Improving quality of care and clinical outcomes for rectal cancer through clinical audits in a multicentre cancer care organisation

Introduction

Colorectal cancer treatment requires a complex, multidisciplinary approach. Because of the potential variability, monitoring through clinical audits is advisable. This study assesses the effects of a quality improvement action plan in patients with locally advanced rectal cancer and treated with radiotherapy.

Methods

Comparative, multicentre study in two cohorts of 120 patients each, selected randomly from patients diagnosed with rectal cancer who had initiated radiotherapy with a curative intent. Based on the results from a baseline clinical audit in 2013, a quality improvement action plan was designed and implemented; a second audit in 2017 evaluated its impact.

Results

Standardised information was present on 77.5% of the magnetic resonance imaging (MRI) staging reports. Treatment strategies were similar in all three study centres. Of the patients whose treatment was interrupted, just 9.7% received a compensation dose. There was an increase in MRI re-staging from 32.5 to 61.5%, and a significant decrease in unreported circumferential resection margins following neoadjuvant therapy (ypCRM), from 34.5 to 5.6% (p <  0.001).

Conclusions

The comparison between two clinical audits showed improvements in neoadjuvant radiotherapy in rectal cancer patients. Some indicators reveal areas in need of additional efforts, for example to reduce the overall treatment time.

P14.93 The utility of the brain 18-FDG-PET and perfusion magnetic resonance imaging in the radionecrosis differential diagnosis

BACKGROUND

Radiation-induced necrosis (RDN) is a side effect observed in patients who underwent stereotactic radiosurgery (SRS) alone or combined with whole brain radiotherapy (WBRT) as treatment for their brain tumors. Nowadays, RDN diagnosis and differentiation from tumor progression using the standard imaging techniques represents a challenge, and histological diagnosis still is the gold standard.Our aim is to assess the positive and negative predictive values (PPV, NPV) of FDG-PET and perfusion magnetic resonance imaging (MRI) in RDN diagnosis.

MATERIAL AND METHODS

From our Pathology department database, all patients with RDN or mixed (tumor plus RDN) brain lesions diagnosis during last 5 years were reviewed. Demographic, clinical and oncologic treatment characteristics were recorded. MRI and FDG-PET images at the suspicion (clinical or radiological) of progression or RDN were registered and compared with the definite diagnosis provided by the tissue sample analysis. Sensitivity, specificity, as such as PPV and NPV for perfusion MRI sequences and FDG-PET image analysis were calculated.

RESULTS

162 patients underwent SRS+/- WBRT in a 5 year period. During follow-up, 11 patients had surgery-confirmed RDN. There are 11 patients (3 women) with 12 lesions, 3 from a breast cancer, 6 from a lung tumor, 1 from a melanoma, 1 atypical meningioma and 1 glioblastoma. 9 of them were treated with both SRS and WBRT, and the 3 others with WBRT alone. The mean age was 65.36 (range: 44–77) years. The median time between the completion of radiation therapy and the suspicion of RDN was 19.7 (range: 3–34) months. With the evolution, it was observed an evident increase in the size of surronding oedema (2–6 times) by FLAIR RMI. We estimate a PPV 0.40 and NPV 0.80 for perfusion MRI, and PPV 0.25 and NPV 0.75 for FDG-PET, respectively.

CONCLUSION

The diagnostic performance of both techniques in our series is low and similar to published data; therefore its results must be carefully interpreted in each case. It is peremptory to implement new diagnostic tools in the standard of care with better diagnostic outcomes.

Role of boost radiotherapy for local control of pure ductal carcinoma in situ after breast-conserving surgery: a multicenter, retrospective study of 622 patients

PURPOSE

To evaluate the effect of boost radiotherapy on ipsilateral breast tumor recurrence (IBTR) for ductal carcinoma in situ (DCIS) after breast-conserving surgery and whole breast radiotherapy (WBRT) with or without boost.

METHODS AND MATERIALS

Retrospective, multicentre study of 622 patients (624 tumors) diagnosed with pure DCIS from 1993-2011.

