Non-operative management for oral cavity carcinoma: Definitive radiation therapy as a potential alternative treatment approach.

PURPOSE: To determine the outcomes of oral cavity squamous cell cancer (OSCC) patients treated with non-surgical approach i.e. definitive intensity-modulated radiation therapy (IMRT). METHODS: All OSCC patients treated radically with IMRT (without primary surgery) between 2005-2014 were reviewed in a prospectively collected database. OSCC patients treated with definitive RT received concurrent chemotherapy except for early stage patients or those who declined or were unfit for chemotherapy. The 5-year local, and regional, distant control rates, disease-free, overall, and cancer-specific survival, and late toxicity were analyzed. RESULTS: Among 1316 OSCC patients treated with curative-intent; 108 patients (8%) received non-operative management due to: medical inoperability (n = 14, 13%), surgical unresectability (n = 8, 7%), patient declined surgery (n = 15, 14%), attempted preservation of oral structure/function in view of required extensive surgery (n = 53, 49%) or extensive oropharyngeal involvement (n = 18, 17%). Sixty-eight (63%) were cT3-4, 38 (35%) were cN2-3, and 38 (35%) received concurrent chemotherapy. With a median follow-up of 52 months, the 5-year local, regional, distant control rate, disease-free, overall, and cancer-specific survival were 78%, 92%, 90%, 42%, 50%, and 76% respectively. Patients with cN2-3 had higher rate of 5-year distant metastasis (24% vs 3%, p = 0.001), with detrimental impact on DFS (p = 0.03) and OS (p < 0.02) on multivariable analysis. Grade ≥ 3 late toxicity was reported in 9% of patients (most common: grade 3 osteoradionecrosis in 6%). CONCLUSIONS: Non-operative management of OSCC resulted in a meaningful rate of locoregional control, and could be an alternative curative approach when primary surgery would be declined, unsuitable or unacceptably delayed.

The Road to Improving Access to Surgical Specialist Consultations: Ontario's Experience with Wait 1 Wait Time Data.

In 2009, the Ontario Ministry of Health and Long-Term Care engaged Cancer Care Ontario to expand the Wait Time Information System to capture surgical consultation data (Wait 1). Over the years, an increasing number of patient and provider reports have shown that Wait 1 wait times account for a significant portion of the total wait time for surgery. With data published online by the ministry in late summer 2017, patients were given access to consultation wait time information for over 200 types of procedures at 92 surgical facilities in Ontario. This article explains how a highly focused data strategy, strong stakeholder and clinical expert support and a comprehensive communications strategy were critical to driving change for a large-scale provincial initiative, which is helping to drive better access for patients and improve transparency and accountability.

Practice patterns in the management of patients with differentiated thyroid cancer in Ontario Canada 2000-2008.

BACKGROUND: The extent of treatment for differentiated thyroid cancer remains controversial. The objective of this study was to describe the variations in practice prior to diagnosis and for the first year after diagnosis, including the investigations, the extent of surgery and the use of RAI 131, for all patients with thyroid cancer (TC) treated Jan 1 2000 to Dec 2008 across Ontario Canada. METHOD: Population-based study of all patients who had a therapeutic surgical procedure for TC based on the data holdings of the Institute of Clinical Investigative Sciences (ICES) linking the Ontario Cancer Registry to the Ontario Health Insurance Plan and to the Canadian Institutes of Health Information. The analysis includes comparisons between health care utilization/geographic regions and between treating specialties. The study population was 12957 patients. RESULTS: There was a 112% increase in case detection over 9 years. Overall the initial (index) surgery was less-than-total thyroidectomy (LTT) in 37.6% and 63.4% of the patients who had total thyroidectomy (TT) as an index surgery went on to adjuvant RAI, however there was wide variation in all aspects of patient care across the province, between Local Health Networks and between surgical specialties. CONCLUSION: In Ontario, there was wide variation for most aspects of the management of TC and, as the incidence of TC is increasing at least 7% per year in females, these data provide a foundation for future discussions, the provision of health care services and research.

Prognostic and predictive markers in medullary thyroid carcinoma.

