Would compliance with cancer care standards improve survival for breast, colorectal and lung cancers?

Mortality after radiotherapy or surgery in the treatment of early-stage non-small-cell lung cancer: a population-based data analysis in the clinical cancer registry of Brandenburg-Berlin

PURPOSE

Stereotactic body radiotherapy (SBRT) is an established treatment method with favorable toxicity for inoperable early-stage non-small-cell lung cancer (NSCLC) patients. This paper aims to evaluate the importance of SBRT in the treatment of early-stage lung cancer patients compared to surgery as standard of care.

METHODS

The German clinical cancer register of Berlin-Brandenburg was assessed. Cases of lung cancer were considered if they had a TNM stage (clinical or pathological) of T1-T2a and N0/x and M0/x, corresponding to UICC stages I and II. In our analyses, cases diagnosed between 2000 and 2015 were included. We adjusted our models with propensity score matching. We compared patients treated with SBRT or surgery regarding age, Karnofsky performance status (KPS), sex, histological grade, and TNM classification. Further, we assessed the association of cancer-related parameters with mortality; hazard ratios (HR) from Cox proportional hazards models were computed.

RESULTS

A total of 558 patients with UICC stages I and II NSCLC were analyzed. In univariate survival models, we found similar survival rates in patients who underwent radiotherapy compared with surgery (HR 1.2, 95% confidence interval [CI] 0.92-1.56; p = 0.2). Our univariate subgroup analyses of patients > 75 years showed a statistically nonsignificant survival benefit for patients treated with SBRT (HR 0.86, 95% CI 0.54-1.35; p = 0.5). Likewise, in our T1 subanalysis, survival rates were similar between the two treatment groups regarding overall survival (HR 1.12, 95% CI 0.57-2.19; p = 0.7). The availability of histological data might be slightly beneficial in terms of survival (HR 0.89, 95% CI 0.68-1.15; p = 0.4). This effect was also not significant. Regarding the availability of histological status in our subgroup analyses of elderly patients, we could show similar survival rates as well (HR 0.70, 95% CI 0.44-1.23; p = 0.14). T1-staged patients also had a statistically nonsignificant survival benefit if histological grading was available (HR 0.75, 95% CI 0.39-1.44; p = 0.4). Concerning adjusted covariates, better KPS scores were associated with better survival in our matched univariate Cox regression models. Further, higher histological grades and TNM stages were related to a higher mortality risk.

CONCLUSION

Using population-based data, we observed an almost equal survival of patients treated with SBRT compared to surgery in stage I and II lung cancer. The availability of histological status might not be decisive in treatment planning. SBRT is comparable to surgery in terms of survival.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review

INTRODUCTION

Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age.

METHODOLOGY

MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis.

RESULTS

Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age.

CONCLUSIONS

Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.

ADVANCE-1: An adapted collaborative benchmarking approach in centre-based lung cancer care

The majority of research within lung cancer is focused on prevention, diagnosis and treatment rather than examining infrastructure or processes of lung cancer centres. Benchmarking is a systematic method for documenting and comparing processes, functions or performance of organisations against the best in the world. ADVANCE-1 is a European Respiratory Society funded pilot study with the main aim of creating a benchmarking tool that can easily document and reflect the structure and process within a lung cancer centre and its associated registry. By doing this we can then compare centres and generate best practice learning points from each centre in order to learn from each other. The ADVANCE-1 study group was constituted by two ERS fellowship-holders and senior lung cancer specialists from the two participating lung cancer services in Glasgow, Scotland, and Berlin, Germany. The study design and benchmarking tools were reviewed externally. Once the benchmarking tools were created, prospective testing was undertaken in the two participating centres in order to allow comparison to ascertain best practice in a so called 'collaborative benchmarking approach'. We were then able to create personalised learning points for each centre. The next phase of the project will be to expand the benchmarking across several European centres in the ADANCE-2 project.

Results of a nationwide survey on multidisciplinary teams on thyroid cancer in Spain

AIM

There is an important lack of knowledge as to the functioning of multidisciplinary teams on thyroid cancer in current clinical practice. We aimed to retrieve data on the composition, structure, and procedures developed by the multidisciplinary units of thyroid cancer in Spain.

METHODS

A nationwide survey consisting of questions about composition, structure, and functioning of multidisciplinary teams was designed. It was available online from November 15, 2017 to February 15, 2018.

