Using practice guidelines to assess cancer care quality

Survival of women with cervical cancer in East Africa: a systematic review and meta-analysis

BACKGROUND

The prognosis for cervical cancer varies greatly between nations. The disparity in cancer survival rates within nations is largely a result of disparities in public knowledge, the accessibility of cancer services, diagnosis and treatment. The purpose of this systematic review and meta-analysis is to assess the survival rate and associated factors among cervical cancer patients in East Africa.

METHODS

Literature search was carried out using Google scholar, PubMed/Medline, Embase and CINHAL. Covidence, a web-based program, was used to import studies for review process. PRISMA guidelines were followed. A total of 110 abstracts were identified from electronic sources. There were five duplicate articles removed. We looked at 105 papers' abstracts and titles, and we excluded 78 of them because they did not fit our inclusion criteria. We conducted a full-text analysis of the remaining 27 papers, leaving out 14 researches that did not fit our inclusion requirements. For final review, 13 studies were included. Using the Joanna Briggs Institute (JBI) assessment checklist, methodological quality was evaluated.

RESULTS

The included articles were cohort studies. They were conducted in Ethiopia, Uganda, Zimbabwe, Kenya, Sudan, Tanzania and Rwanda. One-year, two-year, three-year, four-year and five-year overall survival rates ranged from 67% to 92%, 55% to 84%, 44% to 53%, 32% to 47%, and 26% to 43%, respectively.

CONCLUSIONS

The pooled one-year, two-year, three-year, four-year and five-year survival rates of cervical cancer patients in East Africa were 84%, 71%, 50%, 39% and 36%, respectively. HIV status, late presentation, treatment modalities, older age and presence of comorbidities were the most commonly mentioned prognostic factors for survival.

PROSPERO REGISTRATION NUMBER

CRD42023402551.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR PRACTICE

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

Influence of time between surgery and postoperative radiation therapy and total treatment time in locoregional control of patients with head and neck cancer: a single center experience

OBJECTIVE

This study aimed to evaluate the effect of the delay to initiate postoperative radiation therapy (RT) on locoregional control to head and neck squamous cell carcinoma patients.

METHODS

Retrospective cohort study that included patients submitted to surgery followed by adjuvant RT (with/without chemotherapy). The time interval between surgery and RT was dichotomized by the receiver operating characteristics curve method at 92 days. Other possible sources of heterogeneity with potential impact on locoregional control were explored by regressive analysis.

RESULTS

A total of 168 patients were evaluated. The median time for locoregional recurrence (LRR) was 29.7 months. The relapse-free survival rates were 66.4% and 75.4% for patients who initiated RT more than and within 92 postoperative days (p=0.377), respectively. Doses lower than 60Gy were associated with worse rates of locoregional control (HR=6.523; 95%CI:2.266-18.777, p=0.001). Patients whose total treatment time (TTT) was longer than 150 days had LRR rate of 41.8%; no patient with TTT inferior to 150 days had relapses (p=0.001).

CONCLUSIONS

The interval between surgery and RT did not show influence on locoregional control rates. However, doses <60Gy and the total treatment time >150 days were associated with lower locoregional control rates.

Effect of time to initiation of postoperative radiation therapy on survival in surgically managed head and neck cancer

BACKGROUND

The objective of this study was to determine the effects of National Comprehensive Cancer Network (NCCN) guideline-adherent initiation of postoperative radiation therapy (PORT) and different time-to-PORT intervals on the overall survival (OS) of patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

The National Cancer Data Base was reviewed for the period of 2006-2014, and patients with HNSCC undergoing surgery and PORT were identified. Kaplan-Meier survival estimates, Cox regression analysis, and propensity score matching were used to determine the effects of initiating PORT within 6 weeks of surgery and different time-to-PORT intervals on survival.

RESULTS

This study included 41,291 patients. After adjustments for covariates, starting PORT >6 weeks postoperatively was associated with decreased OS (adjusted hazard ratio [aHR], 1.13; 99% confidence interval [CI], 1.08-1.19). This finding remained in the propensity score-matched subset (hazard ratio, 1.21; 99% CI, 1.15-1.28). In comparison with starting PORT 5 to 6 weeks postoperatively, initiating PORT earlier was not associated with improved survival (aHR for ≤ 4 weeks, 0.93; 99% CI, 0.85-1.02; aHR for 4-5 weeks, 0.92; 99% CI, 0.84-1.01). Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements (aHR, 1.09, 1.10, and 1.12 for 7-8, 8-10, and >10 weeks, respectively).

CONCLUSIONS

Nonadherence to NCCN guidelines for initiating PORT within 6 weeks of surgery was associated with decreased survival. There was no survival benefit to initiating PORT earlier within the recommended 6-week timeframe. Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements. Cancer 2017;123:4841-50. © 2017 American Cancer Society.

