Estimating the optimal perioperative chemotherapy utilization rate for muscle-invasive bladder cancer.

BACKGROUND: Identifying optimal chemotherapy (CT) utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of perioperative CT for muscle-invasive bladder cancer (MIBC). METHODS: The Ontario Cancer Registry and linked treated records were used to identify neoadjuvant and adjuvant CT rates among patients with MIBC during 2004-2013. Monte Carlo simulation was used to estimate the proportion of observed rate variation that could be due to chance alone. The criterion-based benchmarking approach was used to explore whether social and health-system factors were associated with CT rates. We also used the "pared-mean" approach to identify a benchmark population of hospitals with the highest treatment rates. Hospital CT rates were adjusted for case mix and simulated using a multi-level multivariable model and a parametric bootstrapping approach. RESULTS: The study population included 2581 patients; perioperative CT was delivered to 31% (798/2581). Multivariate analysis showed that treatment was strongly associated with patient socioeconomic status and hospital teaching status. The benchmark rate was 36%. Unadjusted CT rates were significantly different across hospitals (range 0%-52%, P < .001). The unadjusted benchmark perioperative CT rate was 45% (95% CI 40%-50%); utilization rate in nonbenchmark hospitals was 28% (95% CI 26%-30%). When using simulated CT rates adjusted for case mix, the benchmark CT rate was 41% (95% CI 35%-47%) and the nonbenchmark hospital CT rate was 30% (95% CI 28%-32%). The simulation analysis suggested that the observed component of variation (38%) was outside the 95% CI (22%-28%) of what could be expected due to chance alone. CONCLUSIONS: There is significant systematic variation in perioperative CT rates for MIBC across hospitals in routine practice. The benchmark perioperative CT rate for MIBC is 36%-41%.

Estimating the optimal rate of adjuvant chemotherapy utilization for stage III colon cancer.

BACKGROUND: Identifying optimal chemotherapy utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of adjuvant chemotherapy (ACT) for stage III colon cancer. METHODS: The Ontario Cancer Registry and linked treated records were used to identify ACT utilization. Monte Carlo simulation was used to estimate the proportion of ACT rate variation that could be due to chance alone. The criterion-based benchmarking approach was used to explore whether socioeconomic or system-level factors were associated with ACT. We also used the "pared-mean" approach to identify a benchmark population of hospitals with the highest ACT rates. RESULTS: The study population included 2801 patients; ACT was delivered to 66% (1861/2801). Monte Carlo simulation suggested that the observed component of variation (15.6%) in ACT rates was within the 95% CI (11.5%-17.3%) of what could be expected due to chance alone; the nonrandom component of ACT rate variation across hospitals was only 1.5%. There was no difference in hospital ACT rate by teaching status (P = .107), cancer center status (P = .362), or having medical oncology on site (P = .840). Unadjusted ACT rates varied across hospitals (range 44%-91%, P = .017). The unadjusted benchmark ACT rate was 81% (95%CI 76%-86%); utilization rate in non-benchmark hospitals was 65% (95%CI 63%-66%). However, after adjusting for case mix, the difference in ACT utilization between benchmark and non-benchmark populations was significantly smaller. CONCLUSIONS: We did not find any system-level factors associated with the utilization of ACT. Our results suggest that the observed variation in hospital ACT rate is not significantly different from variation due to chance alone. Using the "pared-mean" approach may significantly overestimate optimal treatment rates if case mix is not considered.

Real-world data: towards achieving the achievable in cancer care.

The use of data from the real world to address clinical and policy-relevant questions that cannot be answered using data from clinical trials is garnering increased interest. Indeed, data from cancer registries and linked treatment records can provide unique insights into patients, treatments and outcomes in routine oncology practice. In this Review, we explore the quality of real-world data (RWD), provide a framework for the use of RWD and draw attention to the methodological pitfalls inherent to using RWD in studies of comparative effectiveness. Randomized controlled trials and RWD remain complementary forms of medical evidence; studies using RWD should not be used as substitutes for clinical trials. The comparison of outcomes between nonrandomized groups of patients who have received different treatments in routine practice remains problematic. Accordingly, comparative effectiveness studies need to be designed and interpreted very carefully. With due diligence, RWD can be used to identify and close gaps in health care, offering the potential for short-term improvement in health-care systems by enabling them to achieve the achievable.

