Colleen E. McGahan

Impact of Using Audit Data to Improve the Evidence-Based Use of Single-Fraction Radiation Therapy for Bone Metastases in British Columbia

PURPOSE To assess the impact of a population-based intervention to increase the consistency and use of single-fraction radiation therapy (SFRT) for bone metastases. METHODS AND MATERIALS In 2012, an audit of radiation therapy prescriptions for bone metastases in British Columbia identified significant interphysician and -center (26%-73%) variation in the use of SFRT. Anonymous physician-level and identifiable regional cancer center SFRT use data were presented to all radiation oncologists, together with published guidelines, meta-analyses, and recommendations from practice leaders. The use of SFRT for bone metastases from 2007 through 2011 was compared with use of SFRT in 2013, to assess the impact of the audit and educational intervention. Multilevel logistic regression was used to assess the relationship between the usage of SFRT and the timing of the radiation while controlling for potentially confounding variables. Physician and center were included as group effects to account for the clustered structure of the data. RESULTS A total of 16,898 courses of RT were delivered from 2007 through 2011, and 3200 courses were delivered in 2013. The rates of SFRT use in 2007, 2008, 2009, 2010, 2011, and 2013 were 50.5%, 50.9%, 48.3%, 48.5%, 48.0%, and 59.7%, respectively (P<.001). Use of SFRT increased in each of 5 regional centers: A: 26% to 32%; B: 36% to 56%; C: 39% to 57%; D: 49% to 56%; and E: 73% to 85.0%. Use of SFRT was more consistent; 3 of 5 centers used SFRT for 56% to 57% of bone metastases RT courses. The regression analysis showed strong evidence that the usage of SFRT increased after the 2012 intervention (odds ratio 2.27, 95% confidence interval 2.06-2.50, P<.0001). CONCLUSION Assessed on a population basis, an audit-based intervention increased utilization of SFRT for bone metastases. The intervention reversed a trend to decreasing SFRT use, reduced costs, and improved patient convenience. This suggests that dissemination of programmatic quality indicators in oncology can lead to increased utilization of evidence-based practice.

Prognostic factors and sites of metastasis in unresectable locally advanced pancreatic cancer

Due to differences in natural history and therapy, clinical trials of patients with advanced pancreatic cancer have recently been subdivided into unresectable locally advanced pancreatic cancer (LAPC) and metastatic disease. We aimed to evaluate prognostic factors in LAPC patients who were treated with first‐line chemotherapy and describe patterns of disease progression. Patients with LAPC who initiated first‐line palliative chemotherapy, 2001–2011 at the BC Cancer Agency were included. A retrospective chart review was conducted to identify clinicopathologic variables, treatment, and subsequent sites of metastasis. Kaplan–Meier and Cox‐regression survival analyses were performed. A total of 244 patients were included in this study. For the majority of patients (94.3%), first‐line therapy was single‐agent gemcitabine. About 144 (59%) patients developed distant metastatic disease and the most frequent metastatic sites included peritoneum/omentum (42.3%), liver (41%), lungs (13.9%), and distant lymph nodes (9%). Median overall survival (OS) for the entire cohort was 11.7 months (95% CI, 10.6–12.8). Development of distant metastases was associated with significantly inferior survival (HR 3.56, 95% CI 2.57–4.93), as was ECOG 2/3 versus 0/1 (HR 1.69, 95% CI 1.28–2.23), CA 19.9 > 1000 versus ≤1000 (HR 1.59, 95% CI 1.19–2.14) and female gender, (HR 1.57, 95% CI 1.19–2.08). In this population‐based study, 41% of LAPC patients treated with first‐line chemotherapy died without evidence of distant metastases. Prognostic factors for LAPC were baseline performance status, elevated CA 19.9, gender, and development of distant metastasis. Results highlight the heterogeneity of LAPC and the importance of locoregional tumor control.

