Development of an age- and comorbidity- adjusted optimal radiotherapy utilisation rate for lung, rectal, prostate and cervical cancers.

INTRODUCTION: Optimal radiotherapy utilisation (RTU) modelling estimates the proportion of people with cancer who would benefit from radiotherapy. Assessment of comorbidities is an important component of the assessment of suitability for radiotherapy in addition to chronological age and life expectancy. Comorbidities have not been considered in previous optimal RTU models. We aimed to develop an age- and comorbidity- adjusted optimal RTU model for patients with lung, rectal, prostate, and cervical cancer, and compare them to actual RTU rates, with a particular focus on those aged 80+ years, METHODS: New South Wales (NSW) Cancer Registry data (2010-2014) linked to radiotherapy data (2010-2015) and hospitalisation data (2008-2015) were used to determine the number of patients diagnosed with lung, rectal, prostate and cervical cancer. The Cancer Specific C3 'all sites' comorbidity index was calculated from hospital diagnosis data for each patient to determine suitability for radiotherapy. The index was then incorporated into a tumour site-specific decision tree model. The actual RTU was also calculated using the linked datasets. RESULTS: 14,696 patients were diagnosed with non-small cell lung cancer (NSCLC), 1839 with small cell lung cancer (SCLC), 5551 with rectal cancer, 30,935 with prostate cancer and 1216 with cervical cancer in New South Wales from 2010-2014. The proportion of patients aged 80+ years at cancer diagnosis was 25% (3603 patients), 15% (279 patients), 17% (943 patients), 12% (3745 patients), and 7% (88 patients) respectively. The age- and comorbidity- adjusted optimal RTU rates for patients aged 80+ years using the C3 index were 49% (NSCLC), 49% (SCLC), 43% (rectal), 51% (prostate) and 40% (cervical). The corresponding actual RTU rates for patients aged 80+ years were 25%, 32%, 27%, 16%, and 56%. CONCLUSION: Even after adjusting for age and comorbidities, the actual radiotherapy utilisation rates were lower than optimal radiotherapy utilisation rates in patients aged 80+ years except for patients with cervical cancer. This warrants further assessment and research into reasons and solutions.

Gender diversity and leadership in Radiation Oncology in Australia and New Zealand.

INTRODUCTION: There has been a groundswell of discussion and activism surrounding gender diversity. Given the growing importance of this issue, a working group was established under the Faculty of Radiation Oncology (FRO) of the Royal Australian and New Zealand College of Radiologists' (RANZCR) Economics and Workforce Committee (EWC) to review the current status of gender diversity within radiation oncology (RO) in Australia and New Zealand. METHODS: De-identified data were provided from two recent FRO workforce censuses conducted in 2014 and 2018 with permission from the EWC. Further data were provided via direct correspondence with staff at the RANZCR and the Trans-Tasman Radiation Oncology Group (TROG), the major RO research group in Australasia. The data were collated in February 2021. RESULTS: Our results showed that compared to females, male radiation oncologists were more likely to be engaged in full-time active clinical work, hold a postgraduate degree and obtain a consultant or fellowship position following graduation. Male fellows were more likely to have leadership positions within RANZCR and TROG and self-identify as holding any leadership position. The 2018 census revealed that within the trainee cohort, there was almost an equal number of male and female trainees as well as an equal number of male and female trainees holding a postgraduate degree. CONCLUSION: This review is an important first exploration into gender diversity across Australia and New Zealand's RO workforce. Whilst our study indicates that gender disparities exist, there are some indications that this may be equalizing out over time.

Radiotherapy utilisation rates for patients with cancer as a function of age: A systematic review.

INTRODUCTION: There is an increasing incidence of cancer in older people, but limited data on radiotherapy uptake, and in particular, radiotherapy utilisation (RTU) rates. The RTU rate for older adults with cancer may be lower than recommended due to lower tolerance for radiotherapy as well as additional comorbidities, reduced life expectancy and travel for treatment. Radiotherapy use must be aligned with best available, age-specific evidence to ensure older adults with cancer receive optimal benefit without harms. MATERIALS AND METHODS: A systematic review was conducted to synthesise the published data on the actual RTU rate for patients with cancer as a function of age. MEDLINE and EMBASE were systematically searched to identify relevant population-based and hospital-based cohort studies on radiotherapy utilisation for all age groups, published in English, from 1 January 1990 to 1 July 2020. We focused on the following common cancers in older adults for which radiotherapy is recommended: breast, prostate, lung, rectal cancer, glioblastoma multiforme (GBM), and cervical cancer. Age-specific radiotherapy utilisation data were extracted and analysed as a narrative synthesis. RESULTS: From 2606 studies screened, 75 cohort and population-based studies were identified with age-specific radiotherapy utilisation data. The total number of patients in the 75 studies was 4,792,138. The RTU rate decreased with increasing age for all tumour sites analysed, except for patients receiving curative radiotherapy as definitive treatment for prostate or cervical cancer. This reduction with increasing age was demonstrated in both palliative and curative settings. DISCUSSION: There is a global reduction in radiotherapy utilisation with increasing age for most tumour sites. The reduction in delivery of radiotherapy warrants further examination and evidence-based guidelines specific to this population.

