The Patterns of Care Study and Regional Cancer Registry for non-small-cell lung cancer in Japan

Japanese structure survey of radiation oncology in 2009 based on institutional stratification of the Patterns of Care Study

The ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load and geographic distribution was evaluated in order to radiation identify and improve any deficiencies. A questionnaire-based national structure survey was conducted from March 2010 to January 2011 by the Japanese Society for Therapeutic Radiology and Oncology (JASTRO). These data were analyzed in terms of the institutional stratification of the Patterns of Care Study (PCS). The total numbers of new cancer patients and total of cancer patients (new and repeat) treated with radiation in 2009 were estimated at 201,000 and 240,000, respectively. The type and numbers of systems in actual use consisted of Linac (816), telecobalt (9), Gamma Knife (46), (60)Co remote afterloading system (RALS) (29) and (192)Ir RALS systems (130). The Linac systems used dual energy function for 586 (71.8%), 3DCRT for 663 (81.3%) and IMRT for 337 units (41.3%). There were 529 JASTRO-certified radiation oncologists (ROs), 939.4 full-time equivalent (FTE) ROs, 113.1 FTE medical physicists and 1836 FTE radiation therapists. The frequency of interstitial radiation therapy use for prostate and of intensity-modulated radiotherapy increased significantly. PCS stratification can clearly identify the maturity of structures based on their academic nature and caseload. Geographically, the more JASTRO-certified physicians there were in a given area, the more radiation therapy tended to be used for cancer patients. In conclusion, the Japanese structure has clearly improved during the past 19 years in terms of equipment and its use, although a shortage of manpower and variations in maturity disclosed by PCS stratification remained problematic in 2009.

Japanese structure survey of radiation oncology in 2007 based on institutional stratification of patterns of care study

PURPOSE

To evaluate the ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and improve any deficiencies.

METHODS AND MATERIALS

A questionnaire-based national structure survey was conducted from March to December 2008 by the Japanese Society of Therapeutic Radiology and Oncology (JASTRO). These data were analyzed in terms of the institutional stratification of the Patterns of Care Study.

RESULTS

The total numbers of new cancer patients and total cancer patients (new and repeat) treated with radiation in 2007 were estimated at 181,000 and 218,000, respectively. There were 807 linear accelerator, 15 telecobalt, 46 Gamma Knife, 45 (60)Co remote-controlled after-loading, and 123 (192)Ir remote-controlled after-loading systems in actual use. The linear accelerator systems used dual-energy function in 539 units (66.8%), three-dimensional conformal radiation therapy in 555 (68.8%), and intensity-modulated radiation therapy in 235 (29.1%). There were 477 JASTRO-certified radiation oncologists, 826.3 full-time equivalent (FTE) radiation oncologists, 68.4 FTE medical physicists, and 1,634 FTE radiation therapists. The number of interstitial radiotherapy (RT) administrations for prostate, stereotactic body radiotherapy, and intensity-modulated radiation therapy increased significantly. Patterns of Care Study stratification can clearly identify the maturity of structures based on their academic nature and caseload. Geographically, the more JASTRO-certified physicians there were in a given area, the more RT tended to be used for cancer patients.

CONCLUSIONS

The Japanese structure has clearly improved during the past 17 years in terms of equipment and its use, although a shortage of personnel and variations in maturity disclosed by Patterns of Care Study stratification were still problematic in 2007.

Japanese structure survey of radiation oncology in 2005 based on institutional stratification of patterns of care study

PURPOSE

To evaluate the structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and improve any deficiencies.

METHODS AND MATERIALS

A questionnaire-based national structure survey was conducted between March 2006 and February 2007 by the Japanese Society of Therapeutic Radiology and Oncology. These data were analyzed in terms of the institutional stratification of the Patterns of Care Study.

RESULTS

The total numbers of new cancer patients and total cancer patients (new and repeat) treated with radiotherapy in 2005 were estimated at approximately 162,000 and 198,000, respectively. In actual use were 765 linear accelerators, 11 telecobalt machines, 48 GammaKnife machines, 64 60Co remote-controlled after-loading systems, and 119 192Ir remote-controlled after-loading systems. The linear accelerator systems used dual-energy function in 498 systems (65%), three-dimensional conformal radiotherapy in 462 (60%), and intensity-modulated radiotherapy in 170 (22%). There were 426 Japanese Society of Therapeutic Radiology and Oncology-certified radiation oncologists, 774 full-time equivalent radiation oncologists, 117 medical physicists, and 1,635 radiation therapists. Geographically, a significant variation was found in the use of radiotherapy, from 0.9 to 2.1 patients/1,000 population. The annual patient load/FTE radiation oncologist was 247, exceeding the Blue Book guidelines level. Patterns of Care Study stratification can clearly discriminate the maturity of structures according to their academic nature and caseload.

