Allison Ashworth

A Population-Based Study of the Fractionation of Postlumpectomy Breast Radiation Therapy

PURPOSEnThe optimal fractionation schedule of post lumpectomy radiation therapy remains controversial. The objective of this study was to describe the fractionation of post-lumpectomy radiation therapy (RT) in Ontario, before and after the seminal Ontario Clinical Oncology Group (OCOG) trial, which showed the equivalence of 16- and 25-fraction schedules.nnnMETHODS AND MATERIALSnThis was a retrospective cohort study conducted by linking electronic treatment records to a population-based cancer registry. The study population included all patients who underwent lumpectomy for invasive breast cancer in Ontario, Canada, between 1984 and 2008.nnnRESULTSnOver the study period, 41,747 breast cancer patients received post lumpectomy radiation therapy to the breast only. Both 16- and 25-fraction schedules were commonly used throughout the study period. In the early 1980s, shorter fractionation schedules were used in >80% of cases. Between 1985 and 1995, the proportion of patients treated with shorter fractionation decreased to 48%. After completion of the OCOG trial, shorter fractionation schemes were once again widely adopted across Ontario, and are currently used in about 71% of cases; however, large intercenter variations in fractionation persisted.nnnCONCLUSIONSnThe use of shorter schedules of post lumpectomy RT in Ontario increased after completion of the OCOG trial, but the trial had a less normative effect on practice than expected.

Fractionation of Palliative Radiation Therapy for Bone Metastases in Ontario: Do Practice Guidelines Guide Practice?

PURPOSEnTo evaluate the effect of a provincial practice guideline on the fractionation of palliative radiation therapy for bone metastases (PRT.B) in Ontario.nnnMETHODS AND MATERIALSnThe present retrospective study used electronic treatment records linked to Ontarios population-based cancer registry. Hierarchical multivariable regression analysis was used to evaluate temporal trends in the use of single fractions (SFs), controlling for patient-related factors associated with the use of SFs.nnnRESULTSnFrom 1984 to 2012, 43.9% of 161,835 courses of PRT.B were administered as SFs. The percentage of SF courses was greater for older patients (age <50 years, 39.8% vs age >80 years, 52.5%), those with a shorter life expectancy (survival >12 months, 36.9% vs < 1 month, 53.6%), and those who lived farther from a radiation therapy center (<10 km, 42.1% vs > 50 km, 47.3%). The percentage of SFs to spinal fields was lower than that to other skeletal sites (31.5% vs 57.1%). The percentage of SFs varied among the cancer centers (range, 26.0%-67.8%). These differences were all highly significant in the multivariable analysis (P<.0001). In 2004, Cancer Care Ontario released a practice guideline endorsing the use of SFs for uncomplicated bone metastases. The rate of use of SFs increased from 42.3% in the pre-guideline period (1999-2003) to 52.6% in the immediate post-guideline period (2004-2007). However, it subsequently decreased again to 44.0% (2009-2012). These temporal trends were significant after controlling for patient-related factors in the multivariable analysis (P<.0001). Large intercenter variations in the use of SFs persisted after publication of the guideline.nnnCONCLUSIONSnThe publication of an Ontario practice guideline endorsing the use of SF PRT.B was associated with only a transient increase in the use of SFs in Ontario and did little to reduce intercenter variations in fractionation.

Moving toward uniform and evidence-based practice of radiotherapy for management of cervical cancer in Ontario, Canada

