Waiting for radiotherapy in Ontario

Cervical Cancer Progression in Patients Waiting for Radiotherapy Treatment at a Referral Center in Ethiopia: A Longitudinal Study

PURPOSE

Nonmetastatic cervical cancer is curable and can be treated with radiotherapy (RT). A delay in receiving treatment because of long waiting times results in upstaging of the disease stage and negatively affects the treatment outcomes. However, real-world evidence that progression occurs while waiting for treatment is scarce in low-income countries. We evaluated the impact of long waiting times for RT in patients with cervical cancer at a referral center in Ethiopia.

METHODS

A longitudinal study was conducted from January 5, 2019, to May 30, 2020, to address the objectives of this study. Patients with pathologically diagnosed cervical cancer with stage IIB to stage IVA were included in the study. We used Kaplan-Meier analysis to assess overall survival with time. Multivariate Cox regression analysis, using the backward likelihood ratio selection method, was used to fit the final model.

RESULTS

The median waiting time for radical RT after diagnosis was 477 days. Waiting for more than 51 days for RT results in disease progression. Of the 115 patients included in this study, 59 (51.3%) died during the study period. A delay in waiting (adjusted hazard ratio, 3; 95% CI, 1.7 to 4.9) was significantly associated with disease progression and decreased survival.

CONCLUSION

Waiting time to receive RT is very long. Urgent action is required to significantly reduce waiting times and improve the survival of patients with cervical cancer.

Interest of para-aortic lymphadenectomy for locally advanced cervical cancer in the era of PET scanning

BACKGROUND AND OBJECTIVES

Treatment of locally advanced cervical cancer (LACC) involves pelvic chemoradiotherapy, using an extended field in the case of para-aortic involvement. 18-Fluoro-D-glucose positron emission tomography combined with computer tomography (PET-CT) is an accurate method for the detection of metastatic nodes. The objective of this study was to evaluate the performance of PET-CT for lymph node staging of LACC.

METHODS

This bicentric retrospective study included patients with LACC who had a PET-CT scan followed by para-aortic lymphadenectomy between January 2015 and December 2019. Based on pathological findings, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and false-negative (FN) rates of PET-CT for para-aortic node involvement were evaluated.

RESULTS

Seventy-one patients who had undergone laparoscopic lymphadenectomy were included in this study. The intraoperative complication rate was 2.8%. Sensitivity, specificity, NPV and PPV for PET-CT were 55% [95% confidence interval (CI) 44.6-67.1], 84% (95% CI 75-92), 93% (95% CI 87-99) and 33% (95% CI 22-44), respectively. FN rates in the case of negative or positive pelvic PET-CT were 5.7% and 9.5%, respectively.

CONCLUSIONS

Para-aortic lymphadenectomy is recommended for lymph node staging in the case of negative para-aortic PET-CT. In view of the low FN rate of PET-CT, surgical staging should be discussed regardless of pelvic status if the patient presents high surgical risk, or if this delays the commencement of chemoradiotherapy.

The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report

AIMS

Moderately hypofractionated breast irradiation has been evaluated in several prospective studies, resulting in wide acceptance of shorter treatment protocols for postoperative breast irradiation. Reimbursement for radiation therapy varies between private and public systems and between countries, impacting variably financial considerations in the use of hypofractionation. The aim of this study was to evaluate the financial impact of moderately hypofractionated breast irradiation by reimbursement system in different countries.

MATERIALS AND METHODS

The study was designed by an international group of radiation oncologists. A web-questionnaire was distributed to representatives from each country. The participants were asked to involve the financial consultant at their institution.

RESULTS

Data from 13 countries from all populated continents were collected (Europe: Denmark, France, Italy, the Netherlands, Spain, UK; North America: Canada, USA; South America: Brazil; Africa: South Africa; Oceania: Australia; Asia: Israel, Taiwan). Clinicians and/or departments in most of the countries surveyed (77%) receive remuneration based on the number of fractions delivered to the patient. The financial loss per patient estimated resulting from applying moderately hypofractionated breast irradiation instead of conventional fractionation ranged from 5-10% to 30-40%, depending on the healthcare provider.

CONCLUSION

Although a generalised adoption of moderately hypofractionated breast irradiation would allow for a considerable reduction in social and economic burden, the financial loss for the healthcare providers induced by fee-for-service remuneration may be a factor in the slow uptake of these regimens. Therefore, fee-for-service reimbursement may not be preferable for radiation oncology. We propose that an alternative system of remuneration, such as bundled payments based on stage and diagnosis, may provide more value for all stakeholders.

Mental Health Resource Use Among Patients Undergoing Curative Intent Treatment for Bladder Cancer

BACKGROUND

Patients with bladder cancer may experience mental health distress. Mental health-care service (MHS) use can quantify the magnitude of the problem.

METHODS

The Ontario Cancer Registry was used to identify all patients with bladder cancer treated with curative-intent cystectomy or radiotherapy in Ontario, Canada (2004-2013). Population-level databases were used to identify MHS use (visits to general practitioner, psychiatrist, emergency department, or hospitalization). Generalized estimating equations were used to compare rates of MHS use. Baseline, peritreatment, and posttreatment MHS use were defined as visits from 2 years to 3 months before, 3 months before to 3 months after, and from 3 months after to 2 years after start of treatment, respectively.

RESULTS

From 2004 to 2013, 4296 patients underwent cystectomy (n = 3332) or curative-intent radiotherapy (n = 964). Compared with baseline, the rate of MHS use was higher in the peritreatment (adjusted rate ratio [aRR] = 1.64, 95% confidence interval [CI] = 1.48 to 1.82) and posttreatment periods (aRR = 1.45, 95% CI =1.30 to 1.63). By 2 years posttreatment, 24.6% (95% CI = 23.4% to 25.9%) of all patients had MHS use. Patients with baseline MHS use had substantially higher MHS use in the peritreatment (aRR = 5.77, 95% CI = 4.86 to 6.86) and posttreatment periods (aRR = 4.58, 95% CI = 3.78 to 5.55). Female patients had higher use MHS use overall, but males had a higher incremental increase in the posttreatment period compared with baseline (2-sided Pinteraction = .02). Male patients had a statistically significant increase in MHS use following surgery or radiotherapy, whereas female patients only had an increase following surgery.

CONCLUSIONS

MHS use is common among patients undergoing treatment for bladder cancer, particularly in the peritreatment period. Screening for mental health concerns in this population is warranted.

Radiotherapy waiting time in Northern Nigeria: experience from a resource-limited setting

Background

Access and availability of radiotherapy treatment is limited in most low- and middle-income countries, which leads to long waiting times and poor clinical outcomes. The aim of our study is to determine the magnitude of waiting times for radiotherapy in a resource-limited setting.

Methods

This is a retrospective cohort study of patients with the five most commonly treated cancers managed with radiotherapy between 2010 and 2014. Data includes diagnosis, patients’ demographics and treatment provided. The waiting time was categorised into intervals (1) between diagnosis and first radiation consultation (2) First consultation to radiotherapy treatment (3) Decision-to-treat to treatment and (4) Diagnosis to treatment.

Results

A total of 258 cases were involved, including cervical (50%; 129/258), breast (27.5%; 71/258), nasopharynx (12.8%; 33/258), colorectal (5%; 13/258) and prostate cancers (4.7%; 12/258). Mean age was 48 (±12.9) years. Treatment with radical intent comprised 67% (178/258) of cases, while 33% (80/258) had palliative treatment. The median time from diagnosis to first radiation consultation was 40 (IQR 17–157.75) days for all the patients, with prostate cancer having the longest time – 305 days (IQR 41–393.8). The median time between the first radiation oncology consultations and first radiotherapy treatment was 130.5 (IQR 14–211.5) days; cervical cancer patients waited a median of 139 (IQR 13–195.5) days. The median time between diagnosis and first radiotherapy for breast cancer patients was 329 (IQR 207–464) days, compared to 213 (IQR 101.5–353.5) days for all the patients.

