborative process- Since Facility • The BC Cancer Agen- gaged to provide ideas and perspectives to es that ensure physicians Engagement was cy’s new medical staff help create the plan. are included in decision association created a Physicians are also looking to improve their making about their work introduced 4 years common forum for all work environment and patient care, initiat- environment and patient ago, 72 medical staff physicians providing ing more than 200 collaborative projects with care. associations (MSAs) cancer care to collaborate hospital administrators, front-line staff, and But now that’s chang- have partnered across disciplines and re- regional health authority leaders. ing. The Specialist Servic- gions, allowing them to • Last year, physicians at Trail’s Kootenay with their health es Committee’s Facility connect with each other, Boundary Regional Hospital engaged the Engagement Initiative authorities to build and discuss care of their entire hospital—from specialists to admin- supports physicians who a new foundation patients and personal istrators to cleaners—in an extraordinary work in acute care facili- for collaboration. well-being. effort that reduced surgical site infections ties across BC to establish • Internists and family to well below the national average, and the formal structures that in- doctors working at the overall hospital infection rate by 50%. crease their voice and in- University Hospital of • At Lions Gate Hospital in North Van- fluence in their hospital and region. Northern British Columbia in Prince couver, an emergency room physician Since Facility Engagement was introduced George met to better understand each engaged clinical and support staff and ad- 4 years ago, 72 medical staff associations other’s pressures and needs, improve com- ministration in a collaborative effort to re- (MSAs) have partnered with their health au- munication, and explore ways to increase organize space, processes, and manpower thorities to build a new foundation for col- inpatient coverage, leading to collaboration in the department. The changes improved laboration. With funding available for MSA with Northern Health to create a general patient flow and wait times, communication administrative and management support and internal medicine unit. between doctors and nurses, and reduced physician sessional time, MSAs are setting Improved communication with health au- in nonphysician tasks. priorities, renewing relationships with health thorities is another notable change. Physicians, Physicians have also taken the oppor- authority leaders, and initiating collaborative administrators, and health authority executives tunity to explore how they can reduce the activities—more than 1400 to date. are meeting regularly and establishing collab- risk of burnout and provide patient care in Thanks to these efforts, the tide is starting orative processes. More physicians are taking on a healthier way. Physician health is a com- to turn. leadership roles. Progress to date is illustrated mon theme for MSA’s facility engagement by dozens of examples, such as: work, with more than 100 related activities • In Comox-Campbell River, Facility En- underway across BC. gagement opened the door to dialogue • A region-wide collaborative effort to stimu- This article is the opinion of the Specialist and a new working relationship between late action and elevate medical staff well- Services Committee and has not been the physicians and the health authority, being as a strategic organizational/system peer reviewed by the BCMJ Editorial which led to the resolution of congestion priority is underway in Fraser Health, Board.

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representing 12 acute care sites as well as divisions in the community. • The Physician Wellness Committee at Royal Inland Hospital in Kamloops has identified a number of strategies and actions to support physician health, including a FACILITY peer group that provides a safe, confiden- tial environment for physicians to discuss ENGAGEMENT An SSC Initiative challenges and critical incidents. Facility Engagement is also supporting medical staff engagement in the implementa- FORT ST. JOHN GENERAL HOSPITAL tion of electronic health records, starting with NORTHERN HEALTH DAWSON CREEK & DISTRICT HOSPITAL Lower Mainland hospitals that are adopting CHETWYND GENERAL HOSPITAL WRINCH MEMORIAL HOSPITAL the Cerner system. BULKLEY VALLEY MACKENZIE & DISTRICT HOSPITAL DISTRICT HOSPITAL PRINCE RUPERT MILLS MEMORIAL REGIONAL HOSPITAL NORTHERN HAIDA HOSPITAL STUART LAKE HOSPITAL GWAII HOSPITAL AND HEALTH CENTRE LAKES DISTRICT HOSPITAL Moving forward & HEALTH CENTRE QUEEN CHARLOTTE ISLANDS ST. JOHN HOSPITAL GENERAL HOSPITAL There is more work to be done to achieve sus- BC CANCER AGENCY THE UNIVERSITY HOSPITAL OF CENTRE FOR THE NORTH NORTHERN BRITISH COLUMBIA tained change, and further evaluation of the Facility Engagement Initiative will determine its ongoing impact. Meanwhile, physicians and BRITISH COLUMBIA

MCBRIDE & DISTRICT HOSPITAL health authority leaders from many parts of the R.W. LARGE MEMORIAL HOSPITAL province report they are making headway. They VANCOUVER are building trust and having constructive con- COASTAL G.R. BAKER MEMORIAL HOSPITAL versations about plans and decisions that impact HEALTH CARIBOO MEMORIAL HOSPITAL their hospitals, programs, and patient services. PORT HARDY HOSPITAL 100 MILE DISTRICT DR. HELMCKEN GENERAL HOSPITAL MEMORIAL HOSPITAL A sense of optimism is fueling the initiative PORT MCNEILL & DISTRICT HOSPITAL CORMORANT across BC as physicians enjoy renewed team- HEALTH CENTRE INTERIOR work and make positive changes that make a HEALTH GOLDEN & DISTRICT ISLAND CAMPBELL RIVER & GENERAL HOSPITAL difference to their work culture and their pa- DISTRICT GENERAL SHUSWAP LAKE QUEEN VICTORIA HOSPITAL GENERAL HOSPITAL HOSPITAL HEALTH ROYAL INLAND HOSPITAL LILLOOET HOSPITAL & HEALTH CENTRE INVERMERE & DISTRICT tients’ experience and care. HOSPITAL ST. JOSEPH’S GENERAL POWELL RIVER GENERAL HOSPITAL VERNON JUBILEE HOSPITAL Read what physicians are saying about Facil- ARROW LAKES HOSPITAL NICOLA VALLEY SECHELT HOSPITAL GENERAL HOSPITAL TOFINO GENERAL HOSPITAL NANAIMO HOSPITAL & HEALTH CENTRE WEST COAST REGIONAL BC CANCER AGENCY ity Engagement at www.facilityengagement.ca/ GENERAL GENERAL CENTRE FOR THE HOSPITAL HOSPITAL SOUTHERN INTERIOR COWICHAN LADY MINTO / DISTRICT GULF ISLANDS FRASER PRINCETON PENTICTON REGIONAL HOSPITAL whatschanging. Read more examples of progress HOSPITAL HOSPITAL CANYON GENERAL SAANICH PENINSULA HOSPITAL HOSPITAL HOSPITAL n SOUTH GENERAL HOSPITAL at www.facilityengagement.ca/stories. BC CANCER ROYAL JUBILEE & KOOTENAY LAKE HOSPITAL AGENCY VICTORIA GENERAL KOOTENAY BOUNDARY EAST KOOTENAY VANCOUVER HOSPITALS BOUNDARY HOSPITAL REGIONAL HOSPITAL —Sam Bugis, MD ISLAND CENTRE REGIONAL HOSPITAL FRASER CRESTON VALLEY HOSPITAL & ELK VALLEY Vice President, Physician Affairs and Specialist HEALTH CENTRE HOSPITAL HEALTH Practice —Cindy Myles SQUAMISH GENERAL HOSPITAL CHILLIWACK GENERAL HOSPITAL

