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Article
November 25, 2020
Letter to the Editor

Cancer Incidence and Mortality Rates in Multiple Sclerosis
A Matched Cohort Study

January 26, 2021 issue
96 (4) e501-e512

Abstract

Objective

To determine whether cancer risk differs in people with and without multiple sclerosis (MS), we compared incidence rates and cancer-specific mortality rates in MS and matched cohorts using population-based data sources.

Methods

We conducted a retrospective matched cohort study using population-based administrative data from Manitoba and Ontario, Canada. We applied a validated case definition to identify MS cases, then selected 5 controls without MS matched on birth year, sex, and region. We linked these cohorts to cancer registries, and estimated incidence of breast, colorectal, and 13 other cancers. For breast and colorectal cancers, we constructed Cox models adjusting for age at the index date, area-level socioeconomic status, region, birth cohort year, and comorbidity. We pooled findings across provinces using meta-analysis.

Results

We included 53,983 MS cases and 269,915 controls. Multivariable analyses showed no difference in breast cancer risk (pooled hazard ratio [HR] 0.92 [95% confidence interval (CI) 0.78–1.09]) or colorectal cancer risk (pooled HR 0.83 [95% CI 0.64–1.07]) between the cohorts. Mortality rates for breast and colorectal did not differ between cohorts. Bladder cancer incidence and mortality rates were higher among the MS cohort. Although the incidence of prostate, uterine, and CNS cancers differed between the MS and matched cohorts, mortality rates did not.

Conclusion

The incidence of breast and colorectal cancers does not differ between persons with and without MS; however, the incidence of bladder cancer is increased. Reported differences in the incidence of some cancers in the MS population may reflect ascertainment differences rather than true differences.

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Letters to the Editor
25 January 2021
Author Response: Cancer Incidence and Mortality Rates in Multiple Sclerosis: A Matched Cohort Study
Ruth Ann Marrie, Neurologist | University of Manitoba
Colleen Maxwell, Pharmacoepidemiologist | University of Waterloo and ICES, Toronto
Patti Groome, Cancer Epidemiologist | Queen's University and ICES Queen's

Thank you for your interest in our work.1 We agree that a better understanding of the reasons for the elevated risk of bladder cancer observed in the Multiple Sclerosis (MS) cohorts is clinically important for the development of preventive strategies. The administrative health data sources that we used do not readily allow us to identify individuals with neurogenic bladder. Cyclophosphamide protocols for MS most often use intravenous administration within hospital settings—therefore, this therapy is not captured by the databases that capture outpatient prescription dispensations. Clinical cohorts with access to detailed information about bladder dysfunction, exposure to cyclophosphamide, as well as other recognized risk factors for bladder cancer such as smoking and workplace exposures to aromatic amines are likely to be needed to address these questions.2

Disclosure

The authors report no relevant disclosures. Contact [email protected] for full disclosures.  

References

  1. Marrie RA, Maxwell C, Mahar A, et al. Cancer Incidence and Mortality Rates in Multiple Sclerosis: A Matched Cohort Study. Neurology. 2021;96(4):e501-e512. doi:10.1212/WNL.0000000000011219
  2. Cumberbatch MGK, Jubber I, Black PC, et al. Epidemiology of Bladder Cancer: A Systematic Review and Contemporary Update of Risk Factors in 2018. Eur Urol. 2018;74(6):784-795. doi:10.1016/j.eururo.2018.09.001
17 December 2020
Reader response: Cancer incidence and mortality rates in multiple sclerosis: A matched cohort study
Ralf Dr. Böthig, Urologist, Surgeon | Department Neuro‑Urology, Centre for Spinal Cord Injuries, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033 Hamburg, Germany
Wolfgang Dr. Schöps, Urologist | Urological Practice, Sankt Augustin, Germany
Thura Kadhum, Physician | Specialist Clinic for Psychosomatic Rehabilitation, Mittelrheinklinik, Boppard-Bad Salzig, Germany
Klaus Prof. Dr. Golka, Occupational Physician | Leibniz Research Centre for Working Environment and Human Factors at TU Dortmund (IfADo), Dortmund, Germany

