Comparison of Methods for Measuring Radiotherapy Utilisation.

AIMS: Evidence-based estimates of appropriate rates of radiotherapy utilisation are usually stated as the proportion of cancer patients who should receive radiotherapy at least once in their lifetime. However, the prolonged follow-up required to measure the lifetime radiotherapy rate limits its value in monitoring access to radiotherapy in routine practice. The objectives of this study were to evaluate shorter-term methods for measuring radiotherapy utilisation and to determine how well they predict the lifetime radiotherapy rate. MATERIALS AND METHODS: The Ontario Cancer Registry provided records of all cases of cancer diagnosed in Ontario between 1984 and 2015. Records of all radiotherapy delivered by Ontario cancer centres were linked to individual cases in the Ontario Cancer Registry. Patients were followed forward for 20 years to determine the relationship between short-term and long-term rates of use of radiotherapy. Radiotherapy utilisation was also estimated by comparing total radiotherapy workload with cancer incidence; these measures were compared with observed long-term radiotherapy rates. RESULTS: The rate of use of radiotherapy within 1 year of diagnosis (RT1y) was strongly predictive of the rate of use of radiotherapy after 20 years (RT20y); for each annual cohort of cases between 1984 and 1995, RT20y was approximately equal to 1.3 × RT1y. The number of cases treated for the first time with radiotherapy in a specified period, divided by the number of new cases diagnosed in the same period, was about equal to the proportion of cases treated with radiotherapy within 20 years of diagnosis (RT20y). CONCLUSIONS: The lifetime rate of use of radiotherapy may be predicted quite accurately from the rate observed within 1 year of diagnosis, or from the ratio of new cases treated to cancer incidence in a specified period. Either of these measures may therefore be used to audit radiotherapy utilisation against the existing evidence-based targets.

Measuring the Quality of Personal Care in Patients Undergoing Radiotherapy for Prostate Cancer.

AIMS: To describe the quality of the non-technical component of the care (personal care) of patients receiving radical radiotherapy for prostate cancer and to identify elements of personal care that should be priorities for quality improvement. MATERIALS AND METHODS: One hundred and eight patients undergoing radiotherapy for localised prostate cancer completed a self-administered questionnaire that asked them to rate the importance of 143 non-technical elements of care and to rate the quality of their own care with respect to each element. The elements that a patient rated as both 'very important' and less than 'very good' were deemed to be his priorities for improvement. The priorities of the population were established by ranking the elements based on the percentage of patients who identified them as a priority (importance/quality analysis). RESULTS: The response rate was 65%. The percentage of elements rated 'very good' varied from patient to patient: median 79% (interquartile range 69-92%). The percentage of elements rated either 'very good' or 'good' was higher: median 96% (interquartile range 86-98%). Nonetheless, almost every patient rated at least some elements of his care as less than optimal, regardless of the cut-off point used to define optimal quality. Patients assigned their lowest quality ratings to elements relating to the quality of the treatment environment and comprehensiveness of additional services available to them. However, patients rated most of these elements as relatively unimportant, and importance/quality analysis identified elements of care relating to communication of information about the disease and its treatment as the highest priorities for quality improvement. CONCLUSIONS: Most patients rated most elements of their personal care as very good, but almost all were able to identify some elements that were less than optimal. When ratings of quality were integrated with ratings of importance, elements relating to communication emerged as the patients' highest priorities for quality improvement.

Bladder-sparing Radiotherapy for Muscle-invasive Bladder Cancer: A Qualitative Study to Identify Barriers and Enablers.

