Clinical and Demographic Factors Associated With Receipt of Non Guideline-concordant Initial Therapy for Nonmetastatic Prostate Cancer.

OBJECTIVES: To determine the extent to which initial therapy for nonmetastatic prostate cancer was concordant with nationally recognized guidelines using supplemented cancer registry data and what factors were associated with receipt of nonguideline-concordant care. METHODS: Initial therapy for 8229 nonmetastatic prostate cancer cases diagnosed in 2004 from cancer registries in 7 states was abstracted as part of the Centers for Disease Control's Patterns of Care Breast and Prostate Cancer study conducted during 2007 to 2009. The National Comprehensive Cancer Network clinical practice guidelines version 1.2002 was used as the standard of care based on recurrence risk group and life expectancy (LE). A multivariable model was used to determine risk factors associated with receipt of nonguideline-concordant care. RESULTS: Nearly 80% with nonmetastatic prostate cancer received guideline-concordant care for initial therapy. Receipt of nonguideline-concordant care (including receiving either less aggressive therapy or more aggressive therapy than indicated) was related to older age, African American race/ethnicity, being unmarried, rural residence, and especially to being in the high recurrence risk group where receiving less aggressive therapy than indicated occurred more often than receiving more aggressive therapy (adjusted OR=4.2; 95% CL, 3.5-5.2 vs. low-risk group). Compared with life table estimates adjusted for comorbidity, physicians tended to underestimate LE. CONCLUSIONS: Receipt of less aggressive therapy than indicated among high-risk group men with >5-year LE based on life table estimates adjusted for comorbidity was a concern. Physicians may tend to underestimate 5-year survival among this group and should be alerted to the importance of recommending aggressive therapy when warranted. However, based on more recent guidelines, among those with low-risk disease, the proportion considered to be receiving less aggressive therapy than indicated may now be lower because active surveillance is now considered appropriate.

Impact of sociodemographic factors on the radiotherapeutic management of lung cancer: Results of a Quality Research in Radiation Oncology survey.

PURPOSE: The objective of this study is to describe the impact of sociodemographic (SOC) factors on the management of lung cancer patients treated at radiation therapy facilities participating in the Quality Research in Radiation Oncology survey. METHODS AND MATERIALS: A 2-stage stratified random sample of lung cancer patients treated in 2006 to 2007 at 45 facilities yielded 340 stage I-III non-small cell lung cancer (NSCLC) and 144 limited-stage small cell lung cancer (LS-SCLC) cases. Five SOC variables based on data from the 2000 US Census were analyzed for association with the following clinical factors: patients living in urban versus rural settings (U/R); median household income (AHI); % below poverty level (PPV); % unemployed (PUE); and % with college education (PCE). RESULTS: The 340 NSCLC patients were stage I, 16%; stage II, 11%; stage III, 62%; stage unknown, 11%. Histologic subtypes were adenocarcinoma, 31.8%; squamous cell carcinoma, 35.3%; large cell carcinoma, 3.2%; and NSCLC NOS, 27.7%. The median age was 66 years. Median Karnofsky performance status (KPS) was 80. The 144 LS-SCLC had a median age of 63; 73 were male (50.7%). Median KPS was 80. Stereotactic body radiation therapy (SBRT) and modern imaging utilization was associated with treatment at facilities located in higher SOC regions. SBRT was employed in 46.8% stage I NSCLC patients treated in centers where %PUE was below median versus 14.8% in centers where %PUE was above median (P = .02). Four-dimensional computed tomography was utilized in 14.2% of patients treated in centers located in regions with %PPV below median versus 3.7% in centers located in regions with %PPV above median (P < .01). SCLC patients were more likely to receive all of their planned RT when treated at centers located in regions with lower PPV (95.0% vs 79.1%; P = .04). CONCLUSIONS: SOC factors may impact use of modern treatment planning and delivery and multidisciplinary management of NSCLC and SCLC. These results may suggest an impact of these SOC factors on access to health care.

Can patient comorbidities be included in clinical performance measures for radiation oncology?