Director, Facility Physician Engagement, ABBOTSFORD REGIONAL Specialist Services Committee MISSION MEMORIAL HOSPITAL HOSPITAL BC CANCER VANCOUVER AGENCY ABBOTSFORD COASTAL CENTRE RIDGE MEADOWS HEALTH HOSPITAL LANGLEY MEMORIAL HOSPITAL LIONS GATE HOSPITAL UBC / VGH HOSPITALS FRASER & G.F. STRONG REHAB BC CANCER FORENSIC BC CENTRE CENTRE AGENCY PSYCHIATRIC FOR DISEASE VANCOUVER HOSPITAL CONTROL HEALTH CENTRE ROYAL COLUMBIAN & EAGLE RIDGE HOSPITALS BURNABY HOSPITAL SURREY MEMORIAL HOSPITAL ST. PAUL’S & CHILDREN’S MOUNT ST. JOSEPH & WOMEN’S BC CANCER AGENCY HOSPITALS HOSPITAL AND FRASER VALLEY CARE CENTRE CENTRE PROVINCIAL HEALTH SERVICE AUTHORITY (PHSA) RICHMOND HOSPITAL BC Women’s and Children’s PEACE ARCH DISTRICT Hospital HOSPITAL Forensic Psychiatric Hospital BC Cancer Agencies across B.C. DELTA HOSPITAL BC Centre for Disease Control

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Banner Map V4.indd 1 2016-05-29 9:13 PM BCCDC

Shared decision making and breastfeeding: Supporting families’ informed choices

ritish Columbia has the highest rates of patient come together as experts, in clinical of our collaboration we will bring a program to breastfeeding initiation in Canada, but evidence and lived experience respectively. This BC. It will include experiential learning, practi- there is a sharp decline in breastfeeding division of power shifts the conversation from cal cases, cultural safety techniques, strategies in the weeks or months after birth.1 Support- giving patient education to exchanging informa- for building rapport with families, and educa- B 6 n ing families in making difficult infant feeding tion to help the family reach their goals. The tional credits. choices in a nonjudgmental way can support the ideal result of a shared decision-making process —Sarah Munro, PhD health of infants and may is a patient decision that is UBC, Centre for Health Evaluation and help increase breastfeed- informed, consistent with Outcome Sciences (CHÉOS) ing rates by improving the When families choose their personal values, and —Cynthia Buckett, MBA, RD therapeutic relationship infant feeding options acted upon.7 BCCDC with health care profes- other than exclusive The BC Centre for —Julie Sou, MSc CHÉOS sionals. While promotion human milk, they Disease Control, in part- of exclusive human-milk nership with researchers —Nick Bansback, PhD feeding is well inten- frequently experience from UBC and the Centre UBC, CHÉOS tioned and based on evi- guilt, shame, and failure. for Health Evaluation and —Henry Lau, RD dence that it confers more Outcome Sciences, has BCCDC health benefits for parents been developing shared and infants compared to formula,2 a family’s decision-making skills education for health care References 1. Statistics Canada. Breastfeeding trends in Canada. 2013. context and choices are sometimes overlooked. professionals to better support infant feeding Accessed 29 October 2019. www150.statcan.gc.ca/n1/ Breastfeeding may not be the optimal choice choices. To date, our interview study and lit- pub/82-624-x/2013001/article/11879-eng.htm. at a given time due to early return to work, erature review have explored BC health care 2. Dieterich CM, Felice JP, O’Sullivan E, Rasmussen KM. history of smoking or drug use, and other far- professionals’ and families’ needs in making Breastfeeding and health outcomes for the mother -infant dyad. Pediatr Clin North Am 2013;60:31-48. reaching socioeconomic reasons.3,4 When fami- infant feeding decisions from pregnancy to 3. Radzyminski S, Callister LC. Mother’s beliefs, attitudes, lies choose infant feeding options other than 6-months postpartum. and decision making related to infant feeding choices. exclusive human milk, they frequently experi- We learned that BC health care profession- J Perinat Educ 2016;25:18-28. ence guilt, shame, and failure, which can create als begin infant feeding discussions with ques- 4. Fischer TP, Olson BH. A qualitative study to understand mistrust with their health care profession- tions to gain information about the family (“Do cultural factors affecting a mother’s decision to breast 5 or formula feed. J Hum Lact 2014;30:209-216. als. In this context, health care professionals you plan on breastfeeding?”), not for the family 5. Thomson G, Ebisch-Burton K, Flacking R. Shame if you may need more support to engage in complex to gain clarity about their goals and what mat- do—shame if you don’t: Women’s experiences of in- discussions that promote breastfeeding while ters most to them. They also centred the conver- fant feeding. Matern Child Nutr 2015;11:33-46. simultaneously offering safe, informed choices sation on newborn health, such as weight gain 6. O’Connor AM, Légaré F, Stacey D. Risk communica- tion in practice: The contribution of decision aids. BMJ of alternate feeding options. milestones, which can ignore related concerns 2003;327:736-740. Developing health care professionals’ skills that influence parents’ infant feeding choices. 7. Légaré F, Stacey D, Pouliot S, et al. Interprofessionalism in shared decision making is one solution. Existing communication and counseling ap- and shared decision-making in primary care: A step- Shared decision making is a form of non­ proaches used by BC health care profession- wise approach towards a new model. J Interprof Care 2011;25:18-25. directive counseling where the professional and als (e.g., trauma-informed care, motivational interviewing) can underpin the development This article is the opinion of the BC Centre of shared decision-making skills. for Disease Control and has not been peer Training in shared decision making for reviewed by the BCMJ Editorial Board. health care professionals is well established in other parts of Canada, and in the next phase

394 BC Medical Journal vol. 61 no. 10 | december 2019 News We welcome news items of less than 300 words; we and health data, medication lists, current daily may edit them for clarity and length. News items should be emailed to routines, grooming, bathroom needs, and very importantly, likes and dislikes. The caregiver’s [email protected] and must include your mailing address, telephone forms include a list of caregiving goals and, as number, and email address. All writers should disclose any competing the caregiver begins to assist the patient, they interests. report accomplishments, changes, and anoma- lies along with periodic summaries. There is a separate form for the caregiver’s evaluation. Book review: Essential By Godfrey Harris and Jacqueline Njuki. Los No individual forms can provide a complete Caregiving Guide: How to Angeles: The Americas Group, 2019. ISBN- picture of a patient’s or a family’s situation; optimize the extended care 13: 978-0935047905. Paperback, 68 pages. a continuum to care is needed. For example, US$15.95 part-time or a short period of assistance may your loved one needs The concerned and loving daughter notices be needed postsurgery; 24-hour care may be her 72-year-old mother is showing early signs required in advanced cases of dementia or oth- of dementia. She approaches her family physi- er major disorders. Some of the forms in this cian for advice on how best to bring a caregiver booklet could be filled out by a patient with into her mother’s life, how to help the caregiv- adequate ability to communicate; others may er set appropriate goals, and how to supervise be too simplistic for complex situations. the caregiver’s work. The family physician may The family doctor may wish to emphasize suggest that the daughter read this recently that caregiving may extend to many issues— published booklet: Essential Caregiving Guide. safety, administration of medications, com- The booklet is short on text; it is filled with panionship, food and feeding, locomotion and various forms to be used to record pertinent muscle-strength maintenance when appropri- information or to take inventory. The family ate, skin care, general cleanliness, and bowel completes forms about the patient’s personal and urinary care. The kinds of forms needed