AIMS: Bladder-sparing radiotherapy for muscle-invasive bladder cancer (MIBC) may be underutilised in North America. To understand factors driving practice we used the Theoretical Domains Framework (TDF) to identify barriers and enablers of bladder-sparing radiotherapy utilisation. MATERIALS AND METHODS: A convenience sample of Canadian urologists, medical oncologists and radiation oncologists participated in individual semi-structured 1 h interviews. An interview guide was developed using the TDF to assess barriers and enablers of bladder-sparing radiotherapy use. Interviews were recorded and transcribed. Two investigators independently identified barriers and enablers and assigned them to specific themes. Participant recruitment continued until saturation. RESULTS: In total, 71 physicians were invited to participate and 34 (48%) agreed to be interviewed; 13 urologists, 11 radiation oncologists and 10 medical oncologists. We identified the following barriers to the use of bladder-sparing radiotherapy (relevant TDF domains in parentheses): (1) beliefs that radiotherapy has inferior survival compared with cystectomy (beliefs about consequences); (2) lack of referral from urology to radiation oncology (behavioural regulation; memory, attention and decision-making); (3) lack of 'champions' who advocate for radiotherapy (social and professional role); and (4) inadequate multidisciplinary collaboration (environmental context and resources). Predominant enablers to the use of bladder-sparing radiotherapy included: (1) 'champions' who believe in the value of radiotherapy (social and professional role); (2) beliefs by urologists that radiation oncologists should present radiotherapy options to all patients (social and professional role); (3) institutional policy that all MIBC patients should be seen by multiple specialists (environmental context and resources); (4) system facilitators of radiation oncology referral (i.e. nurse navigator) (environmental context and resources); and (5) patient-driven consultations seeking alternatives to cystectomy (social influences). CONCLUSIONS: These findings identify important barriers and enablers to the use of bladder-sparing radiotherapy in MIBC. Physician beliefs, access to multidisciplinary care and institutional context should be considered in efforts to increase the use of bladder-sparing radiotherapy.

The Patterns of Practice and Outcomes of Penile Cancer in Ontario.

AIMS: Penile cancer is a rare malignancy in Western countries. The management guidelines are mainly derived from retrospective studies as there are no randomised trials. The primary objective of this study was to assess patterns of practice and outcomes of penile squamous cell carcinoma in Ontario. Secondary objectives included examining trends in incidence, pathological characteristics and prognostic factors. MATERIALS AND METHODS: All patients diagnosed with penile cancer between 2000 and 2010 were identified from the Ontario Cancer Registry and all available pathology reports related to penile cancer during this period were reviewed. RESULTS: Pathology reports of 419 new cases of penile squamous cell carcinoma were reviewed. There was a significant improvement in completeness of the pathology reports in recent years. The age-adjusted incidence was 0.9 per 100 000 person-years. Most patients presented with a pT1 lesion (63%). A partial penectomy (40%) was the most common surgical procedure. Over 38% of patients identified to be eligible for organ-sparing surgery had a total or partial penectomy. Only 23% of the eligible patients identified to require lymph node dissection underwent the procedure. The 5 year disease-specific survival for stage 0, I, II, III were 94%, 93%, 74% and 52%, respectively. CONCLUSIONS: There is a significant variation in the patterns of practice in Ontario. A large proportion of patients in this cohort were probably overtreated for the primary malignancy and undertreated for the regional nodes.

Adjuvant Chemotherapy for Stage II Colon Cancer: Practice Patterns and Effectiveness in the General Population.

AIMS: Although guidelines do not recommend adjuvant chemotherapy (ACT) for stage II colon cancer, many state that ACT may be considered in high-risk disease. Here we describe practice patterns and outcomes associated with ACT in the general population. MATERIALS AND METHODS: All cases of colon cancer diagnosed in Ontario 2002-2008 were identified using the Ontario Cancer Registry, which was linked to electronic treatment records. Pathology reports were obtained for a 25% random sample of cases. High-risk disease was defined as: T4 tumours, <12 lymph nodes, poorly differentiated histology, lymphovascular invasion. Modified Poisson regression was used to evaluate factors associated with ACT. The Cox proportional hazards model was used to explore the association between ACT and cancer-specific (CSS) and overall survival. RESULTS: The study population included 2488 patients with stage II colon cancer; 1175 (47%) with high-risk disease. ACT was delivered to 18% of all patients and 24% of patients with high-risk disease. ACT rates were higher among younger patients (51% age 20-49 years versus 16% age 70-79, P < 0.001) and varied considerably across geographic regions (range 10-39%, P < 0.001). Among all patients with stage II colon cancer, ACT was not associated with improved CSS (hazard ratio 1.41, 95% confidence interval 1.09-1.82) or overall survival (hazard ratio 1.16, 95% confidence interval 0.94-1.42). Stratified survival analysis for patients with high-risk disease did not show benefit to ACT (CSS hazard ratio 1.14, 95% confidence interval 0.84-1.55; overall survival hazard ratio 1.02, 95% confidence interval 0.79-1.31). CONCLUSION: ACT use varies across age groups and geographic regions. ACT is not associated with improved survival among patients with stage II colon cancer including those with high-risk disease.

