Urologists' referral and radiation oncologists' treatment patterns regarding high-risk prostate cancer patients receiving radiotherapy within 6 months after radical prostatectomy: A prospective cohort analysis.

INTRODUCTION: Previous studies have observed low rates of adjuvant radiotherapy after radical prostatectomy (RP) for high-risk prostate cancer patients. However, it is not clear the extent to which these low rates are driven by urologists' referral and radiation oncologists' treatment patterns. METHOD: The Clinician-Led Improvement in Cancer Care (CLICC) implementation trial was conducted in nine public hospitals in New South Wales, Australia. Men who underwent RP for prostate cancer during 2013-2015 and had at least one high-risk pathological feature of extracapsular extension, seminal vesicle invasion and/or positive surgical margins were included in these analyses. Outcomes were as follows: (i) referral to a radiation oncologist within 4 months after RP ('referred'); (ii) commencement of radiotherapy within 6 months after RP among those who consulted a radiation oncologist ('radiotherapy after consultation'). RESULTS: Three hundred and twenty-five (30%) of 1071 patients were 'referred', and 74 (61%) of 121 patients received 'radiotherapy after consultation'. Overall, the probability of receiving radiotherapy within 6 months after RP was 15%. The probability of being 'referred' increased according to higher 5-year risk of cancer-recurrence (P < 0.001). CONCLUSION: Only 30% of patients with high-risk features are referred to a radiation oncologist with the likelihood of referral being influenced by the perceived risk of cancer-recurrence as well as the urologist's institutional/personal preference. When patients are seen by a radiation oncologist, 61% receive radiotherapy within 6 months after RP with the likelihood of receiving radiotherapy not being heavily influenced by increasing risk of recurrence. This suggests many suitable patients would receive radiotherapy if referred and seen by a radiation oncologist.

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial.

BACKGROUND: This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations. METHODS: Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals' and study Sites' practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists' attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability. RESULTS: Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%). CONCLUSIONS: The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists' attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.

Changing attitudes towards management of men with locally advanced prostate cancer following radical prostatectomy: A follow-up survey of Australia-based urologists.

INTRODUCTION: This study examined whether there has been change among Australia-based urologists' knowledge, attitudes and beliefs relating to guideline-recommended adjuvant radiotherapy for men with adverse pathologic features following radical prostatectomy since a prior survey in 2012 and investigated associations between attitudes and treatment preferences. METHODS: A nationwide survey of Australia-based urologist members of the Urological Society of Australia and New Zealand. RESULTS: Ninety-six respondents completed the 2015 survey (30% response rate) compared with 157 (45% response rate) in 2012. There was no significant change in awareness of national clinical practice guidelines for the management of prostate cancer. When considering adjuvant against salvage radiotherapy, urologists were significantly less favourable towards adjuvant radiotherapy in 2015 than in 2012 for two of three hypothetical clinical case scenarios with a high 10-year risk of biochemical relapse according to Memorial Sloan Kettering Cancer Center nomograms (P < 0.001 for both cases). In 2015, urologists were less positive overall towards the recommendation for post-operative adjuvant radiotherapy for men with locally advanced prostate cancer than in 2012 (P < 0.001), reflecting a significant change across a number of attitudes and beliefs. Of note, urologists felt other urologists would more likely be critical if they routinely referred the target patient group for radiotherapy in 2015 compared with 2012 (P = 0.007). CONCLUSION: In 2015 Australia-based urologists were less favourable towards adjuvant radiotherapy over watchful waiting for men with high-risk pathologic features post-prostatectomy than in 2012. We could find no new published research that precipitated this change in attitude.

Knowledge, attitudes and beliefs towards management of men with locally advanced prostate cancer following radical prostatectomy: an Australian survey of urologists.