BC’s top family physician of 2019

The College of Family Physicians of Canada (CFPC) and the Foun- As the physician lead at the Prince dation for Advancing Family Medicine (FAFM) have selected the George Division of Family Practice, 2019 Family Physicians of the Year as the recipients of the Reg L. Dr Textor is currently spearheading Perkin Awards. Each year 10 recipients (one from each province) are two large initiatives. The first involves nominated by their peers, colleagues, and the CFPC’s chapters for preserving longitudinal family medicine their leadership, contributions to patient care, and commitment to in the community, including a new ap- family medicine teaching and research. The 2019 Family Physician of proach to the care of unattached pa- the Year from British Columbia is Dr Catherine Textor, MD, CCFP tients and opening a new primary care Dr Catherine Textor (EM), from Prince George. medical unit at UHNBC in partner- Dr Textor has worked as a full-service family doctor in Prince ship with Northern Health. The second is developing a model for George for the past 16 years. She is one of four partners who own the delivery of mental health and substance use services in Northern a group family practice providing comprehensive care that includes British Columbia. obstetrical, palliative, and long-term care; home visits; surgical assists; Growing up in a small town on Vancouver Island, the only expo- and in-hospital care for their patients. Obstetrical care is a special area sure Dr Textor had to the medical system was her family doctor. As of interest for the practice, and they take referrals from colleagues in she went through rotations in medical school, she found it difficult Prince George and outlying rural communities in the region. They to pick just one specialty. She loves her job for the variety it brings also teach medical students and residents in their practice and in and the privilege it offers of sharing in the most intimate moments the hospital. For 11 years Dr Textor also did part-time work in the of her patients’ lives. emergency department at the University Hospital of Northern Brit- The complete list of recipients and each recipient’s biography is ish Columbia (UHNBC). available at https://fafm.cfpc.ca/fpoy-2019.

BC Medical Journal vol. 61 no. 10 | december 2019 395 news to record details such as these are not includ- members can access responses in real time us- • Death caps are particularly dangerous be- ed in the booklet and may have to be devised ing an easy-to-use, web-based dashboard. The cause of their resemblance to edible varieties separately. secure platform automatically anonymizes and of mushrooms. They can be mistaken for Further, managerial or supervisory require- randomizes the responses upon receipt before edible puffballs when young or the Asian ments from the family depend on the caregiver’s the data are reported in the dashboard. For more Straw mushroom when older. compassion and experience, and on the circum- information, visit www.gpscbc.ca. • Toxins found in death caps include ama- stances under which the caregiving takes place. toxins, phallotoxins, and virotoxins. The booklet’s text is not inspiring, but the Mushroom poisonings • Symptoms of poisoning include , forms do serve as introductory guides for the on the rise in BC vomiting, watery diarrhea, low blood pres- family and the caregiver. I think it is a good sure, failure, and failure. start as a way to get organized. The BC Centre for Disease Control’s Drug and • Illness begins 8 to 12 hours after ingestion, Caveat: The book is written with the United Poison Information Centre is urging British beginning with gastrointestinal symptoms States’ public health services in mind, but virtu- Columbians to use extreme caution when for- like vomiting and diarrhea, followed by ally all comments about caregiving are just as aging or consuming wild mushrooms. Poison apparent recovery. relevant in Canada. Control received 201 mushroom poisoning calls • Gastrointestinal symptoms recur and —George Szasz, MD as of 30 September 2019, well on track to being damage to the kidney and liver progresses one of the most active years in recent history. over the next 3 to 6 days. Hear from patients: New GPSC Amanita phalloides, also known as the death Patient Experience Tool cap mushroom, has been increasingly popping Tips to stay safe while mushroom hunting: up throughout BC, including in Victoria and • If you are unsure, don’t eat it! Family doctors and teams can now hear from South Vancouver Island, the Gulf Islands, Met- • Only pick and eat mushrooms that are well their patients about their experiences and in- ro Vancouver, and the Fraser Valley region. The known to be edible and easy to distinguish teractions with a practice using a new tool death cap is the most poisonous mushroom from poisonous varieties. developed by the General Practice Services in the world, most often found in urban ar- • If you suspect you’ve consumed a poisonous Committee (GPSC). The Patient Experience eas here. There have been no reported human mushroom, call the Drug and Poison In- Tool is a tablet-based survey that asks patients deaths from BC death cap mushrooms since formation Centre 24-hour phone line at about topics such as wait times, office hours, and 2016 when a child passed away; however, two 1 800 567-8911 and seek medical attention coordination of care. More than 6000 patients dogs have died due to possible death cap poi- immediately. have completed the survey, initially piloted by soning in 2019. • Only hunt for mushrooms in safe terrain 39 clinics throughout BC since 2016. Facts about the Amanita phalloides (death and exercise extreme caution if in remote The Patient Experience Tool data can in- cap): areas. form quality improvement activities in a prac- • Death cap mushrooms are believed to kill • Save one of each kind of mushroom so tice, and practices can opt to share aggregated more people worldwide than any other their identities can be confirmed should data with their local division. Practice team mushroom. symptoms develop.

Celebrating a family medicine milestone and 1969 trailblazers Fifty years ago a pioneering group of 12 family physicians successfully completed the first ever Certification Examination in Family Medicine and earned the Certification in the College of Family Physicians of Canada (CCFP) special designation. They were introduced to recognize the rigorous assessment required for two key priorities: to support the broad scope of skills and knowledge required of family physicians in their central role caring for patients, and to help advance family medicine in Canada. Among the class members is Gerald Stewart, MD, CCFP, FCFP, LM, from Kelowna, BC. Dr Stewart graduated from the UBC Medical School and cared for the people of Kelowna and mentored new generations of family physicians for nearly 60 years. He retired from medicine in 2018. Dr Stewart is also a past president of Doctors of BC, having served in 1984/1985. For the complete list of the class of 1969, visit www.cfpc.ca/meet-some-of-the-members -of-the-class-of-1969.

Dr Gerald Stewart, past president of Doctors of BC, was one of the first recipients of the CCFP designation.