PURPOSEnTo recognize the practice of radiotherapy for management of cervical cancer in Ontario, Canada, and to use the results of the survey to harmonize and standardize practice across the province.nnnMETHODS AND MATERIALSnAn electronic survey (SurveyMonkey) was sent to all 14 provincial cancer centers by Cancer Care Ontario Gynecology Community of Practice (CoP) in 2013. The survey included 72 questions in four different categories: general/demographic, pretreatment assessment, external beam radiotherapy (EBRT), and brachytherapy (BT).nnnRESULTSnTen of 14 centers treated cervical cancer patients and had a dedicated BT suite. All 10 centers had a peer review process for quality assurance. EBRT technique was a 4-field box in eight of 10 centers. The dose/fractionation for pelvic EBRT was 45-50xa0Gy in 1.8-2xa0Gy/fraction in all but one center. Nine of 10 centers used high-dose-rate BT. Only one center offered interstitial BT. For treatment planning, two centers used CT and MRI, five centers used CT, and three centers used orthogonal x-rays. Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology guidelines were used in four of seven of the centers for target volume delineation and in five of seven centers for organs at risk dose constraints. All but one center prescribed and reported dose to Point A.nnnCONCLUSIONSnThe survey identified areas where practice varied across the province. Gynecology CoP used this information to identify priorities for practice change and implemented several strategies to harmonize the care of women with cervical cancer. This highlights the value of interdisciplinary, grass-roots initiatives such as CoPs to standardize practice in a practical manner that directly benefits patients.

Causes of death and subsequent treatment after initial radical or palliative therapy of stage III non-small-cell lung cancer

INTRODUCTIONnStage iii lung cancer is the most advanced stage of lung cancer for which radical (potentially curative) treatment is often discussed. Understanding the reasons for mortality and subsequent treatments in patients with stage iii non-small-cell lung cancer (nsclc) is important.nnnMETHODSnThis retrospective cohort study extracted demographic, clinical, treatment, and outcomes data for patients with newly diagnosed stage iii nsclc diagnosed between 1 January 2008 and 31 December 2012 at a single institution.nnnRESULTSnThe study included 237 patients with stage iii nsclc, 130 of whom were not treated with radical or curative intent (55%). Median survival in the entire cohort was 14 months from diagnosis. For patients treated with radical-intent therapy, causes of death varied with the time period. The hazard rate for death was approximately 2.8 per 100 person-months of follow-up over the entire disease course and was highest between 6 months and 24 months. Over the entire time period, local causes accounted for 29% of deaths; systemic non-central nervous system metastases, for 25%; and brain metastases, for 14%. For patients treated with palliative intent, the overwhelming cause of death was local disease complications or progression (56% of deaths). Only 12% of patients in the palliative treatment group who progressed received subsequent chemotherapy; 23% of patients in the radical group who progressed received palliative chemotherapy. The most frequent subsequent treatment in both groups was radiation therapy.nnnCONCLUSIONSnThe eventual life-ending event in stage iii nsclc varied for the patients who qualified for, and were treated with, radical or curative intent and for the patients who received palliative-intent therapy. Utilization of systemic chemotherapy in patients not fit for radical therapy is low.

Multidisciplinary Clinics in Lung Cancer Care: A Systematic Review

&NA; Multidisciplinary cancer clinics (MDCCs) are recognized in cancer care as an alternate model of care for lung cancer patients. However, the precise MDCC characteristics that could potentially improve the quality of care in lung cancer care have not been clearly defined. We performed a systematic review of the data regarding MDCCs in the treatment of patients with lung cancer to summarize and evaluate the available evidence and to determine valuable clinic characteristics and projected outcomes. We searched Embase, Cochrane, Medline, PubMed, and Web of Science through April 2017 for studies that included ≥ 2 physician specialties in a MDCC for lung cancer. A total of 2374 unique articles were identified, of which 13 met the inclusion criteria. All the studies were either retrospective or qualitative, with many having small sample sizes. The most commonly reported quantitative outcome for MDCCs was a decreased time from diagnosis to treatment; however, this was only statistically significant in 2 studies. Evidence was conflicting regarding improved patient survival. Several studies of MDCCs reported improved qualitative outcomes, including increased patient satisfaction, increased collaboration, and cohesive communication among care providers, although the sample sizes were small. The few studies of MDCCs that included a care coordinator, in addition to physicians from multiple specialties, reported improvements in patient satisfaction. Overall, our review of the reported data revealed a paucity of evidence regarding the value of MDCCs for lung cancer patients, highlighting the need for further studies to understand the optimal medical model to deliver care.

