Assessing guideline adherence and patient outcomes in cervical cancer

Utilization of clinical practice guidelines for cancer care in routine practice and during the coronavirus disease 2019 pandemic in India

AIM

The coronavirus disease 2019 (COVID-19) pandemic affected cancer service delivery and the feasibility of following the standard treatment guidelines. The present paper describes the use of clinical care guidelines for cancer management in routine practice and the approach adopted towards cancer care during the COVID-19 pandemic in India.

METHODS

A web-based survey was done in 107 hospitals (including public and private health facilities) that hosted Hospital-Based Cancer Registries under the National Cancer Registry Programme. The participants comprised Principal Investigators of these registries, who were also medical, surgical, and radiation oncology clinicians. The survey was done between May 1, 2021, and July 31, 2021. Participants were provided with a web link for the survey questionnaire, confidential login, and password.

RESULTS

The study found high utilization of Clinical Practice Guidelines (CPGs) during practice, with eight out of ten physicians constantly to referring them. The study reported lack of knowledge, skills, and training to administer the treatment based on the guidelines followed by organizational infrastructure and affordability of treatment by the patients as the factors hampering utilization. International clinical guidelines were preferred when compared to national guidelines. The COVID-19 pandemic decreased the use of CPGs, wherein six out of ten clinicians reported their use.

CONCLUSION

Stakeholders who formulate clinical guidelines must consider the practical aspects and feasibility of implementing such guidelines during a pandemic and similar situations. This should be coupled with adequate changes in care practice to ensure optimal care delivery and a continuum of cancer care in routine and pandemic-imposed situations.

Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active-cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full-text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active-cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B-cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non-Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good-excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active-cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962).

Treatment compliance among adult cervical cancer patients receiving care at Uganda cancer institute, Uganda: a retrospective data review

BACKGROUND

Cervical cancer is one of the most common cancers and a major cause of morbidity among women globally. Chemoradiation therapy is the preferred standard treatment for women with stage IB to IVA. However, the benefits of this treatment can only be achieved if patients adhere to the treatment guidelines. In this study, the proportion of compliance or adherence to chemo-radiation treatment among cervical cancer patients at Uganda Cancer Institute (UCI) was determined.

METHODS

This was a cross-sectional study that reviewed data retrospectively for 196 cervical cancer patients who were prescribed to chemo-radiation therapy at UCI between November 2020 to May 2021, having been diagnosed with disease stage IB to IVA. Patient data and information on treatment uptake was obtained by review of the patient's medical records. Treatment compliance was determined by calculating the number of participants who completed the prescribed treatment (definitive pelvic concurrent chemoradiation to 50 Gy external beam radiotherapy with weekly concurrent cisplatin followed by intracavitary brachytherapy 24 Gy in 3 fractions at 8 Gy once a week over 3 weeks). Associations between patient factors and treatment adherence were determined using logistic regression analysis. In all statistical tests, a P- value of < 0.05 was considered as significant.

RESULTS

The proportion of patients who were administered with external beam radiation (EBRT), chemotherapy and brachytherapy were 82.6%, 52.04% and 66.2% respectively. However, only 23 of 196 patients (11.7%) were found to have adhered to the treatment plan by completion of all definitive pelvic concurrent chemoradiation to 50 Gy external beam radiotherapy (5 weeks) with weekly concurrent cisplatin (5 cycles) followed by intracavitary brachytherapy 24 Gy in 3 fractions at 8 Gy once a week over 3 weeks (3 sessions). There were no significant associations between patient factors and treatment adherence after multivariable analysis.

CONCLUSIONS

Treatment compliance was found in only 12% of the cohort participants. No association of patient factors with treatment compliance was found. Additional studies on treatment adherence with larger sample sizes are needed to confirm the associations.

Effect of Quality of Life on Radiation Adherence for Patients With Cervical Cancer in an Urban Safety Net Health System

PURPOSE

Outcomes for patients undergoing chemoradiation for cervical cancer are dependent on adherence to radiation therapy (RT). In other diseases, quality of life (QoL) is associated with treatment adherence, but the association between QoL and RT adherence for patients with cervical cancer remains unclear.

