Global application of National Comprehensive Cancer Network resource-stratified guidelines for systemic treatment of colon cancer: a population-based, customisable model for cost, demand, and procurement.

BACKGROUND: Resource-stratified guidelines (RSGs) can inform systemic treatment decisions in the face of limited resources. The objective of this study was to develop a customisable modelling tool to predict the demand, cost, and drug procurement needs of delivering National Comprehensive Cancer Network (NCCN) RSG-based systemic treatment for colon cancer. METHODS: We developed decision trees for first-course systemic therapy for colon cancer based on the NCCN RSGs. Decision trees were merged with data from the Surveillance, Epidemiology, and End Results programme, the International Agency for Research on Cancer's GLOBOCAN 2020 national estimates for colon cancer incidence, country-level income data, and data on drug costs from Redbook (USA), the Pharmaceutical Benefits Scheme (Australia), and the Management Sciences for Health 2015 International Medical Products price guide to estimate global treatment needs and costs, and forecast drug procurement. Simulations and sensitivity analyses were used to explore the effect of scaling up services globally and the effect of alternative stage distributions on treatment demand and cost. We generated a customisable model, in which estimates can be tailored to local incidence, epidemiological, and costing data. FINDINGS: First-course systemic therapy is indicated in 608 314 (53·6%) of 1 135 864 colon cancer diagnoses in 2020. Indications for first-course systemic therapy are projected to rise to 926 653 in 2040; the indications in 2020 might be as high as 826 123 (72·7%), depending on stage distribution assumptions. Adhering to NCCN RSGs, patients with colon cancer in low-income and middle income countries (LMICs) would constitute 329 098 (54·1%) of 608 314 global systemic therapy demands, but only 10% of global expenditure on systemic therapies. The total cost of NCCN RSG-based first-course systemic therapy for colon cancer in 2020 would be between about US$4·2 and about $4·6 billion, depending on stage distribution. If all patients with colon cancer in 2020 were treated according to maximal resources, global expenditure on systemic therapy for colon cancer would rise to around $8·3 billion. INTERPRETATION: We have developed a customisable model that can be applied at global, national, and subnational levels to estimate systemic treatment needs, forecast drug procurement, and calculate expected drug costs on the basis of local data. This tool can be used to plan resource allocation for colon cancer globally. FUNDING: None.

Optimal and actual rates of Stereotactic Ablative Body Radiotherapy (SABR) utilisation for primary lung cancer in Australia.

Background and purpose: Radiotherapy utilisation rates considerably vary across different countries and service providers, highlighting the need to establish reliable benchmarks against which utilisation rates can be assessed. Here, optimal utilisation rates of Stereotactic Ablative Body Radiotherapy (SABR) for lung cancer are estimated and compared against actual utilisation rates to identify potential shortfalls in service provision. Materials and Methods: An evidence-based optimal utilisation model was constructed after reviewing practice guidelines and identifying indications for lung SABR based on the best available evidence. The proportions of patients likely to develop each indication were obtained, whenever possible, from Australian population-based studies. Sensitivity analysis was performed to account for variations in epidemiological data. Practice pattern studies were reviewed to obtain actual utilisation rates. Results: A total of 6% of all lung cancer patients were estimated to optimally require SABR at least once during the course of their illness (95% CI: 4-6%). Optimal utilisation rates were estimated to be 32% for stage I and 10% for stage II NSCLC. Actual utilisation rates for stage I NSCLC varied between 6 and 20%. For patients with inoperable stage I, 27-74% received SABR compared to the estimated optimal rate of 82%. Conclusion: The estimated optimal SABR utilisation rates for lung cancer can serve as useful benchmarks to highlight gaps in service delivery and help plan for more adequate and efficient provision of care. The model can be easily modified to determine optimal utilisation rates in other populations or updated to reflect any changes in practice guidelines or epidemiological data.

Are NCCN Resource-Stratified Guidelines for Breast Cancer Systemic Therapy Achievable? A Population-Based Study of Global Need and Economic Impact.

