Receipt of Care Discordant with Practice Guidelines is Associated with Compromised Overall Survival in Nasopharyngeal Carcinoma

Nonadherence to Multimodality Cancer Treatment Guidelines in the United States

Purpose

Our purpose was to identify patients with cancer who do not receive guideline-concordant multimodality treatment and to identify factors that are associated with nonreceipt of guideline-concordant multimodality treatment.

Methods and Materials

Five cancers for which the multimodal guideline-concordant treatment (with surgery, chemotherapy, and radiation therapy) is clearly defined in national guidelines were selected from the National Cancer Database: (1) nonmetastatic anal cancer, (2) locally advanced cervical cancer, (3) nonmetastatic nasopharynx cancer, (4) locally advanced rectal cancer, and (5) locally advanced non-small cell lung cancer. Multivariable logistic regression was used to determine the odds ratios (with 95% confidence intervals) of receiving the guideline-concordant treatment versus not, adjusting for common confounding variables.

Results

178,005 patients with cancer were included: 32,214 anal, 54,485 rectal, 13,179 cervical, 5061 nasopharyngeal, and 73,066 lung. Overall, 162,514 (91%) received guideline-concordant treatment and 15,491 (9%) did not. Twenty-one percent of patients with cervical cancer, 10% of patients with rectal cancer, 7% of patients with lung cancer, 5% of patients with anal cancer, and 3% of patients with nasopharynx cancer did not receive guideline-concordant treatment. In general, patients who were older, with comorbid conditions, and who were evaluated at low-volume facilities (odds ratios > 1 with P < .05) were less likely to receive guideline-concordant treatment.

Conclusions

Nearly 1 in 10 patients in this cohort are not receiving appropriate multimodal cancer therapy. There appear to be significant disparities in receipt of guideline-concordant treatment based on primary tumor site, age, comorbidities, and reporting facility.

Adherence to Treatment Guidelines and Associated Survival in Older Patients with Prostate Cancer: A Prospective Multicentre Cohort Study

The guidelines on prostate cancer treatment in older men recommend evaluating the patient's underlying health status before treatment selection. We aimed to evaluate the frequency of a guideline-discordant treatment (GDT), identify factors associated with GDT, and assess the relationship between GDT and overall survival. We studied patients with prostate cancer aged 70 or older included in the ELCAPA cohort between 2010 and 2019. Multivariable logistic regression assessed GDT-associated factors. The restricted mean survival time (RMST) assessed the 24- and 36-month OS using stabilized inverse probability of treatment weighting of propensity scores. We included 356 patients (median age: 81 years), and 164 (46%) received a GDT (95% confidence interval (CI) = (41-51%)). Patients with metastases were less likely to receive a GDT (adjusted odds ratio (95% CI) = 0.34 (0.17-0.69); p = 0.003). After weighting, the RMST at 24 months was shorter in the GDT group (13.9 months, vs. 17 months for compliant treatments; difference (95% CI): -3.1 months (-5.3, -1.0); p = 0.004). RMST at 36 months was 18.5 months, vs. 21.8 months (difference: -3.3 months (-6.7, 0.0); p = 0.053). GDT is common in older patients with prostate cancer and especially those with non-metastatic disease. GDT was associated with worse survival, independently of health status and tumour characteristics.

NCCN resource-stratified and harmonized guidelines: A paradigm for optimizing global cancer care

Clinical practice guidelines in oncology lead to improved outcomes in care. However, the most frequently used guidelines are developed for highly resourced systems. Recognizing the significant and increasing burden of cancer in low- and middle-income countries, the National Comprehensive Cancer Network (NCCN) has developed resource-stratified framework and harmonization processes that allow the NCCN Guidelines to be tailored and optimized for specific geographical areas, resource levels, and settings. The critical need for local expertise and involvement in successful development and uptake is emphasized, and the promise of this collaboration for advancement in oncology programs is illustrated.

Clinical Molecular Marker Testing Data Capture to Promote Precision Medicine Research Within the Cancer Research Network

PURPOSE

To evaluate health care systems for the availability of population-level data on the frequency of use and results of clinical molecular marker tests to inform precision cancer care.

METHODS

We assessed cancer-related molecular marker test data availability across 12 US health care systems in the Cancer Research Network. Overall, these systems provide care to a diverse population of more than 12 million people in the United States. We performed qualitative analyses of test data availability for five blood-based protein, nine germline, and 14 tissue-based tumor marker tests in each health care system's electronic health record and tumor registry using key informants, test code lists, and manual review of data types and output. We then performed quantitative analyses to estimate the proportion of patients with cancer with test utilization data and results for specific molecular marker tests.

