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Muñoz-Montecinos C, González-Browne C, Maza F, Carreño-Leiton D, González P, Chahuan B, Quirland C. Cost-effectiveness of intraoperative radiation therapy versus intensity-modulated radiation therapy for the treatment of early breast cancer: a disinvestment analysis. BMC Health Serv Res 2024; 24:417. [PMID: 38570764 PMCID: PMC10988977 DOI: 10.1186/s12913-024-10739-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/18/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Adjuvant radiotherapy represents a key component in curative-intent treatment for early-stage breast cancer patients. In recent years, two accelerated partial breast irradiation (APBI) techniques are preferred for this population in our organization: electron-based Intraoperative radiation therapy (IORT) and Linac-based External Beam Radiotherapy, particularly Intensity-modulated radiation therapy (IMRT). Recently published long-term follow-up data evaluating these technologies have motivated a health technology reassessment of IORT compared to IMRT. METHODS We developed a Markov model to simulate health-state transitions from a cohort of women with early-stage breast cancer, after lumpectomy and adjuvant APBI using either IORT or IMRT techniques. The cost-effectiveness from a private health provider perspective was assessed from a disinvestment point of view, using life-years (LYs) and recurrence-free life-years (RFLYs) as measure of benefits, along with their respective quality adjustments. Expected costs and benefits, and the incremental cost-effectiveness ratio (ICER) were reported. Finally, a sensitivity and scenario analyses were performed to evaluate the cost-effectiveness using lower IORT local recurrence and metastasis rates in IORT patients, and if equipment maintenance costs are removed. RESULTS IORT technology was dominated by IMRT in all cases (i.e., fewer benefits with greater costs). Despite small differences were found regarding benefits, especially for LYs, costs were considerably higher for IORT. For sensitivity analyses with lower recurrence and metastasis rates for IORT, and scenario analyses without equipment maintenance costs, IORT was still dominated by IMRT. CONCLUSIONS For this cohort of patients, IMRT was, at least, non-inferior to IORT in terms of expected benefits, with considerably lower costs. As a result, IORT disinvestment should be considered, favoring the use of IMRT in these patients.
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Affiliation(s)
| | | | - Felipe Maza
- Health Technology Assessment Unit, Arturo Lopez Perez Foundation, Santiago, RM, Chile
| | - Diego Carreño-Leiton
- Health Technology Assessment Unit, Arturo Lopez Perez Foundation, Santiago, RM, Chile
| | - Pablo González
- Radiotherapy Department, Arturo Lopez Perez Foundation, Santiago, RM, Chile
| | - Badir Chahuan
- Breast Surgery Unit, Arturo Lopez Perez Foundation, Santiago, RM, Chile
| | - Camila Quirland
- Health Technology Assessment Unit, Arturo Lopez Perez Foundation, Santiago, RM, Chile
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Contrera KJ, Tam S, Pytynia K, Diaz EM, Hessel AC, Goepfert RP, Lango M, Su SY, Myers JN, Weber RS, Eguia A, Pisters PWT, Adair DK, Nair AS, Rosenthal DI, Mayo L, Chronowski GM, Zafereo ME, Shah SJ. Impact of Cancer Care Regionalization on Patient Volume. Ann Surg Oncol 2023; 30:2331-2338. [PMID: 36581726 DOI: 10.1245/s10434-022-13029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs). METHODS This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution. RESULTS The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299). CONCLUSIONS The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.
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Affiliation(s)
- Kevin J Contrera
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samantha Tam
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Kristen Pytynia
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo M Diaz
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy C Hessel
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Miriam Lango
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arturo Eguia
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | | | - Deborah K Adair
- Department of Global Business Development, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ajith S Nair
- Department of Global Business Development, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren Mayo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory M Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Shalin J Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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3
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Philippson C, Larsen S, Simon S, Vandekerkhove C, De Caluwe A, Van Gestel D, Chintinne M, Veys I, De Neubourg F, Noterman D, Roman M, Nogaret JM, Desmet A. Intraoperative electron radiotherapy in early invasive ductal breast cancer: 6-year median follow-up results of a prospective monocentric registry. Breast Cancer Res 2022; 24:83. [DOI: 10.1186/s13058-022-01582-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Abstract
Background
Intraoperative electron radiotherapy (IOERT) can be used to treat early breast cancer during the conservative surgery thus enabling shorter overall treatment times and reduced irradiation of organs at risk. We report on our first 996 patients enrolled prospectively in a registry trial.
Methods
At Jules Bordet Institute, from February 2010 onwards, patients underwent partial IOERT of the breast. Women with unifocal invasive ductal carcinoma, aged 40 years or older, with a clinical tumour size ≤ 20 mm and tumour-free sentinel lymph node (on frozen section and immunohistochemical analysis). A 21 Gy dose was prescribed on the 90% isodose line in the tumour bed with the energy of 6 to 12 MeV (Mobetron®-IntraOp Medical).
Results
Thirty-seven ipsilateral tumour relapses occurred. Sixteen of those were in the same breast quadrant. Sixty patients died, and among those, 12 deaths were due to breast cancer. With 71.9 months of median follow-up, the 5-year Kaplan–Meier estimate of local recurrence was 2.7%.
Conclusions
The rate of breast cancer local recurrence after IOERT is low and comparable to published results for IORT and APBI. IOERT is highly operator-dependent, and appropriate applicator sizing according to tumour size is critical. When used in a selected patient population, IOERT achieves a good balance between tumour control and late radiotherapy-mediated toxicity morbidity and mortality thanks to insignificant irradiation of organs at risk.
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Miller K, Kreis IA, Gannon MR, Medina J, Clements K, Horgan K, Dodwell D, Park MH, Cromwell DA. The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review. Cancer Treat Rev 2022; 104:102353. [PMID: 35152157 DOI: 10.1016/j.ctrv.2022.102353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age. METHODOLOGY MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis. RESULTS Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age. CONCLUSIONS Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.
