Socioeconomic characteristics of patients with squamous cell carcinoma of the uterine cervix treated with radiotherapy in the 1992 to 1994 patterns of care study.

PURPOSE: To describe the relationship between socioeconomic variables and the treatment of patients with radiotherapy for cervix cancer.40% minority patients. METHODS AND MATERIALS: Sixty-two institutions werw r andomly selected from a list of all radiotherapy facilities in the Unite d States. From these we randomly selected and reviewed 471 cases of squ amous cell carcinoma treated during 1992 to 1994. To create an addition al minority-rich sample, we randomly selected 215 additional cases from 17 randomly selected institutions that admitted >40% minority patients. The median household income of each patient's neighborhood was determined by matching her zip code to data from the 1990 United States Census. RESULTS: Pati ents who lived in low-income neighborhoods, who had only Medicaid covera ge, or who were treated at large academic or minority-rich institutions tended to have a poorer initial performance status, higher-stage or bulk y central disease, and a lower pretreatment hemoglobin level. Ability t o complete treatment did not correlate with ethnicity or income. Howeve r, noncompliant patients tended to be treated at minority-rich instituti ons and were more often < 40 or > 60 years old. Patients who completed definitive treatment were more likely to have had

Patterns of radiotherapy practice for patients with squamous carcinoma of the uterine cervix: patterns of care study.

PURPOSE: To determine the impact of research findings and evolving technology on the patterns of radiotherapy practice for patients with carcinoma of the uterine cervix. METHODS AND MATERIALS: Sixty-two radiation therapy facilities participated in the study after having been selected from a random sample, proportionally stratified according to practice type, of all United States facilities. Each facility submitted a list of patients treated during 1992-1994 with radiation for squamous carcinoma of the cervix. Cases for review were randomly selected from each institution after excluding those of patients who had distant metastases or initial hysterectomy. A total of 471 patients' records were reviewed in the treating institutions to obtain information about patients' characteristics, diagnostic evaluation, tumor extent, treatment approach, and radiotherapy techniques. RESULTS: Of the 61 facilities that treated eligible cases of intact cervical cancer during the 3-year survey period, 35 (57%) treated fewer than three eligible patients per year. Thirty-four (83%) of 41 non-academic facilities vs. 1 (5%) of 20 academic facilities treated fewer than three patients per year. FIGO stages were I, II, III, and IV in 32%, 40%, 24%, and 3% of patients, respectively. Computed tomography (CT) was the most common method of lymph node evaluation, but surgical evaluation, which was performed in 76 (16%) patients, had increased from previous surveys. Fields were designed using a dedicated simulator in 95% of patients; a dedicated CT unit was used for treatment planning in 119 (30%) cases. External beam irradiation was most often given using a four-field technique at 180 cGy per day on a 10-20 MV linear accelerator. The average daily fraction size had decreased from previous surveys, and 13% of patients were treated with daily doses of 170 cGy or less. Most patients were treated with a combination of external beam and low dose-rate (LDR) intracavitary irradiation. Of 425 patients who had treatment with curative intent that included brachytherapy, 362 (85%) had LDR brachytherapy, 45 (11%) had high dose-rate (HDR) brachytherapy, 3 had a combination of HDR and LDR, and 15 had incomplete information about the brachytherapy dose-rate. Forty-six (23%) of 197 patients with Stages I-IIA disease were treated with radiation followed by extrafascial hysterectomy. Of 111 patients treated with curative intent for Stage III-IV disease, 72 (65%) had a combination of external beam and intracavitary radiation therapy, 22 (20%) had external beam plus interstitial brachytherapy, and 17 (15%) were treated with external beam irradiation only. For patients who completed treatment with curative intent and did not have adjuvant hysterectomy or HDR brachytherapy, the median total dose at point A was 82.5 Gy. For all patients who completed treatment with radiation alone, the median total duration of treatment was 63 days; more than 70 days were taken to complete treatment in 33% of cases. Twenty-nine percent of patients received chemotherapy, usually concurrent with their radiation therapy. Only 27% of these patients were on investigational protocols. CONCLUSIONS: Greater participation in well-designed prospective trials might help clinicians address important clinical questions and reduce current inconsistencies in the use of adjuvant treatments. Radiation oncologists should take steps to avoid unnecessary treatment protraction and to improve patient compliance. Future studies will be needed to determine whether the small number of cases being treated in most nonacademic facilities will influence the outcome for patients with invasive cervical carcinoma.

Patterns of care study decision tree and management guidelines for esophageal cancer. American College of Radiology.