396 BC Medical Journal vol. 61 no. 10 | december 2019 news

Learn more witness an overdose to get trained and get a kit alongside the Canadian Society for Exercise Visit the BCCDC’s information page on so they can respond. Take Home Naloxone kits Physiology, one of 17 partner organizations. the death cap mushroom to familiarize are available free of charge at hundreds of loca- The roundtable brought together a group of yourself with what it looks like and what tions across the province and can be found using 40 international, multidisciplinary experts from to do if sighted or ingested: www.bccdc the site finder on https://towardtheheart.com. various organizations who conducted a thor- .ca/health-info/prevention-public-health/ Learn more about the 2018 Harm Re- ough and updated review of the evidence on the death-cap-mushrooms. duction Client Survey findings at www positive effects of exercise in preventing, manag- There are many other varieties of wild mush- .bccdc.ca/health-professionals/data-reports/ ing, and recovering from cancer. Together, the rooms that are less toxic than death caps but harm-reduction-and-substance-use. three papers offer new evidence-backed rec- can also cause severe illness. Search for “wild ommendations for incorporating exercise into mushrooms” on www.bccdc.ca for additional New international exercise prevention and treatment plans and introduce a resources. guidelines for cancer survivors new Moving Through Cancer initiative (https:// For information on which mushrooms in www.exerciseismedicine.org/support_page.php/ For the rising number of cancer survivors BC are edible and which are poisonous, vis- moving-through-cancer/), led by the American worldwide, there’s growing evidence that exer- it UBC’s Mushrooms Up! database: www.zo College of Sports Medicine, to help clinicians cise is an important part of recovery. But how ology.ubc.ca/~biodiv/mushroom. worldwide implement these recommendations. much and what type of exercise is needed? For more information on the Vancouver The new recommendations include: A recent review of research, conducted by Mycological Society and their resources on • For all adults, exercise is important for an international group of experts led by the poisonous mushrooms, visit www.vanmyco cancer prevention and specifically lowers University of British Columbia, has resulted .org/about-mushrooms/poisonous. risk of seven common types of cancer: in the development of new exercise guidelines colon, breast, endometrial, kidney, bladder, Naloxone kits encouraged for for cancer survivors. The updated recommen- esophagus, and stomach. dations, published in Medicine and Science in those who smoke or snort • For cancer survivors, incorporate exercise Sports and Exercise, outline specific “exercise to help improve survival after a diagnosis The BC Centre for Disease Control (BCCDC) prescriptions” to address common side effects, of breast, colon, and prostate cancer. is advising people who use drugs to get trained such as anxiety and fatigue, associated with • Exercising during and after cancer treat- in overdose response and pick up a Take Home cancer diagnoses and treatment. ment improves fatigue, anxiety, depression, Naloxone kit, regardless of how they choose In general, the new guidelines recommend physical function, quality of life, and does to consume, after new research revealed that survivors perform aerobic and resistance train- not exacerbate lymphedema. people who smoke or snort drugs are half as ing for approximately 30 minutes per session, • Continue research that will drive the inte- likely to carry lifesaving naloxone medication. 3 times a week. This is a departure from earlier gration of exercise into the standard of care The warning stems from results of a 2018 survey guidelines, published nearly a decade ago, which for cancer. of people who use drugs in BC and research advised cancer survivors to meet the general • Translate into practice the increasingly ro- published recently in the journal Drug and Al- public health guidelines for all Americans (150 bust evidence base about the positive effects cohol Dependence. The survey, conducted by the minutes of exercise a week). of exercise for cancer patients. team at the BCCDC, found The new recommendations are based on a For more information and links to all three that people who reported smoking or snorting substantive review and analysis of the growing papers visit www.acsm.org/read-research/news drugs as their preferred method of drug use body of scientific evidence in the field. Since room/news-releases/news-detail/2019/10/16/ were half as likely to carry naloxone as those the first guidelines were put forward in 2010, expert-panel-cancer-treatment-plans-should who preferred injecting. This was true even after there have been more than 2500 published -include-tailored-exercise-prescriptions. taking several factors into account, including randomized controlled exercise trials in cancer gender, age, and type of drug used. survivors (an increase of 281%). Patients with mood, anxiety The unpredictability of the street drug sup- The new paper (“Exercise guidelines for disorders share abnormalities cancer survivors”) is one of three papers pub- ply puts people at risk. Data in BC show that in brain’s control circuit people who smoke or snort are experi- lished that summarize the outcomes of an in- encing overdoses and dying. While uncommon, ternational roundtable that explored the role New research published in JAMA Psychiatry there have also been reports of -related of exercise in cancer prevention and control. shows for the first time that patients with deaths among people using , such as The paper’s lead author, Dr Kristin Campbell, mood and anxiety disorders share the same and . associate professor in UBC’s Department of abnormalities in regions of the brain involved The BCCDC is also advising anyone who Physical Therapy, and director of the Clinical in emotional and cognitive control. The find- is around people who use drugs and who may Exercise Physiology Lab, served as the Cana- ings hold promise for the development of new dian representative on the roundtable, working

BC Medical Journal vol. 61 no. 10 | december 2019 397 news treatments targeting these regions of the brain those diagnosed with a mood or anxiety dis- Los Angeles. It is the first study to describe a in patients with major depressive disorder, bi- order, ranging from major depression to post- method specifically designed for children, called polar disorder, posttraumatic stress disorder, traumatic stress disorder. the Pediatric-Buccal-Epigenetic (PedBE) clock, and anxiety disorders. They found that patients exhibited abnor- which measures chemical changes to determine Mood and anxiety disorders account for mally low activity in the inferior prefrontal and the biological age of a child’s DNA. nearly 65% of psychosocial disability worldwide parietal cortex, the insula, and the putamen— Small chemical changes to DNA, known and represent a major public health challenge. regions that are key parts of the brain circuit as epigenetic changes, alter how genes are ex- In Canada, one in three people (approximately for emotional and cognitive control and are re- pressed in certain tissues and cells. Some of 9.1 million) will be affected by mental illness sponsible for stopping ongoing mental activities these changes happen as a person ages and oth- during their lifetime, according to Statistics and switching to new ones. They also discovered ers may be in response to a person’s environment Canada. The defining symptoms of these dis­ hyperactivity in the anterior cingulate cortex, or life experiences. In adults, these patterns of orders are persistent or recurring negative feel- the left amygdala, and the thalamus, which epigenetic changes are well established. They ings, mainly depression and anxiety. work together to process emotional thoughts can be used to accurately predict a person’s age Dr Sophia Frangou is the study’s senior and feelings. from a DNA sample or, if a person’s epigenetic author and a psychiatry professor at UBC. Dr Following her move to UBC, Dr Frangou age differs from their actual age, the clock can Frangou recently joined UBC as the President’s plans to pursue further research to leverage point to differences in health, including age- Excellence Chair in Brain Health at the Djavad these findings toward more targeted interven- related diseases and early mortality. Mowafaghian Centre for Brain Health. She tions, such as noninvasive simulation of specific The PedBE clock was developed using started this research as head of the research regions of the brain, which could improve out- DNA methylation profiles from 1032 healthy team at the Icahn School of Medicine at Mount comes for those living with mood and anxiety children whose ages ranged from a few weeks Sinai, New York. disorders. old to 20 years. The researchers found 94 dif- For the study, Dr Frangou and her research The study is believed to be the largest analy- ferent sites in the genome that, when tested team analyzed more than 9000 brain scans sis of brain scans of patients with mood and together, could accurately predict a child’s age from previously published studies that com- anxiety disorders to date. It was funded by the to within about 4 months. The team also found pared the brain activity of healthy adults to National Institute of Mental Health in the that children who spent longer in the womb US, the German research funding organiza- showed an accelerated rate of DNA change by tion Deutsche Forschungsgemeinschaft, and 3 months, demonstrating that this tool could the ’s Horizon 2020 Research be used to indicate an infant’s developmental and Innovation Programme. stage. The analysis can be done cheaply and British Columbia Medical Journal The study, “Shared neural phenotypes for efficiently on cells collected from a cheek swab. @BCMedicalJournal mood and anxiety disorders” is available at In a small pilot study, the researchers also online at https://jamanetwork.com/journals/ found that children with autism spectrum dis- British Columbia Medical Journal jamapsychiatry/fullarticle/2753513. order (ASD) showed a higher PedBE “age” @BCMedicalJournal than those considered to be developing typi- New DNA “clock” could help cally, suggesting that the clock could be used BCMJ Blog: Physicians’ income inequality measure development in to screen for ASD. High volume is obviously good business, but it is The researchers made the tool freely avail- probably bad medicine. Can a new way of looking at young children able along with the publication of this study so inequality help us see through the weeds? Scientists have developed a molecular “clock” other research teams are able to use and experi- Read the post: bcmj.org/blog/physicians-income- that could reshape how pediatricians measure ment with the tool right away. inequality and monitor childhood growth and potentially The study, “The PedBE clock accurately allow for an earlier diagnosis of life-altering estimates DNA methylation age in pediatric developmental disorders. The research, pub- buccal cells,” is available online at www.pnas lished in Proceedings of the National Academy of .org/content/early/2019/10/09/1820843116. Sciences, describes how the addition of chemi- cal tags to DNA over time can potentially be used to screen for developmental differences and health problems in children. The study was led by researchers at BC Children’s Hospital, the University of British Follow us on Facebook for regular updates Columbia, and the University of California,