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Affiliation(s)
- Katie Miller
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Irene A Kreis
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Melissa R Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jibby Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Karen Clements
- National Cancer Registration and Analysis Service, NHS Digital, 2(nd) Floor, 23 Stephenson Street, Birmingham, UK
| | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Min Hae Park
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Khanna NR, Kumar A, Kataki K, Sehra N, Laskar SG, Mummudi N, Gupta T, Tibdewal A, Pathak R, Wadasadawala T, Krishnatry R, Chopra S, Goda JS, Chatterjee A, Budrukkar A, Gurram L, Engineer R, Murthy V, Swain M, Laskar S, Sarin R, Agarwal JP. Compliance of Radiotherapy Treatment at a Tertiary Cancer Center in India—A Clinical Audit. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1742666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Introduction Noncompliance to planned radiotherapy (RT) treatment is associated with inferior outcomes and also serves as an indicator of quality of care offered to the patients. Identification of the rate of noncompliance and its causative factors can help us develop an insight toward implementing mitigation measures thereby improving the quality of treatment.
Objective To ascertain the incidence of noncompliance and the factors affecting the same in patients offered RT appointments.
Materials and Methods We retrospectively reviewed the records of patients from January 1, 2019, to December 31, 2019, who were noncompliant (defaulted RT simulation or defaulted initiation of RT or defaulted planned RT during the course of RT but excluding planned/unplanned treatment breaks or early conclusions prescribed by the treating radiation oncologist) for the planned RT treatment.
Results Of the 8,607 appointments (7,699 external beam RT and 908 brachytherapy) given to the patients attending the radiation oncology outpatient department in the year 2019, a total of 197 (2.28%) patients were found to be noncomplaint. Ninety-seven patients defaulted RT simulation (49.2%), 53 defaulted RT starting (26.9%), and 47 defaulted while on RT (23.9%). Half of these had either head–neck (29.9%) or gynecological (20.8%) malignancies. Patients with breast cancers had the least noncompliance rates (0.02%). The cause for noncompliance was ascertained in 135 patients (68.5%). The common causes of noncompliance were the desire to continue treatment closer to home (21.5%) followed by logistic (17%), lack of confidence in the curative potential of the planned therapy (17%), and financial reasons (11.8%). Patients with head–neck and gynecological malignancies were more often with advanced staged disease and were planned multimodal treatment protocols. The majority of the 23 patients who defaulted palliative RT were planned for fractionated treatments (73.9%).
Conclusion The incidence of noncompliance in patients planned for RT in our institute can be considered optimum. Appropriate counseling of patients at the time of scheduling appointment, upfront identification of patients at high risk of noncompliance, and assisting patients with financial and logistic challenges are imperative to ensure adherence to planned treatment schedule.
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Affiliation(s)
- Nehal R. Khanna
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anuj Kumar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kaushik Kataki
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nishtha Sehra
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Mummudi
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tejpal Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anil Tibdewal
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rima Pathak
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tabassum Wadasadawala
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jayant Sastri Goda
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Abhishek Chatterjee
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ashwini Budrukkar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Lavanya Gurram
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Monali Swain
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rajiv Sarin
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Leus AJG, Haisma MS, Terra JB, Diercks GFH, Van Kester MS, Halmos GB, Rácz E, Van Dijk BAC, Plaat BEC. Age-related Differences in Tumour Characteristics and Prognostic Factors for Disease Progression in Cutaneous Squamous Cell Carcinoma of the Head and Neck. Acta Derm Venereol 2022; 102:adv00652. [PMID: 34935990 PMCID: PMC9631266 DOI: 10.2340/actadv.v101.347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Guidelines for cutaneous squamous cell carcinoma of the head and neck do not take the age of the patient into account, but instead assume equal tumour characteristics and prognostic factors for poor outcome in younger and elderly patients. The aim of this study was to compare tumour characteristics of younger (< 75 years) and elderly (≥ 75 years) patients and identify age-specific risk factors for progression of disease, comprising local recurrence, nodal metastasis and distant metastasis. Patient and tumour characteristics were compared using χ2 or Fisher's exact tests. Multivariable competing risk analyses were performed to compare risk factors for progression of disease, incorporating the risk of dying before developing progression of disease. A total of 672 patients with primary cutaneous squamous cell carcinoma of the head and neck were retrospectively included. Larger tumour diameter, worse differentiation grade and deeper invasion were observed in older patients. In elderly patients, but not in younger patients, tumour diameter ≥ 40 mm, moderate differentiation grade and an invasion depth ≥ 2 mm were independent risk factors for progression of disease.
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Affiliation(s)
- Alet J G Leus
- Department of Dermatology, University Medical Center Groningen, Hanzeplein 1, NL-9700 RB Groningen. The Netherlands.
