Patterns of radiotherapy for cancer patients in south-eastern Netherlands, 1975-1989

Elderly patients with painful bone metastases should be offered palliative radiotherapy

PURPOSE

To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients.

METHODS AND MATERIALS

The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed.

RESULTS

No significant difference was found in the response rate in patients aged >or=65, >or=70, and >or=75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status.

CONCLUSION

Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.

A population-based study of radiotherapy in a cohort of patients with rectal cancer diagnosed between 1996 and 2000

AIMS

To study, in a population-based setting, the use of delayed radiotherapy (RT) in a cohort of 2008 unselected rectal cancer patients diagnosed between 1996 and 2000.

PATIENTS AND METHODS

Radiation within 6 months of diagnosis was considered part of the primary treatment (PRT). RT given 6 months or later after diagnosis or after PRT was considered as delayed or secondary RT (SRT). Number, percentage and cumulative proportion of patients receiving SRT were calculated. The odds for receiving SRT (total and for recurrent rectal cancer only) were studied by logistic regression analysis, taking into account age, gender, co-morbidity, socio-economic status, stage, prior PRT and RT department (2 departments, each serving general hospitals only).

RESULTS

Forty-six percent of all newly diagnosed patients received RT. Ten percent (n=203) received at least once SRT, either after PRT or as first RT, of which 96 patients for a relapsed rectal tumour (31 after PRT on the rectal tumour, 65 as a first radiation treatment). In a multivariate analysis of patients with rectal recurrence secondary pelvic irradiation was less often given after primary irradiation (OR: 0.7, 95% CI: 0.4-1.1). Patients with a stage III significantly more often received SRT on a recurrence (OR=2.5, 95% CI=1.4-4.5). Generally, patients in the eastern department received more often PRT and less often SRT for recurrence (OR: 0.5, 95% CI: 0.3-0.8).

CONCLUSIONS

Five percent of all patients with rectal cancer received SRT on a recurrent tumour, with a large variation between the two RT departments in the region.

A population based study of radiotherapy in a cohort of patients with breast cancer diagnosed between 1996 and 2000

We studied the use of radiotherapy (RT) (especially secondary RT) in a cohort of 6561 patients in southern Netherlands with invasive breast cancer diagnosed between 1996 and 2000 (median follow-up: 66 months, range 0-107 months). Radiation within 6 months of diagnosis was considered primary RT (PRT). RT given 6 months or later after diagnosis or after PRT was considered secondary RT (SRT). Of all patients, 67% received RT, 3554 only PRT, 323 only SRT and 503 both. The cumulative use of SRT at 100 months was 17%. The 826 patients receiving SRT underwent 1846 courses 0-105 months (median 36) after diagnosis; the retreat rate was 35%. Elderly patients received SRT significantly less often (OR(age50-69)=0.7, 95%CI=0.6-0.8, OR(age> or 70)=0.4, 95%CI=0.3-0.5). The following factors increased the chance for SRT: patients from the eastern region (OR=1.3, 95%CI=1.1-1.6); patients who received PRT (OR=1.3, 95%CI=1.0-1.5) and patients who underwent mastectomy including axillary node dissection as well as unresected patients (OR=1.9, 95%CI=1.5-2.4, OR=2.6, 95%CI=1.7-3.9, respectively). Thirteen percent of all patients with breast cancer received SRT, with a large variation in age and between the 2 RT departments in the region.

Accessibility as a major determinant of radiotherapy underutilization: A population based study

BACKGROUND AND PURPOSE

A survey was conducted of radiotherapy (RT) resources and utilization in a northwestern Italian Region in order to assess geographical variations in radiotherapy utilization rates, and the effects of infrastructure supply on accessibility.

MATERIALS AND METHODS

The survey was conducted by analysing standardized utilization rates based on administrative records. The data were analysed at both Regional and Local Health Unit (LHU) level.

RESULTS

Wide variation was found among LHUs RT utilization rates--the sex- and age-standardized rates varied from 1.8/1000 inhabitants to more than 3/1000 inhabitants. Patients resident in LHUs with no RT service showed a lower probability of accessing RT (standardized rate ratio (SRR), 0.82; 95%IC, 0.80-0.85). The utilization rate decreased in relation to the distance between a patient's residence and the nearest RT service; the reduction was greater for patients > or =70 years of age.

CONCLUSION

The wide geographic variation implies lack of equity in access to services. Utilization levels decreased significantly with increasing distance from the nearest RT service, distance being a barrier to access particularly for older persons. The heterogeneous distribution of services on the Regional territory seems a relevant explanation of differences in utilization rates.

Referral rates and trends in radiotherapy as part of primary treatment of cancer in South Netherlands, 1988–2002

BACKGROUND AND PURPOSE

To study referral rates and time trends in the use of primary radiotherapy (RT).

PATIENTS AND METHODS

The proportion and number of irradiated patients were calculated in a population-based setting among 58,436 cancer patients diagnosed between 1988 and 2002.

RESULTS

The number of patients receiving RT within 6 months of diagnosis (RT6mo) increased by about 3.3% annually, the proportion of all incident cases that received RT6mo remained stable (+/-30%). Only 20% of elderly patients (75+) received RT6mo. The proportion of cancer patients that received RT6mo increased markedly between 1988-1992 and 1998-2002 for patients with prostate cancer (15 and 28%, respectively), rectal cancer (33 and 43%) and brain tumours (48 and 67%). The absolute number of irradiated breast cancer patients increased 30% between 1988 and 2002. Among patients with rectal cancer, a shift occurred from postoperative to preoperative RT since 1995. The percentage of irradiated patients with stage I endometrial cancer decreased from 47% in 1988-1992 to 15% in 1998-2002.