Assessing guideline adherence and patient outcomes in cervical cancer

AIM

To investigate adherence to clinical practice guidelines (CPGs) in cervical cancer and the correlation with clinical outcomes.

METHODS

A retrospective analysis was conducted using patient information from a population-based cancer registry (2005-2011, n = 208). Compliance to 10 widely accepted CPGs was assessed. Univariate and multivariate analyses were performed to assess sociodemographic factors associated with CPG adherence. Multivariate Cox regression was performed to assess the relationship between CPG adherence and 5-year survival.

RESULTS

Adherence to individual CPGs ranged from 47% to 100%. Compliance to all applicable CPGs was seen in 54% (n = 72) of patients, 62% of stage I and II patients and 22% of stage III and IV patients. Poorest adherence was seen with those with locally advanced disease receiving chemoradiotherapy. Patients who lived within 5 km of the treatment facility were more likely to be compliant. No difference was found for either age, country of birth or socioeconomic status group. Five-year survival was greater for stage I and II patients who received guideline adherent care (93.7% vs 69.7%, P = 0.002), and they had a significant lower risk of death on multivariate analysis (HR = 0.22, P = 0.015). There was no significant difference for those with stage III or IV disease.

CONCLUSIONS

In this study, CPG adherence is variable between treatment modalities and only half complied to all applicable CPGs. There was better adherence in those with early-stage disease and this was associated with improved patient outcomes. CPG adherence may be a useful surrogate for quality of care.

Adherence to surveillance guidelines after radical cystectomy: a population-based analysis

OBJECTIVES

Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database.

METHODS AND MATERIALS

The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics.

RESULTS

Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60-0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68-0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70-2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27-1.82). We also observed significant geographic variability in adherence.

CONCLUSION

Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.

Implementation of national comprehensive cancer network evidence-based guidelines to prevent and treat cancer-related infections

Clinical practice guidelines are an important result of evidence-based research. However, current clinical practice remains out of step with the rapid pace of research advancements. Often, decades pass before research is translated into clinical practice. The National Comprehensive Cancer Network (NCCN) has created evidence-based clinical guidelines to promote effective clinical practice. Formerly, the NCCN established guidelines to reduce cancer-related infections only for neutropenic patients; however, they have expanded their guidelines beyond neutropenia to prevent and treat cancer-related infections. Implementing scientific evidence into clinical practice is challenging and complex, and healthcare professionals should understand barriers to implementing clinical practice guidelines to ensure successful translation into practice. This article provides a brief review of NCCN guidelines and describes common barriers encountered during implementation. In addition, a conceptual framework is offered to help identify and address potential concerns before and after adoption of guidelines.

Adherence to stage-specific treatment guidelines for patients with colon cancer

PURPOSE

Adherence to evidence-based treatment guidelines has been proposed as a measure of cancer care quality. We sought to determine rates of and factors associated with adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines for colon cancer.

PATIENTS AND METHODS

Patients within the National Cancer Data Base treated for colon adenocarcinoma (2003 to 2007) were identified. Adherence to stage-specific NCCN guidelines was determined based on disease stage. Hierarchical regression analyses were performed to identify factors predictive of adherence, overtreatment, and undertreatment.

RESULTS

A total of 173,243 patients were included in the final cohort, 123,953 (71%) of whom were treated according to NCCN guidelines. Patients with stage I disease were more likely to receive guideline-based treatment (96%) than patients with stage II (low risk, 66%; high risk, 36%), III (71%), or IV (73%) disease (P < .001). Adherence to consensus-based guidelines increased over time. Factors associated with adherence across all stages included age, Charlson-Deyo comorbidity index score, later year of diagnosis, and insurance status. Among patients with high-risk stage II or stage III disease, older patients with pre-existing comorbidities and patients with lower socioeconomic status were less likely to be offered adjuvant chemotherapy. Among patients with stage I and II disease, young, healthy patients were more likely to be recommended chemotherapy, in discordance with NCCN guidelines.

CONCLUSION

Significant variation exists in the treatment of colon cancer, particularly in treatment of high-risk stage II and stage III disease. The impact of nonadherence to guidelines on patient outcomes needs to be further elucidated.

Medicine as it should be: a cultural shift

Increased use of clinical practice guidelines, evidence-based medicine, and electronic health records can help oncologists meet the challenges of workforce shortages, rising costs, and an aging population, creating a culture of care that benefits payers, providers, and patients.

Utilization of cancer registry data for monitoring quality of care

BACKGROUND

Cancer Program Practice Profile Reports (CP(3)R), established by the Commission on Cancer, are based on 6 guidelines for breast and colorectal cancer care using cancer registry data. The long-term goal is the use of cancer registry data for real-time interventions to optimize the process of individual patient multidisciplinary care.

METHODS

CP(3)R results using 593 analytic breast cancer cases in 2008 were compared in 3 databases: an institutional breast cancer research database, an institutional cancer registry, and a regional Cancer Surveillance System.