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7
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R Khanna N, Ghosh Laskar S, Gupta T, Agarwal JP. Compliance With Radiotherapy Treatment in an Apex Cancer Center of India. JCO Glob Oncol 2022; 8:e2100201. [PMID: 34985910 PMCID: PMC8769151 DOI: 10.1200/go.21.00201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Nehal R Khanna
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Tejpal Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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8
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Prasad A, Carey RM, Brody RM, Bur AM, Cannady SB, Ojerholm E, Newman JG, Ibrahim S, Brant JA, Rajasekaran K. Postoperative Radiation Therapy Refusal in Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma. Laryngoscope 2021; 132:339-348. [PMID: 34254672 DOI: 10.1002/lary.29743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/29/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES/HYPOTHESIS Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct clinical entity with good prognosis, unique demographics, and a trend toward treatment deintensification. Patients with this disease may opt out of recommended postoperative radiation therapy (PORT) for a variety of reasons. The aim of this paper was to examine factors that predict patient refusal of recommended PORT in HPV-associated OPSCC, and the association of refusal with overall survival. STUDY DESIGN Retrospective population-based cohort study of patients in the National Cancer Database. METHODS We conducted a retrospective cohort study of patients in the National Cancer Database diagnosed with OPSCC between January 2010 and December 2015. We primarily assessed overall survival and the odds of refusing PORT based on demographic, socioeconomic, and clinical factors. Analysis was conducted using multivariable logistic regression and multivariable Cox proportional hazards model. RESULTS A total of 4229 patients were included in the final analysis, with 156 (3.7%) patients opting out of recommended PORT. On multivariable analysis, patient refusal of PORT was independently associated with a variety of socioeconomic factors such as race, insurance status, comorbidity, treatment at a single facility, and margin status. Lastly, PORT refusal was associated with significantly lower overall survival compared to receipt of recommended PORT (hazard ratio 1.69, confidence interval 1.02-2.82). CONCLUSIONS Patient refusal of recommended PORT in HPV-associated OPSCC is rare and associated with variety of disease and socioeconomic factors. PORT refusal may decrease overall survival in this population. Our findings may help clinicians when counseling patients and identifying those who may be more likely to opt out of recommended adjuvant therapy. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Aman Prasad
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ryan M Carey
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Andrés M Bur
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas, Kansas City, Kansas, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Eric Ojerholm
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.,Department of Radiation Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Said Ibrahim
- Department of Population Health Sciences, Weill Cornell Medicine, New York City, New York, U.S.A
| | - Jason A Brant
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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9
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Gupta A, Jhawar SR, Sayan M, Yehia ZA, Haffty BG, Yu JB, Wang SY. Cost-Effectiveness of Adjuvant Treatment for Ductal Carcinoma In Situ. J Clin Oncol 2021; 39:2386-2396. [PMID: 34019456 PMCID: PMC10166354 DOI: 10.1200/jco.21.00831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) accounts for 20% of breast cancer cases in the United States and is potentially overtreated, leading to high expenditures and low-value care. We conducted a cost-effectiveness analysis evaluating all adjuvant treatment strategies for DCIS. METHODS A Markov model was created with six competing treatment strategies: observation, tamoxifen (TAM) alone, aromatase inhibitor (AI) alone, radiation treatment (RT) alone, RT + TAM, and RT + AI. Baseline recurrence rates were modeled using the NSABP B17 and RTOG 9804 trials for standard-risk and good-risk DCIS, respectively. Relative risk reductions and adverse event rates for each treatment strategy were derived from meta-analyses of large randomized trials. We used a willingness-to-pay threshold of $100,000 in US dollars/quality-adjusted life-year and a lifetime horizon for two cohorts of women, age 40 and 60 years. Comprehensive sensitivity analyses evaluated the robustness of base-case results. RESULTS RT alone was cost-effective for patients with standard-risk DCIS, and observation was cost-effective for patients with good-risk DCIS, across both age groups. Strategies including TAM or AI resulted in fewer quality-adjusted life-years than observation, because of the prolonged decrement in quality of life outweighing the modest benefit in ipsilateral risk reduction. In sensitivity analysis, RT alone was cost-effective for age 40, good-risk patients when ipsilateral risk reduction matched that of the RTOG 9804 trial, there was minimal increased risk of contralateral breast secondary malignancy, or there was strong patient willingness to pursue RT. CONCLUSION Our findings suggest that cost-effective and clinically optimal treatment strategies are RT alone for standard-risk DCIS and observation for good-risk DCIS, with personalization on the basis of patient age and preference for RT. Hormonal therapy is likely suboptimal for most patients with DCIS.
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Affiliation(s)
- Apar Gupta
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Sachin R Jhawar
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Mutlay Sayan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Zeinab A Yehia
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - James B Yu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Yale School of Public Health, New Haven, CT
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10
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Dohm A, Diaz R, Nanda RH. The Role of Radiation Therapy in the Older Patient. Curr Oncol Rep 2021; 23:11. [PMID: 33387104 DOI: 10.1007/s11912-020-01000-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Older patients represent a unique subgroup of the cancer patient population for which the role of radiation therapy (RT) requires special consideration. This review will discuss many of these considerations as well as various radiation treatment techniques in the context of a variety of disease sites. RECENT FINDINGS Several recent studies give insight into the management of older cancer patients considering their age, performance status, comorbid conditions, quality of life, genetics, cost, and individual goals. RT plays an evolving and pivotal role in providing optimal care for this population. Recent advances in RT technique allow for more precise treatment delivery and reduced toxicity. Studies evaluating the use of radiation therapy in breast, brain, lung, prostate, rectal, pancreatic, esophageal, and oligometastatic cancer are summarized and discussed in the context of treating the older patient population. Individual age, performance and functional status, comorbid conditions, and patients' objectives and goals should all be considered when presenting treatment options for older patients and age alone should not disqualify patients from curative intent treatments. When possible, hypofractionated courses should be utilized as outcomes are often equivalent and toxicities are reduced. In many cases, RT may be preferable to other treatment options due to decreased toxicity profile and acceptable disease control.
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Affiliation(s)
- Ammoren Dohm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Roberto Diaz
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Ronica H Nanda
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA.
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Desideri I, Salvestrini V, Livi L. Recent advances in de-intensification of radiotherapy in elderly cancer patients. F1000Res 2020; 9. [PMID: 32518630 PMCID: PMC7255897 DOI: 10.12688/f1000research.21151.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer in the elderly remains an evolving issue and a health challenge. Several improvements in the radiotherapy field allow the delivery of higher doses/fractions with a safe toxicity profile, permitting the reduction of radiation treatment protocols in the elderly. Regarding breast, prostate, and lung cancer, the under-representation of older patients in clinical trials limits the extension of treatment recommendations to elderly patients in routine clinical practice. Among the feasible alternatives to standard whole breast radiotherapy (WBRT) in older patients are shorter courses using higher hypofractionation (HF) and accelerated partial breast irradiation (APBI). The boost continues to be used in women at high risk of local recurrence but is less widely accepted for women at lower risk and patients over 70 years of age. Regarding prostate cancer, there are no published studies with a focus on the elderly. Current management decisions are based on life expectancy and geriatric assessment. Regimens of HF and ultra-HF protocols are feasible strategies for older patients. Several prospective non-randomized studies have documented the safe delivery of ultra-HF for patients with localized prostate cancer, and multiple phase III trials and meta-analyses have confirmed that the HF regimen should be offered with similar acute toxicity regardless of patient age and comorbidity. A recent pooled analysis from two randomized trials comparing surgery to stereotactic body radiation therapy (SBRT) in older adult patients with early stage non-small cell lung cancer did show comparable outcomes between surgery and SBRT. Elderly cancer patients are significantly under-represented in all clinical trials. Thus, the inclusion of older patients in clinical studies should be strongly encouraged to strengthen the evidence base for this age group. We suggest that the creation of oncogeriatric coordination units may promote individualized care protocols, avoid overtreatment with aggressive and unrecommended therapies, and support de-escalating treatment in elderly cancer patients.
