Three-year survival from diagnosis in surgically treated patients in designated and nondesignated cancer care hospitals in Japan.

The Japanese national and prefectural governments have accredited high-capacity, high-experience cancer care hospitals as "designated cancer care hospitals" to standardize cancer care, centralize patients, and improve clinical outcomes, but the performance of these designated hospitals has not been evaluated. We retrospectively compared 3-year patient survival in national, prefectural, and nondesignated cancer care hospitals in 2010-2012 in Osaka using registry-based data of 86 456 surgically treated cancer patients aged 15 years or older. Hazard ratios and 3-year survival probabilities were compared among national, prefectural, and nondesignated hospitals using a Cox proportional hazard regression model. Subgroup analyses for six cancers (stomach, colorectum, lung, breast, uterus, and prostate) and other cancers were carried out. In 2010-2012, 36 634 (42.4%), 38 048 (44.0%), and 11 774 (13.6%) patients were treated at national, prefectural, and nondesignated hospitals, respectively. The mortality hazard for all-site cancer was significantly lower in national and prefectural designated hospitals (adjusted hazard ratio 0.60 [95% confidence interval, 0.53-0.68] and 0.72 [0.66-0.80], respectively) than in nondesignated hospitals. The adjusted 3-year survival probabilities for all-site cancer were 86.6%, 84.2%, and 78.8% in national, prefectural, and nondesignated hospitals, respectively. Site-specific subgroup analyses revealed significantly lower hazard ratios in national and prefectural hospitals than in nondesignated hospitals for stomach, colorectal, lung, breast, and other cancers. To conclude, the majority of cancer patients underwent surgeries at designated hospitals and had higher 3-year survival probabilities than those treated at nondesignated hospitals. Further centralization of patients from nondesignated to designated hospitals could improve population-level survival.

Quality Assurance of Dose-Escalated Radiation Therapy in a Randomized Trial for Locally Advanced Oesophageal cancer.

PURPOSE: The ongoing phase 2/3 PRODIGE 26/CONCORDE trial compares chemoradiation therapy with and without dose escalation in patients with locally advanced or unresectable esophageal cancer. The results of a benchmark case procedure are reported here to evaluate the protocol compliance of participating centers as part of quality assurance for radiation therapy. METHODS AND MATERIALS: Volume delineation, target coverage, and dose constraints to the organs at risk (OARs) were assessed on treatment plans of a common benchmark case performed by each participating center. The centers were classified in 3 categories: per protocol, minor acceptable deviation (MiD), or major unacceptable deviation (MaD). A plan was rejected if ≥4 MiDs or 1 MaD were found. RESULTS: Thirty-5 centers submitted 43 plans. Among them, 14 (32.6%) were per protocol, 19 (44.2%) presented at least 1 MiD, 2 (4.6%) presented at least 1 MaD, and 8 (18.6%) presented both MiD and MaD. Overall, 11 (25.6%) plans were rejected. Only 1 plan was rejected because gross tumor volume was not correctly delineated. The OAR delineation was respected in all cases. Dose constraints to the OARs were respected in the majority of cases except for the heart, where one-third of the plans presented a deviation. As for the target volume, 3 plans (5.8%) had a major underdosage and 1 plan (1.9%) had a major overdosage. Overall, 58% of all treatments were planned with intensity modulated radiation therapy, whereas 42% were planned with 3-dimensional chemoradiation therapy. Significantly more plans in the intensity modulated radiation therapy group were accepted compared with the 3-dimensional chemoradiation therapy group (P = .03). CONCLUSION: The high frequency of protocol deviations underlines the importance of a quality assurance program in clinical trials. Further work should assess the impact of quality assurance for radiation therapy on patient outcomes.

Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery.