OBJECTIVE: To investigate Australian urologists' knowledge, attitudes and beliefs, and the association of these with treatment preferences relating to guideline-recommended adjuvant radiotherapy for men with adverse pathologic features following radical prostatectomy. SUBJECTS AND METHODS: A nationwide mailed and web-based survey of Australian urologist members of the Urological Society of Australia and New Zealand (USANZ). RESULTS: 157 surveys were included in the analysis (45% response rate). Just over half of respondents (54%) were aware of national clinical practice guidelines for the management of prostate cancer. Urologists' attitudes and beliefs towards the specific recommendation for post-operative adjuvant radiotherapy for men with locally advanced prostate cancer were mixed. Just over half agreed the recommendation is based on a valid interpretation of the underpinning evidence (54.1%, 95% CI [46%, 62.2%]) but less than one third agreed adjuvant radiotherapy will lead to improved patient outcomes (30.2%, 95% CI [22.8%, 37.6%]). Treatment preferences were varied, demonstrating clinical equipoise. A positive attitude towards the clinical practice recommendation was significantly associated with treatment preference for adjuvant radiotherapy (rho = 0.520, P < 0.0001). There was stronger preference for adjuvant radiotherapy in more recently trained urologists (registrars) while preference for watchful waiting was greater in more experienced urologists (consultants) (b = 0.156, P = 0.034; 95% CI [0.048, 1.24]). Urologists' attitudes towards clinical practice guidelines in general were positive. CONCLUSION: There remains clinical equipoise among Australian urologists in relation to adjuvant radiotherapy for men with adverse pathologic features following radical prostatectomy.

Multileaf Collimator Tracking Improves Dose Delivery for Prostate Cancer Radiation Therapy: Results of the First Clinical Trial.

PURPOSE: To test the hypothesis that multileaf collimator (MLC) tracking improves the consistency between the planned and delivered dose compared with the dose without MLC tracking, in the setting of a prostate cancer volumetric modulated arc therapy trial. METHODS AND MATERIALS: Multileaf collimator tracking was implemented for 15 patients in a prostate cancer radiation therapy trial; in total, 513 treatment fractions were delivered. During each treatment fraction, the prostate trajectory and treatment MLC positions were collected. These data were used as input for dose reconstruction (multiple isocenter shift method) to calculate the treated dose (with MLC tracking) and the dose that would have been delivered had MLC tracking not been applied (without MLC tracking). The percentage difference from planned for target and normal tissue dose-volume points were calculated. The hypothesis was tested for each dose-volume value via analysis of variance using the F test. RESULTS: Of the 513 fractions delivered, 475 (93%) were suitable for analysis. The mean difference and standard deviation between the planned and treated MLC tracking doses and the planned and without-MLC tracking doses for all 475 fractions were, respectively, PTV D99% -0.8% ± 1.1% versus -2.1% ± 2.7%; CTV D99% -0.6% ± 0.8% versus -0.6% ± 1.1%; rectum V65% 1.6% ± 7.9% versus -1.2% ± 18%; and bladder V65% 0.5% ± 4.4% versus -0.0% ± 9.2% (P<.001 for all dose-volume results). CONCLUSION: This study shows that MLC tracking improves the consistency between the planned and delivered doses compared with the modeled doses without MLC tracking. The implications of this finding are potentially improved patient outcomes, as well as more reliable dose-volume data for radiobiological parameter determination.

Adjuvant versus salvage radiotherapy following radical prostatectomy: do the AUA/ASTRO guidelines have all the answers?

Debate continues surrounding the indications for adjuvant and salvage radiotherapy as the published randomized trials have only addressed adjuvant treatment. Salvage radiotherapy has been advocated to limit significant toxicity to patients that would not have benefited from immediate adjuvant radiotherapy. The American Urological Association and American Society for Radiation Oncology guideline released in 2013 has since recommended offering adjuvant therapy to all patients with any adverse features and salvage to those with prostate-specific antigen or local recurrence. The suggested criteria is limited in its application as it potentially subjects patients with few adverse features to adjuvant therapy despite not qualifying as high risk according to established postoperative predictive tools such as the Kattan nomogram. This article reviews the indications for postoperative radiotherapy, limitations of the guideline and alternative prognostication tools for clinicians faced with biochemical or locally recurrent post-prostatectomy prostate cancer.