Conclusion

The study shows that waiting time for radiotherapy in Nigeria was generally longer than what is recommended internationally. This reflects the need to improve access to radiotherapy in order to improve cancer treatment outcomes in resource-limited settings.

Waiting times for prostate cancer: A review

Prostate cancer is one of the most common diagnosed cancers in men and the waiting time has become an important issue not only for clinical reasons, but also mostly for the psychological implications on patients. The aim of our study was to review and analyze the literature on waiting times for prostate cancer. In February-March 2019 we performed a search for original peerreviewed papers in the electronic database PubMed (MEDLINE). The key search terms were "prostate cancer AND waiting list", "prostate cancer AND waiting times". We included in our narrative review articles in Italian, English or French, published in 2009-2019 containing original data about the waiting times for prostate cancer. The literature search yielded 680 publications. Finally, we identified 8 manuscripts eligible for the review. The articles were published between 2010 and 2019; the studies involved a minimum of 16 to a maximum of 95438 participants. Studies have been conducted in 6 countries. The waiting times from cancer suspicion to histopathological diagnosis and to treatment had an important reduction in the last years, and this constant decrease could lead to an increase of patients' satisfaction.

Association between waiting time for radiotherapy after surgery for early-stage breast cancer and survival outcomes in Ontario: a population-based outcomes study

Background

After surgery for early-stage breast cancer (bca), adjuvant radiotherapy (rt) decreases the risk of locoregional recurrence and death from bca. It is unclear whether delays to the initiation of adjuvant rt are associated with inferior survival outcomes.

Methods

This population-based retrospective cohort study included a random sample of 25% of all women with stage i or ii bca treated with adjuvant rt in Ontario between 1 September 2001 and 31 August 2002, when, because of capacity issues, wait times for radiation were abnormally long. Pathology reports were manually abstracted and deterministically linked to population-level administrative databases to obtain information about recurrence and survival outcomes. Cox proportional hazards modelling was used to evaluate the association between waiting time and survival outcomes. A composite survival outcome was used to ensure that all possible measurable harms of delay would be captured. The composite outcome, event-free survival, included locoregional recurrence, development of metastatic disease, and bca-specific mortality.

Results

We identified 1028 women with stage i or ii bca who were treated with breast-conserving surgery and adjuvant rt. For the 599 women who were treated with adjuvant radiation without intervening chemotherapy, a waiting time of 12 weeks or more from surgery to the start of radiation appeared to be associated with worse event-free survival after a median follow-up of 7.2 years (hazard ratio for the composite outcome: 1.44; 95% confidence interval: 0.98 to 2.11; p = 0.07). For the 429 women who received intervening adjuvant chemotherapy, a waiting time of 6 weeks or more from completion of chemotherapy to start of radiation was associated with worse event-free survival after a median follow-up of 7.4 years (hazard ratio: 1.50; 95% confidence interval: 1.00 to 2.22; p = 0.047).

Conclusions

Delay to the initiation of adjuvant rt after breast-conserving surgery is associated with inferior bca survival outcomes. The good prognosis for patients with early-stage bca limits the statistical power to detect an effect of delay to rt. Given that there is no plausible advantage to delay, we agree with Mackillop that time to initiation of rt should be kept "as short as reasonably achievable."

The Capital Investment Strategy for Radiation therapy in Ontario: A Framework to Ensure Access to Radiation Therapy

Purpose

Ontario Health (Cancer Care Ontario), formerly known as CCO, is the provincial governmental agency in Ontario, Canada responsible for developing radiation therapy-specific capital investment strategies, updated every 5 years, to ensure equitable access and to gain the highest value from these investments in infrastructure. These plans are informed by the changing landscape of health care delivery, technologic advancements affecting radiation therapy care, patient desire for care closer to home, and expected increases in utilization of radiation therapy services. In this article, we describe the development, model, and final recommendations of CCO's fifth radiation therapy capital investment strategy.

Methods and Materials

A panel of multidisciplinary provincial experts, in combination with 2 patient and family advisors, developed planning principles to guide the development of a patient-centered strategy. Adaption of the previously used model for radiation therapy planning was used.

Results

The development of the capital investment strategy took place from fall 2017 to fall 2018. The model included 3 main factors: patient demand (including utilization targets), machine throughput, and machine demand and supply. The final recommendation is for an investment of 26 new radiation therapy machines in the province by 2028.

Conclusions

The strategy plans for continued province-wide access to quality radiation therapy care and ensures machines are added to the system at the right place and in the right time. Ongoing data collection throughout this period is necessary to ensure the strategy achieves its goals and to allow for planning of future strategies.

Real-world data: towards achieving the achievable in cancer care

The use of data from the real world to address clinical and policy-relevant questions that cannot be answered using data from clinical trials is garnering increased interest. Indeed, data from cancer registries and linked treatment records can provide unique insights into patients, treatments and outcomes in routine oncology practice. In this Review, we explore the quality of real-world data (RWD), provide a framework for the use of RWD and draw attention to the methodological pitfalls inherent to using RWD in studies of comparative effectiveness. Randomized controlled trials and RWD remain complementary forms of medical evidence; studies using RWD should not be used as substitutes for clinical trials. The comparison of outcomes between nonrandomized groups of patients who have received different treatments in routine practice remains problematic. Accordingly, comparative effectiveness studies need to be designed and interpreted very carefully. With due diligence, RWD can be used to identify and close gaps in health care, offering the potential for short-term improvement in health-care systems by enabling them to achieve the achievable.

Use of radiotherapy for bladder cancer: A population-based study of evolving referral and practice patterns

INTRODUCTION

Definitive treatment for muscle-invasive bladder cancer includes either cystectomy or radiotherapy (RT). We describe use of RT and radiation oncology (RO) referral patterns in the contemporary era.

METHODS

The Ontario Cancer Registry and linked records of treatment were used to identify all patients who received cystectomy or RT for bladder cancer from 1994-2013. Physician billing records were linked to identify RO consultation before radical treatment. Multilevel logistic regression models were used to examine patient factors and physician-level variation in referral to RO and use of RT.

RESULTS

A total of 7461 patients underwent cystectomy or RT for bladder cancer from 1994-2013; 5574 (75%) had cystectomy and 1887 (25%) had RT. Use of RT decreased from 43% (126/289) in 1994 to 23% (112/478) in 2008 and remained stable from 2009-2013 (23%, 507/2202). RO referral rate among all cases decreased from 46% (134/289) in 1994 to 30% (143/478) in 2008; however, the rates began to rise in the contemporary era from 31% (137/442) in 2009 to 37% (165/448) in 2013 (p=0.03). Patient factors associated with use of RT include older age, greater comorbidity, and geographic location. Surgeon-level factors associated with greater preoperative referral to RO include higher surgeon case volume and practicing in a teaching hospital.

CONCLUSIONS

One-quarter of patients treated with curative intent therapy for bladder cancer receive RT. While referral rates to RO are increasing, future data will identify the extent to which this has altered practice. Collaborative efforts promoting multidisciplinary care and RO consultation before radical treatment are warranted.