398 BC Medical Journal vol. 61 no. 10 | december 2019 Lito completed his psychiatric residency at the University Hospital in Saskatoon. After We welcome original tributes of less than 300 Obituaries obtaining his FRCPC, he practised in Moose words; we may edit them for clarity and length. Obituaries may be emailed Jaw and Regina, Saskatchewan. In 1991 Lito to [email protected]. Include birth and death dates, full name and name moved to Langley, BC, with his family and deceased was best known by, key hospital and professional affiliations, relevant started working as a consultant psychiatrist at biographical data, and a high-resolution head-and-shoulders photo. Langley Memorial Hospital and at Langley Mental Health Centre, and also opened his private practice. Lito was very involved with the development and growth of psychiatric services in Langley. He was a warm, jovial, kind person In 1978 the family moved to North Van­ and was very dedicated to his profession. Lito couver, where Don transitioned from being was always willing to help others, and whenever a small community GP to having an urban his patients and colleagues were in need, he practice in Lynn Valley and working at Lions was always available and helpful. He retired in Gate Hospital. In 1995 Don and Mary Lou December 2016 when he was diagnosed with relocated to the Comox Valley where Don did pancreatic cancer. some locums before fully retiring. Don used Lito was married to Emy for 40 years. He to say, “It’s not how long you live, it’s how well adored Emy, and she was a source of joy and you live,” and he lived well! —Lang Family comfort throughout his life. Lito was a loving Comox Valley father to his daughter, Andrea; son, Joshua; daughter-in-law, Marielle; and grandfather to Mason. He was also a caring brother to his siblings and warmhearted uncle to his many Dr Donald Wilson Lang nieces and nephews. Spending time with family and friends was very important to Lito, and he 1931–2019 brought a lot of fun and laughter into their lives. Lito had a deep and committed and Dr Donald Wilson Lang died peacefully at was very devoted to his church. He was a the Comox Valley Hospital surrounded by member of Bukas Loob sa Diyos (Catholic family. He is survived by his wife of 63 years, Covenant Community) and served in different Mary Louise; their four children, Susan, An- ministries. He was also a member of the Legion drea, Barbara (Blair MacLean), and Graham of Mary (Our Lady of the Woods) at the St. (Caroline Berka); 11 grandchildren; and twin Nicholas Parish in Langley. Traveling was one great-granddaughters. of Lito’s passions, and he often went on cruises Don and Mary Lou were born and raised in and visited many countries around the world. Edmonton and married soon after they gradu- He was dedicated to a regular fitness program ated from the University of Alberta in 1955 Dr Pascualito Aquino and would go to the gym regularly, even after (Mary Lou with a BSc in public health nursing). Seminiano becoming ill. They settled first in Barrhead, Alberta, where 1947–2019 Lito is survived by his wife, Emy; his chil- Don started his career in the era before univer- dren, Andrea, Joshua, and daughter-in-law sal health care. From 1959 to 1960 they lived Marielle; his grandson, Mason; his sisters, Nim- Dr Pascualito Seminiano passed away from in , England, and Don pursued further fa Diguangco and Elena Andrews; his brother, this life to eternal life on 25 September 2019 medical training. On their return to Canada, Amado Jr. Seminiano; and their families. Lito’s at Langley Memorial Hospital, surrounded by Don joined a family practice in Kimberley, BC. presence and big booming laugh will also be his family. Although the initial plan was to stay for a missed by his colleagues and patients in Langley. short time, Don and his family spent 18 happy Dr Seminiano was best known by his family —N.G. Nair, MBBS, FRCPC years in the “Bavarian City of the Rockies” en- and friends as Lito. He was born on 23 May Langley joying wonderful friends and a marvelous out- 1947 in Donsol Sorsogon, Philippines. He com- —Shilpa C. Shete, MBBS, FRCPC door life. In 1971, Don arranged for a unique pleted his medical degree from the Far Eastern Langley and memorable 1-year practice exchange with University in the Philippines in 1972 and im- a physician in Bowral, Australia. migrated to Canada in 1979. Obituaries continued on page 400

BC Medical Journal vol. 61 no. 10 | december 2019 399 obituaries

of the California Optometric Association and acquired an interest in politics. He returned to Canada and became the chief of staff for federal cabinet minister, the Hon. Ronald (Ron) Bas- ford, and later become the first public relations manager for the Royal Bank in BC. In the early 1970s the BCMA was suf- fering attacks from both within and without the organization, and a decision was made to hire a public relations expert to regain public support for organized medicine and offset the government’s public relations offensive. The BCMA hired Jim in 1973 as its first director

of communications. Jim in his favorite deerstalker hat. Mr James (Jim) Edward Jim had a transformative impact on orga- Gilmore nized medicine during his 20-year tenure at the 1930–2019 BCMA. He convinced BCMA leaders that the Economics Department, was very effective in profession would get nowhere if it dedicated its improving the financial situation for BC doc- On 24 October 2019, the medical profession resources to reacting to crises whenever the gov- tors, and the payment schedule rose to become lost one of its most loyal and dedicated sup- ernment imposed its power against the profes- the highest in Canada on an overall basis and porters. Mr James Edward Gilmore, retired sion. Although individual British Columbians remained there throughout most of Jim’s 20 director of communications and one of the few (including politicians, bureaucrats, journalists, years as director of communications. non-physician honorary members of the BC academics, and others) had immense trust and In addition to the honorary membership Medical Association (as Doctors of BC was support for their own individual doctors, that bestowed upon him by the BCMA, Jim was formerly called) died at the age of 89 years in was not generally the case for doctors as a group. also given the Pat Memorial Award Victoria. Jim obtained BCMA budget support to estab- for his contributions to public relations by the Jim was born on 19 April 1930 in Vancouver, lish a superb Department of Communications Canadian Public Relations Society. Those in- where he lived most of his life. He is survived that developed ongoing campaigns demonstrat- terested in learning more about Jim’s storied by his sister (Gerry), two children (Tracy and ing to the public that organized medicine was career should read Dr Brad Fritz’s article in the Dan), three grandchildren, four great-grand- an important segment of society, particularly January/February 2017 issue of the BC Medical children, and a number of adopted children in the development of public policy for the Journal online at www.bcmj.org/special-feature/ from previous marriages. Jim’s career in the betterment of British Columbians. Jim’s multi­ mr-jim-gilmore%E2%80%94one-good-guys. communications industry began as copy boy faceted communication programs, both inter- Doctors of BC owes a great debt to Mr at the Province at age 15, and subsequently as nally and externally facing, became the envy of James Edward Gilmore. —Norman D. Finlayson, MD a sportswriter and columnist at the News Her- other medical associations across Canada and Former Executive Director, BCMA (1986–98) ald and Vancouver Sun. He branched out into outside Canada, winning many public relations —Dan Gilmore the public relations field as executive director awards. This strategy, along with the work of the