PURPOSE: Resource-stratified guidelines (RSG) for cancer provide a hierarchy of interventions, based on resource availability. We quantify treatment need and cost if National Comprehensive Cancer Network (NCCN) RSGs for breast cancer (BC) are adopted globally. METHODS: We developed decision trees for first-course systemic therapy, merged with SEER and Global Cancer Observatory 2018 incidence data to estimate treatment need and cost if NCCN RSG are implemented globally based on country-level income. Simulations were used to quantify need and cost of globally scaling up services to Maximal. RESULTS: Based on NCCN RSG, first-course chemotherapy is indicated in 0% (Basic), 87% (Core), and 86% (Enhanced) but declined to 50% (Maximal) because of incorporation of genomic profiling. First-course endocrine therapy (ET) is indicated in 80% in all settings. In 2018, treatment need was 1.4 million people for chemotherapy, 183,943 for human epidermal growth factor receptor 2 (HER2) therapies and 1.6 million for ET. The cost per person for chemotherapy or HER2 or immunotherapy increased by 17-fold from Core to Maximal ($1,278-$22,313 Australian dollars [AUD]). The cost of ET per person rose eight-fold from Basic to Maximal ($1,236-$9,809 AUD). If all patients with BC globally were treated with Maximal resources, the need for chemotherapy would decline by 28%, whereas cost of first-course treatment would rise by 1.8-fold ($21-$37 billion AUD) because of more costly therapies. CONCLUSION: NCCN RSGs for BC could result in chemotherapy overtreatment in Core and Enhanced settings. The absence of chemotherapy in Basic settings should be reconsidered, and future iterations of RSG should perform cross-tumor comparisons to ensure equitable resource distribution and maximize population-level outcomes. Our model is flexible and can be tailored to the costs, population attributes, and resource availability of any institution or country for health-services planning.

Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study.

BACKGROUND: The growing demand for cancer surgery has placed a global strain on health systems. In-depth analyses of the global demand for cancer surgery and optimal workforce requirements are needed to plan service provision. We estimated the global demand for cancer surgery and the requirements for an optimal surgical and anaesthesia workforce, using benchmarks based on clinical guidelines. METHODS: Using models of benchmark surgical use based on clinical guidelines, we estimated the proportion of cancer cases with an indication for surgery across 183 countries, stratified by income group. These proportions were multiplied by age-adjusted national estimates of new cancer cases using GLOBOCAN 2018 data and then aggregated to obtain the estimated number of surgical procedures required globally. The numbers of cancer surgical procedures in 44 high-income countries were divided by the actual number of surgeons and anaesthetists in the respective countries to calculate cancer procedures per surgeon and anaesthetist ratios. Using the median (IQR) of these ratios as benchmarks, we developed a three-tiered optimal surgical and anaesthesia workforce matrix, and the predictions were extrapolated up to 2040. FINDINGS: Our model estimates that the number of cancer cases globally with an indication for surgery will increase by 5 million procedures (52%) between 2018 (9 065 000) and 2040 (13 821 000). The greatest relative increase in surgical demand will occur in 34 low-income countries, where we also observed the largest gaps in workforce requirements. To match the median benchmark for high-income countries, the surgical workforce in these countries would need to increase by almost four times and the anaesthesia workforce by nearly 5·5 times. The greatest increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries (from 28 000 surgeons to 58 000 surgeons; 107% increase), followed by lower-middle-income countries (from 166 000 surgeons to 277 000 surgeons; 67% increase). INTERPRETATION: The global demand for cancer surgery and the optimal workforce are predicted to increase over the next two decades and disproportionately affect low-income countries. These estimates provide an appropriate framework for planning the provision of surgical services for cancer worldwide. FUNDING: University of New South Wales Scientia Scholarship and UK Research and Innovation Global Challenges Research Fund.

Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis.

BACKGROUND: Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model. METHODS: We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006-12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations. FINDINGS: Surgical treatment was indicated in 58% (95% CI 57-59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17-27) for prostate cancer to 99% (96-99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (-14%). INTERPRETATION: The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences. FUNDING: University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.

The value of first-line chemotherapy and targeted therapy in the treatment of breast cancer.

OBJECTIVE: To investigate the value (survival benefit and cost) of first-line chemotherapy and targeted therapy in breast cancer at a population level. METHODS: Based on guideline recommendations, a model of optimal utilisation was constructed for first-line chemotherapy and targeted therapy in breast cancer, calculating the survival benefit and average cost of all regimens recommended for each treatment indication at 5 years and at 10 years. RESULTS: Survival benefits from chemotherapy and targeted therapy differ markedly depending on the treatment indications. The cost per life-year gained at 5 years is $38,044 for stages I and II, $33,749 for stage III and $ 151,668 for patients presenting with stage IV breast cancer. The cost per life-year gained at 10 years is $ 13,587 for early breast cancer. The most expensive chemotherapy indication in breast cancer is the treatment of metastatic HER2-positive breast cancer costing $330,978 per LYG for a survival benefit of 11% at 5 years falling to zero survival benefit at 10 years. CONCLUSION: There are large differences in value between the different indications for first-course chemotherapy and targeted therapy in the treatment of breast cancer that should be considered when pricing cancer drugs.

