-
Ewan K A Millar,
Peter H Graham,
Sandra A O'Toole,
Catriona M McNeil,
Lois Browne,
Adrienne L Morey,
Sarah Eggleton,
Julia Beretov,
Constantine Theocharous,
Anne Capp,
Elias Nasser,
John H Kearsley, Geoff Delaney,
George Papadatos,
Christopher Fox,
Robert L Sutherland
[show abstract]
[hide abstract]
ABSTRACT: To determine the clinical utility of intrinsic molecular phenotype after breast-conserving therapy (BCT) with lumpectomy and whole-breast irradiation with or without a cavity boost.
Four hundred ninety-eight patients with invasive breast cancer were enrolled into a randomized trial of BCT with or without a tumor bed radiation boost. Tumors were classified by intrinsic molecular phenotype as luminal A or B, HER-2, basal-like, or unclassified using a five-biomarker panel: estrogen receptor, progesterone receptor, HER-2, CK5/6, and epidermal growth factor receptor. Kaplan-Meier and Cox proportional hazards methodology were used to ascertain relationships to ipsilateral breast tumor recurrence (IBTR), locoregional recurrence (LRR), distant disease-free survival (DDFS), and death from breast cancer.
Median follow-up was 84 months. Three hundred ninety-four patients were classified as luminal A, 23 were luminal B, 52 were basal, 13 were HER-2, and 16 were unclassified. There were 24 IBTR (4.8%), 35 LRR (7%), 47 distant metastases (9.4%), and 37 breast cancer deaths (7.4%). The overall 5-year disease-free rates for the whole cohort were: IBTR 97.4%, LRR 95.6%, DDFS 92.9%, and breast cancer-specific death 96.3%. A significant difference was observed for survival between subtypes for LRR (P = .012), DDFS (P = .0035), and breast cancer-specific death (P = .0482), but not for IBTR (P = .346).
The 5-year and 10-year survival rates varied according to molecular subtype. Although this approach provides additional information to predict time to IBTR, LRR, DDFS, and death from breast cancer, its predictive power is less than that of traditional pathologic indices. This information may be useful in discussing outcomes and planning management with patients after BCT.
Journal of Clinical Oncology 09/2009; 27(28):4701-8. · 18.37 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We estimated the optimal chemotherapy utilisation rate for head and neck cancer as a benchmark for measuring and improving the quality of cancer care.
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.
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%.
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.
European journal of cancer (Oxford, England: 1990) 04/2009; 45(12):2150-9. · 4.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: No benchmarks exist in the screened breast cancer population to establish the optimal proportions of newly detected cancer patients who should receive the ideal treatment. The aim of the study was to estimate the optimal proportion of cases diagnosed in a breast-screening program who should receive treatment according to evidence-based cancer treatment guidelines and to compare these optimal rates with actual treatment rates. METHOD.: Optimal surgery, radiotherapy, chemotherapy, and hormone therapy utilization trees were constructed based on indications from evidence-based treatment guidelines. The proportions with clinical attributes that indicated a possible benefit from a particular treatment were obtained from epidemiologic data from BreastScreen Victoria. The optimal proportions of screen-detected breast cancer patients who should receive various therapies were then calculated using TreeAge software and compared with the actual proportions obtained from the epidemiologic data.
According to the best available evidence, the proportion of screen-detected breast cancer patients who have attributes suitable for various treatments are: breast-conserving surgery (BCS) 85%, mastectomy 15%, radiotherapy 87%, chemotherapy 34%, and hormonal therapy 68%. The actual BCS utilization rate in Victoria was similar to the optimal rate (79% vs 85%), whereas there appeared to be underuse of radiotherapy (62% vs 87%), chemotherapy (19% vs 34%), and hormonal therapy (49% vs 68%) when compared with guideline recommendations.
This research provided optimal treatment utilization rates for screen-detected breast cancer and a comparison of best practice evidence and actual treatment. The results showed comparable rates for surgery but suggested underutilization of radiotherapy, chemotherapy, and hormone therapy.
Cancer 06/2008; 112(9):1912-22. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: 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.
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.
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.
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.
International journal of radiation oncology, biology, physics 05/2008; 72(3):849-58. · 4.59 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Recent literature has suggested that follow- up visits provide psychological support for patients with cancer, but largely without objective evidence.
To examine the psychological impact of follow-up consultations on cancer patients and identify factors that influence patient anxiety.