2019–20 Doctors of BC Board of Directors

President Director-at-Large General Practice Director-at-Large Specialist Dr Kathleen Ross Dr Adam Thompson Dr Barb Blumenauer President-Elect Director-at-Large General Practice Director-at-Large Specialist 1 year Dr Matthew Chow Dr Lawrence Welsh Dr Andrew Yu Board Chair Director-at-Large Specialist Director-at-Large Specialist Dr Jeff Dresselhuis Dr Lloyd Oppel Dr Sophia Wong

400 BC Medical Journal vol. 61 no. 10 | december 2019 GPSC

In-practice coaching and mentoring PSP supports for quality PSP Regional Support Teams (RST) and phy- sician peer mentors are available to guide prac- improvement activities: tices through a facilitation cycle that supports them in undertaking QI activities covered by the new compensation policy and new certifica- Refreshed compensation policy, tion process. The facilitation cycle can help prac- tices maximize efficiencies through activities simplified certification process like identifying changes in practice workflow, developing proactive patient recalls for common tests, and using data (including patient experi- he GPSC recognizes that doctors and Simplified certification process ence data) to inform practice improvements. health care team members invest sig- Effective 1 November 2019, PSP introduced For more information contact a PSP Re- nificant time to ensure that practices a simplified certification process to replace the gional Support Team (see box), or email psp@ n run smoothly and efficiently. As family practice existing process for PSP learning modules, PSP doctorsofbc.ca. T —Alana Godin teams expand, practices are increasingly focused small group learning sessions, and the GPSC Director, Community Practice and Quality, on quality improvement (QI) activities. To bet- patient medical home assessment (doctors cur- Doctors of BC ter support this work, the Practice Support Pro- rently participating in these services will not be gram (PSP) has updated how it compensates affected). The new process will offer more credits, and certifies family physicians and eligible team increased flexibility, and alignment with PSP’s PSP Regional Support Teams members who engage in eligible QI activities. updated compensation policy, detailed above. Fraser Health: [email protected] The process will enable family doctors to Interior Health: [email protected] Refreshed compensation policy earn up to three credits per hour, for up to 15 Northern Health: liana.doherty@ Based on physician feedback, PSP has refreshed hours (maximum of 45 Mainpro+ credits) for northernhealth.ca the way GPs and team members are compen- activities including in-practice visits with an Vancouver Coastal: [email protected] sated for QI activities. Effective 15 June 2019, RST or physician peer mentor, development Vancouver Island Health: [email protected] each eligible team member in a practice can and implementation of action plans, and par- receive compensation for up to 15 hours of ticipation in PSP’s learning sessions. work for participating in any eligible QI activity (for information on eligible and non-eligible QI activities visit www.gpscbc.ca/what-we-do/ professional-development/psp). Team members eligible for compensation for QI activities in- clude MOAs, allied health providers in private practice, and allied health providers employed by a GP practice. Team members who are em- Building Capacity ployed or compensated by a health authority Customized support to are ineligible. optimize family practices For increased efficiency, doctors can now submit one form to claim a sessional payment Through PSP, doctors can build practice capacity, practice more efficiently, for the hours spent on QI activities, and PSP focus more on clinical care and patient relationships, and adopt the attributes of the patient medical home in BC. team members are available to support doctors and practice teams to track their time through- PSP offers doctors and other practice team members: out the process. LEARNING OPPORTUNITIES COACHING AND MENTORING DATA TOOLS

This article is the opinion of the GPSC and has not been peer reviewed by the BCMJ Editorial Board.

Participating doctors are eligible for: BC Medical Journal vol. 61 no. 10 | december 2019 401 Compensation to recognize time spent on practice improvement activities.

Certification to acknowledge new or advanced skills and capabilities.

PSP is an initiative of the General Practice Services Committee (GPSC), one of four collaborative committees that represent a partnership of the BC Government and Doctors of BC. pspbc.ca cohp

processed foods; and Make strong statements Canada’s revolutionary new about restricting consumption of highly pro- cessed foods.”3 In this report the committee rec- food guide ommended that the Minister of Health revise the food guide on the guidance of an advisory body that “comprises experts in relevant areas arlier this year the federal government had become the nutritional backdrop for Cana- of study, including but not limited to nutri- released a revised and dramatically dif- dian society, informing the education of dieti- tion, medicine, , biochemistry, and ferent version of Canada’s Food Guide. tians and forging government policy. Although biology; and does not include representatives EThis is the ninth iteration of a document that it was heavily promoted and widely adopted, of the food or industries.” 3 Remark- has played a central role in informing what it was also increasingly criticized by health ably, the health minister acted on all of these health professionals, the media, and the gov- professionals and nutritional scientists who ex- recommendations, and the current Canada’s ernment tell Canadians about what foods to pressed concern about the heavy involvement of Food Guide gradually came to life. eat and how to eat it. Initially referred to as the agri-foods industry Based on the “healthy Canada’s Official Food Rules, the 1942 docu- in this pivotal document. eating plate” concept,4 ment was released during wartime rationing, Prior to the release of the Most of us on the the 2019 guide focuses and it was intended to prevent nutritional de- 2007 edition, this criticism front lines of obesity on eating whole, unpro- ficiencies and improve the health of Canadians. became palpable for what medicine consider the cessed foods, and has a The concept of food groups was introduced and was perceived by some as a large emphasis on healthy specific amounts of foods from each group were wholesale adoption of un- new food guide one of food behaviors like eating suggested for daily consumption. healthy, highly processed the premier triumphs mindfully, cooking from This information was promulgated through foods and beverages in of democracy, science, scratch at home, enjoy- the media and government publications, and the face of an emerging and common sense. ing wholesome food, and later editions were incorporated into school epidemic of obesity and eating meals with oth- curricula across the country. Limited amounts other diseases that were ers. Although it has been of processed foods were available before the heavily influenced by di- heavily criticized by the 1960s and consumption of whole grains and etary factors. In one CMAJ article, the 2007 food industry and a few health care profes- other whole foods were specifically encour- guide was referred to as an “obesogenic recipe sionals, most of us on the front lines of obe- aged through the food guide. The 1961 edition for dramatic increases in premature death.”1 sity medicine consider it one of the premier reflected the beginning of a revolution in food Yoni Freedhoff, a well-known obesity medicine triumphs of democracy, science, and common processing, storage, and transportation, and the physician, called it “Canada’s Food Guide to sense. In my practice, Canada’s Food Guide widespread availability of processed, canned, Unhealthy Eating.”2 and its many associated resources now play a and packaged convenience foods. The 1977 re- In the years leading up to the 2019 edition, central role in helping me guide patients toward vision was colorfully illustrated and brochure- influential elements of the government began an enjoyable diet based on real food, perhaps like. The involvement of stakeholders from the to recognize the need to promote major shifts for the first time in their lives.n food and agricultural industries in this edition in the diets of Canadians. The 2016 Senate —Michael Lyon, MD paralleled the dramatic shift in Canadians’ diets Standing Committee report, Obesity in Cana- toward more highly processed foods. da, stated that “Canada’s Food Guide has been References By 1992 the food guide was considered at best ineffective, and at worst enabling, with 1. Kondro W. Proposed Canada Food Guide called “obe- sogenic.” CMAJ 2006;174:605-606. the of nutrition, with 24 million copies respect to the rising levels of unhealthy weights 2. Weighty Matters. Canada’s food guide to unhealthy eat- 3 distributed nationwide. Canada’s Food Guide and diet-related chronic diseases in Canada.” ing. Accessed 5 November 2019. www.WeightyMatters The committee recommended that the Minister .ca/2006/11/-food-guide-to-unhealthy-eating of Health immediately undertake a complete .html. This article is the opinion of the Nutrition 3. Obesity in Canada. A whole-of-society approach for revision of the guide in order for it to better Committee, a subcommittee of Doctors a healthier Canada. Report of the Standing Commit- reflect the current state of scientific evidence: tee on Social Affairs, Science and Technology. March of BC’s Council on Health Promotion, and “The revised food guide must: Be evidence- 2016. Accessed 5 November 2019. https://sencanada.ca/ is not necessarily the opinion of Doctors based; Apply meal-based rather than nutrient- content/sen/committee/421/SOCI/Reports/2016-02 of BC. This article has not been peer -25_Revised_report_Obesity_in_Canada_e.pdf. based principles; Effectively and prominently reviewed by the BCMJ Editorial Board. 4. Harvard TH Chan School of Public Health. Healthy describe the benefits of fresh, whole foods com- eating plate. Accessed 5 November 2019. www.hsph pared to refined grains, ready-to-eat meals and .harvard.edu/nutritionsource/healthy-eating-plate.

