Adherence to breast cancer guidelines is associated with better survival outcomes: a systematic review and meta-analysis of observational studies in EU countries

The influence of socioeconomic inequity and guidelines compliance on clinical outcomes of patients with acute biliary pancreatitis. An international multicentric cohort study

BACKGROUND

There is lack of data on the association between socioeconomic factors, guidelines compliance and clinical outcomes among patients with acute biliary pancreatitis (ABP).

METHODS

Post-hoc analysis of the international MANCTRA-1 registry evaluating the impact of regional disparities as indicated by the Human Development Index (HDI), and guideline compliance on ABP clinical outcomes. Multivariable logistic regression models were employed to identify prognostic factors associated with mortality and readmission.

RESULTS

Among 5313 individuals from 151 centres across 42 countries marked disparities in comorbid conditions, ABP severity, and medical procedure usage were observed. Patients from lower HDI countries had higher guideline non-compliance (p < 0.001) and mortality (5.0% vs. 3.2%, p = 0.019) in comparison with very high HDI countries. On adjusted analysis, ASA score (OR 1.810, p = 0.037), severe ABP (OR 2.735, p < 0.001), infected necrosis (OR 2.225, p = 0.006), organ failure (OR 4.511, p = 0.001) and guideline non-compliance (OR 2.554, p = 0.002 and OR 2.178, p = 0.015) were associated with increased mortality. HDI was a critical socio-economic factor affecting both mortality (OR 2.452, p = 0.007) and readmission (OR 1.542, p = 0.046).

CONCLUSION

These data highlight the importance of collaborative research to characterise challenges and disparities in global ABP management. Less developed regions with lower HDI scores showed lower adherence to clinical guidelines and higher rates of mortality and recurrence.

Quality indicators for systemic anticancer therapy services: a systematic review of metrics used to compare quality across healthcare facilities

PURPOSE

The number of systemic anticancer therapy (SACT) regimens has expanded rapidly over the last decade. There is a need to ensure quality of SACT delivery across cancer services and systems in different resource settings to reduce morbidity, mortality, and detrimental economic impact at individual and systems level. Existing literature on SACT focuses on treatment efficacy with few studies on quality or how SACT is delivered within routine care in comparison to radiation and surgical oncology.

METHODS

Systematic review was conducted following PRISMA guidelines. EMBASE and MEDLINE were searched and handsearching was undertaken to identify literature on existing quality indicators (QIs) that detect meaningful variations in the quality of SACT delivery across different healthcare facilities, regions, or countries. Data extraction was undertaken by two independent reviewers.

RESULTS

This review identified 63 distinct QIs from 15 papers. The majority were process QIs (n = 55, 87.3%) relating to appropriateness of treatment and guideline adherence (n = 28, 44.4%). There were few outcome QIs (n = 7, 11.1%) and only one structural QI (n = 1, 1.6%). Included studies solely focused on breast, colorectal, lung, and skin cancer. All but one studies were conducted in high-income countries.

CONCLUSIONS

The results of this review highlight a significant lack of research on SACT QIs particularly those appropriate for resource-constrained settings in low- and middle-income countries. This review should form the basis for future work in transforming performance measurement of SACT provision, through context-specific QI SACT development, validation, and implementation.

The impact of NCCN-compliant multidisciplinary conference on the uptake of active surveillance among eligible patients with localized prostate cancer

INTRODUCTION

We sought to investigate the impact of National Comprehensive Cancer Network (NCCN)-compliant multidisciplinary conference on the uptake of active surveillance (AS) among eligible patients with prostate cancer.

METHODS

Retrospective review of our AS database was performed. Patients who are eligible for AS who sought a second opinion at a comprehensive cancer center (2010-2021) were presented to the multidisciplinary Localized Prostate Cancer Conference (LPCC) that includes urologists, radiation oncologists, pathologists, and patient advocates. Cochrane Armitage test was used to examine trends over time. Multivariable regression models were fit to evaluate variables associated with the receipt of AS.

RESULTS

Seven hundred twelve patients were identified (19% NCCN very low risk, 32% low risk, and 49% intermediate favorable risk). 43% were recommended AS as the preferred option by the community compared to 68% by LPCC, and 65% elected AS. Recommending AS significantly increased between 2010 and 2021 by the community (from 26% to 57%) and by LPCC (from 52% to 82%), while the proportion of men who received AS increased from 47% to 80% during the same period (P < 0.0001 for all). More recent LPCC era 2017 to 2021 (OR 12.31, 95% CI, 5.60-27.03, P < 0.0001), African American race (OR 0.42, 95% CI, 0.18-0.96, P = 0.04), positive cores at biopsy (OR 0.96, 95% CI, 0.94-0.97, P < 0.0001), age (OR 1.14, 95% CI, 1.10-1.18, P < 0.0001), NCCN low risk (OR 0.25, 95% CI, 0.08-0.81, P = 0.02) and NCCN intermediate favorable risk (OR 0.03, 95% CI, 0.01-0.09, P < 0.0001) were associated with receipt of AS.

CONCLUSION

AS recommendation increased significantly over time by community urologists and to a higher extent by NCCN-compliant multidisciplinary conference. The Uptake of AS significantly increased within the same period. More recent LPCC era 2017 to 2021, African American race, the proportion of positive cores at biopsy, age, and NCCN risk were the main determinants of receipt of AS.

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).