Importance: Leading cancer hospitals have increasingly shared their brands with other hospitals through growing networks of affiliations. However, the brand of top-ranked cancer hospitals may evoke distinct reputations for safety and quality that do not extend to all hospitals within these networks. Objective: To assess perioperative mortality of Medicare beneficiaries after complex cancer surgery across hospitals participating in networks with top-ranked cancer hospitals. Design, Setting, and Participants: A cross-sectional study was performed of the Centers for Medicare & Medicaid Services 100% Medicare Provider and Analysis Review file from January 1, 2013, to December 31, 2016, for top-ranked cancer hospitals (as assessed by U.S. News and World Report) and affiliated hospitals that share their brand. Participants were 29 228 Medicare beneficiaries older than 65 years who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between January 1, 2013, and October 1, 2016. Exposures: Undergoing complex cancer surgery at a top-ranked cancer hospital vs an affiliated hospital. Main Outcomes and Measures: Risk-adjusted 90-day mortality estimated using hierarchical logistic regression and comparison of the relative safety of hospitals within each cancer network estimated using standardized mortality ratios. Results: A total of 17 300 patients (59.2%; 8612 women and 8688 men; mean [SD] age, 74.7 [6.2] years) underwent complex cancer surgery at 59 top-ranked hospitals and 11 928 patients (40.8%; 6287 women and 5641 men; mean [SD] age, 76.2 [6.9] years) underwent complex cancer surgery at 343 affiliated hospitals. Overall, surgery performed at affiliated hospitals was associated with higher 90-day mortality (odds ratio, 1.40; 95% CI, 1.23-1.59; P < .001), with odds ratios that ranged from 1.32 (95% CI, 1.12-1.56; P = .001) for colectomy to 2.04 (95% CI, 1.41-2.95; P < .001) for gastrectomy. When the relative safety of each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%; 95% CI, 73.1%-93.3%). Conclusions and Relevance: The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand. Further investigation of performance across trusted cancer networks could enhance informed decision making for complex cancer care.

Place of death for patients with cancer in the United States, 1999 through 2015: Racial, age, and geographic disparities.

BACKGROUND: Place of death is an essential component of high quality cancer care and comprehensive national trends and disparities in place of death are unknown. METHODS: Deidentified death certificate data were obtained via the National Center for Health Statistics. All cancer deaths from 1999 through 2015 were included. Multivariate logistic regression was used to test for disparities in place of death associated with sociodemographic variables. RESULTS: From 1999 through 2015, a total of 9,646,498 cancer deaths occurred. Hospital deaths decreased (from 36.6% to 24.6%), whereas the rate of home deaths (38.4% to 42.6%) and hospice facility deaths (0% to 14.0%) both increased (all P<.001). On multivariate logistic regression, all assessed variables were found to be associated with place of death. Specifically, younger age (age birth-14 years: odds ratio [OR], 2.39; age 25-44 years: OR, 1.62), black (OR, 1.83) or Asian (OR, 1.74) race, and Hispanic ethnicity (OR, 1.41) were associated with hospital death. Being married (OR, 2.17) or widowed (OR, 1.56) was associated with home death whereas increasing educational level (OR, 1.15-1.19) was associated with hospice death (all P<.001). Despite overall improvements, certain disparities were found to increase. For young patients, the likelihood of a hospital death increased from 2.3 times to 3.4 times that of older patients (50.9% for those aged 15-24 years vs 15.0% for those aged ≥85 years in 2015). For black patients, the likelihood of a hospital death increased from 1.29 times to 1.42 times that of white patients (32.8% for black patients vs 23.1% for white patients in 2015). CONCLUSIONS: Hospital cancer deaths decreased by approximately one-third with commensurate increases in home and hospice facility deaths. Many sociodemographic groups experience significant disparities with regard to place of death and may benefit from targeted efforts to improve goal-concordant care.

Hospital Quality Factors Influencing the Mobility of Patients for Radical Prostate Cancer Radiation Therapy: A National Population-Based Study.

