Audit of compliance to adjuvant chemotherapy and radiotherapy guidelines in breast cancer in a cancer network

Physicians' attitudes and perceived barriers to adherence to the national breast cancer clinical practice guidelines in Mexico: a survey study

BACKGROUND

Adherence to clinical practice guidelines improves outcomes for patients with breast cancer. However, their implementation may not be feasible in low- and middle-income countries. This study aimed to evaluate physicians' adherence, attitudes, and barriers towards the Colima Consensus, which is the Mexican national breast cancer clinical practice guideline.

METHODS

A cross-sectional, 31-item survey was e-mailed to Consensus attendees and members of the Mexican Society of Oncology and Mexican Mastology Association. Descriptive statistics, univariate, and multivariate analysis were used to analyze the associations between participants' characteristics, adherence, attitudes, and barriers.

RESULTS

Of 439 respondents, 78% percent adhered to Consensus recommendations and 94% believed it was applicable to their clinical practice. Forty percent reported using the Consensus as their sole breast cancer guideline. This was associated with being a surgical oncologist (OR 3.3, 95% CI 2.0-5.3) and practicing at a public hospital (OR 2.1, 95% CI 1.2-3.7). The most common barriers to adherence were lack of resources and logistical problems. Regarding attitudes towards the Consensus, 90% considered it a good educational tool, 89% considered it a reliable source of information, and 90% thought it improved quality of care.

CONCLUSIONS

We showed high levels of adherence and positive attitudes towards the Colima Consensus, with a significant proportion of physicians using it as their only guideline. Lack of resources and logistical issues were the main barriers to adherence. Our results highlight the relevance of local breast cancer guidelines and suggest a need for the creation of resource-stratified guidelines.

Adherence to clinical practice guidelines (CPGs) for the treatment of cancers in Australia and the factors associated with adherence: a systematic review protocol

INTRODUCTION

Clinical practice guidelines (CPGs) synthesise the latest evidence to support clinical and patient decision-making. CPG adherent care is associated with improved patient survival outcomes; however, adherence rates are low across some cancer streams in Australia. Greater understanding of specific barriers to cancer treatment CPG adherence is warranted to inform future implementation strategies.This paper presents the protocol for a systematic review that aims to determine cancer treatment CPG adherence rates in Australia across a variety of common cancers, and to identify any factors associated with adherence to those CPGs, as well as any associations between CPG adherence and patient outcomes.

METHODS AND ANALYSIS

Five databases will be searched, Ovid Medline, PsychInfo, Embase, Scopus and Web of Science, for eligible studies evaluating adherence rates to cancer treatment CPGs in Australia. A team of reviewers will screen the abstracts in pairs according to predetermined inclusion criteria and then review the full text of eligible studies. All included studies will be assessed for quality and risk of bias. Data will be extracted using a predefined data extraction template. The frequency or rate of adherence to CPGs, factors associated with adherence to those CPGs and any reported patient outcome rates (eg, relative risk ratios or 5-year survival rates) associated with adherence to CPGs will be described. If applicable, a pooled estimate of the rate of adherence will be calculated by conducting a random-effects meta-analysis. The systematic review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

ETHICS AND DISSEMINATION

Ethics approval will not be required, as this review will present anonymised data from other published studies. Results from this study will form part of a doctoral dissertation (MB), will be published in a journal, presented at conferences, and other academic presentations.

PROSPERO REGISTRATION NUMBER

CRD42020222962.

Real-world emetic risk of chemotherapy and the corresponding antiemetic therapy in Japan: A study based on a nationwide database

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) is a major concern of patients with cancer, leading to suboptimal treatment.

AIM

This study assessed the emetic risk associated with intravenous and oral chemotherapy and the prophylactic antiemetic drugs by cancer type in a real-world setting.