PURPOSE: Patient comorbidities may affect the applicability of performance measures that are inherent in multidisciplinary cancer treatment guidelines. This article describes the distribution of common comorbid conditions by disease site and by patient and facility characteristics in patients who received radiation therapy as part of treatment for cancer of the breast, cervix, lung, prostate, and stomach, and investigates the association of comorbidities with treatment decisions. MATERIALS AND METHODS: Stratified two-stage cluster sampling provided a random sample of radiation oncology facilities. Eligible patients were randomly sampled from each participating facility for each disease site, and data were abstracted from medical records. The Adult Comorbidity Evaluation Index (ACE-27) was used to measure comorbid conditions and their severity. National estimates were calculated using SUDAAN statistical software. RESULTS: Multivariable logistic regression models predicted the dependent variable "treatment changed or contraindicated due to comorbidities." The final model showed that ACE-27 was highly associated with change in treatment for patients with severe or moderate index values compared to those with none or mild (P < .001). Two other covariates, age and medical coverage, had no (age) or little (medical coverage) significant contribution to predicting treatment change in the multivariable model. Disease site was associated with treatment change after adjusting for other covariates in the model. CONCLUSIONS: ACE-27 is highly predictive of treatment modifications for patients treated for these cancers who receive radiation as part of their care. A standardized tool identifying patients who should be excluded from clinical performance measures allows more accurate use of these measures.

Treatment patterns for prostate cancer: comparison of Medicare claims data to medical record review.

BACKGROUND: As evidence-based guidelines increasingly define standards of care, the accurate reporting of patterns of treatment becomes critical to determine if appropriate care has been provided. We explore the level of agreement between claims and record abstraction for treatment regimens for prostate cancer. METHODS: Medicare claims data were linked to medical records abstraction using data from the Centers for Disease Control and Prevention's National Program of Cancer Registry-funded Breast and Prostate Patterns of Care study. The first course of therapy included surgery, radiation therapy (RT), and hormonal therapy with luteinizing hormone-releasing hormone agonists. RESULTS: The linked sample included 2765 men most (84.7%) of whom had stage II prostate cancer. Agreement was excellent for surgery (κ=0.92) and RT (κ=0.92) and lower for hormonal therapy (κ=0.71); however, most of the discrepancies were due to greater number of patients reported who received hormonal therapy in the claims database than in the medical records database. For some standard multicomponent management strategies sensitivities were high, for example, hormonal therapy with either combination RT (86.9%) or cryosurgery (96.6%). CONCLUSIONS: Medicare claims are sensitive for determining patterns of multicomponent care for prostate cancer and for detecting use of hormonal therapy when not reported in the medical records abstracts.

Penetration of recommended procedures for lung cancer staging and management in the United States over 10 years: a quality research in radiation oncology survey.

PURPOSE: To document the penetration of clinical trial results, practice guidelines, and appropriateness criteria into national practice, we compared the use of components of staging and treatment for lung cancer among patients treated in 2006-2007 with those used in patients treated in 1998-1999. METHODS AND MATERIALS: Patient, staging work-up, and treatment characteristics were extracted from the process survey database of the Quality Research in Radiation Oncology (QRRO), consisting of records of 340 patients with locally advanced non-small cell lung cancer (LA-NSCLC) at 44 institutions and of 144 patients with limited-stage small cell lung cancer (LS-SCLC) at 39 institutions. Data were compared for patients treated in 2006-2007 versus those for patients treated in 1998-1999. RESULTS: Use of all recommended procedures for staging and treatment was more common in 2006-2007. Specifically, disease was staged with brain imaging (magnetic resonance imaging or computed tomography) and whole-body imaging (positron emission tomography or bone scanning) in 66% of patients with LA-NSCLC in 2006-2007 (vs 42% in 1998-1999, P=.0001) and in 84% of patients with LS-SCLC in 2006-2007 (vs 58.3% in 1998-1999, P=.0011). Concurrent chemoradiation was used for 77% of LA-NSCLC patients (vs 45% in 1998-1999, P<.0001) and for 90% of LS-SCLC patients (vs 62.5% in 1998-1999, P<.0001). Use of the recommended radiation dose (59-74 Gy for NSCLC and 60-70 Gy as once-daily therapy for SCLC) did not change appreciably, being 88% for NSCLC in both periods and 51% (2006-2007) versus 43% (1998-1999) for SCLC. Twice-daily radiation for SCLC was used for 21% of patients in 2006-2007 versus 8% in 1998-1999. Finally, 49% of patients with LS-SCLC received prophylactic cranial irradiation (PCI) in 2006-2007 (vs 21% in 1998-1999). CONCLUSIONS: Although adherence to all quality indicators improved over time, brain imaging and recommended radiation doses for stage III NSCLC were used in <90% of cases. Use of full thoracic doses and PCI for LS-SCLC also requires improvement.