Use of radiotherapy for bladder cancer: A population-based study of evolving referral and practice patterns.

INTRODUCTION: Definitive treatment for muscle-invasive bladder cancer includes either cystectomy or radiotherapy (RT). We describe use of RT and radiation oncology (RO) referral patterns in the contemporary era. METHODS: The Ontario Cancer Registry and linked records of treatment were used to identify all patients who received cystectomy or RT for bladder cancer from 1994-2013. Physician billing records were linked to identify RO consultation before radical treatment. Multilevel logistic regression models were used to examine patient factors and physician-level variation in referral to RO and use of RT. RESULTS: A total of 7461 patients underwent cystectomy or RT for bladder cancer from 1994-2013; 5574 (75%) had cystectomy and 1887 (25%) had RT. Use of RT decreased from 43% (126/289) in 1994 to 23% (112/478) in 2008 and remained stable from 2009-2013 (23%, 507/2202). RO referral rate among all cases decreased from 46% (134/289) in 1994 to 30% (143/478) in 2008; however, the rates began to rise in the contemporary era from 31% (137/442) in 2009 to 37% (165/448) in 2013 (p=0.03). Patient factors associated with use of RT include older age, greater comorbidity, and geographic location. Surgeon-level factors associated with greater preoperative referral to RO include higher surgeon case volume and practicing in a teaching hospital. CONCLUSIONS: One-quarter of patients treated with curative intent therapy for bladder cancer receive RT. While referral rates to RO are increasing, future data will identify the extent to which this has altered practice. Collaborative efforts promoting multidisciplinary care and RO consultation before radical treatment are warranted.

Estimating the need for palliative radiotherapy for non-small cell lung cancer: A criterion-based benchmarking approach.

BACKGROUND AND PURPOSE: Estimates of appropriate treatment rates are required for monitoring and improving access to cancer care. Optimal utilization rates for palliative radiotherapy (PRT) for patients with non-small cell lung cancer (NSCLC) remain undefined. We aim to estimate the appropriate PRT rate for the general NSCLC population. MATERIALS AND METHODS: Ontario's population-based cancer registry identified patients with NSCLC who died of their disease between 2006 and 2010. Multivariate analysis identified factors affecting PRT use, enabling us to define a benchmark population with unimpeded access to PRT. Proportion of cases treated in the last 2 years of life (PRT2y) was standardized to overall population characteristics. Benchmarks were compared to province-wide PRT2y rates. RESULTS: Availability of RT at the diagnosing hospital was the dominant determinant of increased PRT utilization. Patients diagnosed at hospitals with on site RT were therefore designated the benchmark population. The standardized benchmark for PRT2y was 56%, compared to the province-wide rate of 49%. The gap between actual and optimal rates varied across patient ages, treatment indications, and geographic regions. CONCLUSIONS: Approximately 56% of patients who die of NSCLC in Ontario need PRT, but many are never treated.

Radiotherapy utilization in developing countries: An IAEA study.

BACKGROUND: The planning of national radiotherapy (RT) services requires a thorough knowledge of the country's cancer epidemiology profile, the radiotherapy utilization (RTU) rates and a future projection of these data. Previous studies have established RTU rates in high-income countries. METHODS: Optimal RTU (oRTU) rates were determined for nine middle-income countries, following the epidemiological evidence-based method. The actual RTU (aRTU) rates were calculated dividing the total number of new notifiable cancer patients treated with radiotherapy in 2012 by the total number of cancer patients diagnosed in the same year in each country. An analysis of the characteristics of patients and treatments in a series of 300 consecutive radiotherapy patients shed light on the particular patient and treatments profile in the participating countries. RESULTS: The median oRTU rate for the group of nine countries was 52% (47-56%). The median aRTU rate for the nine countries was 28% (9-46%). These results show that the real proportion of cancer patients receiving RT is lower than the optimal RTU with a rate difference between 10-42.7%. The median percent-unmet need was 47% (18-82.3%). CONCLUSIONS: The optimal RTU rate in middle-income countries did not differ significantly from that previously found in high-income countries. The actual RTU rates were consistently lower than the optimal, in particular in countries with limited resources and a large population.