RESULTS

Health systems were able to systematically capture population-level data on all five blood protein markers, six of 14 tissue-based tumor markers, and none of the nine germline markers. Successful, systematic data capture was achievable for tests with electronic data feeds for test results (blood protein markers) or through prior manual abstraction by tumor registrars (select tumor-based markers). For test results stored in scanned image files (particularly germline and tumor marker tests), information on which test was performed and test results was not readily accessible in an electronic format.

CONCLUSION

Even in health care systems with sophisticated electronic health records, there were few codified data elements available for evaluating precision cancer medicine test use and results at the population level. Health care organizations should establish standards for electronic reporting of precision medicine tests to expedite cancer research and facilitate the implementation of precision medicine approaches.

A Multicentre UK Study of Outcomes of Nasopharyngeal Carcinoma Treated With Intensity-Modulated Radiotherapy ± Chemotherapy

AIMS

To report the outcomes of nasopharyngeal carcinoma in adults across three large centres in a non-endemic region in the era of intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

Adult patients with nasopharyngeal carcinoma treated in three large cancer centres with IMRT ± chemotherapy with curative intent between 2009 and 2016 were identified from institutional databases. Radiotherapy was delivered with 70 Gy in 33-35 daily fractions. A univariable analysis was carried out to evaluate the relationship of patient, tumour and treatment factors with progression-free survival (PFS) and overall survival.

RESULTS

In total, 151 patients were identified with a median follow-up of 5.2 years. The median age was 52 years (range 18-85). Seventy-five per cent were of Caucasian origin; 75% had non-keratinising tumours; Epstein Barr virus status was only available in 23% of patients; 74% of patients had stage III or IV disease; 54% of patients received induction chemotherapy; 86% of patients received concurrent chemotherapy. Five-year overall survival, PFS, local disease-free survival, regional disease-free survival and distant disease-free survival were 70%, 65%, 91%, 94% and 82%, respectively. Keratinising squamous cell carcinoma, older age, worse performance status, smoking and alcohol intake were associated with inferior overall survival and PFS.

CONCLUSIONS

Local, regional and distant disease control are relatively high following IMRT ± chemotherapy in a non-endemic population. There was considerable heterogeneity in terms of radiotherapy treatment and the use of chemotherapy, encouraging the development of treatment protocols and expert peer review in non-endemic regions.

Clinical Indices to Drive Quality Improvement in Otolaryngology

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.

Compliance with National Guidelines on the Treatment of Stage II–IVB Nasopharyngeal Carcinoma in a Regional Cancer Center of Southern China

Objective: It is unknown whether the treatment provided to patients with stage II-IVB NPC in southern China adheres to the 2015 NCCN guidelines. Consequently, a retrospective analysis was conducted, in order to evaluate the compliance with NCCN guidelines and identify the areas for improvement. Methods: The present study was a retrospective study that included patients with stage II-IVB NPC in southern China during the period 2013 and 2014. The treatment regimens were compared with the 2015 NCCN guidelines in order to identify potential noncompliance regarding the treatment for stage II–IVB NPC. The statistical analyses included descriptive statistics, univariate and/or multivariate analysis using SPSS version 16.0.0. Results: A total of 215 patients, including 166 men (77.21%) and 49 women (22.79%), were involved in the analysis. Although the overall rate of noncompliance with the NCCN recommendations was 23.26%, the noncompliance rate of concurrent chemoradiation (CCRT), induction of chemotherapy (IC) followed by CCRT and CCRT followed by adjuvant chemotherapy (AC) was 7.02%, 39.76% and 50.00%, respectively. Univariate analysis indicated that NCCN noncompliance regarding the treatment for stage II-IVB NPC did not exhibit a significant correlation with the parameters age, gender, insurance status, education profile, first clinic department, careers, comorbidities and overall clinical stage, but it indicated a significant association with the therapeutic schedule (P<0.05). The multivariate analysis indicated that the NCCN noncompliance regarding the treatment for stage II–IVB NPC exhibited a statistically significant difference between CCRT and CCRT followed by AC (OR=0.10, 95% CI 0.04-0.27, P<0.05 ), although the difference noted between CCRT and IC followed by CCRT was not significantly different (OR=1.71, 95% CI 0.50-5.87,P=0.40). Conclusions: The use of specific therapeutic schedules may affect the noncompliance with NCCN guidelines regarding the treatment for stage II–IVB NPC in southern China, notably with regard to the treatment schedule of CCRT followed by AC.