Patterns of Referral to Radiation Oncology among Patients with Bladder Cancer: a Population-based Study.

AIMS: Radical radiotherapy is a reasonable alternative to cystectomy for some patients with invasive bladder cancer, and postoperative radiotherapy may be indicated in patients at high risk of local recurrence. Here we describe pre- and postoperative radiation oncology consultation among patients with bladder cancer in Ontario. MATERIALS AND METHODS: Records of radiotherapy and surgery were linked to the Ontario Cancer Registry (OCR) to identify all patients who received treatment with curative intent for bladder cancer between 1994 and 2008. Billing records were linked to the OCR to determine which patients were seen by radiation oncology before radical therapy or after cystectomy. Factors associated with radiation oncology consultation were explored by logistic regression. RESULTS: In total, 5259 patients with bladder cancer underwent treatment with curative intent in Ontario between 1994 and 2008. Of these, 3879 had primary cystectomy and 1380 had primary radiotherapy. Thirty-two per cent (1698/5259) of all patients were seen by radiation oncology. Independent factors associated with radiation oncology consultation included advanced age (P < 0.001), greater comorbidity (P < 0.001) and earlier year of diagnosis (P < 0.001). Rates also varied widely across geographical regions (range 20-57%); this variation was highly significant on multivariate analysis (P < 0.001). Only 10% (370/3759) of patients with cystectomy had a preoperative radiation oncology consultation. Ten per cent of patients treated by cystectomy (386/3879) were seen by radiation oncology in the postoperative setting; rates varied widely across regions (range 6-44%). These geographical variations were highly significant in the multivariate analysis (P < 0.001), which also showed that younger patients, those with higher stage (pT or pN), and those with positive margins, were more likely to have a postoperative radiation oncology consultation (all P < 0.001). Only 19% (80/420) of cases with positive margins had a postoperative radiation oncology consultation. CONCLUSIONS: One third of all patients with muscle-invasive bladder cancer in routine practice were seen in consultation by radiation oncology. Few patients who undergo cystectomy have the benefit of either a preoperative or a postoperative opinion about the potential role of radiotherapy in their management. Closer collaboration between radiation oncologists and urologists is warranted.

The Effect of Waiting Times for Postoperative Radiotherapy on Outcomes for Women Receiving Partial Mastectomy for Breast Cancer: a Systematic Review and Meta-Analysis.

AIMS: To determine the effect of delay in postoperative radiotherapy on local recurrence and overall survival in women receiving partial mastectomy for breast cancer. MATERIALS AND METHODS: This was a systematic review and meta-analysis of published literature. Relevant reports were identified from MEDLINE, EMBASE and the Cochrane Register of Controlled Trials in all languages from 1975 to April 2015, in addition to the abstracts from the annual meetings of major radiotherapy conferences from 2000 to 2011. Reference lists were hand searched to find additional relevant reports and OvidSP's 'Find Citing' function was used to find studies citing papers identified in the primary search. Studies were included if they met the following criteria: (i) all patients received partial mastectomy and radiotherapy, (ii) a delay from surgery to radiotherapy was reported and (iii) one or more of local control/failure and/or survival were reported. Observational studies and randomised controlled trials were included. Studies including patients with in situ disease were excluded. Studies were classified as high quality if they adequately controlled for factors known to be associated with the outcomes of interest. Study quality was independently assessed by three authors. Initial disagreements about three studies were resolved by consensus. Only high-quality studies were included in the primary analysis. Delay was modelled as a continuous variable and the relative risk of local recurrence and the relative risk of death are reported per month of delay. The study results were combined using a fixed-effects model. RESULTS: Thirty-four relevant publications including 79 616 patients were identified in the systematic review. Ten high-quality publications reported on local recurrence (13 291 patients) and four high-quality studies reported on overall survival (2207 patients). The relative risk of local recurrence per month of delay was 1.08 (95% confidence interval 1.02-1.14). The relative risk of death per month of delay was 0.99 (95% confidence interval 0.94-1.05). CONCLUSIONS: Delays in post-lumpectomy radiotherapy are associated with a significant increase in the risk of local recurrence. We recommend that waiting times for radiotherapy should be kept as short as reasonably achievable.