Quality of radiotherapy services in post-Soviet countries: An IAEA survey.

BACKGROUND: The quality of radiotherapy services in post-Soviet countries has not yet been studied following a formal methodology. The IAEA conducted a survey using two sets of validated radiation oncology quality indicators (ROIs). METHODS: Eleven post-Soviet countries were assessed. A coordinator was designated for each country and acted as the liaison between the country and the IAEA. The methodology was a one-time cross-sectional survey using a 58-question tool in Russian. The questionnaire was based on two validated sets of ROIs: for radiotherapy centres, the indicators proposed by Cionini et al., and for data at the country level, the Australasian ROIs. RESULTS: The overall response ratio was 66.3%, but for the Russian Federation, it was 24%. Data were updated on radiotherapy infrastructure and equipment. 256 radiotherapy centres are operating 275 linear accelerators and 337 Cobalt-60 units. 61% of teletherapy machines are older than ten years. Analysis of ROIs revealed significant differences between these countries and radiotherapy practices in the West. Naming, task profile and education programmes of radiotherapy professionals are different than in the West. CONCLUSIONS: Most countries need modernization of their radiotherapy infrastructure coupled with adequate staffing numbers and updated education programmes focusing on evidence-based medicine, quality, and safety.

Temporal trends in management and outcomes of testicular cancer: A population-based study.

BACKGROUND: Treatment guidelines for early-stage testicular cancer have increasingly recommended de-escalation of therapy with surveillance strategies. This study was designed to describe temporal trends in routine clinical practice and to determine whether de-escalation of therapy is associated with inferior survival in the general population. METHODS: The Ontario Cancer Registry was linked to electronic records of treatment to identify all patients diagnosed with testicular cancer treated with orchiectomy in Ontario during 2000-2010. Treatment after orchiectomy was classified as radiotherapy (RT), retroperitoneal lymph node dissection (RPLND), chemotherapy, or none. Surveillance was defined as no identified treatment within 90 days of orchiectomy. Overall survival (OS) and cancer-specific survival (CSS) were measured from the date of orchiectomy. RESULTS: The study population included 1564 and 1086 cases of seminomas and nonseminoma germ cell tumors (NSGCTs), respectively. Among patients with seminomas, there was a significant increase in the proportion of patients with no treatment within 90 days of orchiectomy (from 56% to 84%; P < .001); the use of RT decreased over time (from 38% to 8%; P < .001); and the use of chemotherapy remained stable (from 6% to 9%; P = .289). Practice patterns 90 days after orchiectomy remained stable over time among patients with NSGCTs: from 51% to 57% for no treatment (P = .435), from 43% to 43% for chemotherapy (P = .336), and from 9% to 3% for RPLND (P = .476). The OS rates for the entire cohort at 5 and 10 years were 97% and 96%, respectively; the CSS rates were 98% and 98%, respectively. There was no significant change in OS or CSS for patients with seminomas or NSGCTs during the study period. CONCLUSIONS: There has been substantial de-escalation in the treatment of testicular cancer in routine practice since 2000. Long-term survival in routine practice is excellent and has not decreased with the uptake of surveillance strategies. Cancer 2018;124:2724-2732. © 2018 American Cancer Society.

Do radiation oncology outreach clinics affect the use of radiotherapy?

BACKGROUND AND PURPOSE: The scope and effect of radiation oncology (RO) outreach activities within centralized radiotherapy (RT) systems is poorly defined. The purpose of this study was to describe the outreach activities of Ontario's regional cancer centres, and to explore the relationship between radiation oncology (RO) outreach clinics and rates of radiotherapy (RT) utilization at hospitals without RT on site (HWOS-RT). MATERIALS AND METHODS: Ontario RO centres' outreach activities were identified by semi-structured interview. A multivariate analysis determined the association between on-site RT facilities, or presence of RO clinic at HWOS-RT, and RT utilization within one year of diagnosis (RT1Y), for all patients diagnosed with cancer in Ontario in 2011-2012. RESULTS: RO outreach varied widely by region. Of the largest 58 diagnosing hospitals, 14 had RT on-site, 19 had no RT but RO outreach clinic(s) and 25 had no RT or RO clinic. RT was used more frequently for patients diagnosed at hospitals with on-site RT compared to those at HWOS-RT (RT1Y = 35% vs. 29%, RR = 1.32 [95% CI 1.27-1.38]). For HWOS-RT, RT was used more frequently if there was an RO clinic (RT1Y = 31% vs. 29%, RR = 1.06 [95% CI 1.02-1.10]). CONCLUSIONS: RO outreach clinics were associated with a small but significant increase in RT utilization. There is opportunity to improve access to RT by optimizing the effectiveness of RO outreach.