METHODS AND RESULTS

We used the health services utilisation data for patients with cancer diagnosed in 2016. Patients aged at least 20 years at the time of diagnosis and who started their first course of chemotherapy were included. The emetic risk of chemotherapy was determined according to the cancer type and was classified based on clinical practice guidelines. The prescription of antiemetic drugs was assessed. Overall, 172 133 patients were evaluated, of whom 121 103 (70.4%) received intravenous chemotherapy. High-emetic-risk chemotherapy (HEC) was prescribed in 46 458 (27.0%) patients. HEC was prescribed most for patients with oesophageal cancer (80.3%), followed by malignant lymphoma (60.2%) and breast cancer (53.8%). Moderate-emetic-risk chemotherapy (MEC) was prescribed in 60 528 (35.2%) patients and was mostly prescribed for small cell lung cancer (59.9%). Meanwhile, more than 50% of the chemotherapy prescribed for patients with gastric, colorectal, and pancreatic cancer was low-emetic-risk chemotherapy. HEC was accompanied by three-drug antiemetic prophylaxis in more than 90% of patients with small cell lung, non-small cell lung, breast, and oesophageal cancer, whereas only 13.5% of patients with malignant lymphoma were administered CHOP (cyclophosphamide, doxorubicin, vincristine sulphate, and prednisolone) with prophylaxis.

CONCLUSION

The risk of CINV differs with cancer type. HEC was less prescribed compared with MEC. Most patients received the recommended anti-emetic prophylaxis.

Clinicians' attitudes and perceived barriers and facilitators to cancer treatment clinical practice guideline adherence: a systematic review of qualitative and quantitative literature

Background

Clinical Practice Guidelines (CPGs) synthesize the best available evidence to guide clinician and patient decision making. There are a multitude of barriers and facilitators to clinicians adhering to CPGs; however, little is known about active cancer treatment CPG adherence specifically. This systematic review sought to identify clinician attitudes, and perceived barriers and facilitators to active cancer treatment CPG adherence.

Methods

A systematic search was undertaken of five databases; Ovid Medline, PsychInfo, Embase, Scopus, CINAHL, and PROQUEST. The retrieved abstracts were screened for eligibility against inclusion criteria, and a full text review was conducted of all eligible studies. Data were extracted, and a quality assessment was conducted of all included studies. The qualitative papers were thematically analyzed. Attitudes, barriers, and facilitating factors extracted from the quantitative papers were categorized within the qualitative thematic framework.

Results

The search resulted in the identification of 9676 titles. After duplicates were removed, abstracts screened, and full texts reviewed, 15 studies were included. Four themes were identified which related to negative clinician attitudes and barriers to active cancer treatment CPG adherence: (1) concern over CPG content and currency of CPGs; (2) concern about the evidence underpinning CPGs; (3) clinician uncertainty and negative perceptions of CPGs; and (4) organizational and patient factors. The review also identified four themes related to positive attitudes and facilitators to active cancer treatment CPG adherence: (5) CPG accessibility and ease of use; (6) endorsement and dissemination of CPGs and adequate access to treatment facilities and resources; (7) awareness of CPGs and belief in their relevance; and (8) belief that CPGs support decision making, improve patient care, reduce clinical variation, and reduce costs.

Conclusion

These results highlight that adherence to active cancer treatment CPG recommendations by oncology clinicians is influenced by multiple factors such as attitudes, practices, and access to resources. The review has also revealed many similarities and differences in the factors associated with general CPG, and active cancer treatment CPG, adherence. These findings will inform tailored implementation strategies to increase adherence to cancer treatment CPGs.

Trial registration

PROSPERO (2019) CRD42019125748.

Healthcare providers' adherence to breast cancer guidelines in Europe: a systematic literature review

Purpose

Clinical guidelines’ (CGs) adherence supports high-quality care. However, healthcare providers do not always comply with CGs recommendations. This systematic literature review aims to assess the extent of healthcare providers’ adherence to breast cancer CGs in Europe and to identify the factors that impact on healthcare providers’ adherence.

Methods

We searched for systematic reviews and quantitative or qualitative primary studies in MEDLINE and Embase up to May 2019. The eligibility assessment, data extraction, and risk of bias assessment were conducted by one author and cross-checked by a second author. We conducted a narrative synthesis attending to the modality of the healthcare process, methods to measure adherence, the scope of the CGs, and population characteristics.

Results

Out of 8137 references, we included 41 primary studies conducted in eight European countries. Most followed a retrospective cohort design (19/41; 46%) and were at low or moderate risk of bias. Adherence for overall breast cancer care process (from diagnosis to follow-up) ranged from 54 to 69%; for overall treatment process [including surgery, chemotherapy (CT), endocrine therapy (ET), and radiotherapy (RT)] the median adherence was 57.5% (interquartile range (IQR) 38.8–67.3%), while for systemic therapy (CT and ET) it was 76% (IQR 68–77%). The median adherence for the processes assessed individually was higher, ranging from 74% (IQR 10–80%), for the follow-up, to 90% (IQR 87–92.5%) for ET. Internal factors that potentially impact on healthcare providers’ adherence were their perceptions, preferences, lack of knowledge, or intentional decisions.