METHODS AND MATERIALS

This prospective study included patients undergoing RT for cervical cancer from 2017 to 2021 at an urban safety net hospital. The Functional Assessment of Cancer Therapy-Cervical Cancer Version 4 was used to assess QoL based on 5 subscales (physical, functional, social and emotional, and cervical-cancer specific). The survey was administered at radiation consult, then weekly during RT and at follow-up. Patient information was abstracted from the medical record. Radiation nonadherence was defined as missing ≥2 days of external beam RT. The Functional Assessment of Cancer Therapy-Cervical Cancer Version 4 total and subscale scores were compared between adherent and nonadherent patients. Multivariable logistic regression was performed to control for confounding variables.

RESULTS

Ninety-three patients were enrolled, completing 522 surveys. Median age at diagnosis was 46 years (interquartile range, 40-51); 76% of patients were Hispanic, and 12% were Black. Only 30% of patients were nonadherent with RT. A psychiatric comorbidity (P = .012) and symptomatic presentation (P = .027) were associated with decreased adherence. Baseline total QoL was higher in treatment-adherent than in nonadherent patients (median, 124.86; range, 48-160; 108.9, 46-150; P = .01). Higher baseline functional and physical subscale scores were associated with adherence (P < .05). Change from baseline to lowest score during treatment in the emotional subscale was also associated with patient adherence (P < .05). In multivariable analysis, higher baseline physical score, baseline total score, and change in emotional subscale score were associated with adherence (P < .05).

CONCLUSIONS

Poor QoL during chemoradiation for cervical cancer is associated with missed treatments. Physician assessment of a patient's well-being while they are undergoing RT is of utmost importance to improve adherence to treatment.

Improved guideline adherence in oncology through clinical decision-support systems: still hindered by current health IT infrastructures?

PURPOSE OF REVIEW

Despite several efforts to enhance guideline adherence in cancer management, the rate of adherence remains often dissatisfactory in clinical routine. Clinical decision-support systems (CDSS) have been developed to support the management of cancer patients by providing evidence-based recommendations. In this review, we focus on both current evidence supporting the beneficial effects of CDSS on guideline adherence as well as technical and structural requirements for CDSS implementation in clinical routine.

RECENT FINDINGS

Some studies have demonstrated a significant improvement of guideline adherence by CDSSs in oncologic diseases such as breast cancer, colon cancer, cervical cancer, prostate cancer, and hepatocellular carcinoma as well as in the management of cancer pain. However, most of these studies were rather small and designs rather simple. One reason for this limited evidence might be that CDSSs are only occasionally implemented in clinical routine. The main limitations for a broader implementation might lie in the currently existing clinical data infrastructures that do not sufficiently allow CDSS interoperability as well as in some CDSS tools themselves, if handling is hampered by poor usability.

SUMMARY

In principle, CDSSs improve guideline adherence in clinical cancer management. However, there are some technical und structural obstacles to overcome to fully implement CDSSs in clinical routine.

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia

BACKGROUND

The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers.

METHODS

The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127).

RESULTS

Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body.

CONCLUSION

Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer

OBJECTIVE

To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer.

METHODS

In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort.

RESULTS

A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy.

CONCLUSIONS

Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death.

Evolution of patterns of care for women with cervical cancer in Morocco over a decade

BACKGROUND

We conducted a Pattern-of-care (POC) study at two premier-most public-funded oncology centers in Morocco to evaluate delays in care continuum and adherence to internationally accepted treatment guidelines of cervical cancer.

METHOD

Following a systematic sampling method, cervical cancer patients registered at Centre Mohammed VI (Casablanca) and Institut National d'Oncologie (Rabat) during 2 months of every year from 2008 to 2017, were included in this retrospective study. Relevant information was abstracted from the medical records.

RESULTS

A total of 886 patients was included in the analysis; 59.5% were at stage I/II. No appreciable change in stage distribution was observed over time. Median access and treatment delays were 5.0 months and 2.3 months, respectively without any significant temporal change. Concurrent chemotherapy was administered to 57.7% of the patients receiving radiotherapy. Surgery was performed on 81.2 and 34.8% of stage I and II patients, respectively. A very high proportion (85.7%) of operated patients received post-operative radiation therapy. Median interval between surgery and initiation of radiotherapy was 3.1 months. Only 45.3% of the patients treated with external beam radiation received brachytherapy. Radiotherapy was completed within 10 weeks in 77.4% patients. An overall 5-year disease-free survival (DFS) was observed in 57.5% of the patients - ranging from 66.1% for stage I to 31.1% for stage IV. Addition of brachytherapy to radiation significantly improved survival at all stages. The study has the usual limitations of retrospective record-based studies, which is data incompleteness.

