Pattern of Treatment Initiation and Outcomes for Patients With Metastatic Non-small Cell Lung Cancer in Ontario.

INTRODUCTION: The impact of diagnosis and treatment delay on outcomes in advanced non-small cell lung carcinoma (NSCLC) is not well understood. In this study, we examined the effect of the length of time to the first chemotherapy treatment initiation and the other factors affecting overall survival. METHODS: This retrospective study used data from the Institute of Clinical Evaluative Sciences and identified 4520 patients in Ontario who were diagnosed with stage IV NSCLC between 2007 and 2016, treated using chemotherapy. We adjusted the analysis for location (rural vs urban), gender, distance from the nearest cancer center, first chemotherapy treatment used, income, and age.  Results: Type of the chemotherapy, length of time to the first treatment, and distance from the nearest cancer center had a statistically significant impact on survival. Paclitaxel was associated with decreased risk of death compared to vinorelbine (Hazard Ratio (HR)=0.835, 95%CI 0.753-0.925), gemcitabine (HR=0.916, 95%CI 0.998-0.826), and docetaxel (HR=0.771, 95%CI 0.994-0.513). Every additional 10 km distance from the nearest cancer center was associated with a 0.5% increased risk of death (HR=1.005, 95%CI 1.000-1.010). A longer time to the first treatment was associated with increased survival. In fact, every 10 days increase in wait time was associated with a 0.5% decrease in the risk of death (HR=0.995, 95%CI 0.993-0.998).  Conclusion: Chemotherapy treatment using paclitaxel and living closer to the cancer center is associated with better survival. A longer time between diagnosis and treatment leading to better survival could perhaps be explained by patients on the "sicker" end of the spectrum receiving treatment sooner.

Early-Stage Non-Small Cell Lung Cancer Stereotactic Body Radiation Therapy Outcomes in a Single Institution.

Introduction The gold standard treatment of stage I non-small cell lung cancer (NSCLC) is surgical resection. For medically inoperable patients, stereotactic body radiation therapy (SBRT) can provide comparable local control (LC) and overall survival (OS). The objectives of this study are to determine the three-year LC and OS for SBRT compared to early-stage NSCLC patients treated with alternative radiation modalities at our institution. Materials and methods This retrospective study included a total of 139 consecutive patients who were diagnosed with stage I (T1-2 N0 M0) NSCLC and treated with radiation therapy at our institution between 2015 and 2020. Patient demographics and clinical data were obtained from chart reviews. Treatment subgroups were: SBRT (48Gy/4 or 60Gy/8), hypofractionation (60Gy/15), conventional fractionation (60Gy/30 or 50Gy/20), and palliative radiation (20Gy/5, 30Gy/10, or 40Gy/15). Kaplan-Meier curves were plotted for LC and OS. We also performed Cox's proportional hazard regression analysis. Results The median patient age was 74 (range 52-91). The numbers of patients in each treatment subgroup were: SBRT (44), hypofractionation (78), conventional fractionation (8), and palliative (9). Differences in age, gender, and histopathological cell type between subgroups were not statistically significant. Metastatic progression was the most common outcome amongst treatment failures, followed by local recurrence and regional spread. Median post-treatment follow-up in months for each subgroup was: SBRT (20.2), hypofractionated (20.7), conventional fractionation (13.9), and palliative (14.4). Post-treatment three-year LC was found to be significantly better with SBRT (94%) versus hypofractionation (71%), conventional fractionation (80%), and palliative (71%). OS at three years were SBRT (67%), hypofractionation (59%), conventional fractionation (66%), and palliative (44%). As a whole, 72% (100/139) of patients had biopsy-proven NSCLC. Analysis showed biopsy status had no statistical significance with regards to LC or OS. Every 20 years of age had a 3.2x risk of death (95% CI: 1.425-7.268). Concerning the treatment modalities, there were significant differences for the hazard of death compared to SBRT: hypofractionation had 2.58x increased risk while palliative had 5.83x increased risk. The proportion of patients who experienced post-treatment radiation pneumonitis or dermatitis were: SBRT (7%, 2%), hypofractionation (8%, 3%), conventional fractionation (13%, 25%), and palliative (0%, 0%), respectively. No patients who experienced grade III or higher toxicities were observed as defined by Common Terminology Criteria for Adverse Events (CTCAE).  Conclusion Our experience confirms SBRT can provide durable three-year local control with a comparable rate of post-treatment complications versus other radiation modalities for early-stage NSCLC. SBRT appears to be non-inferior to hypofractionation with regards to three-year LC.

Monitoring binary outcomes using risk-adjusted charts: a comparative study.

Monitoring binary outcomes when evaluating health care performance has recently become common. Classical statistical methodologies such as cumulative sum (CUSUM) charts have been refined and used for this purpose. For instance, the risk-adjusted CUSUM chart (RA-CUSUM) for monitoring binary outcomes was proposed for monitoring 30-day mortality following cardiac surgery. The RA-CUSUM inherits optimality properties of the original CUSUM charts in the sense of signaling early when there is change. However, although the RA-CUSUM is a powerful monitoring tool, it will always eventually signal a change with probability 1 even when there is no real change. In other words, the probability of a type I error for the RA-CUSUM is 1. It also turns out that, because of the skewed distribution of the run lengths of the RA-CUSUM, the median is often well below the mean, and as a consequence more than half of all its false alarms occur before the designed average run length. In addition, when the change to be detected occurs at a later time in the series of observations being monitored, the rate of false alarms increases, and the RA-CUSUM may not be appropriate. Therefore, if the price of false alarms is high, it is preferable to use methods that control the rate of false alarms. In this paper, we propose alternative sequential curtailed and risk-adjusted charts that control the type I error rate in the context of monitoring 30-day mortality following cardiac surgery. We explore the merits of each of these methodologies in terms of average run lengths as well as in terms of type I error probabilities, and we compare them to the RA-CUSUM chart. We illustrate the methodologies by using data on monitoring performance of seven surgeons from a medical center.

Children at risk: predictors of car safety seat misuse in Ontario.

When used correctly, child safety seats can reduce the risk of death and serious injury by 54% in toddlers and 71% in infants [National Highway Traffic Safety Administration (NHTSA), 2001. Traffic Safety Facts 2001. Children (DOT HS 809 471), U.S. Department of Transportation, Washington, DC]. The purpose of this study was to identify factors that predict correct use of car safety seats. The study was conducted in a large urban area in Southwestern Ontario and a small urban and rural area in Northern Ontario. Participants were 1263 caregivers who completed a self-report survey on their knowledge and use of car safety seats for their children (N=2199). Logistic regression analysis revealed that female caregivers, caregivers with higher levels of education, and caregivers who reported that finding information about the correct use of child safety seats was "difficult" were more likely to report correctly using car safety seats. The results also showed that children aged 7 months to 8 years old had substantially lower odds of being in the correct car safety seat compared to children aged 6 months or younger, or children aged 9 years or older. The high risk nature of misuse of child seats for infants and younger children may be an important cue to action for health professionals to develop comprehensive prevention strategies.