PURPOSE: The Patterns of Care Study (PCS) of the American College of Radiology periodically develops a decision tree and current management guidelines for major malignancies where radiation has an important role. The decision tree is a framework which depicts the division of patients into treatment groups. The treatment guidelines are useful in management and also serve as a starting point for quality assessment. For the first time, PCS decided to develop consensus management guidelines for esophageal cancer. MATERIALS AND METHODS: A consensus panel was convened to define the key issues and develop guidelines for esophageal cancer management. A modified Delphi process was used to achieve consensus. RESULTS: The consensus panel developed guidelines for the management of patients with adenocarcinoma or squamous cell carcinoma of the esophagus with a Karnofsky performance status of over 50. Patients with clinical stage I or II esophageal cancer can be treated with curative intent using either a primary surgical or primary chemoradiation approach. For patients with clinical stage III malignancy, where the most common approaches are palliative, surgical resection is generally not recommended and chemoradiation is the preferred treatment. CONCLUSION: The PCS has developed treatment guidelines for esophageal cancer based on consensus committee deliberations. These guidelines can be useful for those who manage esophageal cancer.

Radiation therapy for rectosigmoid and rectal cancer: results of the 1992-1994 Patterns of Care process survey.

PURPOSE: To determine the US national practice standards for patients with adenocarcinoma of the rectum treated in radiation oncology facilities. MATERIALS AND METHODS: A national survey of 57 institutions identified 507 eligible patients who received radiation therapy as a component of their treatment for rectal cancer. A stratified two-stage cluster sampling with simple random sampling at each stage for each stratum was used and on-site surveys were performed. RESULTS: Of the 507 patients, 378 (75%) received postoperative therapy, 110 (22%) received preoperative therapy, 17 (2%) received both preoperative and postoperative therapy, and less than 0.5% received intraoperative radiation alone. To more accurately assess the utilization of modern radiation techniques as well as recommendations of the National Cancer Institute (NCI)-sponsored, randomized, postoperative, adjuvant combined modality therapy rectal cancer trials into current practice, the analysis was limited to the 243 (48%) patients with tumor, node, and metastasis staging system classification T3 and/or N1-2M0 disease who underwent conventional surgery with negative margins. Although only 7% were treated on a clinical trial, 90% received chemotherapy for a median of 21 weeks. Most were treated with modern radiation treatment techniques. In contrast, techniques to identify and help exclude the small bowel from the radiation field were not routinely used. CONCLUSION: Despite the fact that only 7% of patients with T3 and/or N1-2M0 disease were treated on a clinical trial, such trials appear to have resulted in a positive influence on the standard of practice within the oncology community. Although there are still some deficiencies, the majority of these patients received combined modality therapy and were treated with modern radiation therapy techniques.

Treatment systems guidelines for primary rectal cancer from the 1996 Patterns of Care Study.

PURPOSE: The Patterns of Care Rectal Cancer Committee was formed to develop consensus recommendations for patients with adenocarcinoma of the rectum limited to the pelvis. METHODS AND MATERIALS: The Committee was composed of a multidisciplinary group of oncologists, and clinical scenarios were chosen to address most of the major treatment controversies in the combined modality treatment of rectal cancer. A literature search was then conducted and the major articles were identified. A modified Delphi technique was used to arrive at consensus. Serial surveys were conducted by distributing questionnaires to the Committee members to consolidate expert opinion. Voting was conducted using a scoring system and opinions were unified to the highest degree possible. RESULTS: Consensus voting was performed for 4 clinical scenarios. Acceptability ratings for treatment were grouped into 3 broad categories: not acceptable, acceptable, and most acceptable. Based on the treatment options, a decision tree was developed that reflects the consensus of the committee. CONCLUSION: These options may help guide treatment decisions in rectal cancer.

Caregivers' knowledge and perceptions of preventing childhood lead poisoning.

Philadelphia is considered a high-risk area for lead poisoning. The Philadelphia Department of Public Health conducts education and outreach to screen children and promote prevention. Prior to this study there were no systematic data on the community's knowledge and perceptions of lead poisoning prevention. A 32-item questionnaire was developed to assess knowledge and perceptions of family caregivers of children younger than age 8. The survey was interviewer administered in pediatric clinics in two geographic areas of the city with documented severe and moderate lead poisoning rates. Eighty family caregivers were interviewed while waiting to see the pediatrician. Caregivers in the sample were connected to a health care system and resided in areas where lead community outreach was concentrated. Nevertheless, results suggest that even caregivers of children in high-risk areas do not mention lead poisoning as a health concern. About 61% of the sample identified eating paint chips as a cause of lead poisoning, whereas only 15% identified lead paint dust as a source of lead poisoning. Approximately 49% of the caregivers reported that they "never" or only "sometimes" perform recommended prevention activities. The Philadelphia Department of Public Health used these findings to review and modify education and outreach to prevent lead poisoning.