Research Highlights
Gender
One of Prof Baxter’s earliest publications was on the topic of what is the impact of gender on the choice of surgery as a career. A survey was sent out 245 fourth-year medical students at the University of Toronto to examine what factors affected their career choice and had a 69% return rate. The results of this survey were that males (27%) were more likely to choose a surgical career than females (10%). The study found that fewer females than males were found to consider or choose a surgical career, possibly due to differences in qualities of importance in specialties, availability of role models and exposure through electives (Baxter NN, et al. The impact of gender on the choice of surgery as a career. Am J Surg. 1996).
In 2016 two studies were conducted of exploring women in academic surgery and their career advancement, family planning, mentorship, discrimination and career satisfaction (Seemann N, et al. Women in Academic Surgery: Why is the Playing Field Still Not Level? Am J Surg 2016 and Webster F, et al. The erasure of gender in academic surgery: a qualitative study. Am J Surg. 2016). This study suggested that women in academic surgery are satisfied with their career choice; they seem to face unnecessary challenges based on their gender. These included difficulties with balancing family and lifestyle responsibilities, discrimination and lack of other women surgeons to act as mentors.
Dr. Baxter then was involved in a study that looked at the perceptions and experiences of a gender gap at a Canadian research institute. The institute included 30.1% women and 69.9% men, indicating a 39.8% gender gap. A total of 95% of the basic scientists were men. Interview participants identified strategies to address this gap, such as establishing transparent search processes, providing opportunities for informal networking and mentorship of female scientists and establishing institutional support for work-life balance (Mascarenhas A, et al. Perceptions and experiences of a gender gap at a Canadian research institute and potential strategies to mitigate this gap, a mixed-methods study. CMAJ Open. 2017).
Her most recent work involved examining sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario comparing the earnings per hour spent operating between male and female surgeons and earnings stratified by surgical specialty in a matched analysis. The study analyzed data from more than 1.5 million surgical procedures claimed by 3, 275 Ontario surgeons from 2014 – 2016 and showed that the hourly earnings of female surgeons were 24% lower than for male surgeons even within a fee-for-service system (Dossa F, et al. Sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario, Canada. JAMA Surg. 2019). A follow up study was then completed with an analysis of nearly 40 million referrals to surgeons and found that male physicians referred a greater proportion of patients to male surgeons, leading to lower volumes and fewer operative referrals to female surgeons. Female physicians were less influenced by surgeon sex when making referral decisions (Dossa F, et al. Sex differences in the pattern of patient referrals to male and female surgeons. JAMA Surg. 2021).
Oncofertility
Prof Baxter has created the first Canadian oncofertility decision aid (DA) Begin Exploring Fertility Options, Risks and Expectations (BEFORE). This decision aid aims (1) to provide information to young breast cancer patients on the available fertility options prior to treatment that may cause infertility in survivorship; (2) to assist young breast cancer patients in making fertility-related decisions that align with their values; and (3) to act as an adjunct to consultation and help young breast cancer patients and health care providers to discuss treatment-related fertility risks and make fertility preservation decisions more effectively. (The "Begin Exploring Fertility Options, Risks and Expectations" (BEFORE) decision aid: development and alpha testing of a fertility tool for premenopausal breast cancer patients. BMC Med Inform Decis Mak. 2019 Oct 28;19(1):203). This work was then expanded and developed ehealth apps to facilitate, support & enhance the quality of shared oncofertility decision making of Canadian men & women at risk of infertility related to cancer treatment.
Adolescents and Young Adults with Cancer
Prof Baxter led the creation of the IMPACT cohort which includes all Ontario (AYA) aged 15-21 years diagnosed between 1992-2011 with any of the 6 targeted malignancy types (bone & soft tissue sarcomas, leukemia, Hodgkin’s & non-Hodgkin’s lymphomas, testicular cancer). This cohort helps determine which factors influence where AYA receive care, the impact of locus of care on the types & intensity of cancer therapy, appropriateness of surveillance for disease recurrence, access to clinical trials & receipt of palliative & survivor care. This data platform is a permanent resource housed at the IC/ES available to other investigators with an interest in AYA cancer (The Initiative to Maximize Progress in Adolescent and Young Adult Cancer Therapy (IMPACT) Cohort Study: A population-based cohort of young Canadians with cancer. BMC Cancer. 2014 Nov;14:805).