PURPOSE: To investigate whether patients requiring radiation treatment are prepared to travel to alternative more distant centers in response to hospital choice policies, and the factors that influence this mobility. METHODS AND MATERIALS: We present the results of a national cohort study using administrative hospital data for all 44,363 men who were diagnosed with prostate cancer and underwent radical radiation therapy in the English National Health Service between 2010 and 2014. Using geographic information systems, we investigated the extent to which men choose to travel beyond ("bypass") their nearest radiation therapy center, and we used conditional logistic regression to estimate the effect of hospital and patient characteristics on this mobility. RESULTS: In all, 20.7% of men (n=9161) bypassed their nearest radiation therapy center. Travel time had a very strong impact on where patients moved to for their treatment, but its effect was smaller for men who were younger, more affluent, and from rural areas (P for interaction always <.001). Men were prepared to travel further to hospitals that offered hypofractionated prostate radiation therapy as their standard schedule (odds ratio 3.19, P<.001), to large-scale radiation therapy units (odds ratio 1.56, P<.001), and to hospitals that were early adopters of intensity modulated radiation therapy (odds ratio 1.37, P<.001). CONCLUSIONS: Men with prostate cancer are prepared to bypass their nearest radiation therapy centers. They are more likely to travel to larger established centers and those that offer innovative technology and more convenient radiation therapy schedules. Indicators that accurately reflect the quality of radiation therapy delivered are needed to guide patients' choices for radiation therapy treatment. In their absence, patient mobility may negatively affect the efficiency and capacity of a regional or national radiation therapy service and offer perverse incentives for technology adoption.

Challenges in the development and implementation of the National Comprehensive Cancer Control Program in Mexico.

Chronic noncommunicable diseases (NCDs), including cancer, have become the leading cause of human morbidity and mortality. In Mexico, cancer is the third leading cause of death, with a high incidence among the economically active population, a high proportion of advanced stages at diagnosis and limited care coverage for patients. However, no public policy aimed at managing this important public health problem has been developed and implemented to date. This manuscript describes the first interinstitutional proposal of a National Program for Cancer Control, considering the known risk factors, early detection, treatment, palliative care and patient rehabilitation. This manuscript also outlines a series of thoughts on the difficulties and needs that the Mexican health system faces in achieving the main objectives of the program: to decrease the incidence of cancer, to increase survival and to improve the quality of life for this group of patients.

Utilization of retroperitoneal lymph node dissection for testicular cancer in the United States: Results from the National Cancer Database (1998-2011).

INTRODUCTION: Retroperitoneal lymph node dissection (RPLND) for the treatment of testicular cancer is a relatively rare and complex operation that may contribute to differences in utilization. We sought to characterize the use of RPLND between different categories of cancer center facilities in the United States. MATERIALS AND METHODS: The National Cancer Database was queried for patients with germ cell tumors treated at different types of cancer centers between 1998 and 2011. The proportion of patients who underwent RPLND was stratified by stage and histology and then compared between treatment facilities. RPLND utilization was then compared between facility types as a function of time. RESULTS: A total of 59,652 patients met inclusion criteria and 5,475 (9.2%) underwent RPLND. The proportion of patients treated with RPLND for non-seminomatous germ cell tumor (NSGCT) was significantly different between cancer center types for all stages (P<0.001) and used most often in academic comprehensive cancer centers. There was no difference in the proportion of RPLND utilization for stage II and III seminoma stratified by treatment facility. There was a significantly decreased trend in the utilization of RPLND for stage I (P = 0.032) NSGCT whereas utilization was increased for stage III NSGCT (P≤0.001) over the study period. CONCLUSIONS: The proportion of patients undergoing RPLND for NSGCT varies significantly by the type of cancer center and is used most often in academic cancer centers. Utilization of RPLND decreased for stage I NSGCT and increased for stage III NSGCTs during the study period.