Hypofractionated radiation treatment in the management of breast cancer

INTRODUCTION

The standard treatment for early-stage breast cancer is breast conservation therapy, consisting of breast conserving surgery followed by adjuvant radiation treatment (RT). Conventionally-fractionated whole breast irradiation (CF-WBI) has been the standard RT regimen, but recently shorter courses of hypofractionated whole breast irradiation (HF-WBI) have been advocated for patient convenience and reduction in healthcare costs and resources. Areas covered: This review covers the major randomized European and Canadian trials comparing HF-WBI to CF-WBI with long-term follow-up, as well as additional recently closed randomized trials that further seek to define the applicability of HF-WBI in clinical practice. Randomized data is summarized in terms of clinical utility and for a variety of clinical applications. Recently published consensus guidelines and practical implementation of HF-WBI including its broader effect on the healthcare system are reviewed. Finally, an assessment of the emerging evidence in support of hypofractionation for locally advanced disease is presented. Expert commentary: HF-WBI has replaced CF-WBI as the accepted standard of care in most women with early-stage breast cancer who do not require regional nodal irradiation. Early data supports the continued study of hypofractionation in the locally advanced setting, however broad adoption awaits longer follow-up and additional data from ongoing clinical trials.

Laparoscopic paraaortic surgical staging in locally advanced cervical cancer: a single-center experience

BACKGROUND

One aim of this study was to assess the efficacy and safety of laparoscopic paraaortic lymphadenectomy for paraaortic lymph node staging in locally advanced cervical carcinoma. The second aim was to identify prognostic factors in the evolution of this disease and to evaluate how the results of the surgery modify the oncological treatment of patients.

MATERIALS AND METHODS

We analyzed 59 patients diagnosed with locally advanced cervical cancer International Federation of Gynecology and Obstetrics stage IB2-IVA who underwent laparoscopic paraaortic lymphadenectomy at our hospital between 2009 and 2015. Depending on the results of the paraaortic lymphadenectomy, treatment consisted of pelvic- or extended-field chemoradiotherapy.

RESULTS

The mean age at diagnosis was 52.3 years. The median operative time was 180 min. The mean hospital stay was 1.7 days. The mean number of paraaortic lymph nodes excised was 16.4. Eight patients (13.5%) had positive paraaortic lymph nodes. Thirteen patients (22%) underwent surgery via the transperitoneal route, and 46 (78%) underwent surgery via the retroperitoneal route. The sensitivity and specificity of computerized axial tomography (CT) scanning for detecting paraaortic lymph node involvement was 75 and 86%, respectively. The statistically significant prognostic factors that affected survival were surgical paraaortic lymph node involvement, radiological pelvic lymph node involvement, and radiological tumor size as assessed with nuclear magnetic resonance. The rate of serious complications was 1.7%.

CONCLUSIONS

Pretherapeutic laparoscopic paraaortic lymphadenectomy for locally advanced cervical carcinoma allows the adaption of radiotherapy fields to avoid false-positive and false-negative imaging results.

Measures of Late Effects in Conservative Treatment of Breast Cancer with Standard or Hypofractionated Radiotherapy

Aims and Background

To confirm the equivalence in terms of late effects between two fractionation schedules of radiotherapy in conservative treatment of breast cancer.

Methods

Fifty-eight patients treated at our institution from 1999 to 2002, with a median follow-up of 15 months (range, 7-46 months), were evaluated retrospectively. Twenty-nine patients (group A) were treated with standard fractionation: 5000 cGy/25fx/5 weeks, and 29 patients (group B) were treated with a hypofractionated schedule: 4500 cGy/15fx/5 weeks, three fractions per week. Late effects were evaluated using the LENT-SOMA scoring scale. The cosmetic results were assessed on a five-point scale. Skin elasticity was measured using a dedicated device (Cutometer SEM 575).

Results

There were no differences in breast volume, age at diagnosis and follow-up between groups. The LENT-SOMA toxicity observed in groups A and B, respectively, was as follows: grade 2-3 pain in five patients in each group; grade 2 breast edema in two and three patients; grade 2-3 and grade 2 fibrosis in six and eight patients; grade 2 and grade 2-3 telangiectasia in two and three patients; grade ≥2 and 2 arm edema in two and one patients; no ulceration or atrophy were observed. Two patients in group A and one patient in group B needed treatment for breast and arm edema and arm edema, respectively. Very good, good-acceptable, and poor cosmetic results were observed in seven and two, fifteen and nineteen, and six and eight patients, respectively. Median skin elasticity loss due to treatment was −4.19% in group A and −6.29% in group B. These results are not statistically different.

Conclusions

LENT-SOMA toxicities were minimal and no differences were observed between groups. Few patients in the hypofractionated group had very good cosmetic results, but it is debatable if radiotherapy was the only cause. Skin elasticity was not different between groups. Our results seem to suggest that it is possible to treat patients with both schedules, with similar late toxicity.

Temporal trends in management and outcomes of testicular cancer: A population-based study

BACKGROUND

Treatment guidelines for early-stage testicular cancer have increasingly recommended de-escalation of therapy with surveillance strategies. This study was designed to describe temporal trends in routine clinical practice and to determine whether de-escalation of therapy is associated with inferior survival in the general population.

METHODS

The Ontario Cancer Registry was linked to electronic records of treatment to identify all patients diagnosed with testicular cancer treated with orchiectomy in Ontario during 2000-2010. Treatment after orchiectomy was classified as radiotherapy (RT), retroperitoneal lymph node dissection (RPLND), chemotherapy, or none. Surveillance was defined as no identified treatment within 90 days of orchiectomy. Overall survival (OS) and cancer-specific survival (CSS) were measured from the date of orchiectomy.

RESULTS

The study population included 1564 and 1086 cases of seminomas and nonseminoma germ cell tumors (NSGCTs), respectively. Among patients with seminomas, there was a significant increase in the proportion of patients with no treatment within 90 days of orchiectomy (from 56% to 84%; P < .001); the use of RT decreased over time (from 38% to 8%; P < .001); and the use of chemotherapy remained stable (from 6% to 9%; P = .289). Practice patterns 90 days after orchiectomy remained stable over time among patients with NSGCTs: from 51% to 57% for no treatment (P = .435), from 43% to 43% for chemotherapy (P = .336), and from 9% to 3% for RPLND (P = .476). The OS rates for the entire cohort at 5 and 10 years were 97% and 96%, respectively; the CSS rates were 98% and 98%, respectively. There was no significant change in OS or CSS for patients with seminomas or NSGCTs during the study period.

CONCLUSIONS

There has been substantial de-escalation in the treatment of testicular cancer in routine practice since 2000. Long-term survival in routine practice is excellent and has not decreased with the uptake of surveillance strategies. Cancer 2018;124:2724-2732. © 2018 American Cancer Society.

Assessment of Oropharyngeal and Laryngeal Cancer Treatment Delay in a Private and Safety Net Hospital System

Objective

To examine the impact of treatment setting and demographic factors on oropharyngeal and laryngeal cancer time to treatment initiation (TTI).

Study Design

Retrospective case series.

Setting

Safety net hospital and adjacent private academic hospital.

Subjects and Methods

Demographic, staging, and treatment details were retrospectively collected for 239 patients treated from January 1, 2014, to June 30, 2016. TTI was defined as days between diagnostic biopsy and initiation of curative treatment (defined as first day of radiotherapy [RT], surgery, or chemotherapy).

Results

On multivariable analysis, safety net hospital treatment (vs private academic hospital treatment), initial diagnosis at outside hospital, and oropharyngeal cancer (vs laryngeal cancer) were all associated with increased TTI. Surgical treatment, severe comorbidity, and both N1 and N2 status were associated with decreased TTI.

Conclusion

Safety net hospital treatment was associated with increased TTI. No differences in TTI were found when language spoken and socioeconomic status were examined in the overall cohort.