Conclusions

A substantial proportion of breast cancer patients are not receiving CGs-recommended care. Healthcare providers’ adherence to breast cancer CGs in Europe has room for improvement in almost all care processes. CGs development and implementation processes should address the main factors that influence healthcare providers' adherence, especially patient-related ones.

Registration:

PROSPERO (CRD42018092884).

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05657-8) contains supplementary material, which is available to authorised users.

Clinicians' attitudes to oncology clinical practice guidelines and the barriers and facilitators to adherence: a mixed methods study protocol

INTRODUCTION

Clinical practice guidelines (CPGs) are designed to reduce inappropriate clinical variation and improve the quality of care. Barriers to CPGs include a lack of awareness of CPGs, access to them, time pressures and concerns regarding the evidence underpinning CPG development, implementation and dissemination. The objectives of this study are to assess clinicians' attitudes to CPGs for cancer treatment and the perceived barriers to and facilitators of CPG adherence in order to inform the implementation of cancer treatment CPGs.

METHODS AND ANALYSIS

A mixed methods study will be conducted using a three-phase, sequential design, with each phase informing the next. In phase 1, a qualitative study using recorded interviews will investigate clinicians' attitudes to CPGs for cancer treatment and perceptions of barriers and facilitators to CPG adherence (n=30); interview transcripts will be analysed thematically. In phase 2, a survey will quantify the frequency of attitudes, barriers and facilitators identified in phase 1, in a broader clinical sample (n=200). In phase 3, a workshop forum will be held to facilitate discussions examining the implications of phase 1 and 2 findings for cancer CPG implementation strategies (n=40) leading to recommendations for improvements to practice. The workshop discussion will be recorded, and the transcript will be analysed thematically.

ETHICS AND DISSEMINATION

This study has received ethics approval in New South Wales, Australia (2019/ETH11722, #52019568810127). Study findings will be published in peer-reviewed journals and will form part of a doctoral thesis and be presented at national and international conferences.

Adherence of Mexican physicians to clinical guidelines in the management of breast cancer: Effect of the National Catastrophic Health Expenditure Fund

Aim

To assess the adherence of physicians to the Medical-Care Guidelines for Malignant Breast Tumors in Mexico, before and after the allocation of federal subsidies from the Catastrophic Health Expenditure Fund (FPGC by its Spanish initials) to accredited hospitals, a strategy implemented with the view of offering free treatment to women with breast cancer (BC).

Material and methods

Based on a cross-sectional design, we gathered information on 479 BC patients who had been attended to at in four FPGC-accredited hospitals. Analysis centered on those treated within either three years before or three years after the accreditation of their attending hospitals. The four hospitals analyzed were located in the North, South, West and Center of the country. Information on all medical procedures performed during treatment was drawn from hospital medical records. Information on the socio-demographic characteristics of the patients was obtained by means of face-to-face interviews conducted in their homes.

Results

Adherence of physicians to the Guidelines grew by 12.8 percent (from 43.4 to 56.2 percent) after FPGC accreditation (p<0.001) and varied according to the clinical stage of the disease, with much lower levels of adherence observed in the advanced stages (p<0.05).

Conclusions

The FPGC strategy increased the adherence of physicians to the Medical-Care Guidelines for Malignant Breast Tumors in Mexico.

Uptake of adjuvant breast cancer treatments recommended by multi-disciplinary meetings

BACKGROUND

Adjuvant therapy for breast cancer is routinely discussed and recommended in multi-disciplinary meetings (MDMs). Current literature explores how treatments received by patients differ from national guidelines; however, it does not explore whether treatment is concordant with MDMs. This study provides an Australian perspective on the uptake of MDM recommendations and reasons for non-concordance.

METHODS

A retrospective cohort study of patients with breast cancer presented at The Royal Melbourne Hospital MDM in 2010 and 2014 to investigate the concordance between MDM recommendations and treatment received.