RESULTS

Seventy-two multidisciplinary units responded to our survey. Of these, 15 (20.8%) focused only in thyroid cancer, while 57 (79.2%) included other endocrine disorders or non-endocrine tumors. The median (interquartile range) of members of the teams was 11 (9-14). The most frequent medical specialties in the units were endocrinology (100%), surgery (94.4%), pathology (80.6%), radiology (75.0%), nuclear medicine (73.6%), and medical oncology (55.6%). The annual number of patients reviewed by the teams was 40 (20-74). 56.9% of the multidisciplinary teams have elaborated clinical protocols for local use. Apart from clinical case discussions in the meetings, 45.8% of the units included educational activities and 36.1% research subjects. Quality indicators were developed by 22% of the teams.

CONCLUSIONS

These results suggest that there are some hopeful signs that international recommendations of having multidisciplinary approach to patients with thyroid cancer are being followed in Spain. This gives us the opportunity to proceed with further studies to analyze the real impact of this high standard of care on patient outcomes.

Characteristics of professionalism of specialists and advantages of multidisciplinary teams in thyroid cancer: results of a national opinion survey

INTRODUCTION

The opinion of professionals about multidisciplinary teams (MDT) in thyroid cancer has not been studied in Spain. This study was intended to ascertain the opinion of specialists about the characteristics of the professionals and the advantages provided by these teams.

METHODS

A survey was designed to assess the opinion about the characteristics of professionalism and the advantages of MDT for patients, professionals, and the health care system. The survey was posted online from November 15, 2017 to February 15, 2018.

RESULTS

A total of 226 surveys were evaluated. The ability for teamwork was considered the most important characteristic to be met by professionals by 37.2% of respondents, while scientific competence was the most important indicator of professionalism for 37.6%. More than two thirds of specialists felt that MDTs improve the choice of treatments and diagnostic procedures, decrease clinical variability, facilitate implementation of clinical guidelines, improve ongoing training, and increase patient satisfaction and hospital prestige. The degree of agreement with the advantages of MDTs was significantly higher among specialists who had a MDT at their hospitals.

CONCLUSIONS

The overall opinion of professionals on the MDT model is highly favorable. Hospital managers and health care authorities should take these facts into account in order to encourage and support implementation of these teams.

Saudi lung cancer management guidelines 2017

BACKGROUND

Lung cancer management is getting more complex due to the rapid advances in all aspects of diagnostic and therapeutic options. Developing guidelines is critical to help practitioners provide standard of care.

METHODS

The Saudi Lung Cancer Guidelines Committee (SLCGC) multidisciplinary members from different specialties and from various regions and healthcare sectors of the country reviewed and updated all lung cancer guidelines with appropriate labeling of level of evidence. Supporting documents to help healthcare professionals were developed.

RESULTS

Detailed lung cancer management guidelines were finalized with appropriate resources for systemic therapy and short reviews highlighting important issues. Stage based disease management recommendation were included. A summary explanation for complex topics were included in addition to tables of approved systemic therapy.

CONCLUSION

A multidisciplinary lung cancer guidelines was developed and will be disseminated across the country.

Patient-mediated knowledge translation (PKT) interventions for clinical encounters: a systematic review

BACKGROUND

Patient-mediated knowledge translation (PKT) interventions engage patients in their own health care. Insight on which PKT interventions are effective is lacking. We sought to describe the type and impact of PKT interventions.

METHODS

We performed a systematic review of PKT interventions, defined as strategies that inform, educate and engage patients in their own health care. We searched MEDLINE, EMBASE and the Cochrane Library from 2005 to 2014 for English language studies that evaluated PKT interventions delivered immediately before, during or upon conclusion of clinical encounters to individual patients with arthritis or cancer. Data were extracted on study characteristics, PKT intervention (theory, content, delivery, duration, personnel, timing) and outcomes. Interventions were characterized by type of patient engagement (inform, activate, collaborate). We performed content analysis and reported summary statistics.

RESULTS

Of 694 retrieved studies, 16 were deemed eligible (5 arthritis, 11 cancer; 12 RCTs, 4 cohort studies; 7 low, 3 uncertain, 6 high risk of bias). PKT interventions included print material in 10 studies (brochures, booklets, variety of print material, list of websites), electronic material in 10 studies (video, computer program, website) and counselling in 2 studies. They were offered before, during and after consultation in 4, 1 and 4 studies, respectively; as single or multifaceted interventions in 10 and 6 studies, respectively; and by clinicians, health educators, researchers or volunteers in 4, 3, 5 and 1 study, respectively. Most interventions informed or activated patients. All studies achieved positive impact in one or more measures of patient knowledge, decision-making, communication and behaviour. This was true regardless of condition, PKT intervention, timing, personnel, type of engagement or delivery (single or multifaceted). No studies assessed patient harms, or interventions for providers to support PKT intervention delivery. Two studies evaluated the impact on providers of PKT interventions aimed at patients.