Peri-Operative Chemotherapy for Bladder Cancer: A Survey of Providers to Determine Barriers and Enablers.

BACKGROUND: Utilization of chemotherapy for patients with muscle-invasive bladder cancer (MIBC) is low. In earlier qualitative work we used the Theoretical Domains Framework (TDF) to determine barriers and enablers of chemotherapy use. In this project we aimed to determine the prevalence of these barriers and enablers in Canadian physicians. METHODS: Practicing Canadian urologists, medical oncologists (MOs) and radiation oncologists (ROs) participated in a specialty-specific web-based quantitative survey to assess potential barriers and enablers to chemotherapy use. Survey questions were developed that were thematically mapped to TDF domains. Logistic regression was used to identify TDF domains associated with high referral/use of chemotherapy. RESULTS: 110 urologists, 47 MOs and 43 ROs completed the survey; response rates were 20%, 35% and 31% respectively. The mean reported survival gain associated with neoadjuvant chemotherapy (NACT) was 9%, 8%, and 7% for urologists, MOs, and ROs respectively. Among participating urologists, the TDF domains 'social and professional role' (OR = 16.5, 95% CI 4.6-59.2), 'social influences' (OR = 5.7, 95% CI 2.4-13.4) 'beliefs about consequences' (OR = 4.9, 95% CI 1.8-13.3) and 'memory, attention and decision-making' (OR = 0.50, 95% CI 0.27-0.91) were associated with MO referral rates. Among MOs, the TDF domains 'behavioural regulation', 'social influences', and 'social and professional role' were associated with greater use of chemotherapy (p < 0.05). No TDF domains were associated with RO referral to MO. CONCLUSIONS: We have identified several factors associated with referral/use of chemotherapy for MIBC. Optimization of multidisciplinary patient care needs to be considered when designing future interventions to close the gap between evidence and practice.

Concurrent chemoradiotherapy for bladder cancer: Practice patterns and outcomes in the general population.

BACKGROUND: Clinical trials have shown that chemoradiotherapy (CRT) improves survival compared to radiation therapy (RT) alone in muscle-invasive bladder cancer. We describe uptake of CRT and comparative effectiveness in routine practice. METHODS: Electronic treatment records were linked to the population-based Ontario Cancer Registry to identify all patients with bladder cancer treated with curative-intent RT in 1999-2013. Modified Poisson regression was used to analyze factors associated with use of CRT. Cox model and propensity score analyses were used to explore factors associated with cancer-specific (CSS) and overall survival (OS). RESULTS: 1192 patients underwent RT during 1999-2013; median age was 79. Use of CRT increased over time: 36% (124/341) in 1999-2003, 38% (153/399) in 2004-2008, 48% (217/452) in 2009-2013 (p = 0.001). Drug details were available for 82% (402/493) of CRT cases; the most common regimens were single-agent Cisplatin (57%, 230/402), single-agent Carboplatin (31%, 125/402) and 5-FU/Mitomycin (4%, 17/402). Factors associated with CRT include younger age (p < 0.001), lower comorbidity (p = 0.001), and geographic region (range 14-89%, p < 0.001). Five year CSS and OS among CRT cases were 45% (95%CI 39-51%) and 35% (95%CI 30-40%). On adjusted analyses CRT was associated with superior survival compared to RT (CSS HR 0.70, 95%CI 0.59-0.84; OS HR 0.74, 95%CI 0.64-0.85); results were consistent on propensity score analysis. There was significant improvement in survival of all RT-treated cases (irrespective or chemotherapy delivery) in 2009-2013 compared to 1999-2003 (CSS HR 0.77, 95%CI 0.61-0.97; OS HR 0.82, 95%CI 0.69-0.98). CONCLUSION: CRT is associated with superior survival compared to RT alone and its uptake corresponded to improved survival among all RT-treated cases in the general population. Uptake of CRT varies widely by geographic region.