Staging for Breast Cancer: A Comparison Between Old and New Approaches

Background/Aim

Staging for breast cancer in advanced stages or prior to neoadjuvant chemotherapy is recommended to be performed with CT scan of the chest and abdomen and a bone scan. This recommendation is valid since 2012, when conventional staging with chest x-ray and ultrasound of the abdomen was replaced by the more sensitive CT scan. However, it remains unclear if this approach improves patient outcome and prognosis.

Patients and Methods

We identified patients who were treated for breast cancer at the breast center of the St. Elisabeth Hospital, Cologne, in 2012 and 2014. Clinical information such as age at diagnosis, stage, tumor biology, grading, and the applied method for staging was abstracted from the patient chart. We also looked for local or distant recurrence and data of survival.

Results

A total of 1,122 patients were identified. Of those, 104 patients developed local or distant recurrence and 54 died. Conventional staging with chest x-ray, abdominal ultrasound and a bone scan was more often in 2012 (482 cases) than in 2014 (135), but CT-staging was more often in 2014 (180 vs. 29 cases). In general, less patients were staged in 2014 than in 2012. There were no significant survival differences between the two groups.

Conclusion

Staging habits changed in 2012 compared to 2014 according to the changes in guidelines. This change did not affect disease-free survival.

Exploring Australian emergency department clinicians' knowledge, attitudes and adherence to the national peripheral intravenous catheter clinical care standard: A cross-sectional national survey

OBJECTIVE

This study aimed to (i) capture clinicians' knowledge, attitude and adherence to the first Australian national peripheral intravenous catheter (PIVC) Clinical Care Standard, (ii) examine the instrument performance of the knowledge related questions and (iii) explore the educational needs for, and barriers to, Standard adherence among Australian ED clinicians.

METHODS

A cross-sectional national online survey was conducted from March to June 2022, using a snowball sampling method. The survey used 5-point Likert scales and multiple-choice questions to capture respondents' knowledge, attitude and adherence to the Standard as well as the educational needs for, and barriers to, Standard adherence.

RESULTS

In total, 433 ED nurses and doctors responded. Although nearly half (n = 206, 47.6%; 95% confidence interval [CI] 55.5-65.8) of respondents claimed that they were unfamiliar with the Standard, questions on PIVC knowledge yielded that most respondents had adequate knowledge of most of the key standards. Respondents' attitudes towards multiple intravenous insertion attempts and ongoing PIVC competency monitoring are not in agreement with the Standard. Self-reported practices regarding routine insertion of idle catheters (55%; 95% CI 49.9-59.9), using antecubital fossa as the first insertion site (84%; 95% CI 80-87), insertion without confidence (46%; 95% CI 41.2-51.1) and lack of routine reviewing the ongoing needs of PIVC (40%; 95% CI 35.3-45.1) were not aligned with the Standard. Unawareness of the Standard and non-practical recommendations were rated as the top barriers to Standard adherence.

CONCLUSION

The findings of the survey suggest that the Standard may need modification to align with the needs of ED clinicians. Future studies need to explore the applicability and relevancy of some recommendations in the ED settings as they may cause low adherence to the Standard.

Identifying the effective behaviour change techniques in nutrition and physical activity interventions for the treatment of overweight/obesity in post-treatment breast cancer survivors: a systematic review

PURPOSE

Updated evidence for the treatment of obesity in cancer survivors includes behavioural lifestyle interventions underpinning at least one theoretical framework. The aim of this systematic review was to assess the effectiveness of theory-based lifestyle interventions for the treatment of overweight/obesity in breast cancer survivors and to report effective behavioural change techniques (BCTs) and components used in these interventions.

METHODS

Four databases were searched for RCTs published between database inception and July 2022. The search strategy included MeSH terms and text words, using the PICO-framework to guide the eligibility criteria. The PRISMA guidelines were followed. Risk-of-bias, TIDier Checklist for interventions' content, and the extent of behaviour change theories and techniques application were assessed. To evaluate the effectiveness of interventions, trials were categorised as "very," "quite," or "non" promising according to their potential to reduce body weight, and BCTs promise ratios were calculated to assess the potential of BCTs within interventions to decrease body weight.

RESULTS

Eleven RCTs met the inclusion criteria. Seven trials were classified as "very", three as "quite" and one study was "non" promising. Studies' size, design, and intervention strategies varied greatly, but the weight-loss goal in all studies was ≥ 5% of the initial body weight through a 500-1000 kcal/day energy deficit and a gradually increased exercise goal of ≥ 30 min/day. Social Cognitive Theory was the most commonly used theory (n = 10). BCTs ranged from 10 to 23 in the interventions, but all trials included behaviour goal setting, self-monitoring, instructions on the behaviour, and credible source. The risk-of-bias was "moderate" in eight studies and "high" in three.

CONCLUSION

The present systematic review identified the components of theory-based nutrition and physical activity behaviour change interventions that may be beneficial for the treatment of overweight/obesity in breast cancer survivors. The strategies mentioned, in addition to reported behavioural models and BCTs, should be considered when developing weight-loss interventions for breast cancer survivors.

Characteristics and impact of interventions to support healthcare providers' compliance with guideline recommendations for breast cancer: a systematic literature review

BACKGROUND

Breast cancer clinical practice guidelines (CPGs) offer evidence-based recommendations to improve quality of healthcare for patients. Suboptimal compliance with breast cancer guideline recommendations remains frequent, and has been associated with a decreased survival. The aim of this systematic review was to characterize and determine the impact of available interventions to support healthcare providers' compliance with CPGs recommendations in breast cancer healthcare.