CONCLUSION

Delays in care continuum need to be further reduced. Increased use of chemoradiation and brachytherapy will improve survival further.

Global challenges of radiotherapy for the treatment of locally advanced cervical cancer

Cervical cancer represents a significant portion of the global cancer burden for women, with low- and middle-income countries carrying the bulk of this burden. Additionally, underserved populations in countries with sufficient resources may have a higher incidence of cervical cancer and poorer outcomes. Concurrent chemoradiotherapy is the standard-of-care treatment for locally advanced cervical cancer, which includes patients with stage IB3 to IVA disease, and it is effective for many patients; however, cervical cancer-related mortality remains high. The critical nature of cervical cancer treatment is underscored by the recent launch of the World Health Organization global initiative to accelerate the elimination of cervical cancer using a triple-intervention strategy of increased vaccination, screening, and treatment. The initiative calls for 90% of all patients diagnosed with cervical cancer to receive the appropriate treatment, but to reach this global goal there are significant barriers related to radiotherapy that must be addressed. We discuss and review evidence of the lack of adherence to guideline-recommended treatment, brachytherapy underutilization, limited access to radiotherapy in low- and middle-income countries, as well as regional limitations within high-income countries, as the major barriers to radiotherapy treatment for locally advanced cervical cancer. We further review ways these barriers are currently being addressed and, in some cases, make additional recommendations to address these issues. Finally, despite receiving recommended treatments, many patients with locally advanced cervical cancer have a poor prognosis. With effective administration of current standards of care, the global community will be able to shift focus to advancing treatment efficacy for these patients. We review several types of therapies under clinical investigation that are additions to concurrent chemoradiotherapy, including immune checkpoint inhibitors, antiangiogenic agents, DNA repair inhibitors, human papillomavirus vaccines, and radiosensitizing nanoparticles.

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.

Racial-Ethnic Comparison of Guideline-Adherent Gynecologic Cancer Care in an Equal-Access System

OBJECTIVE

To compare receipt of National Comprehensive Cancer Network Guideline-adherent treatment for gynecologic cancers, inclusive of uterine, cervical, and ovarian cancer, between non-Hispanic White women and racial-ethnic minority women in the equal-access Military Health System.

METHODS

We accessed MilCanEpi, which links data from the Department of Defense Central Cancer Registry and Military Health System Data Repository administrative claims data, to identify a cohort of women aged 18-79 years who were diagnosed with uterine, cervical, or ovarian cancer between January 1, 1998, and December 31, 2014. Information on tumor stage, grade, and histology was used to determine which treatment(s) (surgery, chemotherapy, radiotherapy) was indicated for each patient according to the National Comprehensive Cancer Network Guidelines during the period of the data (1998-2014). We compared non-Hispanic Black, Asian, and Hispanic women with non-Hispanic White women in their likelihood to receive guideline-adherent treatment using multivariable logistic regression models given as adjusted odds ratios (aORs) and 95% CIs.

RESULTS

The study included 3,354 women diagnosed with a gynecologic cancer of whom 68.7% were non-Hispanic White, 15.6% Asian, 9.0% non-Hispanic Black, and 6.7% Hispanic. Overall, 77.8% of patients received guideline-adherent treatment (79.1% non-Hispanic White, 75.9% Asian, 69.3% non-Hispanic Black, and 80.5% Hispanic). Guideline-adherent treatment was similar in Asian compared with non-Hispanic White patients (aOR 1.18, 95% CI 0.84-1.48) or Hispanic compared with non-Hispanic White women (aOR 1.30, 95% CI 0.86-1.96). Non-Hispanic Black patients were marginally less likely to receive guideline-adherent treatment compared with non-Hispanic White women (aOR 0.73, 95% CI 0.53-1.00, P=.011) and significantly less likely to receive guideline-adherent treatment than either Asian (aOR 0.65, 95% CI 0.44-0.97) or Hispanic patients (aOR 0.56, 95% CI 0.34-0.92).