Patients attending a routine follow-up at Liverpool Cancer Therapy Centre were surveyed. Using the State & Trait Anxiety Inventory (STAI), anxiety scores were obtained before and after consultation.
Two hundred and thirty-one patients participated, 199 patients were treated with curative intent, 62% were male. The mean anxiety score was higher in females and in palliative cases. Lower levels of social support, poor perception of own health and receiving bad news during consultation were associated with higher STAI scores. Satisfaction with cancer treatment was associated with lower STAI scores. There was a small but statistically significant reduction of anxiety scores after consultation (p = 0.02).
When measured objectively, specialist consultation appears to have a small, but statistically significant, positive impact on the level of patient anxiety. Patient satisfaction correlated well with the patient anxiety levels.
Journal of Psychosocial Oncology 02/2008; 26(1):17-30. · 0.98 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The frequency of diagnosis of ductal carcinoma in situ (DCIS) has increased in Australia, largely because of the national screening programme. Ductal carcinoma in situ presents a dilemma because of problems with its diagnosis and variations in reporting pathological and radiological findings, making it difficult to define optimal treatment and communicate information in a way that helps the patient understand the problems and make decisions. There is considerable inter-observer variation, particularly in differentiating low-grade DCIS from ductal hyperplasia, with or without atypia, but pathologists who participate in regular pathological review sessions vary less in their opinions. Mammography remains the main investigative tool for DCIS and the American College of Radiology has recommended standardized reports. A team approach is required for the removal and diagnosis of possible DCIS. Although the team may be best co-located in the one facility, this is not practical in many community hospital settings which lack on-site radiology and pathology services. The decision about how much breast tissue to remove will need to be made for each patient and depends on the size of the microcalcification and how suspicious the mammogram is for DCIS. We recommend the use of synoptic reports for DCIS, and we document the minimum factors that should be reported by pathologists. The evaluation and management of DCIS by a multidisciplinary team will allow the patient access to information required to make often difficult treatment decisions. In this paper, we review the literature about the natural history, pathology, cytology and radiology of DCIS and document the 20 critical steps required for the diagnosis of impalpable, mammographic microcalcifications suspected to be DCIS.
ANZ Journal of Surgery 01/2008; 67(2‐3):81 - 93. · 1.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Survival benefits from radiotherapy for breast cancer described in randomised trials represent only those patients eligible for trials. We estimated the benefit of radiotherapy as an adjuvant treatment for the entire population of breast cancer patients if evidence-based treatment guidelines were followed.
Evidences on 10-year local control and overall survival gain (radiotherapy vs no radiotherapy) were identified from review of literature. The data were incorporated into the optimal radiotherapy utilization tree that we previously reported for all categories of breast cancer patients and overall local control and survival benefits were estimated.
The gains in 10-year local control and overall survival from optimal treatment of all breast cancer patients were 11.1% (95% CI 10.8-11.2%) and 3.1% (95% CI 3.0-3.4%), respectively. The stage-based estimates in local control and survival benefit were: 8% and 0% for Ductal Carcinoma in situ (DCIS), 12% and 2% for stage I-II cancers and 13% and 20% for stage III cancers.
Our model was able to estimate the contribution of radiotherapy in breast cancer treatment if all patients were treated according to the recommended guidelines. These estimates could be used to benchmark population-based survival reports and to assess the cost-effectiveness of radiotherapy for breast cancer treatment.
Radiotherapy and Oncology 07/2007; 84(1):11-7. · 5.58 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Brachytherapy (BT) is an integral part of cervical carcinoma treatment. There have been no attempts to estimate the optimal proportion of new cervical carcinoma cases that should be treated with BT, that is, the optimal rate of brachytherapy utilization (BTU).
Evidence-based guidelines and primary evidence were used to construct a BTU tree for carcinoma of the uterine cervix. Searches were performed of the epidemiological literature to ascertain the proportion of patients who fulfilled criteria for BT. The robustness of the model was tested by sensitivity analyses and by peer review. A patterns of care study of BT in New South Wales for 2003 was conducted, and actual BTU for cervical carcinoma determined. The differences between optimal and actual rates of BTU were assessed.
The optimal cervical carcinoma BTU was 49% (range, 42% to 50%). In New South Wales in 2003, actual BTU was only 30% of 256 cervical carcinoma patients. The major discrepancy was for FIGO stage IB-IIA disease, where there was an underutilization of BT, estimated to be 15% actual use compared with 47% optimal use. In Surveillance, Epidemiology, and End Results (SEER) areas, there was underutilization for stage IB-IIA (22% actual BTU versus 47% optimal BTU) and for stage IIB-IVA (54% actual BTU versus 100% optimal BTU).