Assessing tumor centrality in lung stereotactic ablative body radiotherapy (SABR): the effects of variations in bronchial tree delineation and potential for automated methods.

Accurate delineation of the proximal bronchial tree (PBT) is crucial for appropriate assessment of lung tumor centrality and choice of Stereotactic Ablative Body Radiotherapy (SABR) dose prescription. Here, we investigate variabilities in manual PBT delineation and their potential to influence assessing lesion centrality. A fully automatic, intensity-based tool for PBT contouring and measuring distance to the target is also described. This retrospective analysis included a total of 61 patients treated with lung SABR. A subset of 41 patients was used as a training dataset, containing clinical PBT contour and additional subsequently generated manual contours. The tool was optimized and compared against manual contours in terms of volume, distance to the target and various overlap/similarity metrics. The remaining 20 patients were used as a validation dataset to investigate the dosimetric effects of variations between manual and automatic PBT contours. Considerable interobserver variability was observed, particularly in identifying the superior and inferior borders of the PBT. Automatic PBT contours were comparable to manual contours with average Dice of 0.63 to 0.79 and mean distance to agreement of 1.78 to 3.34 mm. No significant differences in dosimetric parameters were found between automatically and manually generated contours. A moderate negative correlation was found between PBT maximum dose and distance to the lesion (p < 0.05). Variability in manual PBT delineation may result in inconsistent assessment of tumor centrality. Automatic contouring can help standardize clinical practice, support investigations into the link between SABR outcomes and lesion proximity to central airways and the development of predictive toxicity models that incorporate precise measurements of tumor location in relation to high-risk organs.

Estimates of global chemotherapy demands and corresponding physician workforce requirements for 2018 and 2040: a population-based study.

BACKGROUND: The incidence of cancer (excluding non-melanomatous skin cancers) is projected to rise from 17·0 million to 26·0 million between 2018 and 2040. A large proportion of these patients would be likely to derive benefit from chemotherapy, but no studies so far have quantified current and projected global chemotherapy demands. We aimed to estimate changes in national, regional, and global demands for first-course chemotherapy and the cancer physician workforce between 2018 and 2040 if all patients were treated according to best-practice evidence-based guidelines. METHODS: Data for the incidence of 29 types of cancer in 183 countries in 2018, and projections of incidence in 2040, were obtained from GLOBOCAN 2018. Optimal chemotherapy utilisation from evidence-based guidelines was applied to these incidence data to generate the number of new patients requiring first-course chemotherapy in 2018 and 2040. We then estimated the corresponding cancer physician workforce required to deliver this chemotherapy (on the basis of physicians seeing 150 new patients requiring chemotherapy per year). We did sensitivity analyses to investigate how cancer stage at presentation affected chemotherapy demands. We also did sensitivity analyses to explore changes to workforce requirements if each physician was seeing 100 new patients requiring chemotherapy per year or 300 new patients requiring chemotherapy per year. FINDINGS: Between 2018 and 2040, the number of patients requiring first-course chemotherapy annually will increase from 9·8 million to 15·0 million, a relative increase of 53%. The estimated proportion of patients needing chemotherapy who reside in low-income or middle-income countries was 63% (6 162 240 of 9 782 783) in 2018, and will be 67% (10 071 049 of 14 984 560) in 2040. The most common indications for chemotherapy worldwide in 2040 will be lung cancer (accounting for 2 455 137 [16·4%] of 14 984 560 cases eligible for chemotherapy), breast cancer (1 898 740 [12·7%]), and colorectal cancer (1 678 153 [11·1%]). We estimated that, in 2018, 65 000 cancer physicians were required worldwide to deliver optimal chemotherapy-a figure that we estimate will rise to 100 000 by 2040 (with estimates ranging from from 50 000 to 150 000, depending on workload). INTERPRETATION: Strategic investments in chemotherapy service provision and cancer physicians are needed to meet the projected increased demand for chemotherapy in 2040. FUNDING: None.