METHODS

We searched for systematic reviews and primary studies in PubMed and Embase (from inception to May 2021). We included experimental and observational studies reporting on the use of interventions to support compliance with breast cancer CPGs. Eligibility assessment, data extraction and critical appraisal was conducted by one reviewer, and cross-checked by a second reviewer. Using the same approach, we synthesized the characteristics and the effects of the interventions by type of intervention (according to the EPOC taxonomy), and applied the GRADE framework to assess the certainty of evidence.

RESULTS

We identified 35 primary studies reporting on 24 different interventions. Most frequently described interventions consisted in computerized decision support systems (12 studies); educational interventions (seven), audit and feedback (two), and multifaceted interventions (nine). There is low quality evidence that educational interventions targeted to healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified have not been evaluated with appropriate study designs for such purpose. There is very limited data on the costs of implementing these interventions.

CONCLUSIONS

Different types of interventions to support compliance with breast cancer CPGs recommendations are available, and most of them show positive effects. More robust trials are needed to strengthen the available evidence base concerning their efficacy. Gathering data on the costs of implementing the proposed interventions is needed to inform decisions about their widespread implementation.

TRIAL REGISTRATION

CRD42018092884 (PROSPERO).

Novel computational biology modeling system can accurately forecast response to neoadjuvant therapy in early breast cancer

BACKGROUND

Generalizable population-based studies are unable to account for individual tumor heterogeneity that contributes to variability in a patient's response to physician-chosen therapy. Although molecular characterization of tumors has advanced precision medicine, in early-stage and locally advanced breast cancer patients, predicting a patient's response to neoadjuvant therapy (NAT) remains a gap in current clinical practice. Here, we perform a study in an independent cohort of early-stage and locally advanced breast cancer patients to forecast tumor response to NAT and assess the stability of a previously validated biophysical simulation platform.

METHODS

A single-blinded study was performed using a retrospective database from a single institution (9/2014-12/2020). Patients included: ≥ 18 years with breast cancer who completed NAT, with pre-treatment dynamic contrast enhanced magnetic resonance imaging. Demographics, chemotherapy, baseline (pre-treatment) MRI and pathologic data were input into the TumorScope Predict (TS) biophysical simulation platform to generate predictions. Primary outcomes included predictions of pathological complete response (pCR) versus residual disease (RD) and final volume for each tumor. For validation, post-NAT predicted pCR and tumor volumes were compared to actual pathological assessment and MRI-assessed volumes. Predicted pCR was pre-defined as residual tumor volume ≤ 0.01 cm³ (≥ 99.9% reduction).

RESULTS

The cohort consisted of eighty patients; 36 Caucasian and 40 African American. Most tumors were high-grade (54.4% grade 3) invasive ductal carcinomas (90.0%). Receptor subtypes included hormone receptor positive (HR+)/human epidermal growth factor receptor 2 positive (HER2+, 30%), HR+/HER2- (35%), HR-/HER2+ (12.5%) and triple negative breast cancer (TNBC, 22.5%). Simulated tumor volume was significantly correlated with post-treatment radiographic MRI calculated volumes (r = 0.53, p = 1.3 × 10^-7, mean absolute error of 6.57%). TS prediction of pCR compared favorably to pathological assessment (pCR: TS n = 28; Path n = 27; RD: TS n = 52; Path n = 53), for an overall accuracy of 91.2% (95% CI: 82.8% - 96.4%; Clopper-Pearson interval). Five-year risk of recurrence demonstrated similar prognostic performance between TS predictions (Hazard ratio (HR): - 1.99; 95% CI [- 3.96, - 0.02]; p = 0.043) and clinically assessed pCR (HR: - 1.76; 95% CI [- 3.75, 0.23]; p = 0.054).

CONCLUSION

We demonstrated TS ability to simulate and model tumor in vivo conditions in silico and forecast volume response to NAT across breast tumor subtypes.

Impact of Prior Authorization on Patient Access to Cancer Care

Prior authorization (PA) is a type of utilization review that health insurers apply to control service delivery, payments, and reimbursements of health interventions. The original stated intent of PA was to ensure high-quality standards in treatment delivery while encouraging evidence-based and cost-effective therapeutic choices. However, as currently implemented in clinical practice, PA has been shown to affect the health workforce, adding administrative burden to authorize needed health interventions for patients and often requiring time-consuming peer-to-peer reviews to challenge initial denials. PA is presently required for a wide range of interventions, including supportive care medicines and other essential cancer care interventions. Patients who are denied coverage are commonly forced to receive second-choice options, including less effective or less tolerable options, or are exposed to financial toxicity because of substantial out-of-pocket expenditures, affecting patient-centric outcomes. The development of tools informed by national clinical guidelines to identify standard-of-care interventions for patients with specific cancer diagnoses and the implementation of evidence-based clinical pathways as part of quality improvement efforts of cancer centers have improved patient outcomes and may serve to establish new payment models for health insurers, thereby also reducing administrative burden and delays. The definition of a set of essential interventions and guidelines- or pathways-driven decisions could facilitate reimbursement decisions and thus reduce the need for PAs. Structural changes in how PA is applied and implemented, including a redefinition of its real need, are needed to optimize patient-centric outcomes and support high-quality care of patients with cancer.