Challenges in the development and implementation of the National Comprehensive Cancer Control Program in Mexico / Retos del desarrollo e implementación del Programa Nacional de Control Integral del Cáncer en México

Abstract Chronic noncommunicable diseases (NCDs), including cancer, have become the leading cause of human morbidity and mortality. In Mexico, cancer is the third leading cause of death, with a high incidence among the economically active population, a high proportion of advanced stages at diagnosis and limited care coverage for patients. However, no public policy aimed at managing this important public health problem has been developed and implemented to date. This manuscript describes the first interinstitutional proposal of a National Program for Cancer Control, considering the known risk factors, early detection, treatment, palliative care and patient rehabilitation. This manuscript also outlines a series of thoughts on the difficulties and needs that the Mexican health system faces in achieving the main objectives of the program: to decrease the incidence of cancer, to increase survival and to improve the quality of life for this group of patients.

Resumen Las enfermedades crónicas no transmisibles (ECNT), incluido el cáncer, se han convertido en la principal causa de morbimortalidad de la humanidad. En México, el cáncer es la tercera causa de muerte, con una frecuencia elevada en población económicamente activa, una alta proporción de etapas avanzadas al momento del diagnóstico y una limitada cobertura de atención a quienes la padecen. No obstante, hasta el momento no se ha desarrollado e implementado una política pública dirigida al control de este importante problema de salud pública. Este manuscrito muestra la primera propuesta interinstitucional de un Programa Nacional para el Control del Cáncer, considerando los factores de riesgo conocidos, la detección temprana, el tratamiento y los cuidados paliativos y la rehabilitación del paciente. Asimismo se hacen una serie de reflexiones sobre las dificultades y necesidades a las que el sistema de salud mexicano se enfrenta para alcanzar los objetivos principales del programa: reducir la incidencia, incrementar la supervivencia y mejorar la calidad de vida de este grupo de pacientes.

Estimating the Need for Palliative Radiation Therapy: A Benchmarking Approach.

PURPOSE: Palliative radiation therapy (PRT) benefits many patients with incurable cancer, but the overall need for PRT is unknown. Our primary objective was to estimate the appropriate rate of use of PRT in Ontario. METHODS AND MATERIALS: The Ontario Cancer Registry identified patients who died of cancer in Ontario between 2006 and 2010. Comprehensive RT records were linked to the registry. Multivariate analysis identified social and health system-related factors affecting the use of PRT, enabling us to define a benchmark population of patients with unimpeded access to PRT. The proportion of cases treated at any time (PRTlifetime), the proportion of cases treated in the last 2 years of life (PRT2y), and number of courses of PRT per thousand cancer deaths were measured in the benchmark population. These benchmarks were standardized to the characteristics of the overall population, and province-wide PRT rates were then compared to benchmarks. RESULTS: Cases diagnosed at hospitals with no RT on-site and residents of poorer communities and those who lived farther from an RT center, were significantly less likely than others to receive PRT. However, availability of RT at the diagnosing hospital was the dominant factor. Neither socioeconomic status nor distance from home to nearest RT center had a significant effect on the use of PRT in patients diagnosed at a hospital with RT facilities. The benchmark population therefore consisted of patients diagnosed at a hospital with RT facilities. The standardized benchmark for PRTlifetime was 33.9%, and the corresponding province-wide rate was 28.5%. The standardized benchmark for PRT2y was 32.4%, and the corresponding province-wide rate was 27.0%. The standardized benchmark for the number of courses of PRT per thousand cancer deaths was 652, and the corresponding province-wide rate was 542. CONCLUSIONS: Approximately one-third of patients who die of cancer in Ontario need PRT, but many of them are never treated.

Social service counseling in cancer centers certified by the German Cancer Society.

Social workers are an integral part of care provided in cancer centers that are certified according to the requirements of the German Cancer Society. This article reports on the tasks of social workers in German cancer care and on the proportion of patients that receives social service counseling (SSC) in breast, lung, colorectal, skin, gynecological, prostate, pancreas, neurological, and head and neck cancer centers based on data from 367,297 patients treated between 2009 and 2012. The highest proportions of patients (median >75%) are provided with SSC in breast and colorectal cancer centers, whereas the median is below 30% in skin cancer centers. Variation between centers and center types is high.