Determination of factors predictive of outcome for patients undergoing a pancreaticoduodenectomy of pancreatic head ductal adenocarcinomas

INTRODUCTION A pancreaticoduodenectomy is the reference treatment for a resectable pancreatic head ductal adenocarcinoma. The probability of 5-year survival in patients undergoing such treatment is 5-25% and is associated with relatively high peri-operative morbidity and mortality. The objective of the present study was to evaluate risk factors predictive of outcome for patients undergoing a pancreaticoduodenectomy for a pancreatic adenocarcinoma. METHODS This retrospective analysis incorporated data from the Vancouver General Hospital and the British Columbia Cancer Agency (BCCA) from 1999-2007. RESULTS The 5-year survival of 100 patients was 12% with a median survival of 16.5 months. Ninety-day mortality was 7%. Predictors of 90-day mortality included age ≥ 80 years (P < 0.001) and an American Society of Anesthesiologists (ASA) score = 3 (P= 0.012) by univariate analysis and age ≥80 years (P < 0.001) by multivariate analysis. The identifiable predictive factor for poor 5-year survival was an ASA score = 3 (P= 0.043) whereas a Dindo-Clavien surgical complication grade ≥ 3 was associated with a worse outcome (P= 0.013). Referral to the BCCA was associated with a favourable 5-year survival (P= 0.001). CONCLUSIONS   The present study identifies risk factors for patient selection to enhance survival benefit in this patient population.

Relationships between family physicians’ referral for palliative radiotherapy, knowledge of indications for radiotherapy, and prior training: a survey of rural and urban family physicians

BackgroundThe primary objective of this research was to assess the relationship between FPs’ knowledge of palliative radiotherapy (RT) and referral for palliative RT.Methods1001 surveys were sent to FPs who work in urban, suburban, and rural practices. Respondents were tested on their knowledge of palliative radiotherapy effectiveness and asked to report their self-assessed knowledge.ResultsThe response rate was 33%. FPs mean score testing their knowledge of palliative radiotherapy effectiveness was 68% (SD = 26%). The majority of FPs correctly identified that painful bone metastases (91%), airway obstruction (77%), painful local disease (85%), brain metastases (76%) and spinal cord compression (79%) can be effectively treated with RT, though few were aware that hemoptysis (42%) and hematuria (31%) can be effectively treated. There was a linear relationship between increasing involvement in palliative care and both self-assessed (p < 0.001) and tested (p = 0.02) knowledge. FPs had higher mean knowledge scores if they received post-MD training in palliative care (12% higher; p < 0.001) or radiotherapy (15% higher; p = 0.002). There was a strong relationship between FPs referral for palliative radiotherapy and both self-assessed knowledge (p < 0.001) and tested knowledge (p = 0.01).ConclusionsSelf-assessed and tested knowledge of palliative RT is positively associated with referral for palliative RT. Since palliative RT is underutilized, further research is needed to assess whether family physician educational interventions improve palliative RT referrals. The current study suggests that studies could target family physicians already in practice, with educational interventions focusing on hemostatic and other less commonly known indications for palliative RT.

Practice referral patterns and outcomes in patients with primary retroperitoneal sarcoma in British Columbia

BACKGROUND We examined practice referral patterns for primary retroperitoneal sarcoma (PRS) in British Columbia (BC) and associations between the timing of referral to tertiary care and patient outcomes. METHODS Using ICD-10 coding, the Cancer Agency Information System was used to identify patients with PRS from 2000 to 2009 who had been referred to tertiary care and had undergone a surgical resection. RESULTS Eighty-two patients were included. Those referred before surgery were significantly more likely to receive a complete resection (P = .0002) and adjuvant radiation (P = .0000) compared with patients referred after surgery. Referral before surgery was associated with a significantly increased overall (P = .0619) and recurrence-free (P = .0400) survival; however, in the multivariate model this was not significant. CONCLUSIONS Referral before surgery is associated with higher rates of complete resection and the use of adjuvant radiation; furthermore, it is associated with prolonged survival in the univariate but not in the multivariate model.