CONCLUSION

Racial-ethnic differences in guideline-adherent care among patients in the equal-access Military Health System suggest factors other than access to care contributed to the observed disparities.

Cervical Cancer in Sub-Saharan Africa: A Multinational Population-Based Cohort Study of Care and Guideline Adherence

BACKGROUND

Cervical cancer (CC) is the most common female cancer in many countries of sub-Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS).

METHODS

Our observational study covered nine population-based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44-125 patients diagnosed from 2010 to 2016 were selected in each. Cancer-directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines.

RESULTS

Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline-adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow-up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline-adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I-III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio [HRR], 1.73; 95% confidence interval [CI], 0.36-8.37; HRR, 1.97; CI, 0.59-6.56, respectively). CDT without curative potential (HRR, 3.88; CI, 1.19-12.71) and no CDT (HRR, 9.43; CI, 3.03-29.33) showed substantially worse survival.

CONCLUSION

We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one-fifth and possibly up to two-thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients.

IMPLICATIONS FOR PRACTICE

Despite evidence-based interventions including guideline-adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population-based registry study aimed to assess the status quo of presentation, treatment guideline adherence, and survival in eight countries. Patients across sub-Saharan Africa present in late stages, and treatment guideline adherence is remarkably low. Both factors were associated with unfavorable survival. This report warns about the inability of most women with cervical cancer in sub-Saharan Africa to access timely and high-quality diagnostic and treatment services, serving as guidance to institutions and policy makers. With regard to clinical practice, there might be cancer-directed treatment options that, although not fully guideline adherent, have relevant survival benefit. Others should perhaps not be chosen even under resource-constrained circumstances.

Relationship of Adherence to Cervical Cancer Treatment Guideline Towards Patients' Five-year Survival: Systematic Review of Follow-up Trials

Cervical cancer is the one of the most common gynecology malignancies in the world. National Comprehensive Cancer Network (NCCN) guidelines on cervical cancer are widely adopted as national guidelines and clinical practice guidelines. These guidelines are constantly being updated but their effectiveness has not been questioned. Therefore, we conducted a systematic review to assess outcomes with/without guideline adherence in the published studies. This systematic review was conducted according to PRISMA statement. Searching with strategy on PubMed, ProQuest, Scopus, and Wiley databases resulted in three studies that met all criteria, thus assessed further with Newcastle-Ottawa scale, and assessed qualitatively. All three studies adopt NCCN guidelines. We found that the proportion of adherence to cervical cancer treatment guidelines was low, ranging from 42% to 54%, with violations occurring at various clinical stages. One study stated that early stage cervical cancer was more likely to receive guideline adherence (adjusted OR=5.48; 95%CI: 1.94–15.5; p=0.001) than advanced stage. There was a higher five-year survival of cervical cancer patients in the guideline-adhering group than in the nonadhering group. In all three studies, survival in the adherent group was reported as big as 88%, 79%, and 93%, respectively, compared to nonadherent group with 56%, 78%, and 88.1%respectively (p<0.05). One study stated that adherence to guidelines could reduce cervical cancer mortality on stage I and II by 0.22 times (p<0.05). As the conclusion, adherence to guidelines increases survival rates. In the early stages, there are differences in survival.

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.

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.

Treatment patterns for metastatic colorectal cancer in Spain

Purpose

The primary aim of this retrospective study was to describe the treatment patterns according to the type of treatment received by patients with metastatic colorectal cancer (mCRC) in Spain.

Methods

This was a retrospective, observational, multicenter study performed by 33 sites throughout Spain that included consecutive patients aged 18 years or older who had received or were receiving treatment for mCRC.

Results

At the time of inclusion, of the 873 evaluable patients, 507 (58%) had received two lines, 235 (27%) had received three lines, 106 (12%) had received four lines, and the remaining patients had received up to ten lines. The most frequent chemotherapy schemes were the FOLFOX or CAPOX regimens (66%) for first-line treatment, FOLFOX, CAPOX or FOLFIRI (70%) for second-line treatment, and FOLFOX, FOLFIRI or other fluoropyrimidine-based regimens for third- and fourth-line (over 60%) treatment. Sixty percent of patients received targeted therapy as part of their first-line treatment, and this proportion increased up to approximately 70% of patients as part of the second-line of treatment. A relevant proportion of patients were treated with unknown KRAS, and especially the BRAF, mutation statuses.