RESULTS

Most tumors (377/624; 60.4%) received a boost. At a median follow-up of 8.8 years, IBTR occurred in 64 cases (10.3%). A higher percentage of patients with risk factors for IBTR received a boost (p < 0.05). Boost was not associated with lower rates of IBTR than WBRT alone (HR 0.75, 95% CI 0.42-1.35). On the univariate analyses, IBTR was significantly associated with tumor size (11-20 mm, HR 2.32, 95% CI 1.27-4.24; and > 20 mm, HR 2.10, 95% CI 1.14-3.88), re-excision (HR 1.76, 95% CI 1.04-2.96), and tamoxifen (HR 2.03, 95% CI 1.12-3.70). Boost dose > 16 Gy had a protective effect (HR 0.39, 95% CI 0.187-0.824). Multivariate analyses confirmed the independent associations between IBTR and 11-20 mm (p = 0.02) and > 20 mm (p = 0.009) tumours, and re-excision (p = 0.006). On the margin-stratified multivariate analysis, tamoxifen was a poor prognostic factor in the close/positive margin subgroup (HR 4.28 95% CI 1.23-14.88), while the highest boost dose ( > 16 Gy) had a significant positive effect (HR 0.34, 95% CI 0.13-0.86) in the negative margin subgroup.

CONCLUSIONS

Radiotherapy boost did not improve the risk of IBTR. Boost radiotherapy was more common in patients with high-risk disease. Tumor size and re-excision were significant independent prognostic factors.

Preradiotherapy MR Imaging: A Prospective Pilot Study of the Usefulness of Performing an MR Examination Shortly before Radiation Therapy in Patients with Glioblastoma

BACKGROUND AND PURPOSE

Current protocols in patients with glioblastoma include performing an MR examination shortly after surgery and then 2-6 weeks after ending concomitant chemoradiotherapy. The assessment of this first postradiotherapy examination is challenging because the pseudoprogression phenomenon may appear. The aim of this study was to explore if performing an MR examination shortly before radiation therapy (preradiotherapy MR imaging) could improve the radiologic assessment of patients with glioblastoma.

MATERIALS AND METHODS

A preradiotherapy MR imaging examination was prospectively performed before the start of radiation therapy in 28 consecutive patients with glioblastoma who had undergone surgical resection. Tumor response to chemoradiotherapy was assessed twice: with the early postoperative MR examination as baseline and with the preradiotherapy MR imaging examination as baseline. In addition, tumor growth in the preradiotherapy MR imaging examination was evaluated, and its correlation with patient survival was assessed with Kaplan-Meier analysis and Cox regression.

RESULTS

Tumor progression after radiation therapy was found in 16 patients, corresponding to pseudoprogression in 7 of them (44%). Four assessments of pseudoprogression switched to partial response or stable disease when preradiotherapy MR imaging was the baseline examination, and the ratio of pseudoprogression was reduced to 25% (3 of 12). Significant differences in survival were found when patients were stratified according to the pattern of tumor growth on preradiotherapy MR imaging (median overall survival "no-growth," 837 days; "focal-growth," 582 days; "global-growth," 344 days; P = .001).

CONCLUSIONS

Performing a preradiotherapy MR imaging examination may improve the clinical management of patients with glioblastoma by reducing the ratio of pseudoprogression assessments and providing prognostic information.

Abstract P5-17-08: Study of boost radiotherapy's influence on local control in 646 pure ductal carcinoma in situ breast cancer with long-term follow-up

BACKGROUND: Boost radiotherapy (B-RT) improves outcome in patients (pts) with invasive breast cancer. It's use in patients with pure ductal carcinoma in situ (DCIS) is unclear. There are two ongoing randomize trials, results are expected in ten years. Twelve retrospective observational studies have been published since 2006, the recent meta-analysis, support boost in the presence of positive margins.

PATIENTS and METHODS: We analyse a retrospective women's cohort of 646 pure DCIS patients (pts) treated mainly in two Hospitals (n=518) from 1993 to 2014. The other ten Hospitals included 128 pts all 2005 long. Proportions were compared by boost status, using the chi-square tests. The impact of boost radiation on the development of local recurrence (LR) was determined using survival analyses. In the comparison of Kaplan-Meier (K-M) was used log-rank test.