Protocol for Development of American Association of Clinical Endocrinology Clinical Practice Guidelines and Consensus Statements: Summary of Methodology, Process, and Policy - 2023 Update

OBJECTIVE

This 2023 updated protocol summarizes the American Association of Clinical Endocrinology's (AACE's) new framework for the development of clinical practice guidelines and other guidance documents that includes changes to methodology, processes, and policies.

METHODS

AACE has critically reviewed its development processes for guidance documents over the last several years against the National Academy of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines and the Council of Medical Specialty Societies Principles for Development of Specialty Society Clinical Guidelines to determine areas for improvement.

RESULTS

The new AACE framework for development of guidance documents incorporates many changes, including a revised conflicts of interest (COI) policy; strengthened commitment to collection of disclosures and management of relevant COI during development; open calls to membership for authors; new requirements for authors; new diversity, equity, and inclusion (DEI) policy; new empanelment process that incorporates consideration of DEI; and adoption of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to increase the quality of evidence assessment and standardize recommendation grades and statements, among other improvements.

CONCLUSIONS

AACE has revised its policies and adopted a completely new methodology for guideline development in support of the mission to elevate the practice of clinical endocrinology to improve patient care. With the use of an evidence-based medicine framework and by continually assessing and improving its processes for development of guidance, AACE strives to deliver trustworthy, unbiased, and up-to-date information that ensures clinician and patient confidence in AACE content. Further, AACE hopes that these enhancements foster a more collaborative approach to development and increase engagement with the worldwide medical community to improve global health.

The effectiveness of clinical guideline implementation strategies in oncology-a systematic review

IMPORTANCE

Guideline recommendations do not necessarily translate into changes in clinical practice behaviour or better patient outcomes.

OBJECTIVE

This systematic review aims to identify recent clinical guideline implementation strategies in oncology and to determine their effect primarily on patient-relevant outcomes and secondarily on healthcare professionals' adherence.

METHODS

A systematic search of five electronic databases (PubMed, Web of Science, GIN, CENTRAL, CINAHL) was conducted on 16 december 2022. Randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) assessing the effectiveness of guideline implementation strategies on patient-relevant outcomes (overall survival, quality of life, adverse events) and healthcare professionals' adherence outcomes (screening, referral, prescribing, attitudes, knowledge) in the oncological setting were targeted. The Cochrane risk-of-bias tool and the ROBINS-I tool were used for assessing the risk of bias. Certainty in the evidence was evaluated according to GRADE recommendations. This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number CRD42021268593.

FINDINGS

Of 1326 records identified, nine studies, five cluster RCTs and four controlled before-and after studies, were included in the narrative synthesis. All nine studies assess the effect of multi-component interventions in 3577 cancer patients and more than 450 oncologists, nurses and medical staff.

PATIENT-LEVEL

Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain.

PROVIDER-LEVEL

Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.

CONCLUSIONS AND RELEVANCE

Knowledge and skill accumulation through team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched guideline implementation strategies in oncology recently. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.

Implications for surveillance for breast cancer patients based on the internally and externally validated BRENDA-metastatic recurrence score

PURPOSE

Although the incidence of distant relapse is decreasing, 20-30% of patients with early breast cancer die of metastasis. The aim of this study is to characterize patients with metastasis-free survival(MFS) less than 5 years, to analyze the most probable site of metastases according to the internally and externally validated BRENDA-score. The BRENDA-score is a combination of the biological subtype and clinical staging.

METHOD

3832 patients with primary diagnosis of breast cancer and either distant metastatic recurrence within 5 years or MFS ≥ 5 years were assigned to this study. Patients were classified for metastatic recurrence according to the BRENDA-score. 1765 patients were in a validation set. Statistical methods were Kaplan-Meier curves, Cox regression analysis, Exhausted CHAID, likelihood-ratio tests and the Nearest Neighbor Estimation method.

RESULTS

There was a significant(p < 0.001) difference between the Kaplan-Meier MFS-functions of M0-patients stratified by BRENDA-score. The BRENDA score outperforms intrinsic subtypes and the Nottingham prognostic score. It fits the original data and the validation set equally well (p = 0.179).There was a significant(p < 0.001) difference between mean BRENDA-Index for patients with MFS < 5y(21.0 ± 9.0) and patients with MFS ≥ 5y(mean BRENDA-Index 11.7 ± 8.2). 55.6% of the very high risk patients(BRENDA-Index ≥ 27) had metastases within 5 years. The most likely primary metastatic site was bone(30%) followed by liver(19%) and lung(18%). The discriminatory ability(areas under the time dependent ROC curve) of the BRENDA score is good to acceptable for the first 5 years. In the very low/low risk (intermediate, high/very high) risk group 50% of all metastases were diagnosed within 26 months. Guideline adherence had a highly significant influence on outcome independent of the risk group.

CONCLUSION

The evaluation showed that the BRENDA-Score is a robust predictive tool for breast cancer recurrence and site of metastases in the first five years after diagnosis. It outperforms intrinsic subtypes and the Nottingham prognostic score. The BRENDA-score could be a tool for a risk orientated and targeted follow up.

Neonatal hyperbilirubinemia: Assessing variation in knowledge and practice

INTRODUCTION

Neonatal hyperbilirubinemia (NH) is commonly diagnosed and managed by pediatricians in various clinical settings. The 2004 American Academy of Pediatrics (AAP) Clinical Practice Guideline on NH is widely cited, but literature examining variation across pediatric specialties is limited. This study aimed to assess baseline knowledge and practice habits regarding NH among pediatric providers across various specialties immediately prior to the release of the 2022 NH clinical practice guideline.