402 BC Medical Journal vol. 61 no. 10 | december 2019 worKsafeBC

Workplace exposure to rabies

ccupations identified as high risk for Disease progression When a worker is exposed to a bite or rabies exposure and infection include The incubation period is usually 3 to 8 weeks, scratch of an infected source, rabies immu- veterinarians, animal control workers, although rarely can be as short as a few days to noglobulin is used to infiltrate the wound, Orabies diagnostic lab workers, spelunkers ex- as long as several years.2 After an initial period or to infiltrate the exposed area when a bite ploring caves, bat biologists and other wildlife of nonspecific symptoms such as fever, mal- or scratch cannot be ruled out. BC Centre biologists, pest control workers, and workers aise, or anxiety, frank neurological signs ranging for Disease Control has released new interim traveling to countries endemic for canine- from hyperactivity (encephalitis) to paralysis guidelines on postexposure prophylaxis and mediated rabies. While transmission to health appear before the person rabies immunoglobulin.2,9 care workers caring for a patient infected with Tetanus-diphtheria vac- lapses into a coma. Death The rabies virus is rabies has not been documented, theoretically typically occurs within 10 cine should also be up- transmission could occur through direct con- days from the onset of carried in the saliva dated as required. tact of broken skin or mucosa with saliva, tears, symptoms.2 and neural tissue of an If your patient suspects oropharyngeal secretions, cerebrospinal fluid, infected animal and they have been exposed to or neural tissue of an infected individual. Ra- Prevention can be transmitted to rabies at work, encourage bies is a reportable disease under the Canada For workers in occupa- them to file a claim with Food Inspection Agency (CFIA) Health of tions that are high risk humans via the animal’s WorkSafeBC. Providing Animals Act.1 for rabies infection, pre- bite or scratch, or all the relevant clinical in- exposure prophylaxis with through an individual’s formation on a Form 8/11 Causes rabies vaccine is recom- open wounds or is important to help your Rabies is a rare zoonotic disease caused by a mended, followed by a patient with their claim. mucus membranes. Lyssavirus of the Rhabdoviridae family. In booster dose in the event Canada, the disease is usually found in wild ani- of exposure.2,6 For assistance mals such as raccoons, skunks, bats, and foxes. For health care work- If you have questions Domesticated animals can become infected ers, routine precautions, including wearing about a workplace rabies exposure or claim, if they are bitten by an animal with rabies or gowns, goggles, masks, and gloves, are recom- please contact a medical advisor in Occupa- come in contact with its saliva. Canine rabies mended when providing care to persons sus- tional Disease Services at 604 231-8842 or in remains endemic in many countries. Globally, pected of having clinical rabies.8 In the event your nearest WorkSafeBC office, or call the n dog bites provide the greatest risk of rabies of an exposure, public health officials follow Medical Advisor Hotline at 1 855 476-3049. transmission.2-5 In BC, bats are the only known specific criteria to identify high-risk contacts —Geetha Raghukumar, MBBS, DLSHTM, MSc, reservoirs for the rabies virus.2 and provide postexposure prophylaxis.2,3 CIC, CCFP, FRCPC WorkSafeBC Medical Specialist, Occupational The rabies virus is carried in the saliva and Workers should seek immediate medical at- Disease Services neural tissue of an infected animal and can be tention if they suspect they have been exposed —Olivia Sampson, MD, CCFP, MPH, RCPSC transmitted to humans via the animal’s bite or to rabies. In BC, any worker who has had direct WorkSafeBC Manager of Clinical Services scratch, or through an individual’s open wounds contact with a bat should seek medical atten- or mucus membranes. While very rare, trans- tion, and the attending physician should call References mission via nonbite routes, such as airborne the local public health authority for guidance. 6 1. Canada Food Inspection Agency. Rabies in Canada. transmission from bat secretions or direct hu- Public health will conduct a risk assessment to Accessed 13 September 2019. www.inspection.gc.ca/ man-to-human transmission through organ determine whether rabies postexposure prophy- animals/terrestrial-animals/diseases/reportable/rabies/ transplants7 has been reported. laxis is indicated. rabies-in-canada/eng/1356156989919/1356157139999. 2. BC Centre for Disease Control. Rabies. Accessed 13 September 2019. www.bccdc.ca/resource-gallery/Doc Treatment uments/Guidelines%20and%20Forms/Guidelines% Postexposure prophylaxis for rabies includes 20and%20Manuals/Epid/CD%20Manual/Chapter% thorough wound washing, a series of rabies 201%20-%20CDC/BCRabiesGuidelines.pdf. 3. World Health Organization. Rabies. Accessed 13 Sep- This article is the opinion of WorkSafeBC vaccines, and where indicated, rabies immuno- 2 tember 2019. www.who.int/news-room/fact-sheets/ and has not been peer reviewed by the globulin (RIG). Given promptly, rabies post- detail/rabies. 3 BCMJ Editorial Board. exposure prophylaxis is effective. Continued on page 404

BC Medical Journal vol. 61 no. 10 | december 2019 403 CME calendar Rates: $75 for up to 1000 characters (maximum), plus GST per month; there is no partial rate. If the course or event is over before an issue of the BCMJ comes out, there is no discount. Deadlines: Online: Every Thursday (listings are posted every Friday). Print: The first of the month 1 month prior to the issue in which you want your notice to appear, e.g., 1 February for the March issue. The BCMJ is distributed by second-class mail in the second week of each month except January and August. Planning your CME listing: Advertising your CME event several months in advance can help improve attendance; we suggest that your ad be posted 2 to 4 months prior to the event. Ordering: Place your ad at www.bcmj.org/cme-advertising. You will be invoiced upon publication. Payment is accepted by Visa or MasterCard on our secure online payment site.