Clinician-led improvement in cancer care (CLICC)--testing a multifaceted implementation strategy to increase evidence-based prostate cancer care: phased randomised controlled trial--study protocol.

BACKGROUND: Clinical practice guidelines have been widely developed and disseminated with the aim of improving healthcare processes and patient outcomes but the uptake of evidence-based practice remains haphazard. There is a need to develop effective implementation methods to achieve large-scale adoption of proven innovations and recommended care. Clinical networks are increasingly being viewed as a vehicle through which evidence-based care can be embedded into healthcare systems using a collegial approach to agree on and implement a range of strategies within hospitals. In Australia, the provision of evidence-based care for men with prostate cancer has been identified as a high priority. Clinical audits have shown that fewer than 10% of patients in New South Wales (NSW) Australia at high risk of recurrence after radical prostatectomy receive guideline recommended radiation treatment following surgery. This trial will test a clinical network-based intervention to improve uptake of guideline recommended care for men with high-risk prostate cancer. METHODS/DESIGN: In Phase I, a phased randomised cluster trial will test a multifaceted intervention that harnesses the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network to increase evidence-based care for men with high-risk prostate cancer following surgery. The intervention will be introduced in nine NSW hospitals over 10 months using a stepped wedge design. Outcome data (referral to radiation oncology for discussion of adjuvant radiotherapy in line with guideline recommended care or referral to a clinical trial of adjuvant versus salvage radiotherapy) will be collected through review of patient medical records. In Phase II, mixed methods will be used to identify mechanisms of provider and organisational change. Clinicians' knowledge and attitudes will be assessed through surveys. Process outcome measures will be assessed through document review. Semi-structured interviews will be conducted to elucidate mechanisms of change. DISCUSSION: The study will be one of the first randomised controlled trials to test the effectiveness of clinical networks to lead changes in clinical practice in hospitals treating patients with high-risk cancer. It will additionally provide direction regarding implementation strategies that can be effectively employed to encourage widespread adoption of clinical practice guidelines. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910.

FROGG high-risk prostate cancer workshop: patterns of practice and literature review. Part II post-radical prostatectomy.

Australian and New Zealand radiation oncologists with an interest in uro-oncology were invited to undertake a pattern of practice survey dealing with issues encountered in the management of high-risk prostate cancer in the post-prostatectomy setting. Responses from practitioners revealed a lack of consensus regarding the optimal timing of radiation therapy, the use of whole pelvic radiation therapy and the use of androgen deprivation therapy. A review of the literature outlining the current body of knowledge and the clinical studies that will inform future practice is presented.

FROGG high-risk prostate cancer workshop: patterns of practice and literature review: part I: intact prostate.

Australian and New Zealand radiation oncologists with an interest in uro-oncology were invited to participate in a pattern-of-practice survey dealing with the management of intact high-risk prostate cancer. Responses from 46 practitioners (representing 73% of all potential respondents) revealed that high-dose radiation therapy is the standard of care. However, there is variability in practice with regard to the methods used to achieve dose escalation, the use of whole-pelvic radiation therapy and the optimal duration of androgen deprivation therapy employed. A review of the literature outlining the current body of knowledge and the planned and ongoing studies in intact high-risk prostate cancer is presented.

Health-related quality of life using intensity-modulated radiation therapy for post-prostatectomy radiotherapy.