METHODS

A non-probability, convenience, self-selected sampling survey was electronically distributed to 311 subjects across five specialties within one pediatric healthcare institution. The survey included eight multiple choice knowledge-based questions with confidence assessments and five management-based questions assessing respondent agreement on a 5-point scale. To compare groups, the Kruskal-Wallis and Mann-Whitney tests were used for continuous variables, and the chi-square and Fisher's exact tests were used for categorical variables.

RESULTS

The overall survey response rate is 46%. There were significant differences between specialties' knowledge regarding NH (p<0.05). There were also significant differences between specialties' confidence ratings, independent of choosing the correct response (p<0.05). For select management-based questions, there were also significant differences between specialties (p<0.05). A majority of respondents (56%) indicated phototherapy treatment thresholds should remain the same in updated management guidelines.

CONCLUSIONS

Significant variations in knowledge and management of NH were identified among pediatric specialties. This suggests dissemination of new guidelines must be cognizant of different constraints impacting knowledge and practice across specialties.

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.

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.

Effects of evidence-based clinical practice guidelines for breast cancer in health care quality improvements. A second systematic review

Background: Traditionally, EB-CPGs have been believed to mainly improve the quality and consistency of health care, but this claim must be conclusively proven. We used the Donabedian three-dimensional model (structure, process, and patient outcomes) to assess improvements in the quality of medical care derived from implementing EB-CPGs. This study corresponds to the second systematic review carried out as a series of studies on different clinical issues that aim to evaluate the effectiveness of the application of the EB-CPG for improving the quality of care. Methods: We followed the methods described by the Cochrane Handbook and presented a descriptive analysis because of the high heterogeneity found across the included studies. We searched the Cochrane Central Register of Controlled Trials, PubMed, and EBSCO Host databases, as well as the grey literature, between 1990 and April 2021. No language restrictions were applied. Only randomised clinical trials (RCTs) were selected. Results: Of the total of 364 interventions included in the eleven RCTs evaluated, 11 (3%) were related to healthcare structure, 51 (14%) to the healthcare delivery process and 302 (83%) to patient outcomes. Regarding the impact of using the EB-CPGs, in 303 interventions (83%), there were no significant differences between the control and experimental groups. In 4 interventions (1%), the result favoured the control and intervention groups in 57 of the interventions (16%). Conclusions: Our study showed that EB-CPGs slightly enhanced the quality of health care in the three dimensions described by Donabedian. Future RCTs should improve their design and methodological rigour by considering the certainty of the evidence supporting the EB-CPGs recommendations. In that context, broader analyses could be performed, having more concise hypotheses for further research. Registration: PROSPERO CRD42020205594.

Disparities Associated With Patient Adherence to BI-RADS 3 Assessment Follow-up Recommendations for Mammography and Ultrasound

OBJECTIVE

To assess the relationship between sociodemographic factors and adherence rates in patients with a BI-RADS 3 assessment.

METHODS

This retrospective cohort study reviewed data from all patients with a BI-RADS 3 assessment on mammography and ultrasound examinations at a single, multisite academic institution, which serves a diverse urban-suburban population, from January 1, 2015, to December 13, 2017. Appropriate follow-up was defined as returning for the first follow-up examination 3 to 9 months after the index examination. Associations between BI-RADS 3 adherence rates and patient sociodemographic characteristics were evaluated using logistic regression.

RESULTS

There were 4,038 patients in our study period; 2,437 patients (60%) had appropriate follow-up, 765 (19%) patients had delayed follow-up, and 836 patients (21%) were lost to follow-up. The overall malignancy rate was 1.4% (46 of 3,202). Older age, retired employment status, and Medicare insurance status were associated with increased adherence to BI-RADS 3 follow-up recommendations. Black race, single relationship status, Medicaid and self-pay insurance status, and living in a top 15% disadvantaged zip code were associated with decreased adherence. On multivariate analysis, older age remained associated with increased adherence and Medicaid insurance status with decreased adherence. Time between index examination and cancer diagnosis was shorter in patients who had timely follow-up (202 days [interquartile range 183-358] versus 392 days [interquartile range 365-563], P ≤ .001), although there was not a significant difference in stage at diagnosis (P = .46).

DISCUSSION

Multiple sociodemographic factors are associated with low adherence to BI-RADS 3 follow-up recommendations suggesting that more frequent and targeted interventions are needed to close disparity gaps.

The role of caregivers in the clinical pathway of patients newly diagnosed with breast and prostate cancer: A study protocol

Background

Caregivers may play a fundamental role in the clinical pathway of cancer patients. They provide emotional, informational, and functional support as well as practical assistance, and they might help mediate the interaction and communication with the oncologists when care options are discussed, or decisions are made. Little is known about the impact of dyadic dynamics on patient-doctor communication, patient's satisfaction, or adherence to the therapies. This study protocol aims to evaluate the efficacy of a psychological support intervention on patients-caregivers relationship and their alignment in the treatment decision-making (TDM) process and estimate related improvement in patient' compliance/adherence to treatments.

Methods

A total of 102 patients-caregivers' dyads will be involved, among breast and prostate cancer patients. The study entails a pre- post- evaluation through psychological questionnaires, with a randomization of participants in two conditions, the experimental one in which subjects participate in a psychological support consultation, and the control one, where dyads do not receive any intervention. A follow up after 6 months from the enrollment is planned.