Cancer Survivorship
In these studies below Prof Baxter evaluated the long-term consequences of cancer care on cancer survivors. The studies found that men who undergo radiation for prostate cancer have nearly double the risk of rectal cancer than men who undergo surgery only. This has implications for patient counselling and surveillance. They also identified an increased risk of pelvic fracture after irradiation for pelvic malignancies in older female survivors. This has substantial implications for patients and is likely to influence treatment in terms of osteoporosis and fracture prevention in this at risk group.
Quality of Surgical Care
Prof Baxter has used IC/ES (Institute of Clinical Evaluative Sciences) data for two landmark studies evaluating the relationship between surgical care & outcomes. The 1st study (Introduction of surgical safety checklists in Ontario, Canada. NEJM 2014 Mar; 370(11):1029) looked at the outcomes of surgical procedures 3 months before & 3 months after the adoption of surgical safety checklists at 101 hospitals in Ontario. In contrast to other studies, this population-based study showed no significant reduction in operative mortality after checklist implementation.
The 2nd study (Outcomes of daytime procedures performed by attending surgeons after night work. NEJM 2015 Aug; 373(9):845) examined the effect of medical care provided by physicians after midnight on the outcomes of their scheduled elective procedures performed during the day. This study included 38,978 patients, treated by 1448 physicians. The study found no significant difference in the primary outcomes (death, readmission or complication) between patients who underwent a daytime procedure performed by a physician who had provided patient care after midnight & those who underwent a procedure performed by a physician who had not treated patients after midnight.
Evaluating the effectiveness of cancer screening
Prof Baxter has established expertise in the evaluation of cancer screening with a reputation for “out of the box thinking”. With the Canadian Task Force on Preventative Health Care, she conducted a systematic review of the literature regarding the effectiveness of breast self-examination and produced guidelines recommending against the routine teaching of breast self-examination – the systematic review found that routine teaching of breast self-examination did not improve survival from breast cancer but was associated with an increased number of physician visits and benign breast biopsies. The guidelines generated marked controversy at the time of publication, but the conclusions have gained widespread acceptance and have helped lead to a change in Canadian recommendations for breast cancer screening.
Pro Baxter has also published a series of studies evaluating the relationship between colonoscopy and CRC mortality, including the first case-control study demonstrating an association between colonoscopy and CRC mortality. Importantly, these studies have established the impact of colonoscopy is greater for prevention of distal colon/rectal vs. proximal CRC mortality. The variable effectiveness of colonoscopy is now the emphasis of much research and has focused researchers, clinicians, policy makers and the public on quality improvement in endoscopy worldwide.
Her work evaluating patterns of care in lymph node dissection for cancer identified important care gaps, resulted in adoption of lymph node count as a quality metric, and provided insight into the complex relationship between lymph node count and cancer outcomes.
Gender
One of Prof Baxter’s earliest publications was on the topic of what is the impact of gender on the choice of surgery as a career. A survey was sent out 245 fourth-year medical students at the University of Toronto to examine what factors affected their career choice and had a 69% return rate. The results of this survey were that males (27%) were more likely to choose a surgical career than females (10%). The study found that fewer females than males were found to consider or choose a surgical career, possibly due to differences in qualities of importance in specialties, availability of role models and exposure through electives (Baxter NN, et al. The impact of gender on the choice of surgery as a career. Am J Surg. 1996).
In 2016 two studies were conducted of exploring women in academic surgery and their career advancement, family planning, mentorship, discrimination and career satisfaction (Seemann N, et al. Women in Academic Surgery: Why is the Playing Field Still Not Level? Am J Surg 2016 and Webster F, et al. The erasure of gender in academic surgery: a qualitative study. Am J Surg. 2016). This study suggested that women in academic surgery are satisfied with their career choice; they seem to face unnecessary challenges based on their gender. These included difficulties with balancing family and lifestyle responsibilities, discrimination and lack of other women surgeons to act as mentors.