Prevalence and predictors of neoadjuvant therapy for stage IIIA non-small cell lung cancer in the National Cancer Database: importance of socioeconomic status and treating institution.

PURPOSE: The optimal locoregional therapy for stage IIIA non-small cell lung cancer (NSCLC) is controversial, with definitive chemoradiation therapy (CRT) and neoadjuvant therapy followed by surgery (NT-S) serving as competing strategies. In this study, we used the National Cancer Database to determine the prevalence and predictors of NT in a large, modern cohort of patients. METHODS AND MATERIALS: Patients with stage IIIA NSCLC treated with CRT or NT-S between 2003 and 2010 at programs accredited by the Commission on Cancer were included. Predictors were categorized as clinical, time/geographic, socioeconomic, and institutional. In accord with the National Cancer Database, institutions were classified as academic/research program and as comprehensive and noncomprehensive community cancer centers. Logistic regression and random effects multilevel logistic regression were performed for univariable and multivariable analyses, respectively. RESULTS: The cohort consisted of 18,581 patients, 3,087 (16.6%) of whom underwent NT-S (10.6% induction CRT, 6% induction chemotherapy). The prevalence of NT-S was constant over time, but there were significant relative 31% and 30% decreases in pneumonectomy and right-sided pneumonectomy, respectively, over time (P trend <.02). In addition to younger age, lower T stage, and favorable comorbidity score, indicators of higher socioeconomic status were strong independent predictors of NT-S, including white race, higher income, and private/managed insurance. The type of institution (academic/research program vs comprehensive or noncomprehensive community cancer centers, odds ratio 1.54 and 2.08, respectively) strongly predicted NT-S, but treatment volume did not. CONCLUSIONS: Neoadjuvant therapy followed by surgery was an uncommon treatment approach in Commission on Cancer programs, and the prevalence of postinduction pneumonectomy decreased over time. Higher socioeconomic status and treatment at academic institutions were significant predictors of NT-S. Further research should be performed to enable a better understanding of these disparities.

Risk-based selective referral for cancer surgery: a potential strategy to improve perioperative outcomes.

BACKGROUND: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers. METHODS: From the National Cancer Data Base, 940,718 patients from approximately 1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003-2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high- and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals. RESULTS: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers. CONCLUSIONS: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.

Sobrevida de mulheres tratadas por câncer de mama no estado do Rio de Janeiro / Sobrevida de mujeres tratadas por câncer de mama en el estado de Rio de Janeiro, Sureste de Brasil / Survival of breast cancer women in the state of Rio de Janeiro, Southeastern Brazil

OBJETIVO: Avaliar a associação entre sobrevida de mulheres com câncer de mama e estrutura e práticas observadas nos estabelecimentos de assistência oncológica. MÉTODOS: Estudo longitudinal retrospectivo, baseado em informações do Sistema de Autorização de Procedimentos de Alta Complexidade do Sistema Único de Saúde e em amostra aleatória de 310 prontuários de mulheres prevalentes atendidas em 15 unidades hospitalares e ambulatoriais oncológicas com quimioterapia entre 1999 e 2002, no estado do Rio de Janeiro. Foram consideradas como variáveis independentes características da estrutura das unidades oncológicas e as suas intervenções praticadas, controlando o efeito com variáveis sociodemográficas e clínicas das pacientes. Para análise dos dados, foram utilizados a técnica de Kaplan-Meier e o modelo de risco de Cox (pseudo-verossimilhança). RESULTADOS: As análises de Kaplan-Meier apontaram associações significativas entre sobrevida e tempo entre diagnóstico e início do tratamento, realização de cirurgia, utilização de hormonioterapia, tipo de hormonioterapia, combinações terapêuticas, tipo de unidade e plano de saúde, volume de atendimento em câncer de mama do estabelecimento e natureza jurídica da unidade. Estimativas obtidas pelo modelo de Cox indicaram associações positivas entre o hazard de morte e tempo entre diagnóstico e início do tratamento, volume de atendimento de câncer de mama do estabelecimento e tipo de unidade combinado ao uso de plano de saúde; e negativas entre sobrevida e cirurgia de mama e tipo de hormonioterapia. CONCLUSÕES: Os resultados mostram associação entre sobrevida de câncer de mama e o cuidado de saúde prestado pelos serviços credenciados, com implicações práticas para pautar novas propostas para o controle do câncer no Brasil.