CONCLUSIONS

Single interventions involving print material achieved beneficial outcomes as did more complex interventions. Few studies were eligible, and no studies evaluated patient harms, or provider outcomes. Further research is warranted to evaluate these PKT interventions in more patients, or patients with different conditions; different types of PKT interventions for patients and for providers; and potential harms associated with interventions.

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.

[Consensus statement for accreditation of multidisciplinary thyroid cancer units]

Thyroid cancer is the leading endocrine system tumor. Great advances have recently been made in understanding of the origin of these tumors and the molecular biology that makes them grow and proliferate, which have been associated to improvements in diagnostic procedures and increased availability of effective local and systemic treatments. All of the above makes thyroid cancer a paradigm of how different specialties should work together to achieve the greatest benefit for the patients. Coordination of all the procedures and patient flows should continue throughout diagnosis, treatment, and follow-up, and is essential for further optimization of resources and time. This manuscript was prepared at the request of the Working Group on Thyroid Cancer of the Spanish Society of Endocrinology and Nutrition, and is aimed to provide a consensus document on the definition, composition, requirements, structure, and operation of a multidisciplinary team for the comprehensive care of patients with thyroid cancer. For this purpose, we have included contributions by several professionals from different specialties with experience in thyroid cancer treatment at centers where multidisciplinary teams have been working for years, with the aim of developing a practical consensus applicable in clinical practice.

Trends in cancer prognosis in a population-based cohort survey: can recent advances in cancer therapy affect the prognosis?

BACKGROUND

The aim of the study was to investigate trends in cancer prognosis by examining the relationship between period of diagnosis and probability of death from cancer in a population-based cohort.

METHODS

Within a cohort of Japanese men and women aged 40-69 years and free of prior diagnosis of cancer and cardiovascular disease at baseline, data from 4403 patients diagnosed with cancer between 1990 and 2006 and followed up until 2012 were analyzed using survival regression models to assess the presence of an effect of the period of diagnosis (before 1998 versus after 1998) on the risk of dying from cancer.

RESULTS

We noted a significant decrease in risk of dying from cancer among individuals diagnosed after 1998 with lung cancer (hazard ratio [HR]=0.676 [0.571-0.800]) or colorectal cancer (HR=0.801 [0.661-0.970]). A decrease in the estimated five-year probability of death from cancer was also noted between the first (before 1998) and the second (after 1998) period of diagnosis for lung and colorectal cancers (e.g., 85.4% vs. 73.3% for lung cancer and 44.6% vs. 37.7% for colorectal cancer, respectively, for stage III in men aged 60 at diagnosis).

CONCLUSIONS

This study presented the first scientific evidence of improvement in prognosis for lung and colorectal cancer patients in a population-based cohort in Japan. Our results suggest that recent advances in cancer treatment could have influenced cancer survival differently among lung, colorectal and gastric cancers.

Multidisciplinary cancer care: does it improve outcomes?

Multidisciplinary care has been advocated as a solution for increasingly complex treatment decisions in cancer patients. The impact of multidisciplinary care on patient survival has been studied, but evidence is limited by poor methodological quality. Lack of conclusive evidence for increased survival is balanced against improvements in quality of care, guideline adherence, reduction in wait times, and greater satisfaction for patients and care providers.

First data on direct costs of lung cancer management in Morocco

BACKGROUND

Lung cancer is the leading cause of cancer morbidity and mortality. Its management has a significant economic impact on society. Despite a high incidence of cancer, so far, there is no national register for this disease in Morocco. The main goal of this report was to estimate the medical costs of lung cancer in our country.

METHODS

We first estimated the number of annual new cases according to stage of the disease on the basis of the Grand-Casablanca-Region Cancer Registry data. For each sub-group, the protocol of treatment was described taking into account the international guidelines, and an evaluation of individual costs during the first year following diagnosis was made. Extrapolation of the results to the whole country was used to calculate the total annual cost of treatments for lung cancer in Morocco.

RESULTS

Overall approximately 3,500 new cases of lung cancer occur each year in the country. Stages I and II account for only 4% of cases, while 96% are diagnosed at locally advanced or metastatic stages III and IV. The total medical cost of lung cancer in Morocco is estimated to be around USD 12 million. This cost represents approximately 1% of the global budget of the Health Department. According to AROME Guidelines, about 86% of the newly diagnosed lung cancer cases needed palliative treatment while 14% required curative intent therapy. The total cost of early and advanced stages lung cancer management during the first year were estimated to be 4,600 and 3,420 USD, respectively.