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Affiliation(s)
- Isacco Desideri
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
| | - Viola Salvestrini
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
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Bonzano E, Belgioia L, Polizzi G, Siffredi G, Fregatti P, Friedman D, Garelli S, Gusinu M, Vaccara EML, Guenzi M, Corvò R. Simultaneous Integrated Boost in Once-weekly Hypofractionated Radiotherapy for Breast Cancer in the Elderly: Preliminary Evidence. In Vivo 2020; 33:1985-1992. [PMID: 31662528 DOI: 10.21873/invivo.11694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 01/28/2023]
Abstract
AIM To evaluate once-weekly hypofractionated radiotherapy in elderly patients affected by early breast cancer, reporting acute and late toxicity profiles, and treatment feasibility. PATIENTS AND METHODS Fifty patients were treated with a hypofractionated regimen: 28.5±2.5 Gy in five fractions at one fraction weekly. Simultaneous integrated boost (SIB) to the tumor bed in high-risk cases. INCLUSION CRITERIA patients over 70 years old, pT1-2, N0-1a. Acute and late toxicities were assessed based on Radiation Therapy Oncology Group. RESULTS The median follow-up was 20 months and the median patient age was 79 years. SIB was added for 22 patients (44%). Grade 3-4 acute cutaneous toxicities were not observed; grade 2 toxicity occurred only in four patients (8%). Late subcutaneous tissue toxicity consisted of grade 2 fibrosis in two patients (4%), grade 1 in five (10%) and grade 0 in 41(85%). CONCLUSION Limiting fraction numbers with a safer profile may improve the management of breast cancer for the elderly.
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Affiliation(s)
- Elisabetta Bonzano
- Department of Radiation Oncology, IRCCS Policlinico San Martino, Genoa, Italy
| | - Liliana Belgioia
- Department of Radiation Oncology, IRCCS Policlinico San Martino, Genoa, Italy
| | - Giorgia Polizzi
- Department of Radiation Oncology, IRCCS Policlinico San Martino, Genoa, Italy
| | - Guido Siffredi
- Department of Radiation Oncology, IRCCS Policlinico San Martino, Genoa, Italy
| | - Piero Fregatti
- Department of Surgery, IRCCS Policlinico San Martino, Genoa, Italy
| | - Daniele Friedman
- Department of Surgery, IRCCS Policlinico San Martino, Genoa, Italy
| | - Stefania Garelli
- Department of Medical Physics, IRCCS Policlinico San Martino, Genoa, Italy
| | - Marco Gusinu
- Department of Medical Physics, IRCCS Policlinico San Martino, Genoa, Italy
| | | | - Marina Guenzi
- Department of Radiation Oncology, IRCCS Policlinico San Martino, Genoa, Italy
| | - Renzo Corvò
- Department of Radiation Oncology, IRCCS Policlinico San Martino, Genoa, Italy
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Factors analysis on the use of key quality indicators for narrowing the gap of quality of care of breast cancer. BMC Cancer 2019; 19:1099. [PMID: 31718596 PMCID: PMC6852954 DOI: 10.1186/s12885-019-6334-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 11/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are differences in the quality of care among breast cancer patients. Narrowing the quality differences could be achieved by increasing the utilization rate of indicators. Here we explored key indicators that can improve the quality of care and factors that may affect the use of these indicators. METHODS A total of 3669 breast cancer patients were included in our retrospective study. We calculated patient quality-of-care composite score based on patient average method. Patients were divided into high- and low-quality groups according to the mean score. We obtained the indicators with large difference in utilization between the two groups. Multilevel logistic regression model was used to analyze the factors influencing quality of care and use of indicators. RESULTS The mean composite score was 0.802, and the number of patients in the high- and low-quality groups were 1898 and 1771, respectively. Four indicators showed a difference in utilization between the two groups of over 40%. Histological grade, pathological stage, tumor size and insurance type were the factors affecting the quality of care. In single indicator evaluation, besides the above factors, age, patient income and number of comorbidities may also affect the use of these four indicators. Number of comorbidities may have opposite effects on the use of different indicators, as does pathological stage. CONCLUSIONS Identifying key indicators for enhancing the quality-of-care of breast cancer patients and factors that affect the indicator adherence may provide guides for enhancing the utilization rate of these indicators in clinical practice.
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Buszek SM, Lin HY, Bedrosian I, Tamirisa N, Babiera GV, Shen Y, Shaitelman SF. Lumpectomy Plus Hormone or Radiation Therapy Alone for Women Aged 70 Years or Older With Hormone Receptor-Positive Early Stage Breast Cancer in the Modern Era: An Analysis of the National Cancer Database. Int J Radiat Oncol Biol Phys 2019; 105:795-802. [PMID: 31377160 DOI: 10.1016/j.ijrobp.2019.07.052] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Deintensification of adjuvant therapy is being considered for older women with early-stage, biologically favorable breast cancer. Although radiation therapy (RT) can be omitted in some cases, toxicity from hormone therapy (HT) is not trivial, and adherence rates vary. We hypothesized that adjuvant RT alone would produce survival outcomes comparable to those with adjuvant HT alone among elderly patients treated with lumpectomy. METHODS AND MATERIALS We searched the National Cancer Database (2010-2014) for healthy women (aged ≥70 years, Charlson/Deyo [CD] score 0-1) with T1N0 hormone-receptor-positive, HER-2-negative breast cancer treated with lumpectomy and adjuvant HT or RT. Propensity scores were used to match patients for analysis. RESULTS We identified 2995 patients (median age, 78 years), most (81%) with a CD score of 0, clinical stage IA (77%), of whom 65% received HT alone and 35% received RT only after lumpectomy. On multivariate analysis of the matched cohort, older age (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.07-1.13; P < .001), CD score 1 (HR 1.92; 95% CI 1.37-2.70; P = .0002), and living in a metropolitan (vs urban) area (HR 3.09; 95% CI 1.43-6.67; P = .004) were associated with inferior overall survival (OS), whereas treatment with HT (vs RT) was not (HR 1.13; 95% CI 0.85-1.49; P = .406). At a median follow-up of 45 months, no difference was found in OS between HT versus RT cohorts (85% and 86%, respectively; P = .44). CONCLUSIONS For healthy, older women with biologically favorable breast cancer treated with lumpectomy, adjuvant RT or HT is associated with equivalent 5-year OS rates. A randomized controlled trial is warranted to explore these adjuvant monotherapy options in elderly patients with hormone receptor-positive breast cancer.