Development of an age- and comorbidity adjusted- optimal radiotherapy utilisation rate for women with breast cancer.

INTRODUCTION: Optimal radiotherapy utilisation (RTU) modelling estimates the proportion of people with cancer who would benefit from radiotherapy. Older adults with cancer may have comorbidities that can impact physiological reserve and affect radiotherapy recommendations. These have not been considered in previous models. We aimed to develop an age- and comorbidity-adjusted optimal RTU model for breast cancer. METHODS: New South Wales (NSW) Cancer Registry data (2010-2014) linked to radiotherapy data (2010-2015) and hospitalisation data (2008-2015) was used to determine the number of women diagnosed with invasive breast cancer in four pre-specified age groups. The Charlson Comorbidity Index (CCI), Cancer-Specific C3 'all sites' index and the Hospital Frailty Risk Score (HFRS) were derived for each woman from diagnostic codes in hospital records. Women were deemed unfit, and thus unsuitable candidates for radiotherapy, if the comorbidity indices were as follows: CCI ≥2; C3 score ≥ 3; and HFRS ≥5. The proportions of women suitable for radiotherapy in each age group were then incorporated into a breast cancer decision tree model. The actual RTU was also calculated using the linked datasets. RESULTS: 23,601 women were diagnosed with breast cancer in NSW from 2010 to 2014 and 2526 were aged 80+ years. The overall comorbidity adjusted- RTU for women of all ages was 85·9% (CCI), 83·7% (C3) and 81·9% (HFRS). The optimal comorbidity adjusted- RTU for women aged 80+ was 76·1% (CCI), 70·1% (C3) and 61·8% (HFRS). The actual RTU for women aged 80+ years was 24.7%. CONCLUSION: The vast majority of older Australian women with breast cancer are fit for radiotherapy. The overall optimal RTU is only slightly reduced when adjusted for age and comorbidities and was similar using each of the three indices examined. Our data suggest radiotherapy is markedly underutilised for older women with breast cancer.

Factors affecting radiotherapy utilisation in geriatric oncology patients in NSW, Australia.

BACKGROUND AND PURPOSE: Large non-age-specific radiotherapy utilisation rate (RTU) studies have demonstrated that actual RTU is below the optimal recommended utilisation rate for both curative and palliative intent radiotherapy indications. The optimal utilisation rate for the geriatric oncology cohort of patients has not yet been determined. The purpose of this research was to examine the actual RTU for patients treated in New South Wales (NSW), Australia as a function of increasing age, and the relationship between RTU and tumour site, travelling distance and socio-economic status. MATERIALS & METHODS: NSW Central Cancer Registry data (2009-2011) were linked to the NSW Radiotherapy Dataset (2009-2012). RTU was calculated for patients aged <80 years and ≥80 years. RTU was defined as the proportion of patients receiving at least a single course of radiotherapy within 12 months of a cancer diagnosis. RESULTS: 110,645 patients were diagnosed with cancer, of whom 27,721 received at least one course of radiotherapy. The overall RTU was 25%. RTU for patients aged <80 years was 28% compared to 14% for patients aged 80+ years (p < 0.001). On both univariate and multivariate analysis, increasing age, residential address in disadvantaged socioeconomic areas and increasing distance to the nearest radiotherapy department were associated with a reduction in RTU. CONCLUSION: Geriatric oncology patients are less likely to receive radiotherapy than their younger counterparts. Some of the reduction in RTU may be justifiable on the basis of limited life expectancy and co-morbidity. Further research is required to determine the co-morbidity adjusted optimal RTU in older patients.

Breast interest group faculty of radiation oncology: Australian and New Zealand patterns of practice survey on breast radiotherapy.

INTRODUCTION: This patterns of practice study was conducted on behalf of the RANZCR Breast Interest Group in order to document current radiotherapy practices for breast cancer in Australia and New Zealand. The survey identifies variations and highlights potential contentious aspects of radiotherapy management of breast cancer. METHODS: A fifty-eight question survey was disseminated via the Survey Monkey digital platform to 388 Radiation Oncologists in Australia and New Zealand. RESULTS: In total, 156 responses were received and collated. Areas of notable consensus among respondents included hypofractionation (77.3% of respondents would 'always' or 'sometimes' consider hypofractionation in the management of ductal carcinoma in-situ and 99.3% in early invasive breast cancer); margin status in early breast cancer (73.8% believe a clear inked margin is sufficient and does not require further surgery) and use of bolus in post-mastectomy radiotherapy (PMRT) (91.1% of participants use bolus in PMRT). Areas with a wider degree of variability amongst respondents included regional nodal irradiation and components of radiotherapy planning and delivery (examples include the technique used for delivery of boost and frequency of bolus application for PMRT). CONCLUSION: The results of these patterns of practice survey informs radiation oncologists in Australia and New Zealand of the current clinical practices being implemented by their peers. The survey identifies areas of consensus and contention, the latter of which may lead to a development of research trials and/or educational activities to address these areas of uncertainty.