BT for cervical carcinoma is underutilized in New South Wales and in SEER areas. The authors' model of optimal BTU can be used as a quality assurance tool to provide an evidence-based benchmark against which actual patterns of practice can be measured. The model can also be used to help determine adequacy of BT resource allocation.
Cancer 01/2007; 107(12):2932-41. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND.Brachytherapy (BT) is an integral part of cervical carcinoma treatment. There have been no attempts to estimate the optimal proportion of new cervical carcinoma cases that should be treated with BT, that is, the optimal rate of brachytherapy utilization (BTU).METHODS.Evidence-based guidelines and primary evidence were used to construct a BTU tree for carcinoma of the uterine cervix. Searches were performed of the epidemiological literature to ascertain the proportion of patients who fulfilled criteria for BT. The robustness of the model was tested by sensitivity analyses and by peer review. A patterns of care study of BT in New South Wales for 2003 was conducted, and actual BTU for cervical carcinoma determined. The differences between optimal and actual rates of BTU were assessed.RESULTS.The optimal cervical carcinoma BTU was 49% (range, 42% to 50%). In New South Wales in 2003, actual BTU was only 30% of 256 cervical carcinoma patients. The major discrepancy was for FIGO stage IB-IIA disease, where there was an underutilization of BT, estimated to be 15% actual use compared with 47% optimal use. In Surveillence, Epidemiology, and End Results (SEER) areas, there was underutilization for stage IB-IIA (22% actual BTU versus 47% optimal BTU) and for stage IIB-IVA (54% actual BTU versus 100% optimal BTU).CONCLUSIONS.BT for cervical carcinoma is underutilized in New South Wales and in SEER areas. The authors' model of optimal BTU can be used as a quality assurance tool to provide an evidence-based benchmark against which actual patterns of practice can be measured. The model can also be used to help determine adequacy of BT resource allocation. Cancer 2006. © 2006 American Cancer Society.
Cancer 11/2006; 107(12):2932 - 2941. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this one in a series of articles, the objective was to estimate the ideal proportion of patients with cancer who should receive radiotherapy at least once during the course of their illness based on the best available evidence. This estimate should be useful in planning for future radiotherapy facilities. Optimal rates of radiotherapy for patients with central nervous system (CNS) carcinoma, thyroid carcinoma, or carcinoma of unknown primary site (CUP) have not been studied previously.
A systematic review of evidence-based treatment guidelines for the treatment of CNS carcinoma, CUP, and thyroid carcinoma was undertaken. An optimal radiotherapy utilization tree was constructed for each of these malignancies depicting the indications for radiotherapy at various stages of disease. The proportion of patients who had clinical attributes that indicated a possible benefit from radiotherapy was calculated by adding epidemiological data to the radiotherapy utilization tree. The optimal proportion of patients who should receive radiotherapy was then calculated using specialized decision-analysis software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed.
The optimal rates of radiotherapy utilization for carcinoma of the CNS, thyroid carcinoma, and CUP were 92%, 10%, and 61%, respectively. Comparison with actual rates of utilization in South Australia, Sweden, and the U.S. suggested an under-utilization of radiotherapy for CNS carcinoma and CUP. However, the actual rates of radiotherapy for thyroid carcinoma exceeded the optimal rate for some jurisdictions, although some data may have included radioactive iodine, which was not included in the current project.
It was possible to estimate optimal radiotherapy utilization rates based on evidence. This methodology allowed a comparison of optimal rates with actual rates to identify areas in which improvements in the evidence-based use of radiotherapy can be made, and it may provide valuable data for future radiotherapy service planning.