Place of residence and primary treatment of prostate cancer: examining trends in rural and nonrural areas in Wisconsin.

OBJECTIVE: To determine whether rural residents were at a disadvantage compared with urban residents with regard to the receipt of curative therapy for prostate cancer. MATERIALS AND METHODS: Using the Breast and Prostate Cancer Data Quality and Patterns of Care Study II, patients with prostate cancer who were diagnosed in 2004 were identified. Registrars reviewed the medical records of randomly selected patients with incident prostate cancer (n = 1906). The patients' residential address was geocoded and linked to the census tract from the 2000 U.S. Census. The place of residence was defined as rural or nonrural according to the census tract and rural-urban commuting area categorization. The distance from the residence to the nearest radiation oncology facility was calculated. The odds ratio and 95% confidence intervals associated with receipt of noncurative treatment was calculated from logistic regression models and adjusted for several potential confounders. RESULTS: Of the incident patients, 39.1% lived in urban census tracts, 41.5% lived in mixed tracts, and 19.4% lived in rural tracts. Hormone-only or active surveillance was received by 15.4% of the patients. Relative to the urban patients, the odds ratio for noncurative treatment was 1.01 (95% confidence interval 0.59-1.74) for those living in mixed tracts and 0.96 (95% confidence interval 0.52-1.77) for those living in rural tracts. No association was found for noncurative treatment according to the Rural-Urban Commuting Area categorization. The linear trend was null between noncurative treatment and the distance to nearest radiation oncology facility (P = .92). CONCLUSION: The choice of curative treatment did not significantly depend on the patient's place of residence, suggesting a lack of geographic disparity for the primary treatment of prostate cancer.

Quality Research in Radiation Oncology analysis of clinical performance measures in the management of gastric cancer.

BACKGROUND: The specific aim was to determine national patterns of radiation therapy (RT) practice in patients treated for stage IB-IV (nonmetastatic) gastric cancer (GC). METHODS AND MATERIALS: A national process survey of randomly selected US RT facilities was conducted which retrospectively assessed demographics, staging, geographic region, practice setting, and treatment by using on-site record review of eligible GC cases treated from 2005 to 2007. Three clinical performance measures (CPMs), (1) use of computed tomography (CT)-based treatment planning; (2) use of dose volume histograms (DVHs) to evaluate RT dose to the kidneys and liver; and (3) completion of RT within the prescribed time frame; and emerging quality indicators, (i) use of intensity modulated RT (IMRT); (ii) use of image-guided tools (IGRT) other than CT for RT target delineation; and (iii) use of preoperative RT, were assessed. RESULTS: CPMs were computed for 250 eligible patients at 45 institutions (median age, 62 years; 66% male; 60% Caucasian). Using 2000 American Joint Committee on Cancer criteria, 13% of patients were stage I, 29% were stage II, 32% were stage IIIA, 10% were stage IIIB, and 12% were stage IV. Most patients (43%) were treated at academic centers, 32% were treated at large nonacademic centers, and 25% were treated at small to medium sized facilities. Almost all patients (99.5%) underwent CT-based planning, and 75% had DVHs to evaluate normal tissue doses to the kidneys and liver. Seventy percent of patients completed RT within the prescribed time frame. IMRT and IGRT were used in 22% and 17% of patients, respectively. IGRT techniques included positron emission tomography (n=20), magnetic resonance imaging (n=1), respiratory gating and 4-dimensional CT (n=22), and on-board imaging (n=10). Nineteen percent of patients received preoperative RT. CONCLUSIONS: This analysis of radiation practice patterns for treating nonmetastatic GC indicates widespread adoption of CT-based planning with use of DVH to evaluate normal tissue doses. Most patients completed adjuvant RT in the prescribed time frame. IMRT and IGRT were not routinely incorporated into clinical practice during the 2005-2007 period. These data will be a benchmark for future Quality Research in Radiation Oncology GC surveys.