CME ON THE RUN cancer center where their patients are referred. Physician Retreat, 24–29 May, VGH and various videoconference These can be scheduled flexibly over 6 months. Holly­hock, Cortes Island. Physician Heal Thy- locations, 31 Jan–5 Jun (Fri) Participants who complete the program are self workshops focus on the theory and practice eligible for credits from the College of Family of mindfulness and meditation—reviewing def- CME on the Run sessions are held at the Paet- Physicians of Canada. Those who are REAP- initions, clinical evidence, and neuroscience, and zold Lecture Theatre, Vancouver General Hos- eligible receive a stipend and expense coverage introducing key practices of self-compassion, pital and there are opportunities to participate through UBC’s Enhanced Skills Program. For breath work, and sitting meditation to nurture via videoconference from various hospital sites. more information or to apply, visit www.fpon. resilience and healing. This annual meditation Each program runs on Friday afternoons from ca, or contact Jennifer Wolfe at 604 219-9579. retreat is an opportunity to delve deeply into 1–5 p.m. and includes great speakers and learn- meditation practice in order to recharge, heal, ing materials. Dates and topics: 31 Jan (Psy- MINDFULNESS IN MEDICINE WORKSHOPS and build a practice for life. Each workshop chiatry). Topics include: Bipolar II update on AND RETREATS is accredited for 16 Mainpro+ group learn- treatment; When too much becomes a Cortes Island, 24–29 May (Sun–Fri) ing credits and has a 30 person limit, so please problem; Adult ADD diagnosis and manage- register today! Contact us at hello@livingthis ment; Where are we with ? Join Dr Mark Sherman and your community moment.ca, or check out www.livingthis The good, the bad, and the ugly; Sleepless- of colleagues for a transformative retreat! A moment.ca/event for more information. ness beyond the ; Smoking addiction: How can we do better?; Adjunctive therapies for depression; Counseling on cannabis and Doctors worksafebc Continued from page 403 the implications on the developing brain. The Helping next sessions are: 3 Apr (infectious disease and 4. Fooks AR, Cliquet F, Finke, S, et al. Rabies. Nat Rev Dis travel); 1 May (prenatal, pediatric, and adoles- Doctors Primers 3, 17092 (2017). 5. Murphy J, Sifri C, Pruitt R, et al. Human Rabies – Virginia, cents); 5 Jun (internal medicine). To register 24 hrs/day, 2017. MMWR Morb Mortal Wkly Rep 2019;67:1410-1414. and for more information visit ubccpd.ca, call 7 days/week 6. WorkSafeBC. Rabies. Accessed 13 September 2019. 604 675-3777 or e-mail [email protected]. www.worksafebc.com/en/health-safety/ -diseases/infectious-diseases/types/rabies. The Physician GP IN ONCOLOGY TRAINING 7. Vora NM, Basavaraju SV, Feldman KA, et al. Raccoon Health Program of rabies virus variant transmission through solid organ Vancouver, 3–14 Feb (Mon–Fri) British Columbia offers transplantation. JAMA 2013;310:398-407. The BC Cancer’s Family Practice Oncology help 24/7 to B.C. doctors 8. Provincial Infection Control Network of British Colum- bia. Routine practices and additional precautions for Network offers an 8-week General Practitio- and their families for a wide range of preventing the transmission of infection in healthcare ner in Oncology training program beginning personal and professional problems: settings. PHAC 2013. P.117. www.picnet.ca/wp-content/ with a 2-week introductory session every spring physical, psychological and social. uploads/PHAC_Routine_Practices_and_Additional and fall at the Vancouver Centre. This program If something is on your mind, give _Precautions_2013.pdf. provides an opportunity for rural family physi- us a call at 1-800-663-6729 or visit 9. BC Centre for Disease Control. Interim direction for the use of rabies vaccine for post exposure prophy- cians, with the support of their community, to www.physicianhealth.com. laxis in BC. Accessed 13 September 2019. www.bccdc strengthen their oncology skills so that they .ca/resource-gallery/Documents/Guidelines%20and% may provide enhanced care for local cancer 20Forms/Guidelines%20and%20Manuals/Epid/CD% patients and their families. Following the intro- 20Manual/Chapter%201%20-%20CDC/InterimRabies VaccineRPEPGuidelines.pdf. ductory session, participants complete a further 30 days of customized clinic experience at the

404 BC Medical Journal vol. 61 no. 10 | december 2019 Classifieds Advertisements are limited to 700 characters. Rates: Doctors of BC members: $50 + GST per month for each insertion of up to 350 characters. $75 + GST for insertions of 351 to 700 characters. Nonmembers: $60 + GST per month for each insertion of up to 350 characters. $90 + GST for insertions of 351 to 700 characters. Deadlines: Ads must be submitted or canceled by the first of the month preceding the month of publication, e.g., by 1 November for December publication. Visit www.bcmj.org/classified-advertising for more information. Ordering: Place your classified ad online at www.bcmj.org/classified -advertising. Payment is required at the time that you place the ad.

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BC Medical Journal vol. 61 no. 10 | december 2019 405 Classifieds

SOUTH SURREY/WHITE BC, and surrounding area. Sleep Mediterranean coast. Come and UBC—RE-ENTRY RESIDENCY ROCK—FP POSITION, DERMATOLOGY medicine experience not required enjoy the sun of southern Busy family/walk-in practice in as training is provided. Excellent France! 604 522-5196. The University of British South Surrey requires GP to support is provided with a [email protected]. Columbia Department of build family practice. The physician assistant and capable, Dermatology and Skin Science miscellaneous community is growing rapidly friendly staff. Remuneration has a re-entry residency position and there is great need for family includes billing for consults and in dermatology, commencing 1 CANADA-WIDE—MED physicians. Close to beaches and July 2020 for a PGY3. This polysomnogram interpretations. TRANSCRIPTION recreational areas of Metro Minimal on call. For more re-entry dermatology residency Vancouver. 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P 604 638 7921 TF 1 800 665 2262 ext 7921 E [email protected] doctorsofbc.ca/club-mdBC Medical Journal vol. 61 no. 10 | december 2019 407 Building Capacity Customized support to optimize family practices Through PSP, doctors can build practice capacity, practice more efficiently, focus more on clinical care and patient relationships, and adopt the attributes of the patient medical home in BC.

PSP offers doctors and other practice team members:

LEARNING OPPORTUNITIES COACHING AND MENTORING DATA TOOLS

Participating doctors are eligible for:

Compensation to recognize time spent on practice improvement activities.

Certification to acknowledge new or advanced skills and capabilities.

PSP is an initiative of the General Practice Services Committee (GPSC), one of four joint collaborative committees that represent a partnership of the BC Government and Doctors of BC. pspbc.ca 408 BC Medical Journal vol. 61 no. 10 | december 2019