We read with great interest the recent results of the study on multiple sclerosis (MS) and cancer risk.1 The described urinary bladder cancer risk is remarkable. Traumatic and congenital (spina bifida) spinal cord injury (SCI) patients usually suffer from neurogenic bladder dysfunction commonly associated with recurrent urinary tract infections. SCI patients are more likely to develop bladder cancer after paralysis lasts 10 years or more, at a younger age than the general population, and with a dramatically elevated mortality.2,3 This was also observed in a recent mono-centric study of 7,004 SCI patients who managed without chronic indwelling catheters.4 Thus, it would be very interesting if an association with the duration of MS and/or with the duration of the neurogenic bladder dysfunction was observable in the investigated bladder cancer patients. Also, the percentage of patients with a history of taking cyclophosphamide medication, well-known for its bladder carcinogenicity, and the proportion of squamous cell carcinomas to urothelial carcinomas, would be interesting. Squamous cell carcinomas are remarkably increased in SCI patients. 2,3,4 Furthermore, an association with urinary tract infections treated with antibiotics was found to be dose-dependent in a large Danish study, comprising 333 urinary bladder squamous cell carcinoma cases.5

Disclosure

The authors report no relevant disclosures. Contact [email protected] for full disclosures.  

References

  1. Marrie RA, Maxwell C, Mahar A, et al. Cancer incidence and mortality rates in multiple sclerosis: A matched cohort study. Neurology Epub 2020 Nov 25.
  2. Ismail S, Karsenty G, Chartier-Kastler E, et al. Prevalence, management, and prognosis of bladder cancer in patients with neurogenic bladder: A systematic review. Neurourol Urodyn 2018;37:1386-1395.
  3. Rove KO, Husmann DA, Wilcox DT, Vricella GJ, Higuchi TT. Systematic review of bladder cancer outcomes in patients with spina bifida. J Pediatr Urol 2017;13:456.e1-456.e9.
  4. Böthig R, Tiburtius C, Fiebag K, et al. Traumatic spinal cord injury confers bladder cancer risk to patients managed without permanent urinary catheterization: lessons from a comparison of clinical data with the national database. World J Urol 2020;38:2827-2834.
  5. Pottegård A, Kristensen KB, Friis S, Hallas J, Jensen JB, Nørgaard M. Urinary tract infections and risk of squamous cell carcinoma bladder cancer: A Danish nationwide case-control study. Int J Cancer 2020;146:1930-1936.

Information & Authors

Information

Published In

Neurology®
Volume 96Number 4January 26, 2021
Pages: e501-e512
PubMed: 33239364

Publication History

Received: May 8, 2020
Accepted: September 21, 2020
Published online: November 25, 2020
Published in print: January 26, 2021

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Disclosure

Dr. Marrie receives research funding from CIHR, Research Manitoba, Multiple Sclerosis Society of Canada, Multiple Sclerosis Scientific Foundation, Crohn's and Colitis Canada, National Multiple Sclerosis Society, CMSC, and The Arthritis Society; and is supported by the Waugh Family Chair in Multiple Sclerosis. Dr. Maxwell is supported by a University Research Chair (University of Waterloo) and receives funding from CIHR, Canadian Frailty Network, Multiple Sclerosis Society of Canada, CMSC, Ontario Neurodegenerative Disease Research Initiative Phase 2, Velux Stiftung, Queen's University, P.S.I. Foundation, and Ontario MOHLTC Health System Research Fund Program. Dr. Mahar receives research funding from CIHR, Canada Foundation for Innovation, Research Manitoba, the True Patriot Love Foundation, and the University of Manitoba. O. Ekuma and C. McClintock report no disclosures. Dr. Seitz receives research funding from CIHR, the MS Society of Canada, and the University of Calgary. Dr. Webber receives research funding from the MS Society of Canada. Dr. Groome receives research funding from the Multiple Sclerosis Society of Canada. Go to Neurology.org/N for full disclosures.

Study Funding

This study was funded by the MS Society of Canada (EGID 3465). R.A.M. is supported by the Waugh Family Chair in Multiple Sclerosis and a Manitoba Research Chair from Research Manitoba.