Variability of waiting times for the 4 most prevalent cancer types in Ontario: a retrospective population-based analysis

BACKGROUND

Longer waiting times in cancer care are associated with lower care quality and wait-related patient dissatisfaction. We analyzed the variability and median of waiting times from when a patient seeks care to first treatment for the 4 most prevalent cancer types in Ontario.

METHODS

Using retrospective health administrative data, we identified patients with a new diagnosis of prostate, breast, lung or colorectal cancer in Ontario between 2002 and 2012. Treatment interventions were categorized as chemotherapy, radiotherapy or surgery. We used regression analyses to calculate trends for the coefficient of variation, the Gini coefficient and the median waiting time for each cancer type-treatment type pair over the study period.

RESULTS

During the study period, 95 501 new cases of prostate cancer, 89 244 breast cancer cases, 82 604 lung cancer cases and 80 761 colorectal cancer cases were registered. The coefficient of variation and the Gini coefficient of waiting times decreased for all cancer type-treatment type pairs (except for the Gini coefficient for breast cancer-radiotherapy) over the study period. However, both decreasing and increasing trends in median waiting times were observed across cancer type-treatment type pairs.

INTERPRETATION

The variability of waiting time to first treatment for patients with prostate, breast, lung or colorectal cancer decreased between 2002 and 2012, which indicates improvements in equity in access to cancer care. This trend aligns with provincial efforts to improve access to and the efficiency of cancer care treatment in Ontario. The lack of consistent decreases in median waiting time highlights the need to identify improvement opportunities for cancer type-treatment type pairs with increasing median waiting times.

Testing the Timing: Time Factor in Radiation Treatment for Head and Neck Cancers

OPINION STATEMENT

Overall radiation treatment time has long been recognized as an important factor in head and neck tumor control. The concern of tumor growth in waiting time either before starting radiotherapy or during treatment is substantial given its negative impact on clinical outcome. There is an overwhelming evidence that increasing the time to initiate treatment increases the tumor burden and worsens the prognosis. This effect is more pronounced especially in patients with an early stage cancer disease. Delay in treatment initiation is contributed by both health care- and patient-related factors. Health care-related factors include advancement in diagnostic modalities and transfer of patient to academic health care centers accompanied by delayed referrals and long-awaited appointments. Patient-related factors include delayed reporting time and socioeconomic factors. An efficient transition of care along with access of cancer care modalities to community health care centers will not only improve the quality of care in secondary health care centers but also help decrease the patient burden in tertiary centers. A quick and well-structured multidisciplinary appointment program is fundamental in shortening the time required for patient referrals, thus increasing the optimal survival time for Head and Neck cancer patients with early initiation of treatment.

Integer programming for improving radiotherapy treatment efficiency

Background and purpose

Patients received by radiotherapy departments are diverse and may be diagnosed with different cancers. Therefore, they need different radiotherapy treatment plans and thus have different needs for medical resources. This research aims to explore the best method of scheduling the admission of patients receiving radiotherapy so as to reduce patient loss and maximize the usage efficiency of service resources.

Materials and methods

A mix integer programming (MIP) model integrated with special features of radiotherapy is constructed. The data used here is based on the historical data collected and we propose an exact method to solve the MIP model.

Results

Compared with the traditional First Come First Served (FCFS) method, the new method has boosted patient admission as well as the usage of linear accelerators (LINAC) and beds.

Conclusions

The integer programming model can be used to describe the complex problem of scheduling radio-receiving patients, to identify the bottleneck resources that hinder patient admission, and to obtain the optimal LINAC-bed radio under the current data conditions. Different management strategies can be implemented by adjusting the settings of the MIP model. The computational results can serve as a reference for the policy-makers in decision making.

Waiting time for radiation therapy after breast-conserving surgery in early breast cancer: a retrospective analysis of local relapse and distant metastases in 615 patients

Background

Postoperative radiotherapy after breast-conserving surgery (BCS) is the standard in the management of breast cancer. The optimal timing for starting postoperative radiation therapy has not yet been well defined. In this study, we aimed to evaluate if the time interval between BCS and postoperative radiotherapy is related to the incidence of local and distant relapse in women with early node-negative breast cancer not receiving chemotherapy.

Methods

We retrospectively analyzed clinical data concerning 615 women treated from 1984 to 2010, divided into three groups according to the timing of radiotherapy: ≤60, 61–120, and >120 days. To estimate the presence of imbalanced distribution of prognostic and treatment factors among the three groups, the χ2 test or the Fisher exact test were performed. Local relapse-free survival, distant metastasis-free survival (DMFS), and disease-free survival (DFS) were estimated with the Kaplan–Meier method, and multivariate Cox regression was used to test for the independent effect of timing of RT after adjusting for known confounding factors. The median follow-up time was 65.8 months.

Results

Differences in distribution of age, type of hormone therapy, and year of diagnosis were statistically significant. At 15-year follow-up, we failed to detect a significant correlation between time interval and the risk of local relapse (p = 0.09) both at the univariate and the multivariate analysis. The DMFS and the DFS univariate analysis showed a decreased outcome when radiotherapy was started early (p = 0.041 and p = 0.046), but this was not confirmed at the multivariate analysis (p = 0.406 and p = 0.102, respectively).

Conclusions

Our results show that no correlation exists between the timing of postoperative radiotherapy and the risk of local relapse or distant metastasis development in a particular subgroup of women with node-negative early breast cancer.

Fraction size in radiation therapy for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an update of a Cochrane Review first published in 2008 and updated in 2009.

OBJECTIVES

To assess the effect of altered radiation fraction size for women with early breast cancer who have had breast conserving surgery.

SEARCH METHODS

We searched the Cochrane Breast Cancer Specialised Register (23 May 2015), CENTRAL (The Cochrane Library 2015, Issue 4), MEDLINE (Jan 1996 to May 2015), EMBASE (Jan 1980 to May 2015), the WHO International Clinical Trials Registry Platform (ICTRP) search portal (June 2010 to May 2015) and ClinicalTrials.gov (16 April 2015), reference lists of articles and relevant conference proceedings. No language or publication constraints were applied.

SELECTION CRITERIA

Randomised controlled trials of altered fraction size versus conventional fractionation for radiation therapy in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

Two authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors.

MAIN RESULTS

We studied 8228 women in nine studies. Eight out of nine studies were at low or unclear risk of bias. Altered fraction size (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not have a clinically meaningful effect on: local recurrence-free survival (Hazard Ratio (HR) 0.94, 95% CI 0.77 to 1.15, 7095 women, four studies, high-quality evidence), cosmetic outcome (Risk ratio (RR) 0.90, 95% CI 0.81 to 1.01, 2103 women, four studies, high-quality evidence) or overall survival (HR 0.91, 95% CI 0.80 to 1.03, 5685 women, three studies, high-quality evidence). Acute radiation skin toxicity (RR 0.32, 95% CI 0.22 to 0.45, 357 women, two studies) was reduced with altered fraction size. Late radiation subcutaneous toxicity did not differ with altered fraction size (RR 0.93, 95% CI 0.83 to 1.05, 5130 women, four studies, high-quality evidence). Breast cancer-specific survival (HR 0.91, 95% CI 0.78 to 1.06, 5685 women, three studies, high quality evidence) and relapse-free survival (HR 0.93, 95% CI 0.82 to 1.05, 5685 women, three studies, moderate-quality evidence) did not differ with altered fraction size. We found no data for mastectomy rate. Altered fraction size was associated with less patient-reported (P < 0.001) and physician-reported (P = 0.009) fatigue at six months (287 women, one study). We found no difference in the issue of altered fractionation for patient-reported outcomes of: physical well-being (P = 0.46), functional well-being (P = 0.38), emotional well-being (P = 0.58), social well-being (P = 0.32), breast cancer concerns (P = 0.94; 287 women, one study). We found no data with respect to costs.

