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Background: Developing leaders is a critically important activity, especially in cancer services that depend on strong advocates for funding or sustained leadership of organisations. Many global think tanks have warned us about a crisis occurring in leadership. This crisis is not related simply to a lack of leaders, but probably secondary to a lack of competencies in leaders. This distinction allows us to ask whether it would be important to develop skills that will improve the quality of leadership in the future. The author postulates that competencies that will change this perception can be taught. Aim: To show the distinction between leadership competencies considered important, and a potential mechanism for how organisations can drive succession planning. Setting: Every cancer organisation needs leaders. Methods: This article argues that the most important ingredient to impact the pace of change will be the ability to develop and sustain strong leadership. By reviewing current literature it describes what leadership is, and the competencies required to succeed at this. The experience gained by implementing a development unit in Calgary is used to suggest strategies needed by other cancer organisations. Results: Leadership competencies can be taught. The local development unit has demonstrated that a formative approach can be implemented to engage emerging, mid-career and senior leaders. The article suggests practical strategies that will facilitate development of strong academic leaders. Conclusion: Unless leaders are developed, it is quite possible that the momentum for healthy growth of cancer services will be stalled.

BackgroundTwo new cancer centers providing radiation therapy opened in Alberta, Canada, in 2010 and 2013, respectively. We aimed to assess whether opening the new RT centers influenced mastectomy rates for breast cancer.MethodBreast cancer patients who underwent surgery from 2004 through 2015 were identified from the Alberta Cancer Registry. Mastectomy rates for 64 predefined health status areas (HSAs) were calculated after adjusting for patient and system factors. Variations in mastectomy rates among the HSAs were quantified using weighted coefficient of variation (CV). Multivariable logistic regressions were performed to determine associations between driving time and mastectomy use in the entire cohort and in subgroups.ResultsOf the 21,872 patients, the proportion of patients who lived a ≤ 60 min drive from the nearest RT center significantly increased from 68.8% (95% CI 67.7–69.9%) to 80.7% (95% CI 79.5–81.9%) during the study period. Concurrently, the crude provincial mastectomy rate decreased from 56.2% (95% CI 55.3–57.1%) to 45.3% (95% CI 44.1–46.5%). However, variation in adjusted mastectomy rates (weighted CV) across the 64 HSAs increased from 9.5 to 14.6. Factors associated with mastectomy included age, larger tumor size, lymph node involvement, higher tumor grade, molecular subtype, lobular histology type, more comorbidities, academic institution, region, earlier period of diagnosis, and longer driving time to the nearest RT center.ConclusionsOpening new RT centers in previously underserved regions reduced driving times to the nearest center, and was associated with a reduction in mastectomy rates; however, these reductions among regions across the province were not uniform.

Aims Treatment of brain metastases patients has included whole brain radiotherapy (WBRT) for over 50 years, and there is much data showing this to be associated with short-term gains. The integration of resection and radiosurgery to these patients allows some better prognostic groups to experience long-term local control and improvement in quality of life. The recursive partitioning analysis of the Radiation Therapy Oncology Group (RTOG) has been used as a predictive model for over a decade to identify three classes of patients. Number of lesions has been used to define treatment for a good prognostic subgroup that is eligible for surgery or radiosurgery, but there are few prospective studies of poorer prognosis brain metastases patients to evaluate the influence of number of lesions on the prediction of outcome. We examined patient, treatment and outcome parameters of all brain metastases patients in a 5-year period so that we could measure outcome and evaluate various factors on survival. Methods and results This was a population-based study of all brain metastases patients in Southern Alberta between 2000 and 2005. It used an Excel spreadsheet database and STATA 8 software to analyze outcomes. The study included 568 patients representing 4.4% of our radiotherapy population. Median age, performance status and distribution of primary disease sites were comparable with other large series. Overall survival for the whole group was 3.05 months. Independent factors predicting for improved overall survival included younger age, KPS <70, less than four lesions and the use of stereotactic radiosurgery. Presence of extracranial disease or persistence of primary disease did not adversely impact survival outcome. Conclusions This series shows that the number of lesions is a strong predictor of outcome. Integration of this factor into a decision-making model allows for identification of not only good prognosis patients who will benefit from aggressive treatment but it also facilitates decision making for poorer prognosis patients who are less likely to benefit from WBRT. Recursive partitioning RTOG class 2 and 3 patients with more than three lesions did particularly poor and had an overall survival of 3 months with WBRT. We question the value of WBRT in this subgroup and wonder if best supportive care would be more justifiable given the low survival figures achieved.

Women with breast cancer who are undergoing breast-conserving surgery were assigned to receive whole-breast irradiation with or without regional nodal irradiation. At 10 years, disease-free survival in the nodal-irradiation group was improved but overall survival was not. Many women with early-stage breast cancer undergo breast-conserving surgery followed by whole-breast irradiation, which reduces the rate of local recurrence. 1 – 3 Radiotherapy to the chest wall and regional lymph nodes, termed regional nodal irradiation, which is commonly used after mastectomy in women with node-positive breast cancer who are treated with adjuvant systemic therapy, reduces locoregional and distant recurrence and improves overall survival. 4 – 6 An unanswered question is whether the addition of regional nodal irradiation to whole-breast irradiation after breast-conserving surgery has the same effect. Whole-breast irradiation may involve irradiation of the lower axillary and internal mammary lymph nodes. 7 However, regional . . .