Discussion

A positive impact of the psychological support intervention on patients' anxiety, depression, distress, and perceived social support is expected. Such improvements can directly affect patients' satisfaction and adherence to treatments. Data gathered from this study may inform health care providers, policy makers, and public health managers about the importance of caregiver's involvement in the cancer care pathway, and the best way to manage it. A further impact is to develop a specific intervention protocol to support caregivers' involvement in cancer care pathway, improve patient's wellbeing, the interaction with physicians and the compliance with the cancer treatment.

Nonadherence to Multimodality Cancer Treatment Guidelines in the United States

Purpose

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

Methods and Materials

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

Results

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

Conclusions

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

The analysis of breast cancer survival in East Azerbaijan province of Iran; prognostic impact of chemotherapy and hormone therapy protocols

BACKGROUND

The global cancer pattern indicated that there were about 2.3 million newly diagnosed breast cancer cases in 2020 worldwide, and was the most common cancer incident in the world. The aim of the study was to assess the prognostic impact of various treatment modalities and cancer-specific overall and disease-free survival rates.

METHODS

One, 5-, 10-, and 15 -years survival rates were calculated; furthermore, overall survival (OS) and disease free survival (DFS) rates were obtained using Kaplan Meier method. To assess the effects of different treatment methods and all clinico-pathological variables with OS and DFS, cox-regression method was used to achieve adjusted hazard ratios of mortality and recurrence rates.

RESULTS

During the study period, 504 primary breast cancer cases were evaluated, with mean age of 49.69(± 10.68) years. The one, 5-, 10-, and 15- year survival rates were 98.21%, 87.39%, 68.17% and, 60.60%, respectively. Tamoxifen + GnRh Agonist and Tamoxifen protocols decreased the hazard of relapse 46% and 84%, respectively. The best one-year OS was obtained for patients treated with Tamoxifen with an aromatase inhibitor (AI) for about 100% overall survival rate. The breast cancer mortality rate was lower than relapse rate in the first and 5thyears of disease, but 10- and 15- year mortality were higher than 10- and 15 -year relapse rates.

CONCLUSION

Our results revealed better overall survival and disease- free survival among primary breast cancer patients in East Azerbaijan; consequently, this underscores establishing and using better chemotherapy and hormone therapy protocols and sufficient follow-ups.

Long-term survival after treatment for primary anal cancer- results from the Swedish national ANCA cohort study

BACKGROUND

Squamous cell carcinoma of the anus is increasing in incidence but remains a rare disease with good 3- and 5-year recurrence free and overall survival rates of 63%-86%. The treatment includes chemoradiotherapy, mainly with 5-fluoruracil (5FU) and mitomycin. The aim of this study was to describe long-term (up to 9 years after treatment) oncological outcome and the types of treatments given, in a Swedish national cohort of patients diagnosed with anal cancer between 2011 and 2013.

METHOD

Patients were identified in the Swedish Cancer Registry. Patients still alive were contacted and asked for consent. Clinical data were retrieved from National Patient Register at the Swedish National Board of Health and Welfare and from medical records. Unadjusted and adjusted analyses were performed for overall survival.

RESULTS

Three hundred and eighty-eight patients were included in the study of which 338 patients (87%) received treatment with a curative intent. Follow up was 85 months (0-113 months) for patients treated with curative intent (information missing in one patient) 7.5 months (0-55) for patients with treated with a palliative intent. Curative treatment varied and consisted of both chemoradiotherapy and radiotherapy (46-64 Gy) alone. 5-FU, mitomycin and cisplatin were the most used chemotherapy agents. Five-year overall survival for patients treated with curative intent was 73%. In an adjusted analysis 5-FU and mitomycin is associated with a lower mortality than 5-FU and cisplatin but the association was weaker (HR 1.61 (95% CI: 0.904; 2.85) than in the unadjusted analysis.

CONCLUSIONS

In this national cohort overall five-year survival was 73% for patients treated with curative intent. As reported by others our results indicate that 5-FU and mitomycin C should be the preferred chemotherapy in treatment for cure.

Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients

Background

The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST‐segment elevation (non‐ST‐segment elevation myocardial infarction [NSTEMI]) has recommended immediate (<2 h) percutaneous coronary intervention (PCI) in very‐high risk patients and early (<24 h) PCI in high‐risk patients.

Hypothesis

To examine the ESC NSTEMI guidelines adherence in a nationwide survey in Israel using the Acute Coronary Syndrome Israeli Survey (ACSIS). We hypothesized that adherence to the guidlines' recommnded PCI timing in NSTEMI pateints will be inadequate, partly due to the inconsistent evidence regarding its effect on clinical outcomes.

Methods

All NSTEMI patients who underwent PCI during the ACSIS surveys in 2016 and 2018 were included in the analysis.

Results

Out of 1793 NSTEMI patients, 1643 (92%) patients underwent PCI, and door to balloon time was documented in 1078 of them. One hundred and fifty‐six (14.5%) patients and 922 (85.5%) patients were defined as very high‐risk and high‐risk NSTEMI patients, respectively. Of the very high‐risk NSTEMI patients, only 10 (6.4%) underwent immediate coronary angiography, and 50 (32.1%) underwent early coronary angiography. Acute heart failure 139 (89.1%) was the main reason for including NSTEMI patients in the very high‐risk category. Of the high‐risk patients, early coronary angiography was performed in only 405 (43.9%) patients. Patients in whom coronary angiography was postponed were older and had more comorbidities.