Dr. Baxter then was involved in a study that looked at the perceptions and experiences of a gender gap at a Canadian research institute. The institute included 30.1% women and 69.9% men, indicating a 39.8% gender gap. A total of 95% of the basic scientists were men. Interview participants identified strategies to address this gap, such as establishing transparent search processes, providing opportunities for informal networking and mentorship of female scientists and establishing institutional support for work-life balance (Mascarenhas A, et al. Perceptions and experiences of a gender gap at a Canadian research institute and potential strategies to mitigate this gap, a mixed-methods study. CMAJ Open. 2017).
Her most recent work involved examining sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario comparing the earnings per hour spent operating between male and female surgeons and earnings stratified by surgical specialty in a matched analysis. The study analyzed data from more than 1.5 million surgical procedures claimed by 3, 275 Ontario surgeons from 2014 – 2016 and showed that the hourly earnings of female surgeons were 24% lower than for male surgeons even within a fee-for-service system (Dossa F, et al. Sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario, Canada. JAMA Surg. 2019). A follow up study was then completed with an analysis of nearly 40 million referrals to surgeons and found that male physicians referred a greater proportion of patients to male surgeons, leading to lower volumes and fewer operative referrals to female surgeons. Female physicians were less influenced by surgeon sex when making referral decisions (Dossa F, et al. Sex differences in the pattern of patient referrals to male and female surgeons. JAMA Surg. 2021).
Oncofertility
Prof Baxter has created the first Canadian oncofertility decision aid (DA) Begin Exploring Fertility Options, Risks and Expectations (BEFORE). This decision aid aims (1) to provide information to young breast cancer patients on the available fertility options prior to treatment that may cause infertility in survivorship; (2) to assist young breast cancer patients in making fertility-related decisions that align with their values; and (3) to act as an adjunct to consultation and help young breast cancer patients and health care providers to discuss treatment-related fertility risks and make fertility preservation decisions more effectively. (The "Begin Exploring Fertility Options, Risks and Expectations" (BEFORE) decision aid: development and alpha testing of a fertility tool for premenopausal breast cancer patients. BMC Med Inform Decis Mak. 2019 Oct 28;19(1):203). This work was then expanded and developed ehealth apps to facilitate, support & enhance the quality of shared oncofertility decision making of Canadian men & women at risk of infertility related to cancer treatment.
Adolescents and Young Adults with Cancer
Prof Baxter led the creation of the IMPACT cohort which includes all Ontario (AYA) aged 15-21 years diagnosed between 1992-2011 with any of the 6 targeted malignancy types (bone & soft tissue sarcomas, leukemia, Hodgkin’s & non-Hodgkin’s lymphomas, testicular cancer). This cohort helps determine which factors influence where AYA receive care, the impact of locus of care on the types & intensity of cancer therapy, appropriateness of surveillance for disease recurrence, access to clinical trials & receipt of palliative & survivor care. This data platform is a permanent resource housed at the IC/ES available to other investigators with an interest in AYA cancer (The Initiative to Maximize Progress in Adolescent and Young Adult Cancer Therapy (IMPACT) Cohort Study: A population-based cohort of young Canadians with cancer. BMC Cancer. 2014 Nov;14:805).
Cancer Survivorship
In these studies below Prof Baxter evaluated the long-term consequences of cancer care on cancer survivors. The studies found that men who undergo radiation for prostate cancer have nearly double the risk of rectal cancer than men who undergo surgery only. This has implications for patient counselling and surveillance. They also identified an increased risk of pelvic fracture after irradiation for pelvic malignancies in older female survivors. This has substantial implications for patients and is likely to influence treatment in terms of osteoporosis and fracture prevention in this at risk group.
- Baxter NN, Durham SB, Phillips KA, Habermann E, Virnig BA. Risk of Dementia in Older Breast Cancer Survivors: A Population-Based Cohort Study of the Association with Adjuvant Chemotherapy. J Am Geriatr Soc 2009; 57:403-11.