RESULTS: B-RT subgroup is 394 pts (61%), noB-RT 252 (39%). Median follow-up (FU) is 8.8 years. High risk factors: young age, size, margin status and tamoxifen (TMX) show differences among B-RT (p&lt;0.05). 46% were Estrogen Receptor positive (ER+), 30% B-RT and 16% noB-RT. 22% RE+ in B-RT take TMX vs 9.4 % RE+ noB-RT. Total LR 65 (10%). In situ LR 30 pts (4,6%) and Invasive (Inv) 35 (5,4%). By subgroup, LR in B-RT 47 (12%) vs. 18 (7%) in noB-RT. By subtype, In situ LR in B-RT 20 (5.1%) vs. noB-RT 10 (4%). Inv LR in B-RT 27 (6.9%) vs. noB-RT 8 (3.2%). In uni & multivariate analysis, tumour size, Re-Excision, and TMX, are significant LR risk factors (p&lt;0.05). Boost total doses &gt;16 Gy in the B-RT subgroup is a LR significant risk factor related to 10-16 Gy (p∼0.05). TMX and Dose Boost are related (p&lt;0.001). When Dose is introduced in multivariate analysis model, TMX lost signification. Contralateral local recurrence (CLR) in 29 pts (7%). Second tumours 9 pts (NSD between subgroups). Global disease free survival (DFS) is 80.5%, 77% in B-RT vs. 85% in noB-RT. Four pts have a LR combined with CLR; 2 pts have a LR and a second tumor; 1 pt with CLR and second tumour; 1 pt a Inv regional recurrence; 1 pt mixosarcoma in ipsilateral breast and lung metastases. Deaths: 3 pts (0.5%) after an Inv LR; 3 pts (0.5%) after Inv CR; 20 pts other causes; 10 pts lost their FU. Median FU in B-RT subgroup was 9y vs. 8.3y in noB-RT. The maximum FU according LR in B-RT is 20.6y vs. 17.4y in noB-RT. RL is not significant according to Boost (K-M p=0.398). Median LR in situ or inv depending of B-RT vs. noB-RT shows NSD (p=0.663).

CONCLUSIONS: In this large cohort retrospective study with long-term follow-up B-RT was associated with similar LR as noB-RT despite being used more frequently with higher risk disease. Dose boost &gt;16 Gy has a protective effect. Tamoxifen and boost dose are related variables. Further evidence, based on ongoing randomized trials results is essential.

Citation Format: Cambra MJ, Moreno F, Sanz X, Anglada L, Moià M, Reyes V, Arenas M, Pedro A, Ballester R, García V, Sanjosé S, Cusidó M, Jimenez C, Macià M, Solé JM, Farrus B. Study of boost radiotherapy's influence on local control in 646 pure ductal carcinoma in situ breast cancer with long-term follow-up. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-17-08.

[Probabilistic models of mortality for patients hospitalized in conventional units]

BACKGROUND

We have developed a tool to measure disease severity of patients hospitalized in conventional units in order to evaluate and compare the effectiveness and quality of health care in our setting.

PATIENTS AND METHOD

A total of 2,274 adult patients admitted consecutively to inpatient units from the Medicine, Surgery and Orthopaedic Surgery, and Trauma Departments of the Corporació Sanitària Parc Taulí of Sabadell, Spain, between November 1, 1997 and September 30, 1998 were included. The following variables were collected: demographic data, previous health state, substance abuse, comorbidity prior to admission, characteristics of the admission, clinical parameters within the first 24 hours of admission, laboratory results and data from the Basic Minimum Data Set of hospital discharges. Multiple logistic regression analysis was used to develop mortality probability models during the hospital stay.

RESULTS

The mortality probability model at admission (MPMHOS-0) contained 7 variables associated with mortality during hospital stay: age, urgent admission, chronic cardiac insufficiency, chronic respiratory insufficiency, chronic liver disease, neoplasm, and dementia syndrome. The mortality probability model at 24-48 hours from admission (MPMHOS-24) contained 9 variables: those included in the MPMHOS-0 plus two statistically significant laboratory variables: hemoglobin and creatinine.

CONCLUSIONS

Severity measures, in particular those presented in this study, can be helpful for the interpretation of hospital mortality rates and can guide mortality or quality committees at the time of investigating health care-related problems.