RESULTS

The study group comprised 441 patients (161 from 2010 and 280 from 2014). A total of 375 patients were included in the analyses. Overall, 82% of patients had perfect concordance between recommended and received treatment for all modes of adjuvant therapy. Concordance to endocrine therapy was higher for invasive cancers than ductal carcinoma in situ (97% versus 81%, P < 0.0001). Concordance to radiotherapy was high and did not differ according to type of cancer or surgery (ranging from 88 to 91%). Concordance to chemotherapy recommendations was high overall (92%) and did not vary with nodal status. Women aged over 65 years were least likely to be recommended for adjuvant therapy but most likely to concordant with the recommendation.

CONCLUSIONS

Uptake of MDM-recommended treatments is high. There is a minority of patients in whom MDM recommendations are not followed, highlighting that there are extra steps between recommendations at an MDM and decisions with patients. More attention to this issue is appropriate, and the reasons for non-concordance warrant further study.

The adherence paradox: guideline deviations contribute to the increased 5-year survival of breast cancer patients

BACKGROUND

In German breast cancer care, the S1-guidelines of the 1990s were substituted by national S3-guidelines in 2003. The application of guidelines became mandatory for certified breast cancer centers. The aim of the study was to assess guideline adherence according to time intervals and its impact on survival.

METHODS

Women with primary breast cancer treated in three rural hospitals of one German geographical district were included. A cohort study design encompassed women from 1996-97 (N = 389) and from 2003-04 (N = 488). Quality indicators were defined along inpatient therapy sequences for each time interval and distinguished as guideline-adherent and guideline-divergent medical decisions. Based on all of the quality indicators, a binary overall adherence index was defined and served as a group indicator in multivariate Cox-regression models. A corrected group analysis estimated adjusted 5-year survival curves.

RESULTS

From a total of 877 patients, 743 (85 %) and 504 (58 %) were included to assess 104 developed quality indicators and the resuming binary overall adherence index. The latter significantly increased from 13-15 % (1996-97) up to 33-35 % (2003-04). Within each time interval, no significant survival differences of guideline-adherent and -divergent treated patients were detected. Across time intervals and within the group of guideline-adherent treated patients only, survival increased but did not significantly differ between time intervals. Across time intervals and within the group of guideline-divergent treated patients only, survival increased and significantly differed between time intervals.

CONCLUSIONS

Infrastructural efforts contributed to the increase of process quality of the examined certified breast cancer center. Paradoxically, a systematic impact on 5-year survival has been observed for patients treated divergently from the guideline recommendations. This is an indicator for the appropriate application of guidelines. A maximization of guideline-based decisions instead of the ubiquitous demand of guideline adherence maximization is advocated.

The impact of patient compliance with adjuvant radiotherapy: a comprehensive cohort study

Postoperative radiotherapy (RT) is the standard of care for early stage breast cancer. It reduces the risk for local recurrence and prolongs survival. We assessed whether, the omission of RT because of patient's preference may influence the prognosis and, thus, the quality of cancer care. Detailed information from a prospectively collected database of a breast cancer center was analyzed. Multiple regression analysis and univariate and multivariate analysis for risk factors for recurrence were performed. The entire cohort of primary breast cancer patients in a given time period was analyzed. Data from 1903 patients undergoing treatment at breast cancer center between 2003 and 2008 were used. All patient underwent breast conserving surgery and RT was performed for all patients of the cohort. Local tumor control and disease-free survival were calculated. After a median follow-up of 2.18 years (maximum 6.39 years), 5.5% of patients did not follow guideline-based recommendations for RT. There was a significant correlation between noncompliance and patient's age, adjuvant hormonal therapy (97.0%), and adjuvant chemotherapy (96.8%). Seventy local recurrences occurred that corresponds to a local recurrence rate of 3.9%. The difference in regard to local recurrence-free 5-year survival between the compliant patients and the noncompliant patients is absolute 17.9 (93.3% and 75.4%). Noncompliant patients had suffered a 5.02-fold increased risk of local recurrence than compliant patients. The omission of RT after breast-conserving surgery results in a higher local failure rate and significantly worsens clinical outcome. Age may play an important role because of the comorbidities of aged patients or the assumed low RT tolerance in this group. On a clinical level, this data suggests that improvement is needed to correct this situation, and the question remains as to how best to improve RT compliance.