OBJECTIVE: To assess the association between breast cancer survival and infrastructure and practices of cancer care units. METHODS: Retrospective longitudinal study based on data from the Brazilian information system of authorizations for highly complex cancer procedures covered by the National Health System and a sample of 310 medical records of prevalent breast cancer cases attended at 15 inpatient and outpatient cancer care units providing chemotherapy between 1999 and 2002 in the state of Rio de Janeiro, Southeastern Brazil. Independent variables were infrastructure of cancer units, interventions, and sociodemographic and clinical characteristics of women. Kaplan-Meier method and Cox proportional hazards model (pseudolikelihood) were used for data analysis. RESULTS: Kaplan-Meier analyses pointed out significant associations between survival and time between diagnosis and treatment start, surgery, hormone therapy, type of adjuvant hormone therapy, therapy combinations, type of care unit and health insurance, unit size and category. Estimates obtained from the Cox model showed positive associations between hazard of death and time between diagnosis and treatment, unit size and type combined to use of health insurance, and negative associations between survival and surgery and type of hormone therapy. CONCLUSIONS: The study findings show an association between breast cancer survival and health care provided by affiliated services with practical implications for policy making for cancer control in Brazil.

OBJETIVO: Evaluar la asociación entre sobrevida de mujeres con cáncer de mama y estructura y prácticas observadas en los establecimientos de asistencia oncológica. MÉTODOS: Estudio longitudinal retrospectivo, basado en informaciones del Sistema de Autorización de Procedimientos de Alta Complejidad del Sistema Único de Salud y en muestra aleatoria de 310 prontuarios de mujeres prevalentes atendidas en 15 unidades hospitalarias y ambulatorias oncológicas con quimioterapia entre 1999 y 2002, en el estado de Río de Janeiro, Sureste de Brasil. Fueron consideradas como variables independientes características de la estructura de las unidades oncológicas y sus intervenciones practicadas, controlando el efecto con variables sociodemográficas y clínicas de las pacientes. Para análisis de los datos, fueron utilizados la técnica de Kaplan-Meier y el modelo de riesgo de Cox (pseudos-verosimilitud). RESULTADOS: Los análisis de Kaplan-Meier señalaron asociaciones significativas entre sobrevida y tiempo entre diagnóstico e inicio del tratamiento, realización de cirugía, utilización de hormonoterapia, tipo de hormonoterapia, combinaciones terapéuticas, tipo de unidad y seguro de salud, volumen de atención en cáncer de mama del establecimiento y naturaleza jurídica de la unidad. Estimaciones obtenidas por el modelo Cox indicaron asociaciones positivas entre el hazard de muerte y tiempo entre diagnóstico e inicio del tratamiento, volumen de atención de cáncer de mama del establecimiento y tipo de unidad combinado con el uso del seguro de salud; y negativas entre sobrevida y cirugía de mama y tipo de hormonoterapia. CONCLUSIONES: Los resultados muestran asociación entre sobrevida de cáncer de mama y el cuidado de salud prestado por los servicios acreditados, con implicaciones prácticas para pautar nuevas propuestas para el control del cáncer en Brasil.

