Highlights

doi:10.1503/cmaj.160133

Off-label use of domperidone to stimulate lactation

Domperidone increases prolactin levels, and its use to stimulate lactation was first described 30 years ago. However, it has not been approved for this indication in Canada. In this retrospective cohort study that used administrative data, researchers looked at off-label use of domperidone to stimulate milk production in mothers with low milk supply. All women (n = 225 532) who had a live birth from 2002 to 2011 in British Columbia were included. The prevalence of postpartum prescription of domperidone more than doubled during the study period, from 8% to 19% for full-term births and 17% to 32% for preterm births. By the end of the study period, 1 in 3 women with a preterm birth and 1 in 5 women with a full-term birth filled a prescription for the medication during the first 6 months after giving birth (Figure 1). Women who were older, had a higher body mass index, had a chronic disease, had a multiple pregnancy, had a preterm birth or had a cesarean delivery were more likely to fill a prescription for domperidone. Prescribed doses and duration of treatment also increased over the study period. Most prescriptions (92%) were written by primary care physicians. Although the trends seen in this study likely reflect an increase in the rate of exclusive breastfeeding seen in BC during the study period (from 28% to 41%), the authors caution that more research is needed on maternal and infant health outcomes related to domperidone use. CMAJ Open 2016;4:E13-9.

Figure 1:

Domperidone use in the first 6 months postpartum among women in British Columbia with live births.

How do surgeons decide which patients with cancer are referred to oncology services?

For patients diagnosed with early stage non–small-cell lung cancer, breast cancer or colorectal cancer, surgical resection is the primary treatment, with adjuvant therapies (e.g., chemotherapy, radiotherapy) recommended according to disease stage. Although treatment strategies for these cancers are relatively standardized in this patient group, referral rates to and receipt of oncology services vary across Canada. In Nova Scotia, for example, research has shown that 20% to 33% of patients with potentially curable non–small-cell lung cancer or colorectal cancer were not referred for an oncology consultation. This qualitative study, guided by grounded theory, examined decision-making around referral to oncology services by 29 surgeons in Nova Scotia. Seven factors influenced these surgeons’ decision-making: indications and contraindications for therapy; patients’ beliefs and preferences; a belief that oncologists are the experts; knowledge of local standards of care; consultation with oncology colleagues; navigating patient logistics (e.g., lodging, caregiving responsibilities, insurance coverage); and system resources and capacity (Figure 2). These findings point to potential areas for interventions promoting oncology referral for patients for whom adjuvant therapy is recommended by practice guidelines, say the authors. CMAJ Open 2016;4:E7-12.

Figure 2:

Factors influencing surgeons’ decision-making related to referral of patients with potentially curable cancer (non–small-cell lung, breast or colorectal cancer) to oncology services for consideration of adjuvant therapy. The degree of influence depends on decisional proximity.