Chemotherapy compliance in patients with osteosarcoma

PURPOSE

Histological response (HR) to neoadjuvant-chemotherapy (NACT) is considered as a robust prognostic marker in treated osteosarcomas. Chemotherapy compliance can affect both, dose intensity and density and may affect the final outcome in these cases. This vital aspect has been inadequately addressed and therefore merits further investigation.

METHOD

A retrospective study of NACT-treated osteosarcoma patients, during the year 2010 was conducted. Compliance was defined as receipt of planned cycles of chemotherapy in the planned doses, within the planned duration or up to 25% additional time. HR was assessed by grading for histological necrosis (HN). Good responders (GR) included those with tumors showing ≥90% HN.

RESULTS

Of 124 patients, 115 were analyzed for post-NACT HR. Of the 73 (64%) compliant patients, 47 were GR and of the 42 (36%) non-compliant patients, 18 were GR. There was significant association between GR and compliance (P = 0.031). However, at a median follow-up of 7.9 months, there was no significant difference in survival between the noncompliant versus compliant group. Non-compliance was justifiable in 26 patients and not justifiable in 16 patients. Using univariate analysis, T-size, pain, performance status, albumin, LDH, and education were identified as significant factors, while in multivariate analysis, only poor performance status was identified as an independent variable for non-compliance.

CONCLUSIONS

Two-thirds patients were found to be compliant with NACT. There was a significant association between GR and compliant patients. Significant correlation between compliance and survival may be established with a longer follow-up particularly since "good necrosis" is generally predictive of good survival.

Suboptimal chemotherapy is an adverse prognostic factor in osteosarcoma

BACKGROUND

We sought to determine whether suboptimal chemotherapy compromised the prognosis of osteosarcoma patients.

METHODS

A total of 132 eligible patients who underwent chemotherapy between 1998 and 2008 were identified in our database. Information regarding patient demographics, clinical characteristics, and survival status were extracted for analysis. Optimal chemotherapy was defined as receipt of ≥80% of the planned dose intensity of prescribed agents within the planned durations.

RESULTS

The use of optimal chemotherapy resulted in an overall survival benefit with P = 0.006. Patients who failed to complete the optimal chemotherapy protocol had a dismal prognosis of 30.8% overall survival over five years, whereas those who completed the optimal chemotherapy had an overall survival rate over five years of 65.3%. Based on multivariate analysis, patients who were treated with a suboptimal protocol had a higher risk of relapse, metastasis and mortality. The hazard ratio (HR) of recurrence or death for the suboptimal chemotherapy group was as high as 2.512 over that of the optimal chemotherapy group (HR = 2.512, 95% confidence interval = 1.242 to 3.729).

CONCLUSIONS

Chemotherapy is a significant independent prognostic variable, and suboptimal chemotherapy was found to have a detrimental effect on the outcome of patients with osteosarcoma.

Epidemiologic study of compliance to postmastectomy radiation therapy guidelines in breast cancer patients in China between 1999 and 2008

PURPOSE

To evaluate compliance with postmastectomy radiation therapy (PMRT) guidelines in breast cancer patients in China over a 10-year period.

METHODS AND MATERIALS

A hospital-based, nationwide, multicenter retrospective epidemiologic study of primary breast cancer in women was conducted. Seven first-class, upper-level hospitals from different geographic regions of China were selected. One month was randomly selected to represent each year from 1999-2008 in every hospital. All inpatient cases within the selected months were reviewed and demographic, clinical, and pathologic characteristics and treatment patterns were collected. Patients enrolled in this study had to meet the following inclusion criteria: (1) treated with mastectomy and axillary dissection; (2) information regarding whether or not they received postmastectomy radiation therapy was available; and (3) information about staging was available. Patients were divided into 3 groups based on National Comprehensive Cancer Network guidelines. Utilization of PMRT in each group was analyzed and compared between different years and different hospitals.

RESULTS

A total of 2310 patients were analyzed. There were 643 (27.8%) patients in the PMRT recommended group, 557 (24.1%) patients in the controversial group, and 1110 (48.1%) patients in the nonrecommended group. PMRT was used in 48.8% of patients in the recommended group, 15.6% in the controversial group, and 5.7% in the nonrecommended group. There was a trend toward increasing use of radiation therapy in the recommended and controversial groups from 1999-2008. The use of PMRT in the nonrecommended group remained relatively stable from 1999-2008. Fewer positive nodes and nonreceipt of chemotherapy or hormone therapy were associated with underuse of PMRT in the recommended group. In the controversial group, a higher ratio of positive nodes was associated with use of PMRT.