Estimation of the optimal utilisation rates of radical prostatectomy, external beam radiotherapy and brachytherapy in the treatment of prostate cancer by a review of clinical practice guidelines.

BACKGROUND AND PURPOSE: We aimed to construct an evidence-based model of optimal treatment utilisation for prostate cancer, incorporating all local treatment modalities: radical prostatectomy (RP), external beam radiotherapy (EBRT), and brachytherapy (BT); and then to compare this optimal model with actual practice. MATERIALS AND METHODS: Evidence-based guidelines were used to construct a prostate cancer treatment decision-tree. The proportion of patients who fulfilled treatment criteria was drawn from the epidemiological literature. These data were combined to calculate the overall proportion of patients that should optimally have RP, EBRT and/or BT at least once during the course of their disease. The model was peer reviewed and tested by sensitivity analyses and compared with actual practice. RESULTS: Optimal utilisation rates, at some point during the disease course, were: RP, 24% (range 15-30%); EBRT, 58% (range 54-64%); BT, 9.6% (range 6.0-17.9%); and any RT, 60% (range 56-66%). Many patients had indications for more than one of these treatments, and at least one of these treatments was indicated in 76% of patients. The model was sensitive to patient preference estimates. Optimal rates were achievable in some health care jurisdictions. CONCLUSIONS: Modelling optimal utilisation of all local treatment options for a particular cancer is possible. These optimal prostate cancer treatment rates can be used as a planning and quality assurance tool, providing an evidence-based benchmark against which can be measured patterns of practice.

Estimation of an optimal chemotherapy utilisation rate for upper gastrointestinal cancers: setting an evidence-based benchmark for the best-quality cancer care.

Aims. The proportion of patients with upper gastrointestinal cancers that received chemotherapy varies widely in Australia and internationally, indicating a need for a benchmark rate of chemotherapy utilisation. We developed evidence-based models for upper gastrointestinal cancers to estimate the optimal chemotherapy utilisation rates that can serve as useful benchmarks for measuring and improving the quality of care. Materials and Methods. Optimal chemotherapy utilisation models for cancers of the oesophagus, stomach, pancreas, gallbladder, and primary liver were constructed using indications for chemotherapy identified from evidence-based guidelines. Results. Based on the best available evidence, the optimal proportion of upper gastrointestinal cancers that should receive chemotherapy at least once during the course of the patients' illness was estimated to be 79% for oesophageal cancer, 83% for gastric cancer, 35% for pancreatic cancer, 80% for gallbladder cancer, and 27% for primary liver cancer. Conclusions. The reported chemotherapy utilisation rates for upper gastrointestinal cancers (with the exception of primary liver cancer) appear to be substantially lower than the estimated optimal rates suggesting that chemotherapy may be underutilised. Further studies to elucidate the reasons for the potential underutilisation of chemotherapy in upper gastrointestinal tumours are required to bridge the gap between the ideal and actual practice identified.

Estimating the demand for radiotherapy from the evidence: a review of changes from 2003 to 2012.

BACKGROUND AND PURPOSE: In 2003 we estimated that 52.3% of new cases of cancer in Australia had an indication for external beam radiotherapy at least once at some time during the course of their illness. This update reviews the contemporary evidence to define the optimal proportion of new cancers that would benefit from radiotherapy as part of their treatment and estimates the changes to the optimal radiotherapy utilisation rate from 2003 to 2012. MATERIALS AND METHODS: National and international guidelines were reviewed for external beam radiotherapy indications in the management of cancers. Epidemiological data on the proportion of new cases of cancer with each indication for radiotherapy were identified. Indications and epidemiological data were merged to develop an optimal radiotherapy utilisation tree. Univariate and Monte Carlo simulations were used in sensitivity analysis. RESULTS: The overall optimal radiotherapy utilisation rate (external beam radiotherapy) for all registered cancers in Australia changed from 52.3% in 2003 to 48.3% in 2012. Overall 8.9% of all cancer patients in Australia have at least one indication for concurrent chemo-radiotherapy during the course of their illness. CONCLUSIONS: The reduction in the radiotherapy utilisation rate was due to changes in epidemiological data, changes to radiotherapy indications and refinements of the model structure.

Estimation of the optimal brachytherapy utilization rate in the treatment of gynecological cancers and comparison with patterns of care.