Outcomes of unselected patients with pathologic T3N0 rectal cancer

BACKGROUND AND PURPOSE This study compares the outcomes of patients with pathological (p) T3N0 rectal cancer treated with surgery alone (S), surgery and radiation (SR) or surgery, radiation and chemotherapy (SRC), in a population based setting. MATERIALS Three hundred and seven patients with operable, macroscopically resected pT3N0 rectal cancer referred to the BC Cancer Agency between 2000 and 2004 were segregated by treatment type: S (n=65), SR (n=97) and SRC (n=145). Patient characteristics, 5-year locoregional recurrence (LRR) and disease-specific survival (DSS) were compared between treatment cohorts. RESULTS Median age differed significantly between S, SR and SRC patient cohorts: 76, 72 and 64 years respectively. Five-year LRR differed by treatment group, with 29% for S, 6.3% for SR and 3.84% for SRC patients. DSS was superior in SRC compared to S patients (hazard ratio=0.31 [0.17, 0.60]). Co-morbidities and patient preference were most common reasons for omission of radiation. CONCLUSIONS Unselected patients with pT3N0 rectal cancer not treated with peri-operative radiation experience a high rate of LRR and reduced DSS in comparison to patients treated with bimodality and trimodality therapies. Advanced age is significantly associated with omission of therapy in patients with early stage rectal cancer.

Completeness of breast cancer operative reports in a community care setting

OBJECTIVES The narrative operative report represents the traditional means by which breast cancer surgery has been documented. Previous work has established that omissions occur in narrative operative reports produced in an academic setting. The goal of this study was to determine the completeness of breast cancer narrative operative reports produced in a community care setting and to explore the effect of a surgeons case volume and years in practice on the completeness of these reports. MATERIALS AND METHODS A standardized retrospective review of operative reports produced over a consecutive 2 year period was performed using a set of procedure-specific elements identified through a review of the relevant literature and work done locally. RESULTS 772 operative reports were reviewed. 45% of all elements were completely documented. A small positive trend was observed between case volume and completeness while a small negative trend was observed between years in practice and completeness. CONCLUSION The dictated narrative report inadequately documents breast cancer surgery irrespective of the recording surgeons volume or experience. An intervention, such as the implementation of synoptic reporting, should be considered in an effort to maximize the utility of the breast cancer operative report.

A retrospective study on accessibility of palliative radiation therapy in the management of prostate cancer in British Columbia

Timely administration of palliative radiation therapy (PRT) to manage symptoms derived from advanced prostate cancer is necessary to help alleviate discomfort and improve quality of life. Despite PRT being an effective treatment, analyzing utilization rates in British Columbia (BC), Canada for palliative purposes implies it is an under-utilized medical resource. Access to and utilization of radiation therapy (RT) is lower in remote geographical regions and higher in urban regions where a cancer care facility is close in proximity suggesting the presence of geographical barrier affecting access to health care and services. Equitable access to PRT can be achieved by reducing barriers such as geographical distance. This retrospective cohort study describes accessibility of PRT in the management of prostate cancer and the impact of an additional facility on improving access to PRT.

Uptake and impact of synoptic reporting in a community care setting

BACKGROUND Breast cancer surgeries have traditionally been documented in narrative reports. Narrative reports have been shown to be incomplete. Synoptic reports utilize standardized templates to record data and have emerged as an alternative to narrative reports. This study evaluates the uptake and impact of synoptic reporting for breast cancer surgery in a community care setting. METHODS A retrospective review of operative reports documenting breast cancer surgeries over a consecutive 3-year period. RESULTS 772 narrative reports and 158 synoptic reports were reviewed. Synoptic reports were associated with a higher degree of overall completeness (60% vs 45%) when compared to narrative reports. 6 out of 7 surgeons that produced at least 5 synoptic and 5 narrative reports had increases in completeness with use of synoptic reporting. CONCLUSIONS Use of synoptic reporting improves breast cancer operative report completeness and decreases superfluous content when compared to narrative reports. While synoptic report uptake during the study period was suboptimal there exists several means by which it can be improved, including investment in information technology infrastructure and emphasis on stakeholder engagement.