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Affiliation(s)
- Samantha M Buszek
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heather Y Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gildy V Babiera
- Physicians Network, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Hill DA, Friend S, Lomo L, Wiggins C, Barry M, Prossnitz E, Royce M. Breast cancer survival, survival disparities, and guideline-based treatment. Breast Cancer Res Treat 2018; 170:405-414. [PMID: 29569018 PMCID: PMC6002943 DOI: 10.1007/s10549-018-4761-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/16/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE The role of appropriate therapy in breast cancer survival and survival disparities by race/ethnicity has not been fully elucidated. We investigated whether lack of guideline-recommended therapy contributed to survival differences overall and among Hispanics relative to non-Hispanic white (NHW) women in a case-cohort study. METHODS The study included a 15% random sample of female invasive breast cancer patients diagnosed from 1997 to 2009 in 6 New Mexico counties and all deaths due to breast cancer-related causes. Information was obtained from comprehensive medical chart reviews. National Comprehensive Cancer Network (NCCN®) guideline-recommended treatment was assessed among white women aged < 70 who were free of contraindications for recommended therapy, had stage I-III tumors, and survived ≥ 12 months. Hazard ratios (HRs) and 95% confidence intervals (CIs) for breast cancer death were estimated using Cox proportional hazards models. RESULTS Included women represented 4635 patients and 449 breast cancer deaths. Women who did not receive radiotherapy (HR 2.3; 95% CI 1.2-4.4) or endocrine therapy (HR 2.0; 95% CI 1.0-4.0) as recommended by guidelines had an increased risk of breast cancer death, relative to those treated appropriately. Receipt of guideline-recommended therapy did not differ between Hispanic and NHW women for chemotherapy (84.2% vs. 81.3%, respectively), radiotherapy (89.2% vs. 91.1%), or endocrine therapy (89.2% vs. 85.8%), thus did not influence Hispanic survival disparities. CONCLUSIONS Lack of guideline-recommended radiotherapy or endocrine therapy contributed to survival as strongly as other established prognostic indicators. Hispanic survival disparities in this population do not appear to be attributable to treatment differences.
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Affiliation(s)
- Deirdre A Hill
- Internal Medicine Department, University of New Mexico School of Medicine, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA.
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, USA.
| | - Sarah Friend
- Department of Hematology/Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Lesley Lomo
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Charles Wiggins
- Internal Medicine Department, University of New Mexico School of Medicine, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, USA
| | - Marc Barry
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Eric Prossnitz
- Internal Medicine Department, University of New Mexico School of Medicine, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, USA
| | - Melanie Royce
- Internal Medicine Department, University of New Mexico School of Medicine, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, USA
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Rastogi K, Gupta S, Bhatnagar A, Singh D, Gupta K, Choudhary A. Compliance to radiotherapy: A tertiary care center experience. Indian J Cancer 2018; 55:166-169. [DOI: 10.4103/ijc.ijc_517_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Su S, Bao H, Wang X, Wang Z, Li X, Zhang M, Wang J, Jiang H, Wang W, Qu S, Liu M. The quality of invasive breast cancer care for low reimbursement rate patients: A retrospective study. PLoS One 2017; 12:e0184866. [PMID: 28910357 PMCID: PMC5599036 DOI: 10.1371/journal.pone.0184866] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/03/2017] [Indexed: 01/02/2023] Open
Abstract
Though evidence-based treatments have been recommended for breast cancer, underuse of the treatments was still observed. To certain extent, patients' access to care, which can be enhanced by increasing the coverage of health insurance, could account for the current underuse in recommended care. This study aimed to examine the association between different proportions of reimbursement and quality of recommended breast cancer care, as well as length of hospital stay. In this retrospective study, 3669 patients diagnosed with invasive breast cancer between 1 June, 2011 and 30 June, 2013 were recruited. Seven quality indicators from preoperative diagnosis procedures to adjuvant therapy and one composite indicator were selected as dependent variables. Logistic regression and generalized linear models were used to explore the association between quality of care and length of hospital stay with different reimbursement rates. Compared with UEBMI (urban employment basic medical insurance), which represented high level reimbursement rate, patients with lower rates of reimbursement were less likely to receive core biopsy, HER-2 (human epidermal growth factor receptor-2) testing, BCS (breast conserving surgery), SLNB (sentinel lymph nodes biopsy), adjuvant therapy and hormonal treatment. No significant difference in preoperative length of hospital stay was observed among the three insurance schemes, however URBMI (urban resident basic medical insurance) insured patients stayed longer for total length of hospital stay. Significant disparities in utilization of evidence-based breast cancer care among patients with different proportions of reimbursement were observed. Patients with lower rate of reimbursement were less likely to receive recommended care. Our findings could provide important support for further healthcare reform and quality improvement in breast cancer care.