Purpose This study sought to identify the barriers and enablers to leadership enactment in academic health-care settings. Design/methodology/approach Semi-structured interviews (n = 77) with programme stakeholders (medical school trainees, university leaders, clinical leaders, medical scientists and directors external to the medical school) were conducted, and the responses content-analysed. Findings Both contextual and individual factors were identified as playing a role in affecting academic health leadership enactment that has an impact on programme development, success and maintenance. Contextual factors included sufficient resources allocated to the programme, opportunities for learners to practise leadership skills, a competent team around the leader once that person is in place, clear expectations for the leader and a culture that fosters open communication. Contextual barriers included highly bureaucratic structures, fear-of-failure and non-trusting cultures and inappropriate performance systems. Programmes were advised to select participants based on self-awareness, strong communication skills and an innovative thinking style. Filling specific knowledge and skill gaps, particularly for those not trained in medical school, was viewed as essential. Ineffective decision-making styles and tendencies to get involved in day-to-day activities were barriers to the development of academic health leaders. Originality/value Programmes designed to develop academic health-care leaders will be most effective if they develop leadership at all levels; ensure that the organisation’s culture, structure and processes reinforce positive leadership practices; and recognise the critical role of teams in supporting its leaders.

Uterine papillary serous carcinoma (UPSC) affects 1% to 10% of patients with endometrial malignancies. UPSC is more aggressive than conventional endometrial cancer because UPSC presents with advanced disease, similar to epithelial ovarian cancer. There are several biomarkers for UPSC, which indicate that the pathogenesis of this condition is different than epithelial ovarian and conventional endometrial cancer. There are no risk factors for UPSC. Extended surgical staging is the optimal surgical approach for patients without known distant metastases. Patients with stage IA disease do not benefit from further adjuvant therapy. Adjuvant pelvic radiotherapy reduces pelvic relapse in intermediate- and high-risk patients (stage IC, II, and III disease) and extends survival rates of patients when administered with chemotherapy. In this setting, chemotherapy (with or without adjuvant radiotherapy) is a platinum-based regimen, combined with doxorubicin and cyclophosphamide. A newer regimen is paclitaxel, with or without platinum. An alternative approach for treating patients with UPSC has been to use whole abdominal radiotherapy. The results of Gynecologic Oncology Group protocol 122, which involves patients with UPSC who are being treated with chemotherapy and whole abdominal radiotherapy, are expected to reveal a minimal difference between these arms in overall survival rates. In patients experiencing distant or extensive abdominal relapse, management has been palliative, using platinum-based regimens or single-agent therapy to assess response. Treatment for patients with further relapse must be individualized because there are no studies addressing these scenarios. Palliative radiotherapy should be offered to patients needing symptom control for metastatic or progressive local disease. Many of these patients face a significant risk of treatment failure and death because of distant relapse. Therefore, the use of randomized trials to evaluate new therapies is critical.

The report by John Williams1 on ethics and human rights in South African medicine in this issue (see nape 1167) is a good reminder to all of us who practise medicine that we are accountable to the communities we claim to be responsible for. Williams outlines the many serious failings of the professional organizations and individual physicians who practised during apartheid. These include the provision of inferior health care to nonwhite South Africans by way of reduced funding and compromised access to care, the involvement of physicians in practices that harmed \"enemies\" of the government and the failure of the medical profession to oppose unethical policies of the government. Williams also describes the transformation of the country's medical organizations since apartheid was dismantled and the steps being taken to integrate the teaching of ethics into medical education programs. Since the cornerstone of Canadian medicare is the provision of high quality care for all citizens regardless of race, culture, language or religion, we might assume that as far as medical ethics goes all is well in this country. In fact, there is much in Williams' report to challenge our complacency.

Purpose This study sought to identify the barriers and enablers to leadership enactment in academic health-care settings. Design/methodology/approach Semi-structured interviews (n = 77) with programme stakeholders (medical school trainees, university leaders, clinical leaders, medical scientists and directors external to the medical school) were conducted, and the responses content-analysed. Findings Both contextual and individual factors were identified as playing a role in affecting academic health leadership enactment that has an impact on programme development, success and maintenance. Contextual factors included sufficient resources allocated to the programme, opportunities for learners to practise leadership skills, a competent team around the leader once that person is in place, clear expectations for the leader and a culture that fosters open communication. Contextual barriers included highly bureaucratic structures, fear-of-failure and non-trusting cultures and inappropriate performance systems. Programmes were advised to select participants based on self-awareness, strong communication skills and an innovative thinking style. Filling specific knowledge and skill gaps, particularly for those not trained in medical school, was viewed as essential. Ineffective decision-making styles and tendencies to get involved in day-to-day activities were barriers to the development of academic health leaders. Originality/value Programmes designed to develop academic health-care leaders will be most effective if they develop leadership at all levels; ensure that the organisation's culture, structure and processes reinforce positive leadership practices; and recognise the critical role of teams in supporting its leaders.

The TBCC responded by moving some functions off site, because there was no available expansion space at Foothills Hospital. Since 2003, we have completed two phases of renovations in leased space at the Holy Cross Hospital, and the space we are currently renovating will allow us to expand treatment facilities at the Tom Baker site, so we can sustain our comprehensive service to cancer patients for southern Alberta for at least another three years.