AUTHORS' CONCLUSIONS

We found that using altered fraction size regimens (greater than 2 Gy per fraction) does not have a clinically meaningful effect on local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance, late toxicity or patient-reported quality-of-life measures for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins.

Effects of Time to Treatment on Biochemical and Clinical Outcomes for Patients With Prostate Cancer Treated With Definitive Radiation

INTRODUCTION

The purpose of this study was to evaluate if time to treatment (TTT) has an effect on outcomes for patients with localized prostate cancer treated with definitive external beam radiation therapy (EBRT).

PATIENTS AND METHODS

We included 4064 patients (1549 low-risk, 1612 intermediate-risk, and 903 high-risk) treated with EBRT. For each National Comprehensive Cancer Network (NCCN) risk group, TTT (defined as the time between initial positive prostate biopsy and start of RT) was analyzed in 4 intervals: < 3, 3-6, 6-9, and 9-24 months. We recorded the use of androgen deprivation therapy among patients with intermediate-risk and high-risk disease.

RESULTS

The median TTT was 3.3 months (range, 0.6-23.5 months), and it was similar for each risk group (range, 3.3-3.4 months). The median follow up was 64 months. There were no significant differences in biochemical failure, distant metastasis, or overall survival for patients with TTT < 3, 3-6, 6-9, or 9-24 months for each risk group. There were also no significant differences in the outcomes at 5 years when patients with TTT > 3.3 months were compared with those with TTT ≤ 3.3 months for each risk group. For high-risk men, 328 of 450 (72.9%) with TTT > 3.3 months were on androgen deprivation therapy (ADT) versus 299 of 453 (66%) with TTT ≤ 3.3 months. Among men with high-risk cancer treated without ADT, there remained no significant difference in outcomes between TTT > 3.3 months and TTT ≤ 3.3 months.

CONCLUSION

TTT was not associated with significant differences in outcomes among each risk group of men with localized prostate cancer treated with EBRT. Among the high-risk patients, there were no observed detriments in outcomes with TTT > 3.3 months regardless of androgen deprivation therapy use.

Wait times for prostate cancer treatment and patient perceptions of care in Canada: a mixed-methods report

BACKGROUND

Access to cancer care is a significant concern for Canadians. Prolonged delays between cancer diagnosis and treatment have been associated with anxiety, stress, and perceived powerlessness for patients and their family members. Longer wait times can also be associated with poorer prognosis, although the evidence is inconclusive. Here, we report national wait times for radiation therapy and surgery for localized prostate cancer (pca) and the effect of wait time on patient perceptions of their care.

RESULTS

Treatment wait times showed substantial interprovincial variation. The longest 90th percentile wait times for radiation therapy and surgery were, respectively, 40 days and 105 days. In all provinces, waits for radiation therapy were longer for pca patients than for patients with breast, colorectal, or lung cancer. In the focus groups and interviews conducted with 47 men treated for pca, many participants did not perceive that wait times for treatment were prolonged. Those who experienced delays between diagnosis and treatment voiced issues with a lack of communication about when they would receive treatment and a lack of support or information to make an informed decision about treatment. Minimizing treatment delays was an aspect of the cancer journey that participants would like to change because of the stress it caused.

CONCLUSIONS

Although wait time statistics are useful, a review of cancer control in Canada cannot be considered complete unless an effort is made to give voice to the experiences of individuals with cancer. The findings presented here are intended to provide a snapshot of national care delivery for localized pca and to identify opportunities for improvement in clinical practice.

Time interval from breast-conserving surgery to breast irradiation in early stage node-negative breast cancer: 17-year follow-up results and patterns of recurrence

PURPOSE

A retrospective chart review was conducted to determine whether the time interval from breast-conserving surgery to breast irradiation (surgery-radiation therapy interval) in early stage node-negative breast cancer had any detrimental effects on recurrence rates.

METHODS AND MATERIALS

There were 566 patients with T1 to T3, N0 breast cancer treated with breast-conserving surgery and breast irradiation and without adjuvant systemic treatment between 1985 and 1992. The surgery-to-radiation therapy intervals used for analysis were 0 to 8 weeks (201 patients), >8 to 12 weeks (233 patients), >12 to 16 weeks (91 patients), and >16 weeks (41 patients). Kaplan-Meier estimates of time to local recurrence, disease-free survival, distant disease-free survival, cause-specific survival, and overall survival rates were calculated.

RESULTS

Median follow-up was 17.4 years. Patients in all 4 time intervals were similar in terms of characteristics and pathologic features. There were no statistically significant differences among the 4 time groups in local recurrence (P=.67) or disease-free survival (P=.82). The local recurrence rates at 5, 10, and 15 years were 4.9%, 11.5%, and 15.0%, respectively. The distant disease relapse rates at 5, 10, and 15 years were 10.6%, 15.4%, and 18.5%, respectively. The disease-free failure rates at 5, 10, and 15 years were 20%, 32.3%, and 39.8%, respectively. Cause-specific survival rates at 5, 10, and 15 years were 92%, 84.6%, and 79.8%, respectively. The overall survival rates at 5, 10, and 15 years were 89.3%, 79.2%, and 66.9%, respectively.

CONCLUSIONS

Surgery-radiation therapy intervals up to 16 weeks from breast-conserving surgery are not associated with any increased risk of recurrence in early stage node-negative breast cancer. There is a steady local recurrence rate of 1% per year with adjuvant radiation alone.

Curative therapy for bladder cancer in routine clinical practice: a population-based outcomes study

AIMS

Definitive therapy of bladder cancer involves cystectomy or radiotherapy; controversy exists regarding optimal management. Here we describe the management and outcomes of patients treated in routine practice.

MATERIALS AND METHODS

Treatment records were linked to the Ontario Cancer Registry to identify all cases of bladder cancer in Ontario treated with cystectomy or radiotherapy in 1994-2008. Practice patterns are described in three study periods: 1994-1998, 1999-2003, 2004-2008. Logistic regression, Cox model and propensity score analyses were used to evaluate factors associated with treatment choice and survival.

RESULTS

In total, 3879 cases (74%) underwent cystectomy and 1380 (26%) were treated with primary radiotherapy. Cystectomy use increased over time (66, 75, 78%), whereas radiotherapy decreased (34, 25, 22%), P < 0.001. There was substantial regional variation in the proportion of cases undergoing radiotherapy (range 16-51%). Five year cancer-specific survival (CSS) and overall survival were 40 and 36% for surgical cases and 35 and 26% for radiotherapy cases (P < 0.001). In multivariate Cox model and propensity score analyses, there was no significant difference in CSS between surgery and radiotherapy (hazard ratio 0.99, 95% confidence interval 0.91-1.08); radiotherapy was associated with slightly inferior overall survival (hazard ratio 1.08, 95% confidence interval 1.00-1.16).

CONCLUSION

Utilisation of cystectomy for bladder cancer in routine practice has increased over time with no evidence of a significant difference in CSS between radiotherapy and cystectomy.

Quantification of gross tumour volume changes between simulation and first day of radiotherapy for patients with locally advanced malignancies of the lung and head/neck

INTRODUCTION

To quantify changes in gross tumour volume (GTV) between simulation and initiation of radiotherapy in patients with locally advanced malignancies of the lung and head/neck.

METHODS

Initial cone beam computed tomography (CT) scans from 12 patients with lung cancer and 12 with head/neck cancer (head and neck squamous cell carcinoma (HNSCC)) treated with intensity-modulated radiotherapy with image guidance were rigidly registered to the simulation CT scans. The GTV was demarcated on both scans. The relationship between percent GTV change and variables including time interval between simulation and start, tumour (T) stage, and absolute weight change was assessed.