Conclusions

Despite guidelines recommendations for immediate and early PCI in very high‐risk and high‐risk NSTEMI patients, respectively, most patients do not undergo immediate or early PCI according to contemporary guidelines. Further studies are needed to better understand the reasons for guidelines' nonadherence in those high‐risk patients.

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.

Sustainability of healthcare professionals' adherence to clinical practice guidelines in primary care

BACKGROUND

Sustainability of adherence to clinical practice guidelines (CPGs) represents an important indicator of the successful implementation in the primary care setting.

AIM

To explore the sustainability of primary care providers' adherence to CPGs after receiving planned guideline implementation strategies, activities, or programmes.

METHODS

Cochrane Central Register of Controlled Trials (CENTRAL); Cumulative Index to Nursing and Allied Health Literature (CINAHL); EMBase; Joanna Briggs Institute; Journals@Ovid; Medline; PsycoINFO; PubMed, and Web of Science were searched from January 2000 through May 2021 to identify relevant studies. Studies evaluating the sustainability of primary care providers' (PCPs') adherence to CPGs in primary care after any planned guideline implementation strategies, activities, or programmes were included. Two reviewers extracted data from the included studies and assessed methodological quality independently. Narrative synthesis of the findings was conducted.

RESULTS

Eleven studies were included. These studies evaluated the sustainability of adherence to CPGs related to drug prescribing, disease management, cancer screening, and hand hygiene in primary care. Educational outreach visits, teaching sessions, reminders, audit and feedback, and printed materials were utilized in the included studies as guideline implementation strategies. None of the included studies utilized purpose-designed measurements to evaluate the extent of sustainability. Three studies showed positive sustainability results, three studies showed mixed sustainability results, and four studies reported no significant changes in the sustainability of adherence to CPGs. Overall, it was difficult to quantify the extent to which CPG-based healthcare behaviours were fully sustained based on the variety of results reported in the included studies.

CONCLUSION

Current guideline implementation strategies may potentially improve the sustainability of PCPs' adherence to CPGs. However, the literature reveals a limited body of evidence for any given guideline implementation strategy. Further research, including the development of a validated purpose-designed sustainability tool, is required to address this important clinical issue.

TRIAL REGISTRATION

The study protocol has been registered at PROSPERO (No. CRD42021259748 ).

Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture

Background

The quality of clinical practice guidelines (CPGs) should be extensively evaluated. This study aimed to evaluate Japanese CPGs that include recommendations for acupuncture.

Methods

In a literature search, CPGs including recommendations for acupuncture published in Japan until October 2021 were sought. We assessed (1) whether the CPGs were developed in accordance with the Grading Recommendations Assessment, Development and Evaluation (GRADE) system, (2) the quality of the CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II, and (3) whether the strength of the recommendations for acupuncture was consistent with each CPG's predefined procedure.

Results

Seventeen CPGs including 23 recommendations in total were identified and assessed. (1) Three CPGs were in accordance with the GRADE system. (2) The mean score of overall assessment using AGREE II was 4.5 on a 7-point Likert scale. The mean domain scores were 77% for domain 1 (scope and purpose), 54% for domain 2 (stakeholder involvement), 48% for domain 3 (rigor of development), 78% for domain 4 (clarity of presentation), 20% for domain 5 (applicability), and 51% for domain 6 (editorial independence). (3) The strength of the recommendations for acupuncture in two CPGs was judged to be underestimated. Some of the CPGs contained elementary problems that were not considered in AGREE II.

Conclusion

The methodological quality of Japanese CPGs including recommendations for acupuncture was not necessarily high. Since technical issues exist in each field of therapy, the respective experts should be involved in developing and reviewing CPGs to disseminate accurate health information.

The role of evidence-based guidelines in the diagnosis and treatment of functional neurological disorder

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Evidence-based guidelines use systematic reviews to support clinical recommendations.

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Adherence to evidence-based guidelines improves healthcare costs and patient outcomes.

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Recent randomized trials make guidelines for functional neurological disorders possible.

Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.

Adherence to COVID-19 nutritional guidelines and their impact on the clinical outcomes of hospitalized COVID-19 patients

Background & aims

Coronavirus disease 2019 (COVID-19) patients are at high risk of malnutrition, and their doctors are part of a multidisciplinary team, including nutritionists. However, adherence to nutritional guidelines may be difficult in the context of capacity constraints during the COVID-19 pandemic. The aim of this study was to investigate barriers to doctors' adherence to nutritional guidelines and the impacts of guideline adherence on the outcomes of hospitalized COVID-19 patients.

Methods

A multinational electronic survey involving 51 doctors was conducted between November 2020 and January 2021 from 17 COVID-19-designated hospitals in countries with high (Indonesia) and low (Vietnam) numbers of confirmed COVID-19 cases.