Surgical resection and peri-operative chemotherapy for colorectal cancer liver metastases: A population-based study.

BACKGROUND: Most literature describing surgery for colorectal cancer (CRC) liver metastases (LM) comes from high volume centres. Here, we report management and outcomes achieved in routine clinical practice. METHODS: All cases of CRC in Ontario who underwent resection of LM in 1994-2009 were identified using the population-based Ontario Cancer Registry. Electronic treatment records identified chemotherapy delivery. Temporal trends are described for 3 periods: 1994-1999, 2000-2004, 2005-2009. We describe volume of resected CRCLM as a ratio of incident cases per CRCLM resection. Overall (OS) and cancer-specific survival (CSS) are measured from time of LM resection. RESULTS: 2717 patients underwent resection of CRCLM. Between 1994 and 2009 there was a 78% increase in case volume; from one resection for every 48 incident cases to one resection for every 27 incident cases, p < 0.001. Use of peri-operative chemotherapy increased over study periods from 44% (306/700), to 52% (429/830), to 65% (777/1187, p < 0.001). Chemotherapy utilization rates varied across geographic regions (range 43%-69%, p < 0.001). Post-operative mortality rates at 30 and 90 days were 2.5% and 4.3% respectively. Five year OS during the study periods was 36% (95% CI 32-39%), 40% (95% CI 36-43%), and 46% (95% CI 43-49%) (p < 0.001); CSS was 38% (95% CI 35-42%), 42% (95% CI 38-45%), 49% (95% CI 44-53%) (p < 0.001). The temporal improvement in OS/CSS persisted on adjusted analyses. CONCLUSIONS: Outcomes of patients with resected CRCLM in routine practice is comparable to those reported from high volume centres. Survival improved over the study period despite a greater proportion of patients with CRC undergoing liver resection.

Comparing effectiveness with efficacy: outcomes of palliative chemotherapy for non-small-cell lung cancer in routine practice.

INTRODUCTION: Randomized controlled trials (rcts) are the "gold standard" for establishing treatment efficacy; however, efficacy does not automatically translate to a comparable level of effectiveness in routine practice. Our objectives were to □ describe outcomes of palliative platinum-doublet chemotherapy (ppdc) in non-small-cell lung cancer (nsclc) in routine practice, in terms of survival and well-being; and□ compare the effectiveness of ppdc in routine practice with its efficacy in rcts. METHODS: Electronic treatment records were linked to the Ontario Cancer Registry to identify patients who underwent ppdc for nsclc at Ontario's regional cancer centres between April 2008 and December 2011. At each visit to the cancer centre, a patient's symptoms are recorded using the Edmonton Symptom Assessment System (esas). Score on the esas "well-being" item was used here as a proxy for quality of life (qol). Survival in the cohort was compared with survival in rcts, adjusting for differences in case mix. Changes in the esas score were measured 2 months after treatment start. The proportion of patients having improved or stable well-being was compared with the proportion having improved or stable qol in relevant rcts. RESULTS: We identified 906 patients with pre-ppdcesas records. Median survival was 31 weeks compared with 28-48 weeks in rcts. After accounting for deaths and cases lost to follow-up, we estimated that, at 2 months, 62% of the cohort had improved or stable well-being compared with 55%-63% who had improved or stable qol in rcts. CONCLUSIONS: The effectiveness of ppdc for nsclc in routine practice in Ontario is consistent with its efficacy in rcts, both in terms of survival and improvement in well-being.

Estimating the need for palliative radiotherapy for brain metastasis: a benchmarking approach.