Cancer 02/2006; 106(2):453-65. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND
In this one in a series of articles, the objective was to estimate the ideal proportion of patients with cancer who should receive radiotherapy at least once during the course of their illness based on the best available evidence. This estimate should be useful in planning for future radiotherapy facilities. Optimal rates of radiotherapy for patients with central nervous system (CNS) carcinoma, thyroid carcinoma, or carcinoma of unknown primary site (CUP) have not been studied previously.METHODSA systematic review of evidence-based treatment guidelines for the treatment of CNS carcinoma, CUP, and thyroid carcinoma was undertaken. An optimal radiotherapy utilization tree was constructed for each of these malignancies depicting the indications for radiotherapy at various stages of disease. The proportion of patients who had clinical attributes that indicated a possible benefit from radiotherapy was calculated by adding epidemiological data to the radiotherapy utilization tree. The optimal proportion of patients who should receive radiotherapy was then calculated using specialized decision-analysis software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed.RESULTSThe optimal rates of radiotherapy utilization for carcinoma of the CNS, thyroid carcinoma, and CUP were 92%, 10%, and 61%, respectively. Comparison with actual rates of utilization in South Australia, Sweden, and the U.S. suggested an under-utilization of radiotherapy for CNS carcinoma and CUP. However, the actual rates of radiotherapy for thyroid carcinoma exceeded the optimal rate for some jurisdictions, although some data may have included radioactive iodine, which was not included in the current project.CONCLUSIONS
It was possible to estimate optimal radiotherapy utilization rates based on evidence. This methodology allowed a comparison of optimal rates with actual rates to identify areas in which improvements in the evidence-based use of radiotherapy can be made, and it may provide valuable data for future radiotherapy service planning. Cancer 2006. © 2005 American Cancer Society.
Cancer 01/2006; 106(2):453 - 465. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Radiotherapy utilization rates for cancer vary widely internationally. It has previously been suggested that approximately 50% of all cancer patients should receive radiation. However, this estimate was not evidence-based. The aim of this study was to estimate the ideal proportion of new cases of cancer that should receive radiotherapy at least once during the course of their illness based on the best available evidence. An optimal radiotherapy utilization tree was constructed for each cancer based upon indications for radiotherapy taken from evidence-based treatment guidelines. The proportion of patients with clinical attributes that indicated a possible benefit from radiotherapy was obtained by adding epidemiologic data to the radiotherapy utilization tree. The optimal proportion of patients with cancer that should receive radiotherapy was then calculated using TreeAge (TreeAge Software, Williamstown, MA) software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed. The proportion of patients with cancer in whom external beam radiotherapy is indicated according to the best available evidence was calculated to be 52%. Monte Carlo analysis indicated that the 95% confidence limits were from 51.7% to 53.1%. The tightness of the confidence interval suggests that the overall estimate is robust. Comparison with actual radiotherapy utilization data suggests a shortfall in actual radiotherapy delivery. This methodology allows comparison of optimal rates with actual rates to identify areas where improvements in the evidence-based use of radiotherapy can be made. It provides valuable data for radiotherapy service planning. Actual rates need to be addressed to ensure better radiotherapy utilization.
Cancer 10/2005; 104(6):1129-37. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Radiotherapy is used commonly in the treatment of patients with head and neck carcinoma. The benchmark radiotherapy utilization rates for head and neck carcinoma largely are unknown. The objective of the current study was to determine the optimal radiotherapy utilization rate for patients with head and neck carcinoma and to compare this optimal rate with actual utilization rates where actual utilization data were available.
An optimal radiotherapy utilization tree was constructed that depicted all patients with head and neck carcinoma in whom radiotherapy was indicated according to evidence-based treatment guidelines. The proportions of patients with clinical attributes that indicated possible benefit from radiotherapy were obtained from epidemiological data and were inserted into the utilization tree. The optimal proportion of patients with carcinoma of the head and neck who should receive radiotherapy was calculated by merging the evidence-based recommendations with the epidemiological data in the tree. Optimal rates of radiotherapy utilization were compared with actual rates obtained from population-based studies.
Radiotherapy was indicated at some point during their illness in 74% of all patients with head and neck carcinoma. By subsite, the optimal radiotherapy utilization rates were oral cavity, 74%; lip, 20%; larynx, 100%; oropharynx, 100%; salivary gland, 87%; hypopharynx, 100%; nasopharynx, 100%; paranasal sinuses, 100%; and unknown squamous cell carcinoma of the head and neck, 90%. All treatment recommendations were based on Level III or IV evidence. Assessment of actual radiotherapy utilization rates indicated an increased use of radiotherapy over time for head and neck carcinoma. However, there also were some decreases in the use of radiotherapy for some carcinoma subsites over the past 20 years, despite the lower actual rates compared with the optimal rates. The reasons for these reductions in use were not identified.
The actual radiotherapy utilization rate for patients with head and neck carcinoma corresponded reasonably closely to the optimal rate for some populations but also identified some shortfalls for other patient groups. The results of this study provide a way of assessing shortfalls in radiotherapy.
Cancer 07/2005; 103(11):2216-27. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Benchmark radiotherapy utilization rates for genitourinary malignancies are largely unknown, despite the finding that genitourinary cancers comprise approximately 19% of all registered malignancies in Australia.
