Luisa Aliste

Variability in the quality of rectal cancer care in public hospitals in Catalonia (Spain): Clinical audit as a basis for action

AIM Clinical practice guidelines in cancer are a relevant component of Catalonian Cancer Strategy aimed at promoting equity of access to therapy and quality of cancer care. The colorectal cancer (CRC) guideline was first published in 2003 and subsequently updated in 2008. This study examined the quality of therapy administered to patients with rectal cancer in public hospitals in Catalonia (Spain) in 2005 and 2007, according to CRC guideline recommendations. METHODS We conducted a multicentre retrospective cohort study of patients who underwent curative-intent surgery for primary rectal cancer at Catalonian public hospitals in 2005 and 2007. Data were drawn from clinical records. RESULTS The study covered 1831 patients with rectal cancer. Performance of total mesorectal excision (TME) was poorly reported by surgeons (46.4%) and pathologists (36.2%). Pre-operative radiotherapy was performed on 52% of stage-II and -III patients. Compared to high-caseload hospitals, those with a low caseload (≤11 cases/year) registered more Hartmans procedures, worse TME quality, a higher rate of post-operative complications and lower adherence to recommended pre-operative radio-chemotherapy. CONCLUSIONS Reporting quality of care is essential for ascertaining current performance status and opportunities for improvement. In our case, there is a need for the quality of the information included in clinical records to be improved, and variability in adherence to guideline recommendations to be reduced. In view of the fact that heterogeneity in the quality of the health care process was linked to hospital caseload, the health authorities have decided to reorganise the provision of rectal cancer care.

Narrowing the equity gap: the impact of organized versus opportunistic cancer screening in Catalonia (Spain)

Objectives To assess the impact on equity of access of