PURPOSE: We aimed to estimate the optimal proportion of all gynecological cancers that should be treated with brachytherapy (BT)-the optimal brachytherapy utilization rate (BTU)-to compare this with actual gynecological BTU and to assess the effects of nonmedical factors on access to BT. METHODS AND MATERIALS: The previously constructed inter/multinational guideline-based peer-reviewed models of optimal BTU for cancers of the uterine cervix, uterine corpus, and vagina were combined to estimate optimal BTU for all gynecological cancers. The robustness of the model was tested by univariate and multivariate sensitivity analyses. The resulting model was applied to New South Wales (NSW), the United States, and Western Europe. Actual BTU was determined for NSW by a retrospective patterns-of-care study of BT; for Western Europe from published reports; and for the United States from Surveillance, Epidemiology, and End Results data. Differences between optimal and actual BTU were assessed. The effect of nonmedical factors on access to BT in NSW were analyzed. RESULTS: Gynecological BTU was as follows: NSW 28% optimal (95% confidence interval [CI] 26%-33%) compared with 14% actual; United States 30% optimal (95% CI 26%-34%) and 10% actual; and Western Europe 27% optimal (95% CI 25%-32%) and 16% actual. On multivariate analysis, NSW patients were more likely to undergo gynecological BT if residing in Area Health Service equipped with BT (odds ratio 1.76, P=.008) and if residing in socioeconomically disadvantaged postcodes (odds ratio 1.12, P=.05), but remoteness of residence was not significant. CONCLUSIONS: Gynecological BT is underutilized in NSW, Western Europe, and the United States given evidence-based guidelines. Access to BT equipment in NSW was significantly associated with higher utilization rates. Causes of underutilization elsewhere were undetermined. Our model of optimal BTU can be used as a quality assurance tool, providing an evidence-based benchmark against which actual patterns of practice can be measured. It can also be used to assist in determining the adequacy of BT resource allocation.

Estimation of the optimal brachytherapy utilisation rate in the treatment of vaginal cancer and comparison with patterns of care.

INTRODUCTION: Having previously modelled the optimal proportion of uterine cervix and corpus cancers that should be treated with brachytherapy (BT), we aimed to complete the assessment of the role of BT for gynaecological cancers by estimating the optimal proportion of vaginal cancer cases that should be treated with BT, the optimal BT utilisation (BTU) rate for vaginal cancer. We compared this with actual vaginal BTU and assessed quality of BT for vaginal cancer by a Patterns-of-Care Study (POCS). METHODS: Evidence-based guidelines were used to construct an optimal BTU decision tree for vaginal cancer. Searches of the epidemiological literature to ascertain the proportion of patients who fulfilled the criteria for BT were conducted. The robustness of the model was tested by sensitivity analyses and by peer review. A retrospective POCS of BT in New South Wales (NSW) for 2003 was conducted, and actual BTU for vaginal cancer was determined. Differences between optimal and actual BTU were assessed. Quality of BT for vaginal cancer was compared with published benchmarks. RESULTS: The optimal vaginal cancer BTU rate was estimated to be 85% (range 81-87%). In NSW in 2003, actual vaginal cancer BTU was only 42% (95% confidence interval 22-62%). In NSW, only nine patients were treated, all with intra-vaginal cylinders, and two of four to lower than recommended doses. CONCLUSIONS: BT for vaginal cancers is underutilised in NSW compared with the proposed optimal models of care. BT quality may have been suboptimal and this may relate to the rarity of this disease.

A comparison of systemic breast cancer therapy utilization in Canada (British Columbia), Scotland (Dundee), and Australia (Western Australia) with models of "optimal" therapy.

BACKGROUND: Different jurisdictions report different breast cancer treatment rates. Evidence-based optimal utilization models may be specific to the derived population. We compared predicted optimal with actual endocrine and chemotherapy utilization in British Columbia, Canada; Dundee, Scotland; and Perth, Western Australia. DESIGN: Data were analyzed for differences in demography, tumour, and treatment. Epidemiological data were fitted to published Australian optimal radiotherapy utilization trees and region-specific optimal treatment rates were calculated. Optimal and actual systemic therapy rates from 2 population-based and 1 institution-based cancer registries were compared for patients diagnosed with breast cancer between 2000-2004, and 2002 for British Columbia. RESULTS: Chemotherapy rates differed between British Columbia (32%), Perth (29%), and Dundee (24%, p = 0.014). Endocrine therapy rates were similar between British Columbia (56%), Perth (59%), and Dundee (64%, p > 0.05). Actual utilization rates were lower than optimal estimates for chemotherapy, but higher for endocrine therapy. Region-specific optimal utilization rates at diagnosis varied between 50-56% for chemotherapy, and 49-54% for endocrine therapy. Variation was attributed to local differences in demographics, and tumour stage. CONCLUSION: Actual treatment rates varied. There was lower than estimated optimal chemotherapy use but higher than expected use of endocrine therapy.