Survival of breast cancer women in the state of Rio de Janeiro, Southeastern Brazil.

OBJECTIVE: To assess the association between breast cancer survival and infrastructure and practices of cancer care units. METHODS: Retrospective longitudinal study based on data from the Brazilian information system of authorizations for highly complex cancer procedures covered by the National Health System and a sample of 310 medical records of prevalent breast cancer cases attended at 15 inpatient and outpatient cancer care units providing chemotherapy between 1999 and 2002 in the state of Rio de Janeiro, Southeastern Brazil. Independent variables were infrastructure of cancer units, interventions, and sociodemographic and clinical characteristics of women. Kaplan-Meier method and Cox proportional hazards model (pseudolikelihood) were used for data analysis. RESULTS: Kaplan-Meier analyses pointed out significant associations between survival and time between diagnosis and treatment start, surgery, hormone therapy, type of adjuvant hormone therapy, therapy combinations, type of care unit and health insurance, unit size and category. Estimates obtained from the Cox model showed positive associations between hazard of death and time between diagnosis and treatment, unit size and type combined to use of health insurance, and negative associations between survival and surgery and type of hormone therapy. CONCLUSIONS: The study findings show an association between breast cancer survival and health care provided by affiliated services with practical implications for policy making for cancer control in Brazil.

European guidelines for quality assurance in breast cancer screening and diagnosis. Fourth edition--summary document.

Breast cancer is a major cause of suffering and death and is of significant concern to many women. Early detection of breast cancer by systematic mammography screening can find lesions for which treatment is more effective and generally more favourable for quality of life. The potential harm caused by mammography includes the creation of unnecessary anxiety and morbidity, inappropriate economic cost and the use of ionising radiation. It is for this reason that the strongest possible emphasis on quality control and quality assurance is required. Development of the European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis has been an initiative within the Europe Against Cancer Programme. The fourth edition of the multidisciplinary guidelines was published in 2006 and comprises approximately 400 pages divided into 12 chapters prepared by >200 authors and contributors. The multidisciplinary editorial board has prepared a summary document to provide an overview of the fundamental points and principles that should support any quality screening or diagnostic service. This document includes a summary table of key performance indicators and is presented here in order to make these principles and standards known to a wider scientific community.

Length of survival of patients with cancer in hospice: a retrospective analysis of patients treated at a major cancer center versus other practice settings.

This is a retrospective study of the length of survival (LOS) in hospice of patients with cancer treated at a major cancer center compared to other treatment sites. Of 670 patients, the 185 (28%) treated at a major cancer center had unique characteristics, including higher median Palliative Performance Score (PPS) at the time of hospice enrollment (45 versus 40, p = 0.009), and longer median LOS in hospice (35 versus 21 days, p = 0.02: log rank test). Additional variables that predicted longer LOS were higher PPS, Medicare or Medicaid, self-referral, unmarried status, and non-executed advance directives. After adjusting survival for PPS with a Cox proportional hazard model, the hazard ratio for PPS remained statistically significant (95% confidence interval [CI]: 0.95-0.97] while that for the treatment site was not (95% CI: 0.73-1.04]. The performance status, and not the treatment site, was the dominant predictor of the LOS of patients with cancer in hospice.

Catching the proton wave.

Proton therapy is hailed as a huge leap in treating certain cancers. But hospitals that want proton centers need deep pockets, lots of land and the right staff.

The structural characteristics of radiation oncology in Japan in 2003.