To develop an evidence-based benchmark of the optimal proportion of patients with genitourinary malignancies who should receive at least one course of radiotherapy at some time during their illness, the authors studied treatment guidelines and treatment reviews regarding genitourinary malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes that indicated possible benefit from radiotherapy based on evidence. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with genitourinary cancer for whom radiotherapy was considered appropriate.
The proportion of patients with genitourinary malignancies for whom radiotherapy was indicated at some point in their illness, according to the best available evidence, was estimated to be 27% of patients with renal cancer, 58% of patients with bladder cancer, 60% of patients with prostate cancer, and 49% of patients with testicular cancer. The occurrence of ureteric and penile cancers among patients was too rare, and, therefore, these patients were not included in the current study.
There was a large discrepancy between actual radiotherapy utilization and the evidence-based optimal rate. The authors recommended strategies to implement the evidence-based guidelines. Evidence-based benchmarks for radiotherapy utilization rates such as the ones described in the current study were important in the evaluation of the appropriate use of radiotherapy.
Cancer 03/2005; 103(3):462-73. · 4.77 Impact Factor
-
Geoff Delaney
[show abstract]
[hide abstract]
ABSTRACT: The past decade has seen significant advances in the delivery of radiotherapy for breast cancer. This article presents an overview of the most recent advances in radiotherapy for early breast cancer with emphasis on English-language articles published since 1 July 2003.
Breast radiotherapy is usually well tolerated. However, the uptake of radiotherapy in the management of breast cancer is less than ideal. Recent research efforts in radiation oncology have concentrated on addressing the uptake of appropriate radiotherapy by quantifying toxicity, further reducing toxicity, and improving the convenience of radiotherapy. Novel radiation techniques such as partial breast irradiation and shortened radiotherapy treatment courses are under development to make radiotherapy more acceptable to patients and referring clinicians. Issues such as the optimal timing of radiotherapy after surgery and integrating the radiation with newer adjuvant systemic therapies remain important research challenges.
Radiotherapy remains an important component of breast cancer therapy. Improving the acceptance of treatment and minimizing toxicity and inconvenience of treatment should lead to even greater appropriate use.
Current Opinion in Obstetrics and Gynecology 03/2005; 17(1):27-33. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Tangential radiotherapy delivered to women with large breasts can be problematic due to the excessive skin folds and the way that the breast falls into the axilla. This may necessitate excessive lung irradiation to cover the posterior part of the breast volume adequately. Conventional breast rings used to move the breast anteriorly can be very difficult to reproduce and may substantially increase the skin dose and hence skin toxicity due to the bolus effect. An in-house designed microshell device was constructed to improve setup reproducibility and minimize skin dose. Dose comparisons using a phantom were made between this device and 2 other commonly used devices. The microshell successfully reduced the surface dose compared to the other breast rings tested. This device was then investigated on 8 patients under clinical conditions. Skin doses measured on the trial patients were within acceptable limits. During this small pilot study, no patients suffered excessive skin toxicity or required treatment breaks. Due to the microshell's expandable nature, ease of application, which increases patient comfort compared to other breast rings, and the lower surface dose, the microshell is the preferred breast stabilization device for this department when treating patients with large pendulous breasts. We encourage other departments to consider their current method of breast stabilization and compare them to our results.
Medical Dosimetry 02/2005; 30(1):31-5. · 1.00 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The objective of this study was to estimate the ideal proportion of new patients with lymphoma who should receive radiotherapy at some time during the course of their illness, based on the best evidence.
Available evidence of the efficacy of radiotherapy in most clinical situations for lymphoma were identified through extensive literature reviews and treatment guideline searches. Epidemiologic data concerning the distribution of histologic type, disease stage, and other factors that influence the use of radiotherapy were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiologic data to calculate the optimal proportion of patients who should receive radiotherapy according to the best available evidence. Actual radiotherapy utilization rates also were identified.
The proportion of patients with lymphoma in Australia that should receive radiotherapy at some point in their management, according to the best available evidence, was calculated at 65.0%. Multivariate analysis with a Monte Carlo simulation yielded a radiotherapy utilization rate of 64.4%. The actual utilization rates of radiotherapy for lymphoma reported in clinical practice were 22-29%, substantially lower than the optimal rate calculated in this project.
Further research will be required to identify why more patients who are diagnosed with lymphoma are not treated with radiotherapy.