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Affiliation(s)
- Shaofei Su
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Han Bao
- Department of Biostatistics, Public Health College, Inner Mongolia Medical University, Hohhot, PR China
| | - Xinyu Wang
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Zhiqiang Wang
- School of Medicine, University of Queensland, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Xi Li
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Meiqi Zhang
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Jiaying Wang
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Hao Jiang
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Wenji Wang
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Siyang Qu
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
| | - Meina Liu
- Department of Biostatistics, Public Health College, Harbin Medical University, Harbin, PR China
- * E-mail:
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Freischlag K, Sun Z, Adam MA, Kim J, Palta M, Czito BG, Migaly J, Mantyh CR. Association Between Incomplete Neoadjuvant Radiotherapy and Survival for Patients With Locally Advanced Rectal Cancer. JAMA Surg 2017; 152:558-564. [PMID: 28273303 DOI: 10.1001/jamasurg.2017.0010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Failing to complete chemotherapy adversely affects survival in patients with colorectal cancer. However, the effect of incomplete delivery of neoadjuvant radiotherapy is unclear. Objective To determine whether incomplete radiotherapy delivery is associated with worse clinical outcomes and survival. Design, Setting, and Participants Data on 17 600 patients with stage II to III rectal adenocarcinoma from the 2006-2012 National Cancer Database who received neoadjuvant chemoradiotherapy followed by surgical resection were included. Multivariable regression methods were used to compare resection margin positivity, permanent colostomy rate, 30-day readmission, 90-day mortality, and overall survival between patients who received complete (45.0-50.4 Gy) and incomplete (<45.0 Gy) doses of radiation as preoperative therapy. Main Outcomes and Measures The primary outcome measure was overall survival; short-term perioperative and oncologic outcomes encompassing margin positivity, permanent ostomy rate, postoperative readmission, and postoperative mortality were also assessed. Results Among 17 600 patients included, 10 862 were men, with an overall median age of 59 years (range, 51-68 years). Of these, 874 patients (5.0%) received incomplete doses of neoadjuvant radiation. The median radiation dose received among those who did not achieve complete dosing was 34.2 Gy (interquartile range, 19.8-40.0 Gy). Female sex (adjusted odds ratio [OR] 0.69; 95% CI, 0.59-0.81; P < .001) and receiving radiotherapy at a different hospital than the one where surgery was performed (OR, 0.72; 95% CI, 0.62-0.85; P < .001) were independent predictors of failing to achieve complete dosing; private insurance status was predictive of completing radiotherapy (OR, 1.60; 95% CI, 1.16-2.21; P = .004). At 5-year follow-up, overall survival was improved among patients who received a complete course of radiotherapy (3086 [estimated survival probability, 73.2%] vs 133 [63.0%]; P < .001). After adjustment for demographic, clinical, and tumor characteristics, patients receiving a complete vs incomplete radiation dose had a similar resection margin positivity (OR, 0.99; 95% CI, 0.72-1.35; P = .92), permanent colostomy rate (OR, 0.96; 95% CI, 0.70-1.32; P = .81), 30-day readmission rate (OR, 0.92; 95% CI, 0.67-1.27; P = .62), and 90-day mortality (OR, 0.72; 95% CI, 0.33-1.54; P = .41). However, a complete radiation dose had a significantly lower risk of long-term mortality (adjusted hazard ratio, 0.70; 95% CI, 0.59-0.84; P < .001). Conclusions and Relevance Achieving a target radiation dose of 45.0 to 50.4 Gy is associated with a survival benefit in patients with locally advanced rectal cancer. Aligning all aspects of multimodal oncology care may increase the probability of completing neoadjuvant therapy.
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Affiliation(s)
- Kyle Freischlag
- Student, Duke University School of Medicine, Durham, North Carolina
| | - Zhifei Sun
- Department of Surgery, Duke University, Durham, North Carolina
| | - Mohamed A Adam
- Department of Surgery, Duke University, Durham, North Carolina
| | - Jina Kim
- Department of Surgery, Duke University, Durham, North Carolina
| | - Manisha Palta
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Brian G Czito
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
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Matsuo K, Machida H, Ragab OM, Garcia-Sayre J, Yessaian AA, Roman LD. Patient compliance for postoperative radiotherapy and survival outcome of women with stage I endometrioid endometrial cancer. J Surg Oncol 2017; 116:482-491. [PMID: 28543055 DOI: 10.1002/jso.24690] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/26/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES To examine characteristics and survival outcome of women with endometrial cancer who declined postoperative radiotherapy. METHODS A retrospective study was conducted to examine surgically-treated grade 1-2 stage IB and grade 3 stage IA-IB endometrioid endometrial cancer in the Surveillance, Epidemiology, and End Results Program between 1983 and 2013 (n = 10 613). Associations of patient declination for guideline-based postoperative radiotherapy and clinico-pathological demographics or survival outcome were examined on multivariable analysis. RESULTS There were 323 (3.0%) women who declined adjuvant radiotherapy. Women who declined postoperative radiotherapy were more likely to be older, White, Western U.S. residents, and register in recent years (all, adjusted-P < 0.05). On multivariable analysis, patient declination for guideline-based postoperative radiotherapy remained an independent prognostic factor for decreased endometrial cancer-specific survival in unstaged grade 1-2 stage IB or staged/unstated grade 3 stage IA-IB diseases (adjusted-hazard ratio 1.84, 95% confidence interval 1.34-2.51, P = 0.001). Association of patient declination for guideline-based postoperative radiotherapy and decreased overall survival remained independent in the entire cohort on multivariable analysis (adjuvant-hazard ratio 1.71, 95% confidence interval 1.44-2.02, P < 0.001). CONCLUSIONS Our study suggested that patient compliance to guideline-based postoperative radiotherapy is a prognostic factor for women with stage I endometrioid endometrial cancer.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Hiroko Machida
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Omar M Ragab
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Jocelyn Garcia-Sayre
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Annie A Yessaian
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
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Dutta SW, Showalter SL, Showalter TN, Libby B, Trifiletti DM. Intraoperative radiation therapy for breast cancer patients: current perspectives. BREAST CANCER-TARGETS AND THERAPY 2017; 9:257-263. [PMID: 28458578 PMCID: PMC5402914 DOI: 10.2147/bctt.s112516] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Accelerated partial breast irradiation (APBI) provides an attractive alternative to whole breast irradiation (WBI) through normal tissue radiation exposure and reduced treatment duration. Intraoperative radiation therapy (IORT) is a form of APBI with the shortest time interval, as it delivers the entirety of a planned radiation course at the time of breast surgery. However, faster is not always better, and IORT has been met with healthy skepticism. Patients treated with IORT have an increased compliance and overall satisfaction when compared to patients treated with WBI. However, early randomized trial results demonstrated an increased rate of recurrence after IORT, slowing its widespread adoption. Despite these controversies, IORT utilization is increasing nationally and several novel developments are aimed at continuing to minimize the risk of recurrence and treatment-related toxicity while maximizing the patient experience.