CONCLUSIONS

The Japanese structure has clearly improved during the past 15 years in terms of equipment and its use, although the shortage of manpower and variations in maturity disclosed by this Patterns of Care Study stratification remain problematic. These constitute the targets for nationwide improvement in quality assurance and quality control.

Changes in patterns of care for limited-stage small-cell lung cancer: results of the 99-01 patterns of care study-a nationwide survey in Japan

BACKGROUND

This study was undertaken to analyze the practice process of thoracic radiotherapy (TRT) and evaluate changes in patterns of care for patients with limited-stage small-cell lung cancer (LS-SCLC) in Japan.

METHODS AND MATERIALS

The Patterns of Care Study (PCS) conducted the second nationwide survey of care process for patients with LS-SCLC treated by using TRT between 1999 and 2001.

RESULTS

The PCS collected data for 139 patients with LS-SCLC (man-woman ratio, 5:1; median age, 69 years; age > 70 years, 43%; Karnofsky Performance Status > 70, 73%; and Stage III, 88%). Median total dose was 50 Gy. Twice-daily TRT was used in 44% of patients. Median field size was 12 x 14 cm. The most commonly used photon energy was 10 MV (77%), whereas obsolete techniques using (60)Co or X-ray energy less than 6 MV comprised 12%. Three-dimensional conformal therapy was used with 12% of patients. Computed tomography simulation was performed in 40% of cases. Only 12 patients (8.6%) received prophylactic cranial irradiation (PCI). Concurrent chemotherapy and TRT (CCRT) was used for 94 patients (68%). Only 6 patients (4.4%) entered clinical trials. Compared with the previous PCS 95-97, significant increases in the use of CCRT (34-68%; p < 0.0001), twice-daily TRT (15-44%; p < 0.0001), and PCI (1.7-8.6%; p =0.0045) were observed, although the absolute number of patients receiving PCI was still extremely low.

CONCLUSIONS

Evidence-based CCRT and twice-daily TRT has penetrated into clinical practice. However, PCI is not yet widely accepted in Japan.

Postoperative radiotherapy for non-small-cell lung cancer: Results of the 1999–2001 patterns of care study nationwide process survey in Japan

To investigate the practice process of postoperative radiation therapy for non-small-cell lung cancer (NSCLC) in Japan. Between April 2002 and March 2004, the Patterns of Care Study conducted an extramural audit survey for 76 of 556 institutions using a stratified two-stage cluster sampling. Data on treatment process of 627 patients with NSCLC who received radiation therapy were collected. Ninety-nine (16%) patients received postoperative radiation therapy between 1999 and 2001 (median age, 65 years). Pathological stage was stage I in 8%, II in 17%, IIIA in 44%, and IIIB in 20%. The median field size was 9 cmx11 cm, and median total dose was 50 Gy. Photon energies of 6 MV or higher were used for 64 patients, whereas a cobalt-60 unit was used for five patients. Three-dimensional conformal treatment was used infrequently. Institutional stratification influenced several radiotherapy parameters such as photon energy and planning target volume. Smaller non-academic institutions provided worse quality of care. The study confirmed continuing variation in the practice of radiotherapy according to stratified institutions. Outdated equipment such as Cobalt-60 units was used, especially in non-academic institutions treating only a small number of patients per year.

Patterns of Care Study in Japan

BACKGROUND

The Patterns of Care Study (PCS), started in the 1970's, is a well-known study used for clinical quality assurance (QA) in radiation oncology in the United States. PCS has been introduced in Japan since 1996.