CONCLUSIONS

There is an apparent underuse of PMRT in the PMRT recommended group. Efforts should be made to improve the compliance to PMRT guidelines.

A multicenter prospective observational study of the conformity of temozolomide prescriptions in France

CONTEXT

Temozolomide (TMZ) is approved for the treatment of high-grade gliomas such as glioblastoma (GBM) multiforme and refractory anaplastic astrocytoma, but it is also used in indications not mentioned in the summary of product characteristics (SPC). The main objective of this study was to evaluate the conformity of TMZ prescriptions to the French SPC and prescription guidebook.

METHODS

We conducted a prospective observational study of all consecutive patients treated with TMZ in 21 French hospitals between September 2006 and February 2007, accounting for 39% of total TMZ consumption in France. The conformity of TMZ prescriptions was evaluated in terms of the indication, dosage, treatment duration, and combination with other treatments, with respect to the SPC and prescription guidebook.

RESULTS

We enrolled 831 patients (median age, 56 years) who received a total of 5982 TMZ treatment cycles. TMZ was mainly prescribed to patients with newly diagnosed GBM (384 patients), GBM in progression/relapse (28 patients), or anaplastic astrocytoma in progression/relapse (19 patients). Prescriptions conformed to the SPC in 51.9% of cases and to the prescription guidebook in 91.5% of cases. Global conformity with the SPC, in terms of the dosage, treatment duration, and combination with other treatments, was 62% for newly diagnosed GBM treated with radiotherapy plus TMZ, 72% for TMZ maintenance monotherapy, and 66% for GBM and anaplastic astrocytoma in progression/relapse.

CONCLUSION/DISCUSSION

In France, routine TMZ prescriptions conform to the SPC and practice guidebook. This is one of the largest studies of drug use in neuro-oncology in terms of the number of patients and cycles analyzed.

Preoperative chemotherapy for operable breast cancer is associated with better compliance with adjuvant therapy in matched stage II and IIIA patients

INTRODUCTION

Preoperative chemotherapy (PC) for operable breast cancer has shown significant benefits in prospective trials. Many patients are treated in the community setting and some may question the applicability of PC outside the university setting.

METHODS

Retrospective review was performed of stage II and IIIA breast cancer patients treated from January 2002 to July 2009. Fifty-three of 57 patients who underwent PC were matched based on age, tumor size, and hormone receptor status with 53 patients who did not undergo PC. Differences in patient compliance with physician recommendations for all types of adjuvant therapy were evaluated. Crude odds ratios and adjusted odds ratios derived from conditional logistic regression models were calculated.

RESULTS

There were 106 patients included. Patient compliance with chemotherapy was better in the PC group than in the adjuvant chemotherapy (AC) group (100% versus 70%; p = .0001). Similarly, more patients in the PC group completed radiation therapy (96% versus 65%; p = .0003) and initiated hormonal therapy (100% versus 62%; p = .0001). Conditional logistic regression revealed that higher pathologic stage and current cigarette smoking were associated with poorer compliance with chemotherapy. For radiation therapy, the univariate model revealed that compliance with chemotherapy and being employed were associated with completion of radiation, whereas current cigarette smoking and larger pathologic size were associated with poorer compliance with radiation. For hormonal therapy, current cigarette smokers were more likely to be noncompliant with initiation of hormonal therapy.

CONCLUSIONS

PC for operable breast cancer can improve patient compliance with chemotherapy. Current cigarette smokers were more likely to be noncompliant with all types of adjuvant therapy.

Compliance differences between patients with breast cancer in university and county hospitals

PURPOSE

Compliance with recommended breast cancer treatments outside the context of a clinical trial differs from that in study populations. The purpose of this study was to examine differences in compliance of breast cancer treatments.

PATIENTS AND METHODS

We conducted a retrospective review of 529 patients treated at 2 teaching hospitals in the same city from 2003 to 2006. Compliance with adjuvant therapy recommendations and choice of breast-conserving operations were compared between a university hospital (UH) and a county hospital (CH).