Chemotherapy in rectal cancer: variation in utilization and development of an evidence-based benchmark rate of optimal chemotherapy utilization.

BACKGROUND: Published chemotherapy utilization rates for rectal cancer show considerable variation. Optimal chemotherapy utilization rates can serve as benchmarks to assess the quality of cancer care. The purpose of this study was to determine the optimal proportion of patients with rectal cancer who should receive chemotherapy at least once. PATIENTS AND METHODS: An optimal chemotherapy utilization tree was constructed using indications for chemotherapy identified from evidence-based treatment guidelines. Epidemiologic data were merged with treatment indications to calculate an optimal chemotherapy utilization rate; this rate was compared with reported actual rates of chemotherapy utilization. RESULTS: Chemotherapy is indicated at least once in 64% of patients with rectal cancer. Although the actual (Australian and United States data) and optimal utilization rates are comparable for patients presenting in stages II or III rectal cancer, actual utilization rates are higher than the optimal for stage I and lower than optimal for patients presenting in stage IV rectal cancer. CONCLUSION: Chemotherapy may be under-utilized in the initial management of patients presenting with metastatic rectal cancer.

Estimation of an optimal chemotherapy utilisation rate for lung cancer: an evidence-based benchmark for cancer care.

BACKGROUND: Optimal chemotherapy utilisation rates can serve as benchmarks to assess the quality of cancer service delivery. This study aims to determine the optimal proportion of patients with lung cancer that should receive chemotherapy at least once during the course of their illness, based on the best available evidence. METHODS: An optimal chemotherapy utilisation tree was constructed using indications for chemotherapy identified from evidence-based treatment guidelines. Data on the proportion of patient and tumour-related attributes for which chemotherapy was indicated were obtained and merged with the treatment indications to calculate an optimal chemotherapy utilisation rate. This optimal rate was compared with reported actual rates of chemotherapy utilisation. RESULTS: Chemotherapy is recommended at least once in 73% of all patients with lung cancer (93% of small cell lung cancer (SCLC) patients and 69% of non-small cell lung cancer (NSCLC) patients). Comparison of these benchmark rates with international reported actual chemotherapy utilisation rates reveals under-utilisation of chemotherapy in all newly diagnosed lung cancer patients, regardless of histological type and stage, with the exception of stage I NSCLC. CONCLUSION: The optimal chemotherapy utilisation rate can serve as a feasible, evidence-based measure of the quality of cancer care. Chemotherapy may be under-utilised in the initial management of lung cancer.

Estimation of an optimal chemotherapy utilisation rate for breast cancer: setting an evidence-based benchmark for the best-quality cancer care.

BACKGROUND: The proportion of breast cancer patients that received chemotherapy varies widely in high-income countries. An evidence-based estimate of the optimal chemotherapy utilisation rate for a breast cancer population may serve as a useful benchmark for measuring and improving the quality of care. METHODS: An optimal chemotherapy utilisation model was constructed using indications for chemotherapy identified from evidence-based guidelines. Data on the proportion of patient (age, performance status and preference) and tumour (stage, size, grade, nodal status, hormone receptor and HER2 status) attributes were obtained and merged with the treatment indications to calculate an optimal utilisation rate. This model was peer-reviewed by a panel of independent experts. RESULTS: Chemotherapy was indicated in 17 of the 24 possible clinical scenarios depicted in the optimal utilisation model. The estimated optimal proportion of breast cancer patients who should received chemotherapy at least once was 68%. Sensitivity analyses showed that the range of optimal rate was 60-69%. The optimal rate appears to be substantially higher than the reported actual rates (29-49%). CONCLUSION: It is possible to generate an optimal chemotherapy utilisation rate in breast cancer to serve as an evidence-based benchmark. The optimal chemotherapy utilisation rate in breast cancer has remained largely unchanged over the past 15years. The reported actual utilisation rates of chemotherapy in breast cancer populations appear to have remained below the estimated optimal rate, suggesting that potential opportunities for improvement in the compliance to guideline recommended care exist.