CONCLUSION

This study provides health decision-makers with a first estimate of costs and the opportunity to achieve the optimal use of available data to estimate the needs of health facilities in Morocco. A substantial proportion of the burden of lung cancer could be prevented through the application of existing cancer control knowledge and by implementing tobacco control programs.

Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women

OBJECTIVES

To describe the effect of multidisciplinary care on survival in women treated for breast cancer.

DESIGN

Retrospective, comparative, non-randomised, interventional cohort study.

SETTING

NHS hospitals, health boards in the west of Scotland, UK.

PARTICIPANTS

14,358 patients diagnosed with symptomatic invasive breast cancer between 1990 and 2000, residing in health board areas in the west of Scotland. 13,722 (95.6%) patients were eligible (excluding 16 diagnoses of inflammatory cancers and 620 diagnoses of breast cancer at death).

INTERVENTION

In 1995, multidisciplinary team working was introduced in hospitals throughout one health board area (Greater Glasgow; intervention area), but not in other health board areas in the west of Scotland (non-intervention area).

MAIN OUTCOME MEASURES

Breast cancer specific mortality and all cause mortality.

RESULTS

Before the introduction of multidisciplinary care (analysed time period January 1990 to September 1995), breast cancer mortality was 11% higher in the intervention area than in the non-intervention area (hazard ratio adjusted for year of incidence, age at diagnosis, and deprivation, 1.11; 95% confidence interval 1.00 to 1.20). After multidisciplinary care was introduced (time period October 1995 to December 2000), breast cancer mortality was 18% lower in the intervention area than in the non-intervention area (0.82, 0.74 to 0.91). All cause mortality did not differ significantly between populations in the earlier period, but was 11% lower in the intervention area than in the non-interventional area in the later period (0.89, 0.82 to 0.97). Interrupted time series analyses showed a significant improvement in breast cancer survival in the intervention area in 1996, compared with the expected survival in the same year had the pre-intervention trend continued (P=0.004). This improvement was maintained after the intervention was introduced.

CONCLUSION

Introduction of multidisciplinary care was associated with improved survival and reduced variation in survival among hospitals. Further analysis of clinical audit data for multidisciplinary care could identify which aspects of care are most associated with survival benefits.

International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams

BACKGROUND

Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates.

METHODS

One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer.

RESULTS

One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81).

CONCLUSIONS

There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.

Social variations in access to hospital care for patients with colorectal, breast, and lung cancer between 1999 and 2006: retrospective analysis of hospital episode statistics

OBJECTIVES

To determine the extent to which type of hospital admission (emergency compared with elective) and surgical procedure varied by socioeconomic circumstances, age, sex, and year of admission for colorectal, breast, and lung cancer.

DESIGN

Repeated cross sectional study with data from individual patients, 1 April 1999 to 31 March 2006.

SETTING

Hospital episode statistics (HES) dataset.

PARTICIPANTS

564 821 patients aged 50 and over admitted with a diagnosis of colorectal, breast, or lung cancer.

MAIN OUTCOME MEASURES

Proportion of patients admitted as emergencies, and the proportion receiving the recommended surgical treatment.

RESULTS

Patients from deprived areas, older people, and women were more likely to be admitted as emergencies. For example, the adjusted odds ratio for patients with breast cancer in the least compared with most deprived fifth of deprivation was 0.63 (95% confidence interval 0.60 to 0.66) and the adjusted odds ratio for patients with lung cancer aged 80-89 compared with those aged 50-59 was 3.13 (2.93 to 3.34). There were some improvements in disparities between age groups but not for patients living in deprived areas over time. Patients from deprived areas were less likely to receive preferred procedures for rectal, breast, and lung cancer. These findings did not improve with time. For example, 67.4% (3529/5237) of patients in the most deprived fifth of deprivation had anterior resection for rectal cancer compared with 75.5% (4497/5959) of patients in the least deprived fifth (1.34, 1.22 to 1.47). Over half (54.0%, 11 256/20 849) of patients in the most deprived fifth of deprivation had breast conserving surgery compared with 63.7% (18 445/28 960) of patients in the least deprived fifth (1.21, 1.16 to 1.26). Men were less likely than women to undergo anterior resection and lung cancer resection and older people were less likely to receive breast conserving surgery and lung cancer resection. For example, the adjusted odds ratio for lung cancer patients aged 80-89 compared with those aged 50-59 was 0.52 (0.46 to 0.59). Conclusions Despite the implementation of the NHS Cancer Plan, social factors still strongly influence access to and the provision of care.