PURPOSE: To ascertain the basic structural characteristics of radiation oncology facilities in Japan, we conducted a national survey on their status in 2003. The aims of the survey included the following: present status of radiation treatment facilities, equipment, personnel, patient loads, and other factors. METHODS AND MATERIALS: A mail survey verified each potential facility delivering megavoltage radiation therapy and collected data on treatment devices, other equipment, personnel, new patients, and so on. Responses were obtained from 100% of potential facilities. RESULTS: A total of 726 facilities delivered radiation therapy, with 859 megavoltage devices, 203 RALS (remote after-loading system) and other radioactive sources, with 941 FTE (full-time employee) radiation oncologists including 369 FTE Japanese Society of Therapeutic Radiation Oncology-certified radiation oncologists, 1555 FTE radiation therapists, and 70 FTE physicists in 2003. Megavoltage devices included two heavy ion units and four proton units. In total, there were 149,793 new patients and 146,351 (98%) by external irradiation; 4379 (3%) were treated by brachytherapy with or without external irradiation. Eighty-six percent of the facilities had treatment-planning computers, but 4% had no treatment-planning capability. Six percent (44 facilities) of all facilities used hyperthermia, 12% (85 facilities) intraoperative radiation therapy, and 2% (12 facilities) intensity-modulated radiation therapy. CONCLUSION: Facilities surveys continue to provide a source of census data on radiation oncology in Japan, allowing comparisons among facility groups and over time.

Status of postmastectomy radiotherapy in the United States: a patterns of care study.

PURPOSE: The Patterns of Care Study performed this first known practice survey to establish a national profile of the delivery of postmastectomy radiotherapy (RT) in operable breast cancer. METHODS AND MATERIALS: A Patterns of Care Study research associate collected data from 55 randomly selected institutions. The survey data included 132 items describing the patient, pathologic features, and treatment course for patients with clinical Stage I, II, and IIIA breast cancer undergoing postmastectomy RT in 1998 and 1999. A multivariate analysis was performed to determine the impact of tumor factors and type of treatment facility on the radiation fields used. RESULTS: A weighted sample size of 13,720 was obtained from a sampling of 405 patient records. The mean tumor size was 3.5 cm, and the mean number of axillary nodal metastases was 4.55. Lymphatic vascular invasion was noted in 34%, microscopic skin or dermal lymphatic invasion in 16%, positive or close margins in 36%, and extracapsular nodal extension in 23%. Radiotherapy included the chest wall in all cases and the regional nodes in 78%. When nodal RT was delivered, it included a supraclavicular field, supplemental axillary field, and/or an internal mammary field in 98%, 46%, and 23% of cases, respectively. Chest wall and supraclavicular RT was delivered in >90% of instances with 6-MV photons to doses between 45 and 50 Gy. More variation was seen in the delivery of the axillary and internal mammary RT. On multivariate analysis, the presence of four or more positive nodes and treatment at a large-volume facility were the factors most frequently associated with the use of regional radiation fields. CONCLUSION: This Patterns of Care Study survey has demonstrated that breast cancer patients undergoing postmastectomy RT in 1998 and 1999 had a high proportion of factors associated with an increased risk of locoregional failure. The practice patterns established in this study provide a baseline for comparison with future survey results.

Centralizing surgery for gynecologic oncology--a strategy assuring better quality treatment?

OBJECTIVE: The objective of this study was to assess the association between the type of hospital and the previously reported shortcomings in surgical treatment for ovarian and endometrial carcinomas in Hesse, Germany. METHODS: The types of hospitals)primary, secondary, tertiary and central care referral or university clinic) at which patients with endometrial and ovarian cancer were treated were correlates with the following variables: patients' functional status, tumor stage (FIGO), the performance of lymphadenectomy and/or omentectomy, and the frequency of intraoperative and postoperative complications. Data came from the GQH project, which assessed all diagnostic, surgical, and postoperative gynecologic procedures undertaken in Hesse between 1997 and 2001. RESULTS: In 1119 cases of endometrial cancer significantly fewer (P < 0.001) lymphadenectomies were performed in primary care hospitals despite the fact that patients treated in primary care hospitals were younger and had a better functional status and lower tumor stage than patients treated in other types of hospitals. In ovarian cancer too, lymphadenectomy rates varied considerably with the type of hospital (P = 0.010) even when the analyses were restricted to patients whose functional status was good (ASA