Article

Factors associated with guideline-concordant use of radiotherapy after mastectomy in the national comprehensive cancer network.

Dana-Farber Cancer Institute, Boston, MA, USA.
International journal of radiation oncology, biology, physics (Impact Factor: 4.18). 06/2008; 72(5):1434-40. DOI: 10.1016/j.ijrobp.2008.03.020
Source: PubMed

ABSTRACT We examined the rates and determinants of appropriate and inappropriate use of postmastectomy radiotherapy (PMRT), as defined by the National Comprehensive Cancer Network (NCCN) practice guidelines, among women with Stage I-II breast cancer (American Joint Committee on Cancer, 5th edition).
Using clinical characteristics, 1,620 consecutive patients at eight NCCN institutions who had undergone mastectomy between July 1997 and June 2002 were classified into three cohorts according to whether the guidelines (1) recommended PMRT, (2) recommended against PMRT, or (3) made no definitive PMRT recommendation. We defined the absence of PMRT in the first cohort as underuse and receipt of PMRT in the second cohort as overuse. Multivariate logistic regression analysis was applied to investigate the association of clinical and sociodemographic factors with PMRT.
Overall, 23.8% of patients received PMRT. This included 199 (83.6%) of 238 in the "recommend PMRT" cohort, 58 (5.6%) of 1,029 in the "recommend against PMRT" cohort, and 127 (38.6%) of 329 in the "consider PMRT" cohort. The only factor associated with underuse in the "recommend PMRT" cohort was nonreceipt of chemotherapy (odds ratio [OR], 0.08; p <0.0001). In addition to tumor characteristics, the factors associated with overuse in the "recommend against PMRT" cohort included age <50 years (OR, 2.28; p = 0.048), NCCN institution (OR, 1.04-8.29; p = 0.026), higher education (OR, 3.49; p = 0.001), and no reconstructive surgery (OR, 2.44; p = 0.019). The factors associated with PMRT in the "consider PMRT" cohort included NCCN institution (OR, 1.1-9.01; p <0.0001), age <50 years (OR, 2.26; p = 0.041), and tumor characteristics.
The results of our study have shown that concordance with definitive treatment guidelines was high. However, when current evidence does not support a definitive recommendation for PMRT, treatment decisions appear to be influenced, not only by patient age and clinical characteristics, but also by institution-specific patterns of care.

0 Followers
 · 
81 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Although postmastectomy radiation therapy (PMRT) improves survival for patients with high-risk breast cancer, previous literature suggested that it is underused. The impact of recent clinical guidelines on PMRT use is unknown. Accordingly, the authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort to determine whether the use of PMRT has increased in response to evidence-based guidelines. In total, 38,322 women aged ≥66 years who underwent mastectomy for invasive breast cancer between 1992 and 2005 were identified. Time trends in the receipt of PMRT for low-risk (T1/T2 N0), intermediate-risk (T1/T2 N1), and high-risk (T3/T4 and/or N2/N3) patients were characterized. Multivariate logistic regression identified risk factors for PMRT omission. The receipt of PMRT by patients with high-risk breast cancer increased from 36.5% (95% confidence interval, 26%-46.9%) to 57.7% (95% confidence interval, 46.9%-68.4%) between 1996 and 1998 with the publication of landmark clinical trials. However no further increase in PMRT use was observed between 1999 and 2005 despite publication of multiple guidelines endorsing its use; during this period, only 54.8% (2729 of 4978) of high-risk patients received PMRT. Within this high-risk group, patients with smaller tumors or less advanced lymph node disease were at risk for PMRT omission. After an initial increase in PMRT use in response to clinical trials, the use of PMRT did not increase further in response to guideline publication, and nearly 50% of patients with high-risk breast cancer still do not receive PMRT. Additional research is needed to determine how clinical guidelines can be used to bridge the gap between level I evidence and clinical practice. Cancer 2011;. © 2011 American Cancer Society.
    Cancer 10/2011; 117(20):4595-605. DOI:10.1002/cncr.26081 · 4.90 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Breast radiation therapy (RT) is a care standard following breast-conservation surgery (BCS), improving local control and survival in women. But in 2004, a Phase III trial demonstrated radiation following BCS provides no survival and limited local control benefit to women aged ≥70 with Stage I, estrogen receptor–positive cancers, who receive endocrine therapy (ET).This led to BCS+ET alone being incorporated as a Category I option in National Comprehensive Cancer Network (NCCN) Guidelines in 2004 for older women. We examined factors associated with change in radiation use in elderly patients at 13 NCCN centers. Study Design We identified women treated at NCCN centers meeting age and stage criteria, during 2000-2009. Factors considered a priori potentially associated with RT use were evaluated in univariate and multivariable models, including year of diagnosis, tumor and patient characteristics, axillary surgery, and treating institution. Date of diagnosis was classified as 2000-2004 vs 2005-2009, reflecting when guidelines changed. Results Among 1292 eligible cases, 78% received RT. In multivariable analysis, diagnosis after 2004 (P=0.0003), older age (P<0.0001), higher co-morbidity score (P=0.0006), smaller tumors (P=0.0146), and omission of axillary surgery (P<0.0001) predicted RT omission. 94% of women aged 70-74 received RT in 2000, compared with 88% in 2009. For the same times and age ≥80 RT use was 80% vs 41%. Finally, RT use was associated with treating institution (P<0.0001). Conclusions Following guideline changes for RT use in older women, NCCN centers demonstrated wide variation in implementing change. This suggests other factors are also influencing guideline uptake.
    Journal of the American College of Surgeons 10/2014; 219(4). DOI:10.1016/j.jamcollsurg.2014.05.013 · 4.45 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The effect of combined high temperature and high pressure on the degradation of the four main cyanidin-3-glycosides in raspberries was investigated. Anthocyanin degradation accelerated with increasing temperature as well as with increasing pressure, revealing a synergistic effect of both process variables. Degradation rate constants were estimated using a first order kinetic model. Temperature and pressure dependence of the degradation rate constants were expressed as activation energies and activation volumes according to Arrhenius and Eyring equations, respectively. In search of statistical differences between the Ea–kref- and Va–kref-parameters estimated simultaneously, 90% joint confidence regions were constructed. A combined Arrhenius–Eyring model was found suitable to describe the combined temperature–pressure dependence of the degradation rate constants. Cyanidin-3-glucorutinoside showed the slowest degradation in comparison to the other cyanidins. Cyanidin-3-rutinoside experienced the smallest effect of temperature and the strongest effect of pressure compared to the others.
    Journal of Food Engineering 08/2011; 105(3):513-521. DOI:10.1016/j.jfoodeng.2011.03.015 · 2.58 Impact Factor

Preview

Download
4 Downloads
Available from