Authors

Affiliations & Disclosures

Ruth Ann Marrie, MD, PhD
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Multiple Sclerosis Journal, Editorial Board Multiple Sclerosis Journal-ETC, Co-Editor
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
Received support as principal investigator from the Canadian Institutes of Health Research (2010-2022), and Research Manitoba (2014-2021).
Research Support, Academic Entities:
1.
Waugh Family Chair in Multiple Sclerosis
Research Support, Foundations and Societies:
1.
Received support as principal investigator from Multiple Sclerosis Society of Canada (2009-2022) and the National Multiple Sclerosis Society (2013-2020), and as co-principal investigator from Multiple Sclerosis Scientific Foundation (2009-2021). Received support from Consortium of Multiple Sclerosis Centers (2004-2009, 2011-2014, 2016-2021), Crohn's and Colitis Canada (2014- 2021)
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Colleen Maxwell, PhD
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Canadian Journal of Cardiology, Editorial Board Member, Nov 2007 to 2019. I have not received any compensation for my work on this board. Journal of Population Therapeutics and Clinical Pharmacology (formerly the Canadian Journal of Clinical Pharmacology), Associate Editor, May 2004 to 2019. I have not received any compensation for my work as an associate editor with this journal. Canadian Geriatrics Journal, Associate Editor, January 2014 to present. I have not received any compensation for my work on this board. Neuroepidemiology, Frontiers in Neurology, Review Editor, May 2019 - present. I have not received any compensation for my work on the editorial board. JAMDA, Editorial Board Member, Aug 2020 - present. I have not received any compensation for my work on the editorial board.
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1) Queen's University Dean's Research Fund, Co- investigator, 2019-2020. (2) CIHR and Partners, Phase Two of the Canadian Consortium on Neurodegeneration in Aging (CCNA), Co-investigator, 2019- 2024. (3) Multiple Sclerosis Society of Canada, Co-investigator, 2019-2022. (4) Ontario Brain Institute Integrated Discovery Program, ONDRI-2, Aim 4, Co-investigator, 2018-2023. (5) Velux Stiftung, Co-investigator, 2018-2020. (6) Canadian Frailty Network 2018 Catalyst Grant (Cat2018- 01), Co-investigator, 2018-2019. (7) Queen's University, Co-investigator, 2018-2020. (8) Canadian Frailty Network, CAT2017-21, Principal Investigator, 2018-2019. (9) CIHR Project Grant, Co-investigator, 2018-2021. (10) P.S.I. Foundation, Co-investigator, 2017-2019. (11) Ontario Ministry of Health and Long Term Care - Health System Research Fund Program Award, Co- investigator, 2017-2021. (12) CIHR Catalyst Grant, Co-investigator, 2017-2018. (13) Multiple Sclerosis Society of Canada Operating Research Grant, Co-investigator, 2017-2019. (14) Consortium of Multiple Sclerosis Centers (CMSC) Pilot Grant, Co-investigator, 2016-2017. (15) CIHR Program Grant, Co-investigator, 2016-2021. (16) Canadian Frailty Network/TVN Strategic Impact Grant, Co-PI, 2014-2017. (17) CIHR Project Grant, Principal Investigator, 2014- 2017. (18) CIHR Project Grant, Co-investigator, 2014-2017. (19) CIHR - Canadian Consortium on Neurodegeneration in Aging (CCNA) Team Grant, Co-investigator, 2014-2019.
Research Support, Academic Entities:
1.
(1) Queen's University (I am co-investigator on research grants being led by Dr. Dallas Seitz), 2018-2020. (2) Baycrest Centre for Geriatric Care (I am Co-investigator on Phase 2 of CCNA led by PI at Baycrest), 2019-2024. (3) University of Calgary (I am Co-investigator on several grants led by Dr. Kirsten Fiest), 2018-2021. (4) University of Waterloo (I am Co-investigator on several research grants), 2017-2020.
Research Support, Foundations and Societies:
1.
Physician Services Incorporated (P.S.I) Foundation. Multiple Sclerosis Scientific Research Foundation.
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Alyson Mahar, PhD
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Okechukwu Ekuma, MSc
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Chad McClintock, MSc
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Dallas Seitz, MD, PhD
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
Site investigator for trial sponsored by Hoffmann La Roche
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Colleen Webber, PhD
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Patti A. Groome, PhD
From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health & Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.A.G.) and Division of Cancer Care and Epidemiology, Cancer Research Institute (P.A.G.), Queen's University, Kingston; Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary; Ottawa Hospital Research Institute (C.W.); and Bruyère Research Institute (C.W.), Ottawa, Canada.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence Dr. Marrie [email protected]
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

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