916 Evaluation of a multidisciplinary cancer clinic: improving time to oncology assessment and treatment for patients with new lung cancer

Background Delays in the management of lung cancer (LC) are associated with inferior outcomes. Multidisciplinary cancer clinics (MDCC) can improve timeliness and quality of care. Objectives Decrease time from LC diagnosis to oncology assessment from 13 to 3 days, and to treatment from 30 to <20 days, within 6 months. Methods We implemented a weekly MDCC, involving Respirologists, Medical Oncologists (MO) and Radiation Oncologists (RO), where patients with new LC diagnoses received concurrent oncology consultation. We retrospectively analysed data pre-MDCC (November 2016 – February 2017) and prospectively for improvements (February – July 2017). Improvement cycles included MDCC clinic launching and a debriefing/troubleshootingu2009meeting. Data are reported as n(%), and means as per Statistical Process Control XmR(i) charts. Results 117 patients (44 pre-MDCC, 73 post-MDCC) were analysed. Most patients had stage 4 (44, 37.6%) or stage 1 LC (32, 27%). All patients saw Respirology, in addition to MO (85, 72.6%), RO (113, 96.6%), or both (83, 71.0%). The proportion of treated patients was unchanged pre- vs. post-MDCC (88.6%, 85.4%). Mean days from diagnosis to oncology assessment decreased from 14.3 to 5.0 days. Time from diagnosis to first treatment decreased from 39.8 to 27.2 days after the first improvement cycle, and to 18.1 days after the second improvement cycle (Figure 1), with less variation in time to treatment after improvement events.Abstract 916 Figure 1 Effect of MDCC on time from lung cancer diagnosis to first cancer treatment Conclusions MDCC shortens time from LC diagnosis to oncology assessment and treatment. Time to treatment improved more than time to oncology assessment, suggesting the improvement is likely related to benefits beyond just faster oncology assessment.

146: Current Practice of External Beam Radiotherapy and Brachytherapy for Management of Endometrial Cancer in Ontario, Canada

CARO 2016 _________________________________________________________________________________________________________ excluded. The query identified 142 patients who received treatment for clinical Stage II disease. Median age was 38 years (range: 19 – 68), 33 had Stage IIA, 47 IIB, and 62 had IIC disease. Fifty-nine patients were treated with radiation therapy (RT) while 83 received chemotherapy (CT). Only three patients with Stage IIA got CT, and only five with IIC got RT. Median RT dose was 30 Gy. Most common CT regimens used were EP (n = 68) and BEP (n = 13). Results: After a median follow up of 18 years, 24 patients had died, and there were 16 recurrences (three in the contra-lateral testis). Patients were more likely to die of second cancers (n = 7) and myocardial infarctions (n = 6), than from progressive Seminoma (n = 3). Two patients died during treatment (neutropenia and sepsis). The 10and 15-year overall survival (OS) was, IIA: 93.8% and 93.8%; IIB: 91.4% and 88.3%; IIC: 83.2% and 76.0%. The 10-year cumulative incidence of relapse (CIR) for Stage IIA patients treated with RT was 3.4%. Stage IIC patients treated with CT had a 10-yr CIR of 10.6%. The 10-year CIR for Stage IIB patients treated with RT (n = 24) versus CT (n = 23) was 29.8% versus 0% (p = 0.005). Seventeen patients developed a second malignancy (SM); non-melanoma skin cancers were excluded. The 15-year cumulative incidence of SM was 7.3% for patients treated with RT, versus 9.7% for those treated with CT (p = 0.321). Conclusions: Long-term outcomes for patients with Stage II Seminoma continue to be excellent. Patients are more likely to die of second cancers and cardiovascular disease than from progressive seminoma.