RESULTS

The 2 populations demonstrated similar rates of breast conservation (72% vs. 69%). Although use of radiation therapy at the CH was acceptable (82%), patients at the UH were more likely to undergo radiation therapy (95%). The use of hormone therapy was similar at the UH and the CH (> 93%). Patients were more likely to follow physician recommendations for adjuvant chemotherapy at the UH (89%) compared with the CH (70%; P = .0005). Univariate analysis revealed that patient age, tumor size, stage, grade, and estrogen receptor status were all significant predictors of patient compliance with chemotherapy. Preoperative chemotherapy was a strong predictor of patient compliance with chemotherapy (P < .0001). In multivariate analysis, all of the factors predictive of patient compliance in univariate analysis remained significant except tumor grade.

CONCLUSION

Preoperative chemotherapy appeared to increase compliance compared with adjuvant chemotherapy in the CH population. Compared with national standards, breast-conserving operations and radiation therapy compliance can be accomplished in an acceptable percentage of underinsured patients.

Improving on national quality indicators of breast cancer care in a large public hospital as a means to decrease disparities for African American women

BACKGROUND

In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for stage I, II, and III breast cancer. The purpose of this study was to document compliance with the 3 NQF breast quality indicators during 2 time intervals in a metropolitan public hospital.

MATERIALS AND METHODS

Tumor registry and medical records were used to identify patient demographics and treatments before (2005-2006) and after (2008) implementations in 2007 as a result of the NQF audit. Program changes included: hiring a dedicated medical oncology nurse practitioner, requiring the radiation oncology case manager to attend weekly multidisciplinary conferences, educating Patient Navigators of the importance of multimodal care, and providing support groups for patients addressing importance of completion of all treatment options.

RESULTS

A total of 213 female patients were diagnosed with and treated for stage I, II, or III breast cancer in 2005-2006 and 2008. Of these, 189 (89%) were African American (AA) women. Also, 70 patients of 86 (81.3%) received radiation therapy, 60 of 77 (77.9%) received or were considered for adjuvant chemotherapy, and 124 of 144 (86.1%) for hormonal therapy according to NQF indicators. After 2007, patients receiving radiation therapy increased from 75.8 to 95.8%. Patients receiving or considered for adjuvant chemotherapy or hormonal therapy increased from 73.7 to 93.7% and from 84.1 to 90.0%, respectively.

CONCLUSIONS

NQF breast cancer indicators provided a mechanism to improve compliance of multimodal treatment in our center. Raising awareness of these indicators in the multidisciplinary conference, hiring dedicated personnel, and educating patients has led to major improvements in breast cancer care.

Using National Quality Forum breast cancer indicators to measure quality of care for patients in an AVON comprehensive breast center

In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for quality of care for breast cancer. The aim of this study was to measure quality of care at our AVON Center for Breast Care (AVONCBC) using these indicators. We retrospectively reviewed tumor registry and medical records of females under age 70 diagnosed with breast cancer in years 2005-2006. For patients diagnosed with hormone receptor negative breast cancer, 22 of 29 (75.9%) and 28 of 32 (87.5%) were considered for or received chemotherapy in 2005 and 2006, respectively. Of those patients, 21 of 29 (72.4%) and 24 of 32 (75.0%) were considered for or received chemotherapy within the NQF 4-month period. For patients undergoing breast conserving surgery (BCS), 20 of 23 (86.9%) in 2005 and 37 of 39 (94.9%) in 2006 were referred for adjuvant radiation therapy. The proportion of patients who received radiation therapy within 1 year of diagnosis was 18 of 23 (78.2%) and 29 of 39 (74.4%) for diagnosis years 2005 and 2006, respectively. The vast majority of patients in our AVONCBC are referred to medical and/or radiation oncology for adjunctive therapy and about three-fourths receive treatment compliant with the NQF QI. To increase our compliance rate, we are developing methods to improve access to the multiple disciplines in our AVONCBC. Using the NQF indicators serves to assess hospital performance at a systems-level and as a useful method for tracking cancer quality of care.

HER2 testing and subsequent trastuzumab treatment for breast cancer in a managed care environment

BACKGROUND

Degree of physician adherence to 2001 guidelines recommending routine testing of human epidermal growth factor receptor 2 (HER2) status among newly diagnosed, recurrent, and metastatic breast cancer (BC) cases, and frequency of trastuzumab use in HER2-positive patients are not well documented.