Cancer 02/2005; 103(2):383-92. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The objective of this study was to estimate the ideal proportion of new patients with leukemia and myeloma who should receive radiotherapy at some time during the course of their illness based on the best evidence.
Available evidence of the efficacy of radiotherapy in most clinical situations for leukemia and myeloma was identified through extensive literature reviews and treatment guideline searches. Epidemiologic data concerning the distribution of types, disease stages, and other factors that influence the use of radiotherapy were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiological data to calculate the optimal proportion of patients who should receive radiotherapy according to the best available evidence. Actual radiotherapy utilization rates also were identified.
The proportion of patients diagnosed with myeloma in Australia who should receive radiotherapy based on the evidence was 38%. There was wide variation in the proportion of patients who actually received radiotherapy for myeloma from 24% up to 55%. The recommended proportion of patients diagnosed with myeloma in Australia who, according to the best available evidence, should receive at least a single course of radiotherapy was 38%. The proportion of patients diagnosed in Australia with leukemia who should receive radiotherapy at some point in their management, according to the best available evidence, was calculated at 4%, which corresponded with actual practice.
Further research will be required to determine why more patients who are diagnosed with myeloma are not treated with radiotherapy.
Cancer 02/2005; 103(2):393-401. · 4.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To assess whether oral sucralfate is effective in preventing late rectal injury in prostate cancer patients treated with radiotherapy.
A double-blind, placebo-controlled, randomized trial was conducted across four institutions in Australia. Patients receiving definitive radiotherapy for prostate cancer were randomized to receive either 3 g of oral sucralfate suspension or placebo twice daily. Data on patients' symptoms were collected for 2 years, and flexible sigmoidoscopy was scheduled at 12 months after treatment.
A total of 338 patients were randomized, of whom 298 had adequate follow-up data available for an analysis of late symptoms. Of the 298 patients, 143 were randomized to receive sucralfate and 155 placebo. The cumulative incidence of Radiation Therapy Oncology Group Grade 2 or worse late rectal toxicity at 2 years was 28% for placebo and 22% for the sucralfate arm (p = 0.23; 95% confidence interval for the difference -3% to 16%). Seventeen percent of patients in the sucralfate group had significant bleeding (Grade 2 or worse) compared with 23% in the placebo group (p = 0.18, 95% confidence interval -15% to 3%). No statistically significant difference was found between the two groups with respect to bowel frequency (p = 0.99), mucus discharge (p = 0.64), or fecal incontinence (p = 0.90). Sigmoidoscopy findings showed a nonstatistically significant reduction in Grade 2 or worse rectal changes from 32% with placebo to 27% in the sucralfate group (p = 0.25).
This trial demonstrated no statistically significant reduction in the incidence of late rectal toxicity in patients randomized to receive sucralfate. However, this result was considered inconclusive, because the trial was unable to exclude clinically important differences in the late toxicity rates.
International Journal of Radiation OncologyBiologyPhysics 12/2004; 60(4):1088-97. · 4.11 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Radiotherapy usage rates exhibit wide variations both within and between countries. Current estimates of the proportion of cancer patients who should optimally receive radiotherapy are based either on expert opinion or on the measurement of actual usage rates rather than on the best available scientific evidence.
With the goal of developing an evidence-based benchmark for radiotherapy use in the treatment of malignancies of the cervix, vagina, vulva, and ovary (endometrial malignancies are covered in a separate article), the authors reviewed international evidence-based treatment guidelines. Optimal radiotherapy usage trees were constructed, and proportions of patients with clinical indications for radiotherapy were obtained from epidemiologic data. These ideal usage rates were compared with actual radiotherapy utilization rates recorded in Australia and elsewhere.
According to the best available evidence, radiotherapy is indicated at least once for 58% of patients with cervical carcinoma, 4% of patients with ovarian carcinoma, 100% of patients with vaginal carcinoma, and 34% of patients with vulvar carcinoma. A review of the limited data available suggests that actual radiotherapy usage rates for patients with gynecologic malignancies are comparable to optimal usage rates.
Actual practice appears to approximate the authors' model of optimal radiotherapy use. This finding reflects the high level of agreement among treatment guidelines as well as the existence of high-quality evidence related to the management of gynecologic malignancies, and it may also be indicative of the fact that a large proportion of patients are treated in specialist units. The management of gynecologic malignancies may serve as a good example in the development of management strategies for other types of cancer.
Cancer 09/2004; 101(4):671-81. · 4.77 Impact Factor