Palliative radiotherapy (PRT) is useful in the management of many patients with brain metastases, but the need for this treatment in the general cancer population is unknown. The objective of this study was to estimate the appropriate rate of use of PRT for brain metastases (PRT.Br). Ontario's population-based cancer registry was used to identify patients who died of cancer. Radiotherapy records from all the province's radiotherapy centres were linked to Ontario's cancer registry to identify patients who received PRT.Br in the last 2 years of life. Multivariate analysis was used to identify social and health system-related barriers to the use of PRT.Br and to identify a subpopulation of patients with unimpeded access to PRT.Br. The rate of use of PRT.Br was measured in this benchmark subpopulation. The benchmark rate was standardised to the case mix of the overall cancer population. The study population included 231,397 patients who died of cancer in Ontario between 1998 and 2007. Overall, 13,944 patients received at least one course of PRT.Br in the last 2 years of life (6.0%). Multivariate analysis showed that the use of PRT.Br was strongly associated with: the availability of radiotherapy at the diagnosing hospital; the socioeconomic status of the community where the patient lived; and the distance from his/her home to the nearest radiotherapy centre. The benchmark subpopulation was defined as patients diagnosed in a hospital with radiotherapy facilities on site and who resided in a high income community, within 50 km of the nearest radiotherapy centre. The standardised benchmark rate of PRT.Br was 8.0% (95% confidence interval 7.5%, 8.5%). The overall shortfall between the actual rate and the benchmark was 25%, but varied by primary cancer site: lung, 27.6%; melanoma, 19.4%; breast, 13.9%. The magnitude of the shortfall in the use of PRT.Br varied widely across the province. At least 8.0% of patients who die of cancer require PRT.Br at least once in the last 2 years of life, but PRT.Br is widely underutilised in Ontario. The 25% shortfall in the use of PRT.Br reported here is much greater than the previously reported 7.8% shortfall in the overall lifetime rate of use of any radiotherapy in Ontario.

Curative therapy for bladder cancer in routine clinical practice: a population-based outcomes study.

AIMS: Definitive therapy of bladder cancer involves cystectomy or radiotherapy; controversy exists regarding optimal management. Here we describe the management and outcomes of patients treated in routine practice. MATERIALS AND METHODS: Treatment records were linked to the Ontario Cancer Registry to identify all cases of bladder cancer in Ontario treated with cystectomy or radiotherapy in 1994-2008. Practice patterns are described in three study periods: 1994-1998, 1999-2003, 2004-2008. Logistic regression, Cox model and propensity score analyses were used to evaluate factors associated with treatment choice and survival. RESULTS: In total, 3879 cases (74%) underwent cystectomy and 1380 (26%) were treated with primary radiotherapy. Cystectomy use increased over time (66, 75, 78%), whereas radiotherapy decreased (34, 25, 22%), P < 0.001. There was substantial regional variation in the proportion of cases undergoing radiotherapy (range 16-51%). Five year cancer-specific survival (CSS) and overall survival were 40 and 36% for surgical cases and 35 and 26% for radiotherapy cases (P < 0.001). In multivariate Cox model and propensity score analyses, there was no significant difference in CSS between surgery and radiotherapy (hazard ratio 0.99, 95% confidence interval 0.91-1.08); radiotherapy was associated with slightly inferior overall survival (hazard ratio 1.08, 95% confidence interval 1.00-1.16). CONCLUSION: Utilisation of cystectomy for bladder cancer in routine practice has increased over time with no evidence of a significant difference in CSS between radiotherapy and cystectomy.

Delivery of perioperative chemotherapy for bladder cancer in routine clinical practice.