RESULTS

For lung cancer patients, the GTV increased a median of 35.06% (range, -16.63% to 229.97%) over a median interval of 13 days (range, 7-43), while for HNSCC patients, the median GTV increase was 16.04% (range, -8.03% to 47.41%) over 13 days (range, 7-40). These observed changes are statistically significant. The magnitude of this change was inversely associated with the size of the tumour on the simulation scan for lung cancer patients (P < 0.05). However, the observed changes in GTV did not correlate with the duration of the interval for either disease site. Similarly, T stage, absolute weight change and histologic type (the latter for lung cancer cases) did not correlate with degree of GTV change (P > 0.1).

CONCLUSION

While the observed changes in GTV were moderate from the time of simulation to start of radiotherapy, these findings underscore the importance of image guidance for target localisation and verification, particularly for smaller tumours. Minimising the delay between simulation and treatment initiation may also be beneficial.

Timing of radiotherapy following breast-conserving surgery: outcome of 1393 patients at a single institution

BACKGROUND

The role of postoperative radiotherapy in breast-conserving therapy is undisputed. However, optimal timing of adjuvant radiotherapy is an issue of ongoing debate. This retrospective clinical cohort study was performed to investigate the impact of a delay in surgery-radiotherapy intervals on local control and overall survival.

PATIENTS AND METHODS

Data from an unselected cohort of 1393 patients treated at a single institution over a 17-year period (1990-2006) were analyzed. Patients were assigned to two groups (CT+/CT-) according to chemotherapy status. A delay in the initiation of radiotherapy was defined as > 7 weeks (CT- group) and > 24 weeks (CT+ group).

RESULTS

The 10-year regional recurrence-free survival for the CT- and CT+ groups were 95.6 and 86.0 %, respectively. A significant increase in the median surgery-radiotherapy interval was observed over time (CT- patients: median of 5 weeks in 1990-1992 to a median of 6 weeks in 2005-2006; CT+ patients: median of 5 weeks in 1990-1992 to a median of 21 weeks in 2005-2006). There was no association between a delay in radiotherapy and an increased local recurrence rate (CT- group: p = 0.990 for intervals 0-6 weeks vs. ≥ 7 weeks; CT+ group: p = 0.644 for intervals 0-15 weeks vs. ≥ 24 weeks) or decreased overall survival (CT- group: p = 0.386 for intervals 0-6 weeks vs. ≥ 7 weeks; CT+ group: p = 0.305 for intervals 0-15 weeks vs. ≥ 24 weeks).

CONCLUSION

In the present cohort, a delay of radiotherapy was not associated with decreased local control or overall survival in the two groups (CT-/CT+). However, in the absence of randomized evidence, delays in the initiation of radiotherapy should be avoided.

An analytical solution to patient prioritisation in radiotherapy based on utilitarian optimisation

The detrimental impact of a radiotherapy waiting list can in part be compensated by patient prioritisation. Such prioritisation is phrased as an optimisation problem where the probability of local control for the overall population is the objective to be maximised and a simple analytical solution derived. This solution is compared with a simulation of a waiting list for the same population of patients. It is found that the analytical solution can provide an optimal ordering of patients though cannot explicitly constrain optimal waiting times. The simulation-based solution was undertaken using both the analytical solution and a numerical optimisation routine for daily patient ordering. Both solutions provided very similar results with the analytical approach reducing the calculation time of the numerical solution by several orders of magnitude. It is suggested that treatment delays due to resource limitations and resulting waiting lists be incorporated into treatment optimisation and that the derived analytical solution provides a mechanism for this to occur.

Quality of care indicators and their related outcomes: a population-based study in prostate cancer patients treated with radiotherapy

BACKGROUND AND PURPOSE

We describe variations across the regional cancer centres in Ontario, Canada for five prostate cancer radiotherapy (RT) quality indicators: incomplete pre-treatment assessment, follow-up care, leg immobilization, bladder filling, and portal film target localization. Along with cancer centre volume, we examined each indicator's association with relevant outcomes: long-term cause-specific survival, urinary incontinence, and gastrointestinal and genitourinary late morbidities.

MATERIALS AND METHODS

We conducted a population-based retrospective cohort study of 924 prostate cancer patients diagnosed between 1990 and 1998 who received RT within 9 months of diagnosis. Data sources included treating charts and registry and administrative data. The associations between indicators and outcomes were analysed using regression techniques to control for potential confounders.

RESULTS

Practice patterns varied across the regional cancer centres for all indicators (p<0.0001). Incomplete pre-treatment assessment was associated with worse cause-specific survival although this result was not significant when adjusted for confounding (adjusted RR=1.78, 95% CI=0.79-3.98). Treatment without leg immobilization (adjusted RR=1.72, 95% CI=1.16-2.56) and with an empty bladder (adjusted RR=1.98, 95% CI=1.08-3.63) was associated with genitourinary late morbidities. Treatment without leg immobilization was also associated with urinary incontinence (adjusted RR=2.18, 95% CI=1.23-3.87).

CONCLUSIONS

We documented wide variations in practice patterns. We demonstrated that measures of quality of care can be shown to be associated with clinically relevant outcomes in a population-based sample of prostate cancer patients.

Sequencing of chemotherapy and radiotherapy for early breast cancer

BACKGROUND

After surgery for localised breast cancer, radiotherapy (RT) improves both local control and breast cancer-specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy (CT) improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early-stage breast cancer is unclear.

OBJECTIVES

To determine the effects of different sequencing of adjuvant CT and RT for women with early breast cancer.

SEARCH METHODS

An updated search was carried out in the Cochrane Breast Cancer Group's Specialised Register (20 May 2011), MEDLINE (14 December 2011), EMBASE (20 May 2011) and World Health Organization (WHO) International Clinical Trials Registry Platform (20 May 2011). Details of the search strategy and methods of coding for the Specialised Register are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'.

SELECTION CRITERIA

We included randomised controlled trials evaluating different sequencing of CT and RT.

DATA COLLECTION AND ANALYSIS

We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included trials. We derived odds ratios (OR) and hazard ratios (HR) from the available numerical data. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments.

MAIN RESULTS

Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for local recurrence-free survival, overall survival, relapse-free survival and metastasis-free survival based on 1166 randomised women in three trials. Concurrent chemoradiation increased anaemia (OR 1.54; 95% confidence interval (CI) 1.10 to 2.15), telangiectasia (OR 3.85; 95% CI 1.37 to 10.87) and pigmentation (OR 15.96; 95% CI 2.06 to 123.68). Treated women did not report worse cosmesis with concurrent chemoradiation but physician-reported assessments did (OR 1.14; 95% CI 0.42 to 3.07). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), RT before CT was associated with an increased risk of neutropenic sepsis (OR 2.96; 95% CI 1.26 to 6.98) compared with CT before RT, but other measures of toxicity did not differ.

AUTHORS' CONCLUSIONS

The data included in this review, from three well-conducted randomised trials, suggest that different methods of sequencing CT and RT do not appear to have a major effect on recurrence or survival for women with breast cancer if RT is commenced within seven months after surgery.

Sequencing of chemotherapy and radiotherapy for early breast cancer

BACKGROUND

After surgery for localised breast cancer, radiotherapy (RT) improves both local control and breast cancer-specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy (CT) improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early-stage breast cancer is unclear.

OBJECTIVES

To determine the effects of different sequencing of adjuvant CT and RT for women with early breast cancer.

SEARCH METHODS

An updated search was carried out in the Cochrane Breast Cancer Group's Specialised Register (20 May 2011), MEDLINE (14 December 2011), EMBASE (20 May 2011) and World Health Organization (WHO) International Clinical Trials Registry Platform (20 May 2011). Details of the search strategy and methods of coding for the Specialised Register are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'.