Regional, provider, and economic factors associated with the choice of active surveillance in the treatment of men with localized prostate cancer.

Data on initial treatment of 8232 cases of localized prostate cancer diagnosed in 2004 were obtained by medical record abstraction (including hospital and outpatient locations) from seven state cancer registries participating in the Centers for Disease Control and Prevention's Breast and Prostate Cancer Data Quality and Patterns of Care Study. Distinction was made between men receiving no therapy with no monitoring plan (no therapy/no plan [NT/NP]) and those receiving active surveillance (AS). Overall, 8.6% received NT/NP and 4.7% received AS. Older age at diagnosis, lower clinical risk group, and certain registry locations were significant predictors of use of both AS and NT/NP. AS was also related to having more severe comorbidities, whereas nonwhite race was predicted receiving NT/NP. Men receiving AS lived in areas with a higher number of urologists per 100 000 men than those receiving NT/NP. In summary, physician and clinical factors were stronger predictors of AS, whereas demographic and regional factors were related to receiving NT/NP. Physicians appear reluctant to recommend AS for younger patients with no comorbidities.

Frequency of use of imaging tests in the diagnosis of pulmonary embolism: effects of physician specialty, patient characteristics, and region.

OBJECTIVE: The purpose of this study was to ascertain whether clinical practice in diagnosing pulmonary embolism is consistent with recommendations in the literature and to explore variations in practice across site of care (e.g., emergency department), physician and patient characteristics, and geographic location. MATERIALS AND METHODS: Medicare 5% research identifiable files were analyzed. The cases of patients with emergency department visits or inpatient stays for a diagnosis of pulmonary embolism or for symptoms related to pulmonary embolism (shortness of breath, chest pain, and syncope) were identified. We determined the number of patients who underwent each type of relevant imaging test and evaluated variations in the first non-chest-radiographic test by site of care and treating physician specialty. Using logistic regression, we studied variations in the use of common imaging tests, exploring variations associated with patient characteristics, physician specialty, site of care, and geographic location. RESULTS: For patients in whom pulmonary embolism might have been suspected, the most common tests were echocardiography (26% of the patients), CT or CT angiography of the chest (11%), cardiac perfusion study (6.9%), and duplex ultrasound (7.3%). For patients with an inpatient diagnosis of pulmonary embolism, the most common tests were chest CT or CT angiography (49%), duplex ultrasound (18%), echocardiography (10.9%), and ventilation-perfusion scintigraphy (10.9%). For patients for whom pulmonary embolism might have been suspected, many large variations were found in practice patterns among physician specialties and geographic locations. There were fewer variations among patients with the inpatient diagnosis of pulmonary embolism. CONCLUSION: Physician practice in the diagnosis of pulmonary embolism is broadly consistent with recommendations. However, variations by physician specialty and geographic location may be evidence of inappropriate imaging.

Imaging evaluation for suspected pulmonary embolism: what do emergency physicians and radiologists say?

OBJECTIVE: The utility of various imaging techniques and strategies for the diagnosis of pulmonary embolism has been studied in randomized control trials and extensively described in the literature. CT and ventilation-perfusion scintigraphy are the mainstays of diagnosis, and MRI is emerging. The purpose of this study was to assess the diagnostic approach to pulmonary embolism practiced by emergency physicians and advised by radiologists. MATERIALS AND METHODS: Questionnaires were sent to emergency physicians and radiologists in Pennsylvania. The questions covered diagnostic strategies for the detection of pulmonary embolism in the usual situations and in clinical circumstances in which the primary imaging technique is considered less desirable. RESULTS: Sixty-two radiologists and 52 emergency physicians completed the survey. Ninety percent of radiologists and 96% of emergency physicians answered that CT was their first-line choice for the diagnosis of pulmonary embolism. The use of ventilation-perfusion scintigraphy increased in the care of patients with renal failure and allergy to iodinated contrast material. MRI was chosen infrequently. CONCLUSION: CT is the overwhelmingly preferred technique for the diagnosis of pulmonary embolism. The role of ventilation-perfusion scintigraphy increases when the use of iodinated contrast material is contraindicated. MRI does not seem to have an important role in practice.