- Baxter NN, Hartman LK, Tepper JE, Ricciardi R, Durham SB, Virnig BA. Postoperative irradiation for rectal cancer increases the risk of small bowel obstruction with surgery. Ann Surg 2007; 245:553-9.
- Baxter NN, Durham SB, Tepper J, Virnig BA. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology 2005; 128:819-24.
- Baxter NN, Habermann E, Tepper JE, Durham SB, Virnig BA. Risk of Pelvic Fracture in Older Women following Pelvic Irradiation. JAMA 2005; 294:2587-93.
Quality of Surgical Care
Prof Baxter has used IC/ES (Institute of Clinical Evaluative Sciences) data for two landmark studies evaluating the relationship between surgical care & outcomes. The 1st study (Introduction of surgical safety checklists in Ontario, Canada. NEJM 2014 Mar; 370(11):1029) looked at the outcomes of surgical procedures 3 months before & 3 months after the adoption of surgical safety checklists at 101 hospitals in Ontario. In contrast to other studies, this population-based study showed no significant reduction in operative mortality after checklist implementation.
The 2nd study (Outcomes of daytime procedures performed by attending surgeons after night work. NEJM 2015 Aug; 373(9):845) examined the effect of medical care provided by physicians after midnight on the outcomes of their scheduled elective procedures performed during the day. This study included 38,978 patients, treated by 1448 physicians. The study found no significant difference in the primary outcomes (death, readmission or complication) between patients who underwent a daytime procedure performed by a physician who had provided patient care after midnight & those who underwent a procedure performed by a physician who had not treated patients after midnight.
Evaluating the effectiveness of cancer screening
Prof Baxter has established expertise in the evaluation of cancer screening with a reputation for “out of the box thinking”. With the Canadian Task Force on Preventative Health Care, she conducted a systematic review of the literature regarding the effectiveness of breast self-examination and produced guidelines recommending against the routine teaching of breast self-examination – the systematic review found that routine teaching of breast self-examination did not improve survival from breast cancer but was associated with an increased number of physician visits and benign breast biopsies. The guidelines generated marked controversy at the time of publication, but the conclusions have gained widespread acceptance and have helped lead to a change in Canadian recommendations for breast cancer screening.
Pro Baxter has also published a series of studies evaluating the relationship between colonoscopy and CRC mortality, including the first case-control study demonstrating an association between colonoscopy and CRC mortality. Importantly, these studies have established the impact of colonoscopy is greater for prevention of distal colon/rectal vs. proximal CRC mortality. The variable effectiveness of colonoscopy is now the emphasis of much research and has focused researchers, clinicians, policy makers and the public on quality improvement in endoscopy worldwide.
Her work evaluating patterns of care in lymph node dissection for cancer identified important care gaps, resulted in adoption of lymph node count as a quality metric, and provided insight into the complex relationship between lymph node count and cancer outcomes.
- Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L. Association of Colonoscopy and Death from Colorectal Cancer: A Population-Based, Case–Control Study. Ann Intern Med 2009; 150:1-8.
- Jacob BJ, Moineddin R, Sutradhar S, Baxter NN, Urbach DR. Effect of colonoscopy on colorectal cancer incidence and mortality: an instrumental variable analysis. Gastrointest Endosc. 2012 Aug;76(2):355-364.
- Baxter NN, Warren JL, Barrett MJ, Stukel TA, Doria-Rose VP. Association of Colonoscopy and Colorectal Cancer Mortality in a US Cohort According to Site of Cancer and Colonoscopist Specialty. J Clin Onc 2012 Jul 20;30(21):2664-9.
- Baxter NN, Sutradhar R, Forbes SS, Paszat LF, Saskin R, Rabeneck L. Analysis of administrative data finds endoscopist quality measures associated with post-colonoscopy colorectal cancer. Gastroenterology. 2011; 140:65-72
- Baxter NN, Virnig DJ, Rothenberger DA, Morris AM, Jessurun J, Virnig BA. Lymph node evaluation in colorectal cancer patients: A population-based study. J Natl Cancer Inst. 2005; 97(3):219-25