SELECTION CRITERIA

We included randomised controlled trials evaluating different sequencing of CT and RT.

DATA COLLECTION AND ANALYSIS

We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included trials. We derived odds ratios (OR) and hazard ratios (HR) from the available numerical data. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments.

MAIN RESULTS

Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for local recurrence-free survival, overall survival, relapse-free survival and metastasis-free survival based on 1166 randomised women in three trials. Concurrent chemoradiation increased anaemia (OR 1.54; 95% confidence interval (CI) 1.10 to 2.15), telangiectasia (OR 3.85; 95% CI 1.37 to 10.87) and pigmentation (OR 15.96; 95% CI 2.06 to 123.68). Treated women did not report worse cosmesis with concurrent chemoradiation but physician-reported assessments did (OR 1.14; 95% CI 0.42 to 3.07). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), RT before CT was associated with an increased risk of neutropenic sepsis (OR 2.96; 95% CI 1.26 to 6.98) compared with CT before RT, but other measures of toxicity did not differ.

AUTHORS' CONCLUSIONS

The data included in this review, from three well-conducted randomised trials, suggest that different methods of sequencing CT and RT do not appear to have a major effect on recurrence or survival for women with breast cancer if RT is commenced within seven months after surgery.

Managing patient pathways to achieve lung cancer waiting time targets: mixed methods study

Objectives

England's National Health Service (NHS) introduced a 62-day target, from referral to treatment, to make lung cancer patient pathways more efficient. This study aims to understand pathway delays that lead to breaches of the target when patients need care in both secondary and tertiary setting, so more than one institution is involved.

Design

Mixed methods cross case analysis.

Setting

Two tertiary referral hospitals in London.

Participants

Database records of 53 patients were analysed. Nineteen sets of patient notes were used for pathway mapping. Seventeen doctors, four nurses, eight managers and administrators were interviewed.

Main outcome measures

Qualitative methods include pathway mapping and semi-structured interviews. Quantitative analysis of patient pathway times from cancer services records.

Results

The majority of the patient pathway (68.4%) is spent in secondary centres. There is more variability in the processes of secondary centres but tertiary centres do not have perfect processes either. Three themes emerged from discussions: information flows, pathway performance and the role of the multidisciplinary approach.

Conclusions

The actions of secondary centres have a greater influence on whether a patient breaches the 62-day target, compared with tertiary centres. Nevertheless variability exists in both, with potential for improvement.

Nodal-staging surgery for locally advanced cervical cancer in the era of PET

Chemoradiation therapy is deemed the standard treatment by many North American and European teams for treatment of locally advanced cervical cancer. The prevalence of para-aortic nodal metastasis in these tumours is 10-25%. PET (with or without CT) is the most accurate imaging modality to assess extrapelvic disease in such tumours. The true-positive rate of PET is high, suggesting that surgical staging is not necessary if uptake takes place in the para-aortic region. Nevertheless, false-negative results (in the para-aortic region) have been recorded in 12% of patients, rising to 22% in those with uptake during PET of the pelvic nodes. In such situations, laparoscopic surgical para-aortic staging still has an important role for detection of patients with occult para-aortic spread misdiagnosed on PET or PET-CT, allowing optimisation of treatment (extension of radiation therapy fields to include the para-aortic area). Complications of the laparoscopic procedure were noted in 0-7% of patients. Survival of individuals (missed by PET) with para-aortic nodal metastasis of 5 mm or less (and managed by extended field chemoradiation therapy) seems to be similar to survival of those without para-aortic spread, suggesting a positive therapeutic effect of the addition of staging surgery. Nevertheless, the effect on survival of potential delay of chemoradiation owing to use of PET and staging surgery, and acute and late complications of surgery followed by chemoradiation therapy (particularly in case of extended field chemoradiation to para-aortic area), need to be studied.

A diagnostic program for patients suspected of having lung cancer

BACKGROUND

A standardized diagnostic program, initiated to reduce the length of the diagnostic track and to improve application of diagnostic tools for patients referred with suspicious abnormalities on standard chest radiographs, was evaluated.

METHODS

The findings on integrated positron emission tomography/computed tomography (PET-CT) determined the choice of invasive investigations to be performed the same day. Diagnostic results, time courses, and number and sorts of applied invasive investigations were assessed.

RESULTS

In 297 eligible patients, malignant disease was diagnosed in 72% and benign disease was diagnosed in 26% of patients. One percent of the patients had no abnormalities at all. For 85% of patients with malignancy, investigations were completed in 1 day, resulting in a diagnosis and definitive clinical disease stage. The median time from start of the analysis to informing the patient about diagnosis and tumor stage was 7 days. One invasive investigation was performed in 53% of patients in the study group, and at least 2 investigations were performed in 33% of patients. Bronchoscopies formed a part of the diagnostic process in 59% of patients. Surgical diagnostic procedures were performed in 8% of patients.

CONCLUSION

The diagnostic program resulted in a short time to diagnosis, with finalization of invasive investigations in 1 day in the majority of patients. The imaging-based choice of invasive investigations precluded bronchoscopies in a substantial portion of the patients.

Radiation treatment waiting times for breast cancer patients in Manitoba, 2001 and 2005

INTRODUCTION

Our study examined the wait time from ready-to-treat to radiation therapy for cohorts of breast cancer patients requiring adjuvant radiation therapy in 2001 and in 2005 after the implementation of strategies to reduce wait times for radiation treatment. We also examined the overall time from diagnosis to radiation treatment and whether distance from the cancer treatment centre or month of referral had an effect on wait times.

METHODS

This population-based retrospective study looked at representative samples of women newly diagnosed with breast cancer in 2001 and 2005. Patients who required radiation treatment to the breast or chest wall were followed from first contact to the start of radiation treatment.

RESULTS

Time from ready-to-treat to first radiation treatment was significantly reduced for patients in 2005 as compared with 2001, regardless of whether chemotherapy was administered before radiation treatment. Time from diagnosis to radiation treatment was not different by year for those who received radiation only. Time from diagnosis to chemotherapy was significantly longer in 2005. No effect of month of diagnosis on wait times was observed.

INTERPRETATION

A significant improvement in the median wait time from ready-to-treat to first radiation treatment was noted from 2001 to 2005. This improvement may be attributable to measures taken to reduce such waits. However, we observed an increase in the median time from diagnosis to referral and from referral to consultation with medical or radiation oncology (or both), so that the overall time from diagnosis to radiation treatment was not different. Although specific intervals related to radiation treatment delivery were improved, the entire trajectory of breast cancer care experienced by patients needs to be considered.

Fraction size in radiation treatment for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an updated version of the original Cochrane Review published in Issue 3, 2008.

OBJECTIVES

To determine the effect of altered radiation fraction size on outcomes for women with early breast cancer who have undergone breast conserving surgery.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE, EMBASE and the WHO ICTRP search portal to June 2009, reference lists of articles and relevant conference proceedings. We applied no language constraints.

SELECTION CRITERIA

Randomised controlled trials of unconventional versus conventional fractionation in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

The authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors.

MAIN RESULTS

Four trials reported on 7095 women. The women were highly selected: tumours were node negative and 89.8% were smaller than 3 cm. Where the breast size was known, 87% had small or medium breasts. The studies were of low to medium quality. Unconventional fractionation (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not affect: (1) local recurrence risk ratio (RR) 0.97 (95% CI 0.76 to 1.22, P = 0.78), (2) breast appearance RR 1.17 (95% CI 0.98 to 1.39, P = 0.09), (3) survival at five years RR 0.89 (95% CI 0.77 to 1.04, P = 0.16). Acute skin toxicity was decreased with unconventional fractionation: RR 0.21 (95% CI 0.07 to 0.64, P = 0.007).