The actual role of CT and ventilation-perfusion scanning in workup for suspected pulmonary embolism: evidence from hospitals.

OBJECTIVE: Over the past two decades, CT has been found valuable in the diagnosis of pulmonary embolism (PE). We sought to ascertain the relative roles of CT and ventilation-perfusion (V/Q) scanning, the previously preferred technique, in the diagnosis of PE in recent practice and whether there is variation among hospital types. MATERIALS AND METHODS: Using the Medicare anonymized 5% of beneficiaries complete claims file for 2005, we studied the use of relevant CT and V/Q scanning in the evaluation of patients with a diagnosis of PE and of patients with symptoms that might have been due to PE (chest pain, syncope, difficulty breathing). In 2008, we surveyed the radiology departments of Pennsylvania hospitals about the use of CT and V/Q scanning for PE, service availability hours, and what equipment was used. RESULTS: In all data, we found that CT was used approximately six times as frequently as V/Q scanning. In the Medicare data, only small differences in frequency of use of CT and V/Q scanning were associated with hospital characteristics. Academic hospitals did not differ in a major way from other hospitals, nor did small or rural hospitals. In the survey, 97% of radiology departments reported that CT was available for evaluation of PE 24 hours a day 7 days a week. Ninety-three percent of departments reported V/Q scanning was available at some times; 77% reported V/Q available at all times. CONCLUSION: CT was a fully disseminated and dominant technique for the diagnosis of PE by 2005, and it was readily available at small and rural hospitals. The lack of availability of off-hours V/Q scanning at a substantial fraction of hospitals may be a problem for patients with contraindications to CT.

Using QRRO survey data to assess compliance with quality indicators for breast and prostate cancer.

PURPOSE: Quality Research in Radiation Oncology (QRRO) has embarked on a new national process survey to provide benchmark data that will allow radiation oncologists to assess the quality of care in their own practices by measuring quality indicators (QIs) and comparing individual with national practice. METHODS: Investigators at QRRO developed QIs on the basis of nationally recognized, evidence-based guidelines such as those of the National Comprehensive Cancer Network, as well as additional emerging QIs for processes involving rapidly emerging technology. They specifically defined the QIs as clinical performance measures. Published results of the national survey database for patients treated in 1998 and 1999 were reviewed and additional analyses conducted to assess data adequacy to measure compliance with these clinical performance measures. RESULTS: Examples of workup QIs for breast cancer patients showed that 97% underwent diagnostic bilateral mammography, 96% underwent pathology reviews, 83% underwent the determination of estrogen receptor status, 81% underwent the determination of progesterone receptor status, and 31% underwent the determination of human epidermal growth factor receptor 2 status. Compliance with treatment QIs for field recommendations on the basis of nodal findings can be measured. Of patients with prostate cancer, 90% underwent digital rectal examinations, 99% underwent prostate-specific antigen tests, and 99% had their Gleason scores determined. Compliance with QIs on the basis of prognostic group can also be measured. CONCLUSIONS: Benchmarking utilization patterns provides a foundation for assessing the appropriateness of cancer care in the future. The QRRO database is a rich data source, and the new survey will provide contemporary benchmark data for these measures.

Outcome results of the 1996-1999 patterns of care survey of the national practice for patients receiving radiation therapy for carcinoma of the esophagus.

PURPOSE: A Patterns of Care Study of patients treated from 1996 to 1999 evaluated the national practice for patients receiving radiation therapy for carcinoma of the esophagus in the United States. METHODS: A national survey was conducted at 59 institutions in a stratified random sample selected from a master list of radiation therapy facilities throughout the United States. Patient, tumor, and treatment characteristics were evaluated. Multivariate comparisons of survival times were made using the Cox proportional hazards model. RESULTS: Adenocarcinoma was diagnosed in 51% of patients and squamous cell carcinoma in 49% of patients. Sixteen percent of patients were clinical stage (CS) I (using the 1983 American Joint Committee on Cancer system), 39% were CS II, and 33% were CS III. Significant variables in the multivariate analysis of survival times included clinical stage, treatment approach, and facility size. Patients with CS III disease had a higher hazard risk of death as compared with CS I patients (hazard ratio [HR], 2.01; P = .001), whereas those treated with chemoradiotherapy followed by surgery (HR, 0.32; P < .0001) had a decreased risk of death compared with chemoradiotherapy-only patients. Patients at small centers had a higher risk of death (HR, 1.32; P = .03) compared with patients treated at larger facilities. CONCLUSION: Concurrent chemoradiotherapy continued to be the most commonly utilized treatment approach during the time period studied. The observation that patients undergoing surgical resection following chemoradiation have a decreased HR or chance of death compared with other treatment schemes supports the need for a randomized trial comparing these strategies.