Perioperative chemotherapy for bladder cancer: A qualitative study of physician knowledge, attitudes, and behaviour.

INTRODUCTION: Use of chemotherapy for muscle-invasive bladder cancer (MIBC) is known to be low. To understand factors driving practice we use the Theoretical Domains Framework (TDF) to identify barriers and enablers of chemotherapy use. METHODS: A convenience sample of Canadian urologists, medical oncologists (MOs), and radiation oncologists (ROs) participated in individual, semi-structured, one-hour telephone interviews. An interview guide was developed using the TDF to assess potential barriers and enablers of chemotherapy use. Interviews were recorded and transcribed. Two investigators independently identified barriers and enablers and assigned them to specific themes. Participant recruitment continued until saturation. RESULTS: A total of 71 physicians were invited to participate and 34 (48%) agreed to be interviewed: 13 urologists, 10 MOs, and 11 ROs. We identified the following barriers to the use of chemotherapy (relevant TDF domains in parentheses): 1) belief that the benefits of chemotherapy are not clinically important (beliefs about consequences); 2) inadequate multidisciplinary collaboration (environmental context and resources); 3) absence of "champions" advocating the use of chemotherapy (social and professional role); and 4) a lack of organizational clarity/policy regarding the referral process (environmental context and resources). The predominant enablers identified included: 1) "champions" who believe in the value of chemotherapy (social and professional role); 2) urologists who refer all patients to MO (behavioural regulation; memory, attention, and decision-making); and 3) system-level factors, including automatic multidisciplinary referral (environmental context and resources). CONCLUSIONS: We have identified several system-level factors associated with delivery of chemotherapy. Behaviour change interventions should optimize multidisciplinary care of patients with MIBC. PATIENT SUMMARY: Despite the fact that chemotherapy before or after surgery improves survival of patients with bladder cancer, several studies have shown that many patients in routine practice are not treated. In this study, we identify important system-level and physician-level factors that must be considered in efforts to improve patient care.

Perioperative chemotherapy for bladder cancer in the general population: Are practice patterns finally changing?

BACKGROUND: Uptake of perioperative chemotherapy for muscle-invasive bladder cancer (MIBC) has been historically poor. We describe contemporary use of neoadjuvant (NACT) and adjuvant chemotherapy (ACT) as well as medical oncology (MO) referral patterns in routine practice. METHODS: Electronic treatment records were linked to the population-based Ontario Cancer Registry to identify all MIBC patients treated with cystectomy in Ontario 1994 to 2013. Physician billing records were used to identify consultation with MO. Practice patterns in the contemporary era (2009-2013) are compared with data from 1994 to 2008. RESULTS: A total of 5,582 patients had cystectomy for MIBC. Use of NACT increased from 4% in 1994 to 2008 to 19% in 2009 to 2013 (P<0.001); rates continued to rise in the most recent era from 12% in 2009 to 27% in 2013 (P<0.001). ACT was delivered to 20% of patients in 2009 to 2013 (19% in 1994-2008, P = 0.875). Use of any chemotherapy (NACT or ACT) in 2009 to 2013 was 35% compared to 23% in 1994 to 2008 (P<0.001). Preoperative referral rates during 2009 to 2013 to MO were greater than 1994 to 2008 (32% vs. 11%, P<0.001); referral rates continued to increase in recent years from 21% in 2009 to 44% in 2013 (P<0.001). The proportion of referred patients ultimately treated with NACT increased substantially; from 32% in 1994 to 1998 to 54% in 2009 to 2013 (P<0.001). CONCLUSIONS: After many years of practice lagging behind evidence, use of NACT in the general population has increased substantially. Our results suggest that increased uptake has been driven by greater preoperative referral to MO as well as greater propensity of MOs to treat referred patients.

Bladder-sparing radiotherapy for muscle-invasive bladder cancer: A survey of providers to determine barriers and enablers.