BACKGROUND: Few articles have documented regimens and timing of perioperative chemotherapy for bladder cancer in routine practice. Here, we describe practice patterns in the general population of Ontario, Canada. METHODS: In this retrospective cohort study, treatment and physician billing records were linked to the Ontario Cancer Registry to describe use of neoadjuvant (NACT) and adjuvant (ACT) chemotherapy among all patients with muscle-invasive bladder cancer treated with cystectomy in Ontario 1994-2008. Time to initiation of ACT (TTAC) was measured from cystectomy. Multivariate Cox regression was used to identify factors associated with overall (OS) and cancer-specific survival (CSS). RESULTS: Of 2944 patients undergoing cystectomy, 4% (129/2944) and 19% (571/2944) were treated with NACT and ACT, respectively. Five-year OS was 25% [95% confidence interval (CI) 17% to 34%] for NACT, 29% (95% CI 25% to 33%) for ACT cases. Among patients with identifiable drug regimens, cisplatin was used in 82% (253/308) and carboplatin in 14% (43/308). The most common regimens were gemcitabine-cisplatin (54%, 166/308) and methotrexate, vinblastine, doxorubicin, cisplatin (MVAC) (21%, 66/308). Mean TTAC was 10 weeks; 23% of patients had TTAC >12 weeks. TTAC >12 weeks was associated with inferior OS [hazard ratio (HR) 1.28, 95% CI 1.00-1.62] and CSS (HR 1.30, 95% CI 1.00-1.69). In adjusted analyses, OS and CSS were lower among patients treated with carboplatin compared with those treated with cisplatin; OS HR 2.14 (95% CI 1.40-3.29) and CSS HR 2.06 (95% CI 1.26-3.37). CONCLUSIONS: Most patients in the general population receive cisplatin, and this may be associated with superior outcomes to carboplatin. Initiation of ACT beyond 12 weeks is associated with inferior survival. Patients should start ACT as soon as they are medically fit to do so.

Factors associated with referral to medical oncology and subsequent use of adjuvant chemotherapy for non-small-cell lung cancer: a population-based study.

BACKGROUND: Adjuvant chemotherapy (act) for non-small-cell lung cancer (nsclc) is associated with improved survival in the general population, but may be underutilized. We explored the factors associated with referral to medical oncology and subsequent use of act among all patients with resected nsclc in Ontario, Canada. METHODS: The Ontario Cancer Registry was used to identify all incident cases of nsclc diagnosed in Ontario during 2004-2006. We linked electronic records of treatment and of physician billing to identify surgery, act, and medical oncology consultation. A multivariate logistic regression model was used to evaluate factors associated with referral to medical oncology and subsequent use of act. RESULTS: Among 3354 cases of nsclc resected in Ontario during 2004-2006, 1830 (55%) were seen postoperatively by medical oncology, and 1032 (31%) were treated with act. Patients more than 70 years of age were less likely than younger patients to have a consultation [odds ratio (or): 0.4; p < 0.001]. A higher proportion of cases with stage ii or iii nsclc than with stage i disease were referred (ors: 2.7, 2.0 respectively; p < 0.005). We observed substantial geographic variation in the proportion of surgical cases referred (range: 32%-88%) that was not explained by differences in case mix. Among cases referred to medical oncology, older patients (age 60-69 years, or: 0.4; age 70+ years, or: 0.1; p < 0.001) with greater comorbidity (Charlson comorbidity index: 3+; or: 0.5; p < 0.05) and a longer postoperative stay (median length of stay: 7+ days; or: 0.7; p = 0.001) were less likely to receive act. Use of act was greater in patients with stage ii or iii than with stage i disease (ors: 3.0, 2.7 respectively; p < 0.001); use also varied with geographic location (range: 46%-63%). CONCLUSIONS: The initial decision to refer to medical oncology is associated with age and stage of disease, and those factors have an even greater effect on the decision to offer act. Comorbidity and postoperative length of stay were not associated with initial referral, but were associated with use of act in patients seen by medical oncology.

The use of palliative whole brain radiotherapy in the management of brain metastases.

AIMS: To describe the use of palliative whole brain radiotherapy (WBRT) in the management of brain metastases in the general cancer population and to identify factors associated with variations in its use. MATERIALS AND METHODS: We conducted a retrospective population-based study of patients who died of cancer in Ontario from 1984 to 2007 and identified those who received WBRT before death. Univariate and multivariate analyses were carried out to identify factors associated with the use of WBRT. RESULTS: Of the 494 709 patients who died of cancer, 5.7% received WBRT. The rate of use of WBRT varied across the province, with county rates ranging from 1.3 to 8.8%. Younger patients and patients living in communities of higher socioeconomic status were more likely to receive WBRT, as were patients diagnosed in a hospital with a radiotherapy facility or living closer to a radiotherapy centre (P < 0.0001). The rate of use of WBRT was stable over the study period. CONCLUSION: There are inequities in the use of WBRT for the management of brain metastases that are not associated with need. Strategies to increase patient access to WBRT need to be developed and evaluated to ensure optimal outcomes.

A population-based study of factors affecting the use of radiotherapy for endometrial cancer.