The 1999 patterns of care study of radiotherapy in localized prostate carcinoma: a comprehensive survey of prostate brachytherapy in the United States.

BACKGROUND: The objective of the current study was to provide descriptive information on a representative national sample of patients with prostate carcinoma who were treated with prostate brachytherapy (PB) in calendar year 1999. METHODS: A random survey was conducted by the Patterns of Care Study in radiation oncology of 59 facilities (1 facility had no eligible patients) that treated patients with prostate carcinoma in 1999 in the United States. A weighted sample size of 36,496 patients with prostate cancer was included in the 1999 survey (unweighted sample size, 554 patients). The main measures were the clinical characteristics of men prior to treatment and the technical characteristics of PB. Patients were classified into three prognostic groups according to T stage, pretreatment prostate specific antigen (PSA) level, and Gleason score. RESULTS: A weighted sample size of 13,293 patients (36%; unweighted sample size, 162 patients) was treated with PB. Compared with a weighted sample size of 23,203 patients (64%; unweighted sample size, 392 patients) was treated with external beam radiotherapy (EB), patients who received PB were significantly younger (mean age: PB group, 67.7 years; EB group, 70.8 years; P = 0.0006). The mean pretreatment PSA level for the PB group was lower compared with the EB group (9.9 ng/mL vs. 13.33 ng/mL; P = 0.0015). The prognostic groupings were more favorable for patients in the PB group compared with patients in EB group (P = 0.0365). The utilization of androgen deprivation therapy (ADT) in the PB group was similar to the utilization of ADT in the EB group (40.4% vs. 51.3%; P = 0.2282). The vast majority of men who were treated with PB received low-dose-rate, permanent sources (89%). Fifty-four percent of men received PB monotherapy (PBM), and the remaining 46% were treated with EB in addition to PB (EBPB). The prognostic groupings were more favorable for patients in the PBM group compared with patients in the EBPB group (P = 0.0037). Of the men who were treated with low-dose-rate PB, 59% were treated with iodine-125 (I-125), and 41% were treated with palladium-103 (Pd-103). I-125 was used more frequently in men who were treated with PBM, and Pd-103 was used more frequently in men who were treated with EBPB. Postimplantation dosimetry was documented in 61.0% of men who were treated with low-dose-rate PB. Computed tomography imaging was used for 46.5% of men. CONCLUSIONS: PB was used in 36% of men who were treated with radiotherapy nationally. The mean age of men who were treated with PB was younger than the population of men who were treated with EB alone. Nearly 50% of men who received PB also received EB. EB was used more frequently in men with higher-risk disease. ADT was used in 40% of patients in the PB group. Techniques and prescription doses were consistent with published guidelines.

The national practice for patients receiving radiation therapy for carcinoma of the esophagus: results of the 1996-1999 Patterns of Care Study.