CONCLUSIONS

The percentage of cancer patients who received primary RT remained stable throughout 1988-2002, being consistently lower for older patients. The increased number of irradiated patients was due mainly to earlier detection and the ageing of the population. To clarify the overall percentage of patients irradiated, population-based studies on RT given after 6 months since diagnosis are warranted.

Hospital variation in referral for primary radiotherapy in South Netherlands, 1988–1999

In this study, we have assessed whether referral for primary radiotherapy varied according to hospital size in a region with 1 million inhabitants served by community hospitals. We studied 20178 patients diagnosed with breast, non-small cell lung, prostate, rectal, or endometrial cancer between 1988 and 1999. We used logistic regression analysis, adjusted for age, stage and period of diagnosis. Medium-sized and small hospitals referred breast cancer patients more often (OR=2.2, 95%CI: 2.0-2.5, OR=1.2, 95%CI: 1.1-1.4, respectively), and patients with prostate cancer less often (OR=0.7 (0.5-0.8) and 0.7 (0.6-0.9), respectively). Referral rates for patients with non-small cell lung and rectal cancer showed minor differences according to hospital size, referral for endometrial cancer was somewhat higher for patients from medium-sized hospitals (OR=1.5 (1.0-2.1)). Time trends in variation were shown, but differences according to hospital size only decreased over time for rectal cancer. Despite multidisciplinary oncology meetings and treatment guidelines there were large variations in rates of referral for radiotherapy.

Stable overall referral rates of primary radiotherapy for newly diagnosed cancer patients in the ageing population of South-Eastern Netherlands, 1975–1998

BACKGROUND AND PURPOSE

To determine the primary radiotherapy (RT) consumption in a population of almost one million inhabitants, served by one RT centre. Primary RT was defined as being planned, started or finished within 4-6 months of diagnosis. Application was evaluated according to tumour category, stage and year of diagnosis during three 8-year periods: 1975-1982, 1983 -1990 and 1991-1998.

RESULTS

Most patients were between 60 and 75 years. The number of patients receiving primary RT increased with 3% annually over the whole studied period, but remained proportionally stable for males at 30% and decreased for females from 36.2 to 34.6%. A decrease of referral rates for patients with gynaecological cancer was observed. The introduction of breast-conserving therapy in 1981 and of population screening for women aged 50-69 years in 1992 led to a considerable increase of primary RT. The eightfold increase in number of irradiated patients with localised prostate cancer rather reflected a higher detection rate than an increased referral rate. Except for an important increase of irradiated patients with rectal cancer, largely due to the shift to preoperative RT since 1994, and of patients with brain cancer, only slight alterations in referral rates were observed for the other cancers.

CONCLUSIONS

Use of primary RT remained proportionally steady and modest. The marked increase in workload was mainly due to more and earlier detection of breast and prostate cancer and treatment changes in rectal cancer. Decreases were observed for each of the gynecological cancers.

Brachytherapy in the elderly

A rapidly and constantly increasing aged population in the western countries poses a wide range of specific problems to oncologists. A different way to face medical issues should be sought for older patients with cancer, looking at the characteristics that are peculiar to the elderly from different points of view. Brachytherapy is an effective form of radiotherapy which, for its specific characteristics, may be a valid alternative to more complex modalities of treatment, thus allowing a better sparing of normal tissues and structures yet achieving a similar tumor control rate. This paper reviews the literature on the subject of cancer treatment in the elderly, focusing on radiotherapy and brachytherapy, to evaluate the current attitude toward this problem in the medical community and to see if it is possible to identify a patient population that will benefit from this technique.

Symptom duration and delay in referral for palliative radiotherapy in cancer patients: a pilot study

OBJECTIVE

To estimate the frequency of delay in referral for palliative radiotherapy (PRT), and to identify factors associated with delay.

DESIGN

Prospective survey over three months in 1997.

SETTING

Radiotherapy department of a cancer centre in Melbourne, Victoria.

PARTICIPANTS

158 consecutive patients prescribed PRT in the lung, breast, urology and haematology units.

MAIN OUTCOME MEASURES

Duration of symptoms; incidence of "unreasonable" delay in referral; and incidence of negative clinical outcome associated with referral delay.

RESULTS

The median duration of symptoms before prescription of radiotherapy was four weeks. Thirty-eight patients (24%) were considered to have had an unreasonable delay in referral, with median symptom duration of 15 weeks, and median delay in referral of 12 weeks. Causes of delay were classified as "diagnostic uncertainty" (29%), "other treatment given" (18%), "patient related" (18%), "language difficulty" (3%), and "unexplained" (32%). Twenty-seven of these 38 patients (71%) had negative outcomes, including persistent pain, neurological deterioration and persistent respiratory symptoms.

CONCLUSIONS

These data suggest that delay in referral for PRT is not uncommon, has a variety of causes and can result in negative clinical outcomes. There appears to be a need for greater awareness of patients' symptoms and of the role of PRT among clinicians caring for patients with cancer.

Radiotherapy of prostate cancer: established results and new developments

Radical radiotherapy has been established as an effective modality for eradicating localised prostate cancer. No satisfactory comparisons have been made with patients treated by total prostatectomy, but in surgically staged patients with negative lymph nodes survival after radiotherapy exceeds that of an aged matched population, cancer deaths occurring in only 6-15% of patients and 85% remaining free of local recurrence after 10 years. Results are predictably less satisfactory in surgically unstaged cases and for more advanced localised presentations. Nevertheless, radical radiotherapy achieves local control of disease in the majority of patients. Improved local control may be obtained by increasing radiation dose but at the expense of increased radiation-induced side-effects. Conformal radiotherapy and combined modality treatment with the neoadjuvant or adjuvant androgen deprivation show considerable promise as novel methods to improve the therapeutic ratio, and prospective randomised studies are underway to test these approaches.