Conclusions

This study reveals inconsistencies regarding adherence to the recommendations of the ESMO guidelines for the management of mCRC in Spain. Improved adherence to the standard practice described in such guidelines for the determination of RAS and BRAF mutation statuses and the use of targeted therapies in first-line treatment should be considered to guarantee that patients can benefit from the best therapeutic approaches available.

Current Quality of Gynecologic Cancer Care in North America

Evaluating the quality of care received by gynecologic cancer patients in the real world is essential for excellent outcomes. The recent population-based literature looking at quality of care was reviewed for all gynecologic malignancies. Outcomes are generally highest when care is provided by high-volume providers in high-volume cancer centers. Provision of care according to clinical practice guidelines has also been demonstrated to improve outcomes in many situations. Disparities exist for marginalized groups in terms of the care they receive and subsequent outcomes. Health systems need to improve care for these populations.

Stereotactic Body Radiation Therapy, Intensity-Modulated Radiation Therapy, and Brachytherapy Boost Modalities in Invasive Cervical Cancer: A Study of the National Cancer Data Base

BACKGROUND AND PURPOSE

Our objective was to determine whether stereotactic body radiotherapy (SBRT), intensity-modulated radiation therapy (IMRT), and brachytherapy boost techniques have comparable overall survival in treating cervical cancer when adjusted for known prognostic factors.

MATERIALS AND METHODS

We used the National Cancer Database to study women with invasive cervical cancer who were treated with radiation between 2004 and 2013. A logistic regression model was built to identify factors associated with the receipt of SBRT and IMRT. Outcomes were compared using Kaplan-Meier and propensity score matching.

RESULTS

Of all 15,905 patients, 14,394 (90.5%) received brachytherapy, 42 (0.8%) received SBRT, and 1468 (9.2%) received IMRT. After propensity score matching, there was no significant difference in overall survival (OS) for patients who received SBRT boost versus brachytherapy boost (hazard ratio = 1.477, 95% confidence interval = 0.746-2.926, P = 0.263) but a significant OS detriment in patients who received IMRT boost versus brachytherapy boost (hazard ratio = 1.455, 95% confidence interval = 1.300-1.628, P < 0.001).

CONCLUSIONS

In a propensity-matched analysis, those who received SBRT boost had equal OS when compared with brachytherapy, but those who received IMRT boost had worse OS when compared with brachytherapy.

Patient compliance for postoperative radiotherapy and survival outcome of women with stage I endometrioid endometrial cancer

BACKGROUND AND OBJECTIVES

To examine characteristics and survival outcome of women with endometrial cancer who declined postoperative radiotherapy.

METHODS

A retrospective study was conducted to examine surgically-treated grade 1-2 stage IB and grade 3 stage IA-IB endometrioid endometrial cancer in the Surveillance, Epidemiology, and End Results Program between 1983 and 2013 (n = 10 613). Associations of patient declination for guideline-based postoperative radiotherapy and clinico-pathological demographics or survival outcome were examined on multivariable analysis.

RESULTS

There were 323 (3.0%) women who declined adjuvant radiotherapy. Women who declined postoperative radiotherapy were more likely to be older, White, Western U.S. residents, and register in recent years (all, adjusted-P < 0.05). On multivariable analysis, patient declination for guideline-based postoperative radiotherapy remained an independent prognostic factor for decreased endometrial cancer-specific survival in unstaged grade 1-2 stage IB or staged/unstated grade 3 stage IA-IB diseases (adjusted-hazard ratio 1.84, 95% confidence interval 1.34-2.51, P = 0.001). Association of patient declination for guideline-based postoperative radiotherapy and decreased overall survival remained independent in the entire cohort on multivariable analysis (adjuvant-hazard ratio 1.71, 95% confidence interval 1.44-2.02, P < 0.001).

CONCLUSIONS

Our study suggested that patient compliance to guideline-based postoperative radiotherapy is a prognostic factor for women with stage I endometrioid endometrial cancer.