METHODS

Patients newly diagnosed with BC managed by an identifiable hematologist/oncologist between June 1, 2005 and June 30, 2006 were identified from an administrative claims database of three health plans (n = 3,521). From these, a subset of 380 patients was identified for medical chart review. HER2 testing (occurrence, type of test used), HER2 status (positive, negative, unknown), and trastuzumab usage were evaluated.

RESULTS

HER2 testing occurred in 88% of all newly diagnosed patients with BC and in 98.1% of those with stage 1 or higher breast cancer (n = 322), for whom testing is recommended. Among those with HER2 testing performed (n = 335), 21.5% were positive (HER2(+)), 77.3% were negative (HER2(-)), and 1.2% were unknown. Of the 52 patients who used trastuzumab, only one patient did not have documented HER2 overexpression. Of the 45 HER2(+) women who had stage 2 or higher BC, 13% did not receive trastuzumab.

CONCLUSIONS

HER2 testing status was extremely high among newly diagnosed BC patients treated by hematologists/oncologists in a managed care environment. There was almost no evidence of inappropriate prescribing of trastuzumab, but 1 of every 7.5 patients with HER2-overexpressing stage 2 or higher breast cancer did not receive the agent.

[Transversal study of breast cancer treatment in Spain]

OBJECTIVES

The study's objectives were to observe and describe chemotherapy treatment (CT) used in breast cancer (BC) patients in Spain and estimate its cost.

METHODS

Multi-centre and transversal study, which included consecutive BC patients treated with chemotherapy between 10 and 15 May 2004 in 110 centres throughout Spain. Information was gathered on the general characteristics of the centres, the patient data and the treatments administered. This information was collected prospectively based on the data available in the pharmacy service and/or the patient's clinical history. The following information was requested: demographic, clinical, CT administered during the week of the study, established guidelines, inclusion in clinical trials and the direct costs of the medication.

RESULTS

A total of 2,134 patients were included (99.7% women) from 16 autonomous communities and the average age was 51.5. The majority of the treatments were administered in general hospitals (89.7%), public or public health partnership hospitals (91.5%) and level 3 specialist hospitals (64.5%). Among these patients, 120 (5.6%) received treatment as part of a clinical study. A total of 51% of patients received adjuvant or neoadjuvant treatment, mainly for stage IIA disease (28.7%). A total of 1011 patients presented metastatic disease (MD). The estimated average cost of chemotherapy treatment was euro428.5 per cycle and the group of patients with MD incurred the greatest cost (euro640.4 per cycle).

CONCLUSIONS

The results show the current situation of CT for BC in Spain and a great deal of variability is observed both in the use of drugs as well as in the associated costs.

External audit of clinical practice and medical decision making in a new Asian oncology center: Results and implications for both developing and developed nations

PURPOSE

The external audit of oncologist clinical practice is increasingly important because of the incorporation of audits into national maintenance of certification (MOC) programs. However, there are few reports of external audits of oncology practice or decision making. Our institution (The Cancer Institute, Singapore) was asked to externally audit an oncology department in a developing Asian nation, providing a unique opportunity to explore the feasibility of such a process.

METHODS AND MATERIALS

We audited 100 randomly selected patients simulated for radiotherapy in 2003, using a previously reported audit instrument assessing clinical documentation/quality assurance and medical decision making.

RESULTS

Clinical documentation/quality assurance, decision making, and overall performance criteria were adequate 74.4%, 88.3%, and 80.2% of the time, respectively. Overall 52.0% of cases received suboptimal management. Multivariate analysis revealed palliative intent was associated with improved documentation/clinical quality assurance (p = 0.07), decision making (p = 0.007), overall performance (p = 0.003), and optimal treatment rates (p = 0.07); non-small-cell lung cancer or central nervous system primary sites were associated with better decision making (p = 0.001), overall performance (p = 0.03), and optimal treatment rates (p = 0.002).

CONCLUSIONS

Despite the poor results, the external audit had several benefits. It identified learning needs for future targeting, and the auditor provided facilitating feedback to address systematic errors identified. Our experience was also helpful in refining our national revalidation audit instrument. The feasibility of the external audit supports the consideration of including audit in national MOC programs.