INTRODUCTION: Post-prostatectomy radiotherapy (PPRT) with intensity-modulated radiation therapy (IMRT) has the potential to decrease toxicity by reducing dose to surrounding structures. We assessed its impact on health-related quality of life (HRQoL). METHODS: PPRT patients were enrolled in a prospective HRQoL database. To be eligible, patients were required to be treated with IMRT and have a minimum of 15-month follow up. HRQoL was assessed at baseline, 3, 9 and 15-24 months using the Expanded Prostate Cancer Index Composite questionnaire. Higher scores reflected better HRQoL. Results were analysed as both population means and as individual scores where a moderate change was 10-20 points and a substantial change was >20 points. RESULTS: There were 64 patients eligible and 83% of the cohort received salvage radiotherapy. Prescribed dose was 64 Gy in 32 fractions for adjuvant and 66 Gy in 33 fractions for salvage IMRT. Mean function scores for urinary, bowel and sexual domains were similar at baseline and 15 months (83.5, 94.2 and 16.9 vs. 82.2, 93.1 and 14.3, respectively). Mean global physical functioning (51.0 vs. 48.1) and mental functioning (51.6 vs. 54.2) showed no difference over time. Individual patient scores by 2 years showed a >20-point deterioration in urinary (12.5%), bowel (1.6%), sexual function (9.4%), physical functioning (3.1%) and mental functioning (1.6%). CONCLUSION: This report on HRQoL following post-prostatectomy IMRT demonstrates no variation in mean scores in any domain and only 1.6% of patients reporting a greater than 20-point deterioration between baseline and 15-24 months in bowel function.

Post-prostatectomy radiation therapy: consensus guidelines of the Australian and New Zealand Radiation Oncology Genito-Urinary Group.

BACKGROUND AND PURPOSE: Three randomised trials have demonstrated the benefit of adjuvant post-prostatectomy radiotherapy (PPRT) for high risk patients. Data also documents the effectiveness of salvage radiotherapy following a biochemical relapse post-prostatectomy. The Radiation Oncology Genito-Urinary Group recognised the need to develop consensus guidelines on to whom, when and how to deliver PPRT. MATERIALS AND METHODS: Draft guidelines were developed and refined at a consensus conference in June 2006 attended by 63 delegates where urological, radiotherapy and diagnostic imaging experts spoke on aspects of PPRT. Unresolved issues were further developed by working parties and redistributed until consensus was reached. RESULTS: Central to the recommendations is that patients with positive surgical margins, seminal vesicle invasion and/or extracapsular extension have a high risk of residual local disease and should be informed of the options of either immediate adjuvant radiotherapy or active surveillance with early salvage in the event of biochemical recurrence. Salvage radiotherapy should be instituted at the earliest confirmation of biochemical recurrence. Detailed contouring guidelines have been developed, defining the regions at risk of residual microscopic disease which should be included in the clinical target volume. The recommended doses are 60-64Gy for adjuvant, and 60-66Gy for salvage radiotherapy. The role of hormone therapy in conjunction with PPRT is yet to be defined. CONCLUSIONS: These consensus guidelines have been developed to give clinical and technical guidance to radiation oncologists and urologists in the management of high risk post-prostatectomy patients.

Concordance with national guidelines for colorectal cancer care in New South Wales: a population-based patterns of care study.

OBJECTIVE: To investigate predictors of evidence-based surgical care in a population-based sample of patients with newly diagnosed colorectal cancer. DESIGN, PATIENTS AND SETTING: Prospective audit of all new patients with colorectal cancer reported to the New South Wales Central Cancer Registry between 1 February 2000 and 31 January 2001. MAIN OUTCOME MEASURES: Concordance with seven guidelines from the 1999 Australian evidence-based guidelines for colorectal cancer; predictors of guideline concordance; the mean proportion of relevant guidelines followed for individual patients. RESULTS: Questionnaires were received for 3095 patients (91.6%). Between 0 and 100% of relevant guidelines were followed for individual patients (median, 67%). Concordance with individual guidelines varied considerably. Patient age independently predicted non-concordance with guidelines for adjuvant therapy and preoperative radiotherapy. Adjuvant chemotherapy was more likely if a patient with node-positive colon cancer was treated in a metropolitan hospital or by a general surgeon. Surgeons with a high caseload or specialty in colorectal cancer were more likely to perform colonic pouch reconstruction, prescribe thromboembolism or antibiotic prophylaxis, and were less likely to refer patients with high-risk rectal cancer for adjuvant radiotherapy. Bowel preparation was less likely among older patients and in high-caseload hospitals. CONCLUSION: Effective strategies to fully implement national colorectal cancer guidelines are needed. In particular, increasing the use of appropriate adjuvant therapy should be a priority, especially among older people.