BACKGROUND: To understand barriers and enablers to use of curative-intent radiotherapy (RT) for muscle-invasive bladder cancer using the Theoretical Domains Framework (TDF). METHODS: Canadian urologists, radiation oncologists (ROs) and medical oncologists (MOs) participated in a web-based survey to assess barriers and enablers to use of RT. Survey questions were thematically mapped to TDF domains. Logistic regression was used to identify TDF domains associated with high referral/use of RT. RESULTS: 64 urologists, 29 ROs and 26 MOs participated. Participants reported comparable survival at five years with cystectomy (51%) and RT with concurrent chemotherapy (50%). Despite this, participants reported low RT referral/treatment rates: Urologists referred a median of 2/10 patients to RO; ROs treated a median of 5/10 patients referred; and MOs referred a median of 2/8 patients not referred to RO by urology. Among urologists, the TDF domains 'beliefs about consequences' (OR=8.1, 95% CI 1.5-44.9), 'social and professional role' (OR=11.2, 95% CI 2.3-53.6) and 'environmental context and resources' (OR=5.9, 95% CI 1.5-23.3) were associated with higher rates of RO referral. CONCLUSIONS: We have identified factors associated with referral for RT among patients with bladder cancer. These factors should be addressed as part of a concerted effort to increase utilization of RT.

Temporal trends in the association between socioeconomic status and cancer survival in Ontario: a population-based retrospective study.

BACKGROUND: Cancer survival is known to be associated with socioeconomic status. The income gap between the richer and poorer segments of the population has widened over the last 20 years in Canada. The purpose of this study was to investigate temporal trends in disparities in cancer-specific survival related to socioeconomic status in Ontario. METHODS: There were 920 334 cancer cases between 1993 and 2009 in the Ontario Cancer Registry. We linked median household income from the Canadian census to the registry. We calculated 5-year cancer-specific survival rates for all cancers combined and for specific cancer sites by socioeconomic status quintile and year of diagnosis, and modelled time to death using Cox regression. RESULTS: Between 1993 and 2009, for all cancers combined, the hazard of death decreased by 3.1% (hazard ratio [HR] 0.969 [95% confidence interval (CI) 0.967-0.971]) per year in the richest quintile and by 1.2% (HR 0.988 [95% CI 0.987-0.990]) per year in the poorest quintile. The corresponding values for breast cancer were 4.3% (HR 0.957 [95% CI 0.951-0.964]) and 2.0% (HR 0.980 [95% CI 0.975-0.986]); for lung cancer, 1.4% (HR 0.986 [95% CI 0.982-0.990]) and 0.3% (HR 0.997 [95% CI 0.995-1.000]); for colorectal cancer, 3.7% (HR 0.963 [95% CI 0.958-0.968]) and 1.8% (HR 0.982 [95% CI 0.978-0.985]); and for head and neck cancer, 3.1% (HR 0.969 [95% CI 0.958-0.979]) and 1.0% (HR 0.990 [95% CI 0.983-0.996]). INTERPRETATION: Between 1993 and 2009, cancer-specific survival in Ontario improved more among patients from affluent communities than among those from poorer communities. This phenomenon cannot be explained by increased disparity in income.

Simultaneous resection of primary colorectal cancer and synchronous liver metastases: a population-based study.

BACKGROUND: Simultaneous resection of primary colorectal cancer (CRC) and synchronous liver metastases (LM) is gaining interest. We describe management and outcomes of patients undergoing simultaneous resection in the general population. METHODS: All patients with CRC who underwent surgical resection of LM between 2002 and 2009 were identified using the population-based Ontario Cancer Registry and linked electronic treatment records. Synchronous disease was defined as having resection of CRCLM within 12 weeks of surgery for the primary tumour. RESULTS: During the study period, 1310 patients underwent resection of CRCLM. Of these, 226 (17%) patients had synchronous disease; 100 (44%) had a simultaneous resection and 126 (56%) had a staged resection. For the simultaneous and the staged groups, the mean number of liver lesions resected was 1.6 and 2.3, respectively (p < 0.001); the mean size of the largest lesion was 3.1 and 4.8 cm, respectively (p < 0.001); and the major hepatic resection rate was 21% and 79%, respectively (p < 0.001). Postoperative mortality for simultaneous cases at 90 days was less than 5%. Five-year overall survival and cancer-specific survival for patients with simultaneous resection was 36% (95% confidence interval [CI] 26%-45%) and 37% (95% CI 25%-50%), respectively. Simultaneous resections are common in the general population. A more conservative approach is being adopted for simultaneous resections by limiting the extent of liver resection. Postoperative mortality and long-term survival in this patient population is similar to that reported in other contemporary series. CONCLUSION: Compared with a staged approach, patients undergoing simultaneous resections had fewer and smaller liver metastases and underwent less aggressive resections. One-third of these patients achieved long-term survival.