Estimation of an optimal chemotherapy utilisation rate for colon cancer: an evidence-based benchmark for cancer care.

BACKGROUND: Optimal chemotherapy (CT) utilisation rates can serve as benchmarks to assess the quality of cancer care. This study aims to determine the optimal proportion of patients with colon cancer that should receive chemotherapy at least once. METHODS: An optimal chemotherapy utilisation tree was constructed using indications for chemotherapy identified from evidence-based treatment guidelines. Data on the proportion of patient and tumour-related attributes for which chemotherapy was indicated were obtained and merged with the treatment indications to calculate an optimal chemotherapy utilisation rate (CTU rate). This optimal rate was compared with reported actual rates of chemotherapy utilisation. RESULTS: Chemotherapy is indicated at least once in 55% of patients with colon cancer. While 89% of colon cancer patients presenting with Stage IV disease should optimally receive chemotherapy, 38-52% actually received chemotherapy as part of their initial treatment. CONCLUSION: The optimal chemotherapy utilisation rate can serve as an evidence-based benchmark in the planning and evaluation of chemotherapy services. Chemotherapy may be under-utilised in the initial management of patients presenting with metastatic colon cancer.

Estimation of an optimal chemotherapy utilisation rate for head and neck carcinoma: setting an evidence-based benchmark for the best-quality cancer care.

BACKGROUND: We estimated the optimal chemotherapy utilisation rate for head and neck cancer as a benchmark for measuring and improving the quality of cancer care. METHODS: An optimal chemotherapy utilisation tree was constructed using indications for chemotherapy that were identified from evidence-based treatment guidelines. Data on the proportion of patient and tumour-related attributes for which chemotherapy was indicated were obtained and merged with the treatment indications to calculate the optimal utilisation rate. The robustness of the model was tested with sensitivity analysis and Monte Carlo simulation. The optimal chemotherapy utilisation rate was compared with actual utilisation rates reported. RESULTS: Chemotherapy is indicated at least once in 36% (95% CI, 33-38%) of all patients with head and neck carcinoma. The optimal utilisation rates by subsites were as follows: lip, 8%; oral cavity, 40%; nasopharynx, 69%; oropharynx, 66%; hypopharynx, 74%; larynx, 43%; salivary gland, 48% and paranasal sinus with nasal cavity, 38%. CONCLUSIONS: The optimal proportion of patients who should receive chemotherapy in the head and neck carcinoma population has risen significantly over the past 20 years. This temporal rise does not appear to be reflected in the limited actual utilisation rates that are available for comparison. Large population-based studies are recommended to further assess the current practice and compliance to guideline recommended care.

Estimation of optimal brachytherapy utilization rate in the treatment of malignancies of the uterine corpus by a review of clinical practice guidelines and the primary evidence.

PURPOSE: Brachytherapy (BT) is an important treatment technique for uterine corpus malignancies. We modeled the optimal proportion of these cases that should be treated with BT-the optimal rate of brachytherapy utilization (BTU). We compared this optimal BTU rate with the actual BTU rate. METHODS AND MATERIALS: Evidence-based guidelines and the primary evidence were used to construct a decision tree for BTU for malignancies of the uterine corpus. Searches of the literature to ascertain the proportion of patients who fulfilled the criteria for BT were conducted. The robustness of the model was tested by sensitivity analyses and peer review. A retrospective Patterns of Care Study of BT in New South Wales for 2003 was conducted, and the actual BTU for uterine corpus malignancies was determined. The actual BTU in other geographic areas was calculated from published reports. The differences between the optimal and actual rates of BTU were assessed. RESULTS: The optimal uterine corpus BTU rate was estimated to be 40% (range, 36-49%). In New South Wales in 2003, the actual BTU rate was only 14% of the 545 patients with uterine corpus cancer. The actual BTU rate in 2001 was 11% in the Surveillance, Epidemiology, and End Results areas and 30% in Sweden. CONCLUSION: The results of this study have shown that BT for uterine corpus malignancies is underused in New South Wales and in the Surveillance, Epidemiology, and End Results areas. Our model of optimal BTU can be used as a quality assurance tool, providing an evidence-based benchmark against which can be measured actual patterns of practice. It can also be used to assist in determining the adequacy of BT resource allocation.