AUTHORS' CONCLUSIONS

Two new studies have been published since the last version of the review, altering our conclusions. We have evidence from four low to medium quality randomised trials that using unconventional fractionation regimens (greater than 2 Gy per fraction) does not affect local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance or late toxicity for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins. Long-term follow up (> 5 years) is available for a small proportion of the patients randomised. Longer follow up is required for a more complete assessment of the effect of altered fractionation.

The relationship between adiposity and gleason score in men with localized prostate cancer

BACKGROUND

We investigated the relationship between body mass index (BMI) at the time of cancer diagnosis and malignant phenotype as measured by Gleason score.

METHODS

This was a population-based cross-sectional study conducted on 1,096 prostate cancer patients treated for cure in Ontario, Canada between 1990 and 1998. An electronic-linked data set was enhanced by retrospective chart review. BMI was categorized as: normal (BMI <25.0), overweight (BMI 25.0-29.9), and obese (BMI ≥30). We also investigated the role of diabetic status. Gleason scores were categorized as: 2-4, 5-6, 7, and 8-10. We assessed the effect modification by patient age.

RESULTS

BMI was not associated with Gleason score; 9.7% of those with normal BMI had a Gleason score ≥8, and 9.4% fell into this Gleason category in both the overweight and obese groups (P = 0.73). 11.7% of diabetics had a Gleason score ≥8 compared to 9.3% in the non-diabetic group (P = 0.79). Both of these results persisted in a multivariate analysis controlling for age and diagnosis year. When stratified by age, only the Gleason score distribution in the youngest cohort (50- to 59-year olds) indicated higher Gleason scores in the obese group, with marginally significant results (P = 0.16).

CONCLUSIONS

With a possible exception in younger men, elevated BMI at the time of diagnosis does not appear to be associated with aspects of aggressive behavior associated with Gleason grade. The effect of adiposity on prostate cancer outcome is complex, requiring further study that includes attention to factors such as length of exposure, concomitant co-morbidities, and ethnicity.

Wait times in prostate cancer diagnosis and radiation treatment

INTRODUCTION

Wait times for cancer diagnosis and treatment are a significant concern for Canadians. Men with prostate cancer experience longer waiting times for diagnosis and treatment than those observed for other cancers. Longer waits are associated with both patient and family psychosocial distress and may be associated with worse prognosis.

METHODS

Men referred for treatment of prostate cancer at a single Canadian cancer centre were interviewed. The intervals from suspicion to definitive therapy were calculated, factors associated with delays along this pathway were identified, and common causes of delay identified by patients were described.

RESULTS

A total of 41 consecutive patients participated. The median interval from suspicion to the first fraction of radiotherapy for all patients was 247 days (interquartile range [IQR] 168-367 d). The median diagnostic interval was 53 days (IQR 28-166 d). The median treatment interval was 127 days (IQR 100-180 d). Patients under 70 years old and patients with

INTERPRETATION

In this study, 12% and 0% of patients met Canadian Strategy for Cancer Control and Canadian Association of Radiation Oncologists wait time recommendations, respectively. A large component of wait time is patient driven. Alternate strategies should be developed and measured to shorten the intervals between the suspicion and treatment of prostate cancer.

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Affiliation(s)

Christiaan Stevens Fellow, Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, ON
Susan J Bondy
D Andrew Loblaw

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Adoption of adjuvant chemotherapy for non-small-cell lung cancer: a population-based outcomes study

PURPOSE

Since 2004, several clinical trials have demonstrated that adjuvant chemotherapy (ACT) improves survival in patients with early-stage non-small-cell lung cancer (NSCLC). Here, we evaluate the uptake of ACT and its impact on outcomes in the general population of Ontario, Canada.

METHODS

All patients diagnosed with NSCLC in Ontario from 2001 to 2006 who underwent surgical resection (n = 6,304) were identified using the Ontario Cancer Registry. We linked electronic records of treatment to the registry. We described uptake of ACT and compared survival of all patients with surgically resected NSCLC diagnosed from 2001 to 2003 with patients diagnosed from 2004 to 2006. As a proxy measure of ACT-related toxicity, we evaluated hospitalizations within 6 months of surgery.

RESULTS

Demographic, disease, and treatment-related characteristics did not differ between the 2001 to 2003 and 2004 to 2006 study cohorts. Over the study period, the proportion of patients receiving ACT increased from 7% (192 of 2,950 patients) to 31% (1,032 of 3,354 patients; P < .001). The proportion of patients admitted to hospital within 6 months of surgery remained stable and (36% in the 2001 to 2003 cohort and 37% in the 2004 to 2006 cohort). However, within 2 years of surgery, there was a 33% reduction in the proportion of patients admitted to hospital with metastatic disease (P < .001). During the study period, there was a substantial improvement in 4-year survival among surgically resected patients, from 52.5% (2001 to 2003) to 56.1% (2004 to 2006; P = .001).

CONCLUSION

There has been a rapid uptake of ACT for NSCLC, which was not associated with an increased rate of hospitalization. The adoption of ACT was associated with a substantial improvement in overall survival, suggesting that the benefits seen in clinical trials are generalizable to the general population.

Impact of interval from breast conserving surgery to radiotherapy on local recurrence in older women with breast cancer: retrospective cohort analysis

OBJECTIVES

To determine if the length of interval between breast conserving surgery and start of radiotherapy affects local recurrence and to identify factors that might be associated with delay in older women with breast cancer.

DESIGN

Retrospective cohort analysis with Cox proportional hazards models to study the association between time to radiotherapy and local recurrence, and propensity score and instrumental variable analyses to confirm findings. Logistic regression investigated factors associated with later start of radiotherapy.

SETTING

Linked database (Surveillance, Epidemiology, and End Results Program-Medicare) in the United States

PARTICIPANTS

18 050 women aged over 65 with stage 0-II breast cancer diagnosed in 1991-2002 who received breast conserving surgery and radiotherapy but not chemotherapy.

MAIN OUTCOME MEASURE

Local recurrence.

RESULTS

Median time from surgery to start of radiotherapy was 34 days, with 29.9% (n=5389) of women starting radiotherapy after six weeks. Just over 4% (n=734) of the cohort experienced a local recurrence. After adjustment for clinical and sociodemographic factors, intervals over six weeks were associated with increased likelihood of local recurrence (hazard ratio 1.19, 95% confidence interval 1.01 to 1.39, P=0.033). When the interval was modelled continuously (assessing accumulation of risk by day), the effect was statistically stronger (hazard ratio 1.005 per day, 1.002 to 1.008, P=0.004). Propensity score and instrumental variable analysis confirmed these findings. Instrumental variable analysis showed that intervals over six weeks were associated with a 0.96% increase in recurrence at five years (P=0.026). In multivariable analysis, starting radiotherapy after six weeks was significantly associated with positive nodes, comorbidity, history of low income, Hispanic ethnicity, non-white race, later year of diagnosis, and residence outside the southern states of the US.

CONCLUSIONS

There is a continuous relation between the interval from breast conserving surgery to radiotherapy and local recurrence in older women with breast cancer, suggesting that starting radiotherapy as soon as possible could minimise the risk of local recurrence. There are considerable disparities in time to starting radiotherapy after breast conserving surgery. Regions of the US known to have increased rates of breast conserving surgery had longer intervals before radiotherapy, suggesting limitations in capacity. Given the known negative impact of local recurrence on survival, mechanisms to ameliorate disparities and policies regarding waiting times for treatment might be warranted.