CONTEXTE: La résection simultanée des cancers colorectaux primitifs et des métastases hépatiques synchrones suscitent de plus en plus d'intérêt. Nous décrivons la prise en charge et les résultats de patients de la population générale ayant subi une résection simultanée. MÉTHODES: Tous les patients atteints d'un cancer colorectal ayant bénéficié d'une résection chirurgicale des métastases hépatiques entre 2002 et 2009 ont été identifiés au moyen du Registre des cas de cancer de l'Ontario en population générale et des dossiers électroniques associés sur le traitement. La maladie synchrone a été définie comme le fait d'avoir subi une chirurgie de résection des métastases hépatiques du cancer colorectal dans les 12 semaines de la chirurgie de la tumeur primitive. RÉSULTATS: Pendant la période de l'étude, 1310 patients ont subi une résection des métastases hépatiques du cancer colorectal. Sur ce nombre, 226 (17 %) patients présentaient une maladie synchrone; 100 (44 %) patients ont subi une résection simultanée et 126 (56 %) patients ont subi une résection en 2 temps. Dans les groupes des résections simultanées et des résections en 2 temps, le nombre moyen de lésions hépatiques réséquées était de 1,6 et de 2,3, respectivement (p < 0,001); la taille moyenne de la lésion la plus importante était de 3,1 et de 4,8 cm, respectivement (p < 0,001) et le taux de résection hépatique majeure était de 21 % et de 79 %, respectivement (p < 0,001). La mortalité postopératoire après résection simultanée à 90 jours était inférieure à 5 %. La survie globale à 5 ans et la survie par cause des patients avec résection simultanée étaient de 36 % (intervalle de confiance [IC] de 95 %, 26 %-45 %) et de 37 % (IC 95 %, 25 %-50 %), respectivement. Les résections simultanées sont courantes au sein de la population générale. On commence à adopter une approche plus conservatrice pour les résections simultanées en limitant l'étendue de la résection hépatique. La mortalité postopératoire et la survie à long terme de cette population de patients sont semblables à celles signalées dans d'autres séries récentes. CONCLUSION: Comparativement à l'approche en 2 temps, les patients avec résections simultanées présentaient moins de métastases hépatiques et des métastases de plus petite taille, et les résections pratiquées étaient moins agressives. Le tiers de ces patients ont obtenu une survie à long terme.

Palliative Chemotherapy for Bladder Cancer: Treatment Delivery and Outcomes in the General Population.

BACKGROUND: Palliative chemotherapy for advanced bladder cancer is recommended in clinical practice guidelines because of the results achieved in clinical trials. However, real-world treatment and outcomes have not been well described. We report the treatment delivery and survival associated with palliative chemotherapy in routine clinical practice. MATERIALS AND METHODS: The population-based Ontario Cancer Registry was linked to electronic records of treatment to identify all patients with bladder cancer treated with palliative chemotherapy in Ontario during 1994 to 2008. Treatment regimens were identified for those cases treated at regional cancer centers. Overall survival (OS) and cancer-specific survival (CSS) were determined from the start of palliative chemotherapy. A Cox proportional hazards model was used to identify the factors associated with OS and CSS. RESULTS: The palliative chemotherapy regimen was identified for 710 patients with bladder cancer in Ontario during 1994 to 2008. Gemcitabine-cisplatin (Gem-Cis) was delivered to 37% (261 of 710), gemcitabine-carboplatin (Gem-Carbo) to 14% (96 of 710), and MVAC (methotrexate, vinblastine, Adriamycin, and cisplatin) to 8% (56 of 710). Other regimens were delivered to 42% of cases. The proportion of cases treated with Gem-Cis increased during the study period: 3% in 1994 to 1999, 32% in 2000 to 2003, and 52% in 2004 to 2008 (P < .001). The median survival and 5-year OS by regimen was 10 months and 16% for Gem-Cis, 7 months and 6% for Gem-Carbo, and 10 months and 13% for MVAC, respectively. Multivariate analysis controlling for age and comorbidity demonstrated improved survival for Gem-Cis and MVAC compared with Gem-Carbo (hazard ratio, 1.53; 95% confidence interval, 1.19-1.98). CONCLUSION: The median survival associated with palliative chemotherapy for bladder cancer in routine practice is slightly inferior to the outcomes reported in clinical trials. However, consistent with the clinical trial results, a proportion of patients treated with palliative chemotherapy will achieve long-term survival. Gem-Carbo is associated with inferior survival compared with Gem-Cis and MVAC in routine practice.