AIMS: To describe the use of adjuvant radiotherapy for endometrial cancer in Ontario, and identify factors associated with its use, and to determine whether variation in the use of radiation is associated with differences in survival. MATERIALS AND METHODS: This was a retrospective, population-based, cohort study of all patients who had a hysterectomy for endometrial cancer in Ontario between 1992 and 2003. We used multiple logistic regression to identify health system-related factors associated with the use of radiotherapy, while controlling for disease- and patient-related factors. Survival and cancer cause-specific survival were compared among regions of the province with higher and lower rates of use of radiotherapy. RESULTS: The study population included a total of 9411 women with a median age of 63 years. Overall, 26.2% received adjuvant radiotherapy. Patients living further from regional cancer centres were slightly less likely to receive radiation (P = 0.02). Patients who had their surgery during longer prevailing waiting times for radiotherapy were less likely to receive radiation (P = 0.04). The use of radiotherapy varied widely from 18.0 to 34.3% among the catchment areas of provincial radiotherapy centres (P < 0.0001). In the overall population, there was no difference in survival among regions with higher and lower rates of use of radiotherapy. However, in the subgroup of cases with clear cell and serous carcinomas, both overall survival and cancer cause-specific survival were significantly lower in regions with lower rates of use of radiotherapy (P < 0.05). This difference remained significant after controlling for other factors (P < 0.05; hazard ratio 1.43; 95% confidence limits 1.06-1.93). CONCLUSIONS: Health system-related factors unrelated to patients' needs affect the use of adjuvant radiotherapy in Ontario. Lower rates of use of adjuvant radiotherapy are associated with lower rates of survival in patients with serous and clear cell carcinomas.

Laryngeal cancer treatment and survival differences across regional cancer centres in Ontario, Canada.

AIMS: We conducted a population-based study of practice patterns and outcome across the regional cancer centres providing care to patients with laryngeal cancer in the Province of Ontario, Canada. MATERIALS AND METHODS: : This was a retrospective cohort study of 1547 patients with cancers of the glottic or supraglottic larynx diagnosed between 1982 and 1995. Data were collected via chart review, including: patient and disease characteristics, treatment, waiting times and treatment volumes. Vital status was obtained from the Ontario Cancer Registry. Variations across the nine regional cancer centres are described and their effect on outcome explored. All analyses were stratified by stage I and II separately from stage III and IV. RESULTS: Treatments differed across centres (P<0.0001); for instance, in the stage I and II group, use of a daily dose of >2.54Gy varied from 0 to 87.6% and in the stage III and IV group, total laryngectomy rates varied from a low of 6% to a high of 53%. The percentage of patients waiting more than 6 weeks from diagnosis to first treatment varied from 17 to 49% (P<0.0001). Multivariate analysis revealed cause-specific survival differences that were not explained by control for case mix, treatment or waiting times. Differences ranged from an 82% risk reduction in one centre compared with the reference (stage I and II group, P=0.008) to a 153% increase in risk (stage III and IV group, P=0.02). Centre case volumes were not associated with cause-specific survival. CONCLUSIONS: This study quantifies the degree of variation that can occur in the treatment and outcome of people with cancer. We cannot properly assess whether care delivery is of high quality until we have a better understanding of the factors that drive such variations.

Defining the need for prostate cancer radiotherapy in the general population: a criterion-based benchmarking approach.

AIMS: Determining the appropriate rate of radiotherapy is important for ensuring optimal radiotherapy utilisation and accessibility. A criterion-based benchmark (CBB) approach was developed as an alternative to evidence-based methods of determining the need for radiotherapy in prostate cancer. Our primary objective was to determine the initial/lifetime CBB radiotherapy rates in prostate cancer and to compare results with evidence-based estimates. Secondary objectives were to compare observed radiotherapy rates in Ontario, Canada and the USA with the estimated rates. MATERIALS AND METHODS: Benchmarks were defined in Ontario as communities in proximity to cancer centres and without long waiting lists. Surgical and radiotherapy data, encompassing both external beam radiation and brachytherapy, for 1997-2001 were collected for Ontario cancer patients. The Surveillance, Epidemiology and End Results (SEER) public use file described treatment in the USA. RESULTS: In total, 35 379 cases of prostate cancer were diagnosed in Ontario and 93 275 in SEER. CBB estimates of the initial/lifetime need for radiotherapy were 37.2% (95% confidence interval: 35.8-38.7) and 59.1% (54.3-63.9). Our group's evidence-based estimate (Ebest) rates were 32.3% (28.5-36.1) and 61.2% (55.6-66.8). Observed initial radiotherapy rates were 28.0% (27.5-28.4) in Ontario and 37.0% (36.7-37.3) in SEER. In Ontario, the estimated lifetime rate was 42.6% (41.2-44.0). CONCLUSIONS: CBB provides a reasonable estimate of the need for radiotherapy in prostate cancer. Observed initial radiotherapy rates in the USA were concordant with the CBB estimate. The CBB suggests a shortfall in radiotherapy utilisation for prostate cancer in Ontario.