RESULTS

Compliance with the CP(3)R guidelines calculated using the 3 databases was 80% to 98% for radiation therapy following breast-conserving surgery, 78% to 88% for combination chemotherapy of hormone receptor-negative stage T1c, II, or III disease, and 53% to 85% for hormone therapy of hormone receptor-positive stage T1c, II, or III disease. There was a high rate of discrepancy of tumor characteristics, treatment, and CP(3)R resulting from inaccurate and incomplete data.

CONCLUSIONS

Using national cancer databases prospectively to monitor and ensure optimal multidisciplinary cancer care will require dramatic changes in cancer registry processes.

National Collaborative to Improve Oncology Practice: The National Cancer Institute Community Cancer Centers Program Quality Oncology Practice Initiative Experience

Collaboration between QOPI and the NCCCP sites represents an evolution in the QOPI process, in which QOPI provides a metric for measuring quality and serves as a springboard for comprehensive quality improvement across independent but mutually committed practices.

Costs of cancer care: a view from the centers for Medicare and Medicaid services

Fee-for-service Medicare pays for a very substantial portion of all cancer care delivered in the United States. By virtue of its size and visibility, its payment policies at times also influence those of other health care payers. As a result, Medicare affects both the overall economics and the incentive structures of oncology care. Three aspects of how Medicare finances cancer care are particularly germane to the issue of costs. First, Medicare finances all aspects of cancer care in independent payment units, paying separately for physician services, laboratory tests, procedures, imaging, radiation, drug administration, and drugs. Second, Medicare is currently managing and monitoring a very substantial overhaul in payment for cancer care, which aims to reduce or eliminate incentives that have favored aggressive and costly treatments in clinical situations where alternative therapeutic approaches might have been equivalent or preferable. Third, Medicare is trying to increase the focus on care quality and transparency, as improved efficiency and greater value is needed if costs of care are to be contained. Understanding these three aspects of cancer care financing can help clarify what Medicare is capable of doing to control the rising costs that are occurring in cancer today.

Effect of patient socioeconomic status and body mass index on the quality of breast cancer adjuvant chemotherapy

PURPOSE

The purpose of this study was to investigate the relationship between socioeconomic status (SES) and the use of intentionally reduced doses of chemotherapy in the adjuvant treatment of breast cancer.

PATIENTS AND METHODS

Patients with breast cancer treated with a standard chemotherapy regimen (n = 764) were enrolled in a prospective registry after signing informed consent. Detailed information was collected on patient, disease, and treatment, including chemotherapy doses. Zip code level data on median household income, proportion of people living below the poverty level, and educational attainment were obtained from the US Census. Doses for the first cycle of chemotherapy lower than 85% of standard were considered to be reduced. Univariate analyses and multivariate logistic regression were performed to identify factors associated with the use of reduced first cycle doses.

RESULTS

In univariate analysis, individual education attainment, zip code SES measures, body mass index, and geographic region were all significantly associated with receipt of intentionally reduced doses of chemotherapy. In multivariate analysis, controlling for geography, factors independently associated with reduced doses were obesity (odds ratio [OR], 2.47; 95% CI, 1.36 to 4.51), severe obesity (OR, 4.04; 95% CI, 1.46 to 11.19), and education less than high school (OR, 3.07; 95% CI, 1.57 to 5.99).

CONCLUSION

Social disparities in breast cancer outcomes may be in part the result of lower quality chemotherapy doses in the adjuvant treatment of breast cancer. Efforts to address such prescribing patterns may help reduce SES disparities in breast cancer survival.

Trends in the use of postoperative radiotherapy for resected non–small-cell lung cancer

PURPOSE

A 1998 meta-analysis of postoperative radiotherapy (PORT) for non-small-cell lung cancer (NSCLC) found that PORT did not improve outcomes. Yet practice guidelines differ in their recommendations with regard to PORT use. We examine temporal trends in PORT use before and after the 1998 meta-analysis.

METHODS AND MATERIALS

Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, we identified 22,953 patients with Stage I, II, or IIIA NSCLC who had resection between 1992 and 2002 in the United States and characterized each patient according to nodal status (N0, N1, or N2 disease). We measured use of PORT by calendar year. We examined the association between clinical and demographic characteristics and receipt of PORT using logistic regression.

RESULTS

For N0, N1, and N2 NSCLC, PORT use has declined. The proportion of patients with N0 disease receiving PORT declined from 8% in 1992 to 4% in 2002. For patients with N1 disease, PORT use declined from 51% in 1992 to 19% in 2002; and for patients with N2 disease, PORT use declined from 65% in 1992 to 37% in 2002.

CONCLUSION

In the context of uncertainty about what constitutes optimal adjuvant treatment for resected NSCLC, PORT use has substantially declined.