Utilization of pre-operative imaging for colon cancer: A population-based study.

OBJECTIVE: To assess the use of pre-operative imaging for colon cancer and to identify factors associated with utilization in routine clinical practice. METHODS: This population-based, retrospective cohort study used a random sample of 25% of colon cancer patients treated with surgery in the province of Ontario (2002-2008). Pre-operative imaging (<16 weeks from surgery) of the chest, abdomen-pelvis was identified. Modified poisson regression was used to analyze factors associated with practice patterns. RESULTS: Of the 7,249 included patients, 48% had pre-operative imaging (CT abdomen and imaging of the chest) in keeping with guideline recommendations. The rate of guideline concordant pre-operative imaging increased over time: 64% in the most recent study period (2006-2008) versus 31% (2002-2004); P < 0.001. Variables associated with use of chest imaging: Age, co-morbidity, surgeon volume, and geographic region; no association with gender, hospital volume, or socio-economic status. Variables associated with use of abdomen imaging: Hospital volume and geographic region; no association with age, gender, comorbidity, socio-economic status, or surgeon volume. CONCLUSION: In clinical practice, the majority of patients were not receiving pre-operative imaging that was in line with clinical practice guidelines; however, use increased over time indicating a possible association with dissemination of clinical practice guidelines. J. Surg. Oncol. 2017;115:202-207. © 2016 Wiley Periodicals, Inc.

The relationship between time to initiation of adjuvant chemotherapy and survival in breast cancer: a systematic review and meta-analysis.

BACKGROUND: It is known that adjuvant chemotherapy improves survival in women with breast cancer. It is not known whether the interval between surgery and the initiation of chemotherapy influences its effectiveness. PURPOSE: To determine the relationship between time to initiation of adjuvant chemotherapy and survival in women with breast cancer, through a systematic review of the literature and meta-analysis. METHODS: Systematic review of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Database of Controlled Trials, Google Scholar, and abstracts presented at major international oncology conferences. The primary meta-analysis included only high-validity studies which directly measured the time from surgery to initiation of adjuvant chemotherapy and which controlled for major prognostic factors. Outcomes reported in the original studies were converted to a regression coefficient (ß) and standard error corresponding to a 4-week delay in the initiation of chemotherapy. These relative risks were combined in both fixed- and random-effects models. Homogeneity was assessed by the Cochran χ 2 statistic and the I 2 statistic. Potential publication bias was investigated using standard error-based funnel plots. RESULTS: Meta-analysis of 8 high-validity studies demonstrated that a 4-week increase in TTAC was associated with a significant increase in the risk of death in both the fixed-effects model (RR 1.04; 95 % CI, 1.01-1.08) and random-effects model (RR 1.08; 95 % CI, 1.01-1.15). The association remained significant when the most highly weighted studies were sequentially removed from this analysis, and also when additional, lower validity studies were included in this analysis. Funnel plots showed no significant asymmetry to suggest publication bias. CONCLUSIONS: Increased waiting time from surgery to initiation of adjuvant chemotherapy is associated with a significant decrease in survival. Avoidance of unnecessary delays in the initiation of adjuvant chemotherapy has the potential to save the lives of many women with breast cancer.