Demographic differences between cancer survivors and those who die quickly of their disease.

AIMS: Some people diagnosed with cancer die extremely quickly of their disease. We investigated whether certain demographic and geographical characteristics were associated with these early deaths. MATERIALS AND METHODS: The Ontario Cancer Registry enhanced with census data was used to study early death in patients aged 40-69 years, diagnosed between 1990 and 1997 with colorectal, female breast, head and neck, lung, prostate, stomach, or primary cancer of unknown origin. For each site, cases were either those who constituted the quickest 10% of deaths, or those who died within 30 days, whichever was the larger number (n = 5022). Controls were those still alive at 1 year (n = 59 406). Analyses were stratified by disease site and logistic regression identified independent effects. Characteristics included: age, gender, area-level socioeconomic status, county of residence, urban/rural residence, diagnosis year, and distance to a cancer centre. RESULTS: Lower socioeconomic status (all sites) and increasing age (all sites except prostate and primary of unknown origin) were most strongly and consistently associated with early death. Male gender was a risk factor for early death from lung cancer. Living in urban areas was a risk factor for breast, lung, and unknown primary cancers. CONCLUSIONS: People living in poorer and/or urban areas and the young-elderly are more susceptible to a very late cancer diagnosis. Unequal access to cancer care can lead to devastating consequences for vulnerable sectors of society.

Defining the need for breast cancer radiotherapy in the general population: a criterion-based benchmarking approach.

AIMS: Determining the appropriate rate of radiotherapy is important for ensuring optimal radiotherapy utilisation and accessibility. A criterion-based benchmark (CBB) was developed for estimating the need for radiotherapy in incident breast cancer cases. Our primary objective was to compare an evidence-based estimate (Ebest) of need against the CBB. These estimates were then compared with radiotherapy rates in Ontario, Canada and the USA. Surgical rates were also examined. MATERIALS AND METHODS: Benchmarks were defined in Ontario as communities in proximity to cancer centres and without long waiting lists. Patient data from 1997 to 2001 were prospectively collected from radiotherapy cancer centres. Surgical data were obtained from the Canadian Institute for Health Information database. The public use file of Surveillance, Epidemiology and End Results (SEER) described treatment in the USA. RESULTS: In total, 4241 cases of breast cancer were diagnosed in benchmark communities. The overall radiotherapy rate by Ebest was 64.0% (95% confidence interval: 58.1-69.8%) compared with the CBB of 60.7% (59.3-62.1%). In comparison, Ontario's overall radiotherapy rate was 55.6% (55.0-56.1%) and in SEER it was 49.3% (48.9-49.6%). Adjuvant radiotherapy rates after lumpectomy were 100% in Ebest and 83.6% (82.0-85.1%) by the CBB. The Ebest and CBB post-mastectomy rates were 21.9% (20.6-23.3%) and 34.6% (32.5-36.7%), respectively. Observed post-lumpectomy radiotherapy rates were 75.1% in Ontario and 65.3% in SEER. Post-mastectomy radiotherapy rates were 29.5% in Ontario and 17.0% in SEER. CONCLUSIONS: CBB provides a reasonable estimate of the overall need for radiotherapy in breast cancer. Observed radiotherapy rates in Ontario and the USA suggest an age-related decrease in the use of radiotherapy. The benchmark estimate suggests a shortfall of adjuvant breast radiotherapy utilisation in Ontario.