Results

In general, doctors reported concerns related to nutritional practices in patients with Covid-19 which included feeling stress when performing medical nutritional therapy (65%), lacking self-efficacy or confidence in performing nutritional care (49%), lacking clear nutritional guidelines (45%), and experiencing budget limitations (33%). A regression analysis adjusted for age, country, and the number of hospitalized COVID-19 cases revealed that guideline knowledge (β: −1.01 (−1.78, −0.23); p = 0.012) and awareness of guidelines (β: −1.37 (−2.66, −0.09); p = 0.037) were negatively correlated with the length of stay of critically ill COVID-19 patients, but non-significant after adjusting for specialization of the doctor. When stratified according to country, a significant relationship between guideline adherence and length of stay of critically ill patients was only found in Vietnam [guideline adherence: β: −0.55 (−1.08, −0.03); p = 0.038; guideline knowledge: β: −1.01 (−1.9, −0.13); p = 0.027] after adjusting for age, specialty, and number of hospitalized COVID-19 cases. In Indonesia, the significant relationship between guideline adherence and mortality of COVID-19 patients remained strong (β: −14 (−27, −1); p = 0.033) after adjusting for age, specialty, and number of hospitalized COVID-19 cases

Conclusions

Inadequate nutritional knowledge is a key barrier to guideline adherence, and this was international and may be related to doctors' specialties and the COVID-19 pandemic. Adherence to nutritional guidelines may represent a prognostic factor for survival in COVID-19 patients.

A quality evaluation of the clinical practice guidelines on breast cancer using the RIGHT checklist

Background

Breast cancer is the most frequent type of cancer in women. The methodological quality of clinical practice guidelines (CPGs) on breast cancer has been shown to be heterogeneous. The aim of our study was to evaluate the quality of breast cancer CPGs published in years 2018-2020, using the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist.

Methods

We searched Medline (via PubMed), Chinese National Knowledge Infrastructure (CNKI), Wanfang and Chinese Biomedical Literature (CBM) as well as websites of guideline organizations for CPGs on breast cancer published between 2018 and 2020. We used the RIGHT checklist to evaluate the reporting quality of the included guidelines by assessing whether the CPGs adhered to each item of the checklist and calculated the proportions of appropriately reported RIGHT checklist items. We also presented the adherence reporting rates for each guideline and the mean rates for each of the seven domains of the RIGHT checklist.

Results

A total of 45 guidelines were included. Eighteen (40.0%) guidelines had an overall reporting rate below 50% and only three (6.7%) reported more than 80% of the items. The domains “Basic information” and “Background” had the highest reporting rates (75.9% and 62.5%, respectively). The mean reporting rates of the domains “Evidence”, “Recommendation”, “Review and quality assurance”, “Funding and declaration and management of interests” and “Other information” were 42.7%, 53.0%, 33.3%, 45.0%, and 44.4%, respectively.

Conclusions

The reporting quality varied among guidelines for breast cancer, showing the need for improvement in reporting the contents. Guideline developers should pay more attention to reporting the evidence, review and quality assurance, and funding and declaration and management of interests in future.

Prognostic Significance of Pretreatment Staging With 18F-FDG PET in Esophageal Cancer: A Nationwide Population-Based Study

PURPOSE OF THE REPORT

Without the routine use of 18F-FDG PET for initial staging of esophageal cancer, it may lead to inaccurate staging and suboptimal treatment. The purpose of this study was to evaluate the prognostic significance of pretreatment 18F-FDG PET in nonmetastatic esophageal cancer by comparing the survival between patients with and without pretreatment PET.

MATERIALS AND METHODS

We selected newly diagnosed esophageal cancer patients without metastasis between 2009 and 2015 from Taiwan Cancer Registry and National Health Insurance Research Database. Pretreatment 18F-FDG PET staging was determined according to the implementation of PET within 90 days before starting treatment. Overall survival was calculated from the day of treatment initiation to the death from any cause. Survival curves were compared between patients with and without PET staging using the log-rank test.

RESULTS

Of the 9078 patients included, 1765 (19.4%) and 7313 (80.6%) patients were staged with and without pretreatment PET, respectively. The median follow-up time for all patients and survivors was 1.29 years and 5.46 years, respectively. The pretreatment PET group had a lower risk of death than the no pretreatment PET group (hazards ratio, 0.74; 95% confidence interval, 0.70-0.79; P < 0.001). After adjusting for age, stage, histology, and tumor location, pretreatment PET remained significantly correlated with a lower risk of death (hazards ratio, 0.78; 95% confidence interval, 0.73-0.83; P < 0.001).

CONCLUSIONS

The utilization of pretreatment 18F-FDG PET for staging in nonmetastatic esophageal malignancy is associated with a lower risk of death even after adjusting for age, stage, histology, and tumor location.

Breast cancer in previously thyroidectomized patients: which thyroid disorders are a risk factor?

The aim of this study was to evaluate whether there are thyroid diseases in which breast cancer will appear later as well as the role of autoimmunity. This was a retrospective observational study. A total of 410 females (thyroid surgery and later breast cancer) and 524 females (thyroid surgery only) were compared with regard to pathological thyroid findings, thyroid hormones, thyroid autoimmunity and type of breast cancer. Thyroid autoimmunity, especially antithyroid peroxidase antibodies, significantly increased the risk of breast cancer (p < 0.01); however, this was not true for other thyroid diseases, including thyroid cancer. No variant of breast cancer was predominant, and only thyroid autoimmunity was associated with the risk of breast cancer. Further research is needed to explain the impacts of different antithyroid antibodies.

Several studies have long hypothesized a link between thyroid disease and breast cancer. The authors' study retrospectively examined a large cohort of patients who initially underwent thyroid surgery and subsequently had breast cancer compared with a control group consisting of patients with only breast cancer. This comparison showed that only autoimmune thyroid disease was a risk factor for subsequent breast cancer, whereas no significant association of thyroid cancer with breast cancer was found.