Unlike papillary thyroid carcinoma, medullary thyroid carcinoma is insensitive to adjuvant treatment with radioactive iodine. The clinical management of patients with advanced or metastatic disease remains challenging since no effective systemic adjuvant therapy is available. We aimed to identify markers of aggressive disease and novel drugable protein targets that would provide systemic adjuvant treatment for patients with advanced medullary thyroid carcinoma. We therefore examined morphologic features of aggressive behavior and the expression of 41 proteins involved in apoptosis, cell cycle, angiogenesis, inflammation, cell adhesion, tumor-specific markers, and WNT, SHH, and AKT pathways using tissue microarray from 23 patients with medullary thyroid carcinoma. Protein expression was determined using computerized image analysis software. Statistical analysis was carried out to correlate clinical data with the average score for each marker. Angioinvasion proved to be the most reliable predictor of disease recurrence and death. The rate of angioinvasion was 43 %. All angioinvasive medullary thyroid carcinomas had locoregional and/or distant metastasis; 60 % of angioinvasive medullary thyroid carcinomas developed distant metastasis. We identified expression of several potentially important protein targets such as COX-1/2, Bcl-2a, Gst-π, Gli-1, Gli-2, Gli-3, and Bmi-1 that may be therapeutically targeted in medullary thyroid carcinoma. More importantly, the immunohistochemical profile of SSTRs in medullary thyroid carcinoma may also have clinical relevance for the administration of peptide receptor radionuclide treatment. Successful outcome of clinical trials directed against these novel targets would provide much needed systemic adjuvant treatment for patients with advanced medullary thyroid carcinoma, and our data suggest the possibility of stratifying patients who are likely to require adjuvant therapy before their burden of disease precludes successful therapeutic effect.

Contract management of Ontario's cancer surgery wait times strategy.

The province of Ontario, as a result of the First Ministers' Meeting, was committed to addressing surgery wait times in Ontario. The Ministry of Health and Long-Term Care's response to this commitment was the Wait Times Strategy (WTS) initiative, which addressed access issues with the aim of positively impacting wait times in cancer surgery. Cancer Care Ontario (CCO) was tasked with managing the cancer surgery WTS. CCO engaged in accountability agreements with Ontario hospitals to provide incremental cancer surgery volumes, in return for one-time funding. Through the use of accountability agreements, CCO was able to tie service volume delivery, quality care initiatives and reporting requirements to funding. Other elements of the cancer surgery WTS implementation included the development of wait times definitions, guidelines and targets; the use of a performance management system; facilitation by existing regional cancer leads and continued development of regional cancer programs. Eight key lessons were learned: (1) baseline volume guarantees are critical to ensuring that wait times are positively impacted; (2) there is a need to create a balance between accountability and systems management; (3) clinical quality initiatives can be tied to funding initiatives; (4) allocations of services should be informed by many factors; (5) regional leadership is key to ensuring that local needs are met; (6) data are invaluable in improving performance; (7) there is regional disparity in service delivery, capacity and resources across the province; and (8) program sustainability is an underlying goal of the WTS for cancer surgery. The implication is that accountability agreements can be leveraged to create sustainable health management systems.

Accuracy of recorded tumor, node, and metastasis stage in a comprehensive cancer center.

PURPOSE: The benefits of recording the tumor, node, and metastasis (TNM) stages of cancer patients are well accepted, but little is known about how accurately this is performed. An audit was performed to determine the accuracy of recorded stage and to act as a baseline before the implementation of an education program. PATIENTS AND METHODS: All new patient referrals to Princess Margaret Hospital between July 1 and August 31, 1997, were reviewed. An audit panel composed of five health record technicians (HRTs) and 10 doctors was assembled. Each auditor reviewed 10% of the health record. If there was a discrepancy between the stage in the health record and the auditor stage, then the final stage was determined by the audit committee. Analysis of the agreement between the health record, the physician auditor, the HRT auditor, and the final stage was performed. RESULTS: A total of 855 patients were referred with a new diagnosis of a malignancy for which there was a TNM stage system; 833 patients (97.4%) had a stage assigned. There was agreement between the health record stage and final stage in 80% (95% confidence interval [CI], 77% to 82%) of cases for clinical stage, compared with 90% (95% CI, 87% to 92%) for pathologic stage. Of the major site groups, lung was the least accurately recorded. The most common major discrepancies were due to the recording of X when a definite category could be assigned. CONCLUSION: This audit demonstrates the importance of staging and provides impetus to develop staging guidelines and education programs.