PURPOSE: A Patterns of Care Study (PCS) was conducted to evaluate the standards of practice for patients receiving radiation therapy for esophageal cancer from 1996 to 1999. This study examined the evaluation and treatment schemes used during this time and compared these results to the PCS data obtained between 1992 and 1994 to identify any fundamental changes in national practice. METHODS: A national survey was conducted using a two-stage cluster sampling technique. Specific information was collected on 414 patients with esophageal cancer who received radiotherapy (RT) as part of definitive or adjuvant management at 59 institutions. Patients were staged according to the 1983 AJCC. Eligibility criteria for case review included RT between 1996 and 1999, no evidence of distant metastasis (including CT evidence of either supraclavicular or celiac nodes >1 cm), squamous cell or adenocarcinoma histology, Karnofsky performance status >60, tumors in the thoracic esophagus with <2 cm extension into the stomach, and no prior malignancies within the last 5 years. Statistical analysis was performed on the database using SUDAAN software to accurately reflect the type of sampling technique used by PCS. For the purpose of this analysis, institutions were stratified as either large or small based on the number of new cases seen each year. For the purposes of comparison, the 1992-1994 PCS esophageal survey results were subjected to the same statistical procedures and tests. RESULTS: The median age of patients was 64 years. Seventy-seven percent were male, and 23% were female. Karnofsky performance status was >or=80% in 85% of patients. The racial profile mirrors the previous survey with 75% Caucasian, 21% African-American, 3% Asian, and <1% Hispanic. A review of the histology revealed a nearly 50:50 split between squamous cell and adenocarcinoma. Sixteen percent were clinical Stage I, 39% clinical Stage II, and 33% clinical Stage III according to the 1983 AJCC system. Workup included endoscopy (96%), CT of the chest (87%), CT of the abdomen (75%), and esophagram (64%). Endoscopic ultrasound (EUS) was used in 18% of cases as compared to <2% in the original survey (p < 0.0001). Patients treated at large centers were more likely to undergo EUS than those treated at small centers (23% vs. 12%, p = 0.047). Fifty-six percent of patients received concurrent chemoradiation as definitive treatment. There was a significant increase in the use of concurrent chemoradiation before planned surgical resection as compared to the original survey (27% vs. 10%, p = 0.007). Other schemes included RT alone (10%), postoperative RT (1%), and postoperative chemoradiation (5%). Forty-six percent of patients with adenocarcinoma underwent trimodality therapy as compared to 19% with squamous cell carcinomas (p = 0.0002). Patients undergoing preoperative chemoradiation were more likely to have had an EUS. The median total dose of external RT was 50.4 Gy, and the median dose per fraction was 1.8 Gy. Brachytherapy was used in 6% of cases. The chemotherapy agents most commonly used included 5-fluorouracil (82%), cisplatin (67%), and paclitaxel (22%). Paclitaxel was more commonly employed as part of a preoperative chemoradiation regimen than in the setting of definitive chemoradiation (46% vs. 12%, p = 0.03). Compared to the original survey, paclitaxel use significantly increased between 1996 and 1999 (0.2% vs. 22%, p = 0.001). CONCLUSIONS: The Patterns of Care Survey confirms the use of concurrent chemoradiation as part of the national standards of practice for the management of esophageal cancer patients. A comparison with the previous study documents the significant rise in the use of EUS, preoperative chemoradiation followed by surgery, and the increasing use of paclitaxel as part of a combined modality regimen.

Patterns of Care Study quantitative evaluation of the quality of radiotherapy in Japan.

BACKGROUND: Quality assurance (QA) of clinical practice is important for any medical specialty. Programs based on the Patterns of Care Study (PCS) have been developed to compare the quality of radiotherapeutic care at individual institutions, with the national average representing the process and outcome of radiotherapy. The feasibility of these programs was analyzed. METHODS: Calculation programs for the national average and standard score were developed to evaluate quantitatively the process and outcome of radiotherapy at individual institutions as well as at the national level. The programs were used to evaluate the quality of radiotherapy for 561 esophageal carcinoma patients surveyed in the Japanese PCS. RESULTS: As a representative example of QA measurement, the national average for the 5-year survival rate for these patients in the nonsurgery group was 5%. The regional averages for those in academic and nonacademic institutions were 9% and 1%, respectively (P = 0.0142), showing a significant difference between these two institutional strata. The standard score compared with the national average for institution No.105, for example, was 16.3 (P < 0.0001), with the positive value indicating that the outcome at this institution was significantly higher than the national average. The corresponding figure compared with the regional average was -0.3 (P = 0.7391), with the negative value indicating the outcome is not superior to the regional average of academic institutions. CONCLUSIONS: These programs make it possible to compare quantitatively the quality of radiation therapy at individual institutions with the national and regional averages. They should also be useful for nationwide QA projects in radiation oncology as well as in other medical specialities.