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Affiliation(s)
| | - Shayna L Showalter
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
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22
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de Moor JS, Virgo KS, Li C, Chawla N, Han X, Blanch-Hartigan D, Ekwueme DU, McNeel TS, Rodriguez JL, Yabroff KR. Access to Cancer Care and General Medical Care Services Among Cancer Survivors in the United States: An Analysis of 2011 Medical Expenditure Panel Survey Data. Public Health Rep 2016; 131:783-790. [PMID: 28123224 DOI: 10.1177/0033354916675852] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Cancer survivors require appropriate health care to manage their unique health needs. This study describes access to cancer care among cancer survivors in the United States and compares access to general medical care between cancer survivors and people who have no history of cancer. METHODS We assessed access to general medical care using the core 2011 Medical Expenditure Panel Survey (MEPS). We assessed access to cancer care using the MEPS Experiences With Cancer Survey. We used multivariable logistic regression to compare access to general medical care among 2 groups of cancer survivors (those who reported having access to all necessary cancer care [n = 1088] and those who did not [n = 70]) with self-reported access to general medical care among people who had no history of cancer (n = 22 434). RESULTS Of the 1158 cancer survivors, 70 (6.0%) reported that they did not receive all necessary cancer care. Adjusted analyses found that cancer survivors who reported not receiving all necessary cancer care were also less likely to report receiving general medical care (78.0%) than cancer survivors who reported having access to necessary cancer care (87.1%) and people who had no history of cancer (87.8%). CONCLUSIONS This study provides nationally representative data on the proportion of cancer survivors who have access to necessary cancer care and yields insight into factors that impede survivors' access to both cancer care and general medical care. This study is a reference for future work on access to care.
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Affiliation(s)
- Janet S de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Katherine S Virgo
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chunyu Li
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Neetu Chawla
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Xuesong Han
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | | | - Donatus U Ekwueme
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Juan L Rodriguez
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - K Robin Yabroff
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
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Evaluating the effect of clinical care pathways on quality of cancer care: analysis of breast, colon and rectal cancer pathways. J Cancer Res Clin Oncol 2016; 142:1079-89. [PMID: 26762849 DOI: 10.1007/s00432-015-2106-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/27/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Substantial gaps exist between clinical practice and evidence-based cancer care, potentially leading to adverse clinical outcomes and decreased quality of life for cancer patients. This study aimed to evaluate the usefulness of clinical pathways as a tool for improving quality of cancer care, using breast, colon, and rectal cancer pathways as demonstrations. METHODS Newly diagnosed patients with invasive breast, colon, and rectal cancer were enrolled as pre-pathway groups, while patients with the same diagnoses treated according to clinical pathways were recruited for post-pathway groups. RESULTS Compliance with preoperative core biopsy or fine-needle aspiration, utilization of sentinel lymph node biopsy, and proportion of patients whose tumor hormone receptor status was stated in pathology report were significantly increased after implementation of clinical pathway for breast cancer. For colon cancer, compliance with two care processes was significantly improved: surgical resection with anastomosis and resection of at least 12 lymph nodes. Regarding rectal cancer, there was a significant increase in compliance with preoperative evaluation of depth of tumor invasion, total mesorectal excision treatment of middle- or low-position rectal cancer, and proportion of patients who had undergone rectal cancer surgery whose pathology report included margin status. Moreover, total length of hospital stay was decreased remarkably for all three cancer types, and postoperative complications remained unchanged following implementation of the clinical pathways. CONCLUSIONS Clinical pathways can improve compliance with standard care by implementing evidence-based quality indicators in daily practice, which could serve as a useful tool for narrowing the gap between clinical practice and evidence-based care.
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Xiao C, Miller AH, Felger J, Mister D, Liu T, Torres MA. A prospective study of quality of life in breast cancer patients undergoing radiation therapy. Adv Radiat Oncol 2016; 1:10-16. [PMID: 27453954 PMCID: PMC4950982 DOI: 10.1016/j.adro.2016.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose The purpose of this study was to examine the impact of radiation therapy on quality of life (QOL) of breast cancer patients during and until 1 year after radiation therapy treatment. Methods and materials Thirty-nine breast cancer patients treated with breast-conserving surgery were enrolled in a prospective study before whole breast radiation therapy (50 Gy plus a 10-Gy boost). No patient received chemotherapy. Data were collected before, at week 6 of radiation therapy, and 6 weeks and 1 year after radiation therapy. The primary outcome variable was quality of life (QOL), measured by Medical Outcomes Study 36-Item Short Form Version 2 (SF-36). Risk factors potentially associated with total SF-36 scores and its physical and mental health component summary scores were also examined, including age, race, marital status, smoking history, menopausal status, endocrine treatment, cancer stage, sleep abnormalities (assessed by the Pittsburgh Sleep Quality Index), and perceived stress levels (assessed by the Perceived Stress Scale). Mixed effect modeling was used to observe QOL changes during and after radiation therapy. Results Total SF-36 scores did not change significantly during and up to 1 year after radiation therapy compared with baseline measures. Nevertheless, increased body mass index (BMI) and increased perceived stress were predictive of reduced total SF-36 scores over time (P = .0064, and P < .0001, respectively). In addition, increased BMI was predictive of reduced physical component summary scores of the SF-36 (P = .0011), whereas increased perceived stress was predictive of worse mental component summary scores (P < .0001). Other proposed potential risk factors including skin toxicity from radiation therapy were not significant. Conclusions Radiation therapy did not worsen QOL in breast cancer patients. However, pre-radiation therapy patient characteristics including BMI and perceived stress may be used to identify women who may experience decreased physical and mental function during and up to 1 year after radiation therapy.