METHODS

Three national PCS surveys have been performed by means of external audit to evaluate patterns of care for the patients with carcinoma of any of esophagus and cervix treated with radiation between 1992 and 1994, for those with carcinoma of any of esophagus, cervix, breast, lung and prostate between 1995 and 1997, and for those with any of the five disease sites between 1999 and 2001. In the first PCS, feasibility of the study was confirmed. In the second PCS, two-stage cluster sampling of institutions and patients was performed and national averages for the survey items were calculated as QA measures. In the third PCS, additional imaging data were collected. The Japan/USA PCS workshops were held at San Francisco in 2001 and at Tokyo in 2003.

RESULTS

Significant variations in process and structure were observed according to institutional stratification. In academic institutions, external beam energy > or =6 MV for deep-seated tumors of esophagus, lung, prostate and cervix, and brachytherapy for those of cervix and esophagus were used more frequently. There was an average of less than one full-time equivalent radiation oncologist in most non-academic institutions. These variations influenced the outcomes. There were also significant differences between USA and Japan in various aspects, e.g. a difference in radiation dose of 20% for uterine cervix cancer patients. It is higher in the USA. The number of new cancer patients requiring radiation is increasing steeply (120,000 in 2000 and 170,000 in 2005). Based on PCS data, structural guidelines were published and distributed throughout Japan.

CONCLUSION

PCS is useful for establishing the clinical QA for radiation oncology as well as other specialties through detailed monitoring and evaluation of their structures, processes and outcomes.

The med AUSTRON / ÖGRO patterns of care study on radiotherapy indications in Austria

PURPOSE

In Austria a national survey was conducted by Med AUSTRON/Osterreichische Gesellschaft for Radio--Onkologie, Radiobiologie und Medizinische Radiophysik (OGRO) in order to estimate the indications, patient numbers and radiotherapy treatment planning procedures and performances at all Austrian radiotherapy institutes. Results were correlated with incidence rates (Austrian cancer registry) to determine patterns of radiotherapy practice in Austria.

MATERIAL AND METHODS

At 12 radiotherapy departments of Austria data of all patients receiving irradiation within a 3 months (2002/2003) period were assessed. On the basis of a questionnaire number of treated patients, indications, and parameters of disease (stage, histology) and treatment modalities were evaluated. Results were analysed with regard to different tumour groups, according to academic and non academic hospitals, and correlated with epidemiological data on cancer incidence.

RESULTS

In total, 3783 patients were registered within this period. According to the different tumour entities percentages of patients receiving radiotherapy within initial treatment varied from 3% to 90 % (e.g. brain tumours: 77%, breast cancer: 90%, prostate cancer: 35%). The most frequent indications to radiotherapy per radiotherapy department were breast cancer (range 22%-35%; mean 26%), urological tumours (range 6%-27%; mean 12%) and bone metastases (mean 10%, range 3%-17%).

CONCLUSION

In Austria breast cancer, urological tumours and bone metastases are representing the most common indications to radiotherapy. Among the different departments variations in indications to radiotherapy were observed. Our study is the first evaluation of radiotherapeutic management in Austria.

Patterns of care in radiotherapy of breast cancer in Austria 1985: data acquisition and comparison with data of US-PCS 1983

PURPOSE

In Austria, a Patterns of Care Study (PCS) has been conducted to evaluate the standards of practice for breast cancer patients. The year 1985 was selected in order to establish a base data set.

MATERIALS AND METHODS

At all nine radiation therapy facilities active in patient treatment in 1985, ten patients charts were randomly selected and reviewed. Evaluation of the radiotherapeutic standards was the principal purpose, however, surgical and histopathological parameters were also considered.

RESULTS

Results of the Austrian PCS (including 90 patients) were compared with the "1983 Patterns of Care Process Survey for Definitive Breast Irradiation" performed in 1983 in the U.S. (including 191 patients). Documentation of pathologic tumour size (83% vs. 73%), histologic tumour subtype (99% vs. 97%) and microscopic margin analysis (60% vs. 51%) showed comparable results. Technical equipment was obviously quite different in the two countries, cobalt therapy was used in 25% in the US-PCS compared to 71% in the Austrian PCS. A clear difference also was obtained concerning the use of wedges for tangential breast/thoracic wall fields (64% vs. 21%) and the frequency of portal films (93% vs. 26%).

CONCLUSIONS

Comparing both PCS studies, we found overall many similarities. Differences could be obtained in the quality level of radiation treatment, as for example use of wedges for tangential fields and the number of portal films. In a next step, a further Austrian PCS is planned to compare the Austrian base data from 1985 with quality standards from 1993 and 2001.