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Affiliation(s)
- Canhua Xiao
- Emory University School of Nursing, Atlanta, Georgia
| | - Andrew H Miller
- Emory University Department of Psychiatry and Behavioral Sciences, Atlanta, Georgia
| | - Jennifer Felger
- Emory University Department of Psychiatry and Behavioral Sciences, Atlanta, Georgia
| | - Donna Mister
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Tian Liu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mylin A Torres
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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25
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Yu JI, Choi DH, Huh SJ, Park W, Nam SJ, Kim SW, Lee JE, Kil WH, Im YH, Ahn JS, Park YH. Proportion and clinical outcomes of postoperative radiotherapy omission after breast-conserving surgery in women with breast cancer. J Breast Cancer 2015; 18:50-6. [PMID: 25834611 PMCID: PMC4381123 DOI: 10.4048/jbc.2015.18.1.50] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/16/2015] [Indexed: 01/16/2023] Open
Abstract
PURPOSE The present study was conducted to investigate the proportion and clinical outcomes of breast cancer patients who did not receive postoperative radiotherapy (PORT) after breast-conserving surgery (BCS). METHODS This retrospective study included all breast cancer patients received curative BCS without PORT between 2003 and 2013. In the PORT omission group, characteristics and local recurrence differences were compared between the recommended group and the refused group. To compare the local recurrence-free survival (LRFS) of the PORT omission group and the control group who received PORT, subjects were selected by using the pooled data of patients treated between 1994 and 2007. RESULTS During the study period, 96 patients did not receive PORT among a total of 6,680 patients who underwent BCS. Therefore, the overall rate of PORT omission was 1.4%. Among the 96 patients, 20 were recommended for PORT omission (recommended group) and 76 refused PORT (refused group). The median follow-up period of all study participants was 19.3 months (range, 0.3-115.1 months). Patients in the recommended group were older (p=0.004), were more likely to be postmenopausal (p=0.013), and had more number of positive prognostic factors compared with the refused group. Overall, 12 cases of disease recurrence, including 11 cases of local recurrence, developed in the PORT-refused group. The LRFS of the PORT-omission group was significantly inferior to that of patients who received PORT after BCS (p<0.001). In the PORT-omission group, significant favorable prognostic factors for LRFS were having histologic grade 1 or 2 disease (p=0.023), having no axillary lymph node metastasis (p=0.039), receiving adjuvant endocrine therapy (p=0.046), and being in the recommended group (p=0.026). CONCLUSION The rate of PORT omission in the present study is very low among women who underwent surgery compared to that of other studies worldwide. PORT omission is significantly related to a high local recurrence rate.
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Affiliation(s)
- Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Jae Huh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Ho Kil
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Hyuck Im
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Ahn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeon Hee Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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26
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Arenas M, Sabater S, Gascón M, Henríquez I, Bueno MJ, Rius À, Rovirosa À, Gómez D, Lafuerza A, Biete A, Colomer J. Quality assurance in radiotherapy: analysis of the causes of not starting or early radiotherapy withdrawal. Radiat Oncol 2014; 9:260. [PMID: 25472662 PMCID: PMC4263009 DOI: 10.1186/s13014-014-0260-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 11/12/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The aim of this study was to analyse the reasons for not starting or for early of radiotherapy at the Radiation Oncology Department. METHODS All radiotherapy treatments from March 2010 to February 2012 were included. Early withdrawals from treatment those that never started recorded. Clinical, demographic and dosimetric variables were also noted. RESULTS From a total of 3250 patients treated and reviewed, 121 (4%) did not start or complete the planned treatment. Of those, 63 (52%) did not receive any radiotherapy fraction and 58 (48%) did not complete the course, 74% were male and 26% were female. The mean age was 67 ± 13 years. The most common primary tumour was lung (28%), followed by rectum (16%). The aim of treatment was 62% radical and 38% palliative, 44% of patients had metastases; the most common metastatic site was bone, followed by brain. In 38% of cases (46 patients) radiotherapy was administered concomitantly with chemotherapy (10 cases (22%) were rectal cancers). The most common reason for not beginning or for early withdrawal of treatment was clinical progression (58/121, 48%). Of those, 43% died (52/121), 35 of them because of the progression of the disease and 17 from other causes. Incomplete treatment regimens were due to toxicity (12/121 (10%), of which 10 patients underwent concomitant chemotherapy for rectal cancer). CONCLUSIONS The number of patients who did not complete their course of treatment is low, which shows good judgement in indications and patient selection. The most common reason for incomplete treatments was clinical progression. Rectal cancer treated with concomitant chemotherapy was the most frequent reason of the interruption of radiotherapy for toxicity.
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Affiliation(s)
- Meritxell Arenas
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Institut d'Investigacions Sanitàries Pere Virgili (IISPV), Universitat Rovira i Virgili (URV), Tarragona, Spain.
| | - Sebastià Sabater
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain.
| | - Marina Gascón
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Institut d'Investigacions Sanitàries Pere Virgili (IISPV), Universitat Rovira i Virgili (URV), Tarragona, Spain.
| | - Ivan Henríquez
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Institut d'Investigacions Sanitàries Pere Virgili (IISPV), Universitat Rovira i Virgili (URV), Tarragona, Spain.
| | - M José Bueno
- Department of Quality, Hospital Universitari Sant Joan de Reus, Tarragona, Spain.
| | - Àngels Rius
- Department of Statistics, Hospital Universitari Sant Joan de Reus, Tarragona, Spain.
| | - Àngels Rovirosa
- Department of Radiation Oncology, Hospital Universitari Clínic de Barcelona, Barcelona, Spain.
| | - David Gómez
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Institut d'Investigacions Sanitàries Pere Virgili (IISPV), Universitat Rovira i Virgili (URV), Tarragona, Spain.
| | - Anna Lafuerza
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Institut d'Investigacions Sanitàries Pere Virgili (IISPV), Universitat Rovira i Virgili (URV), Tarragona, Spain.
| | - Albert Biete
- Department of Radiation Oncology, Hospital Universitari Clínic de Barcelona, Barcelona, Spain.
| | - Jordi Colomer
- Hospital Universitari Sant Joan de Reus and Group SAGESSA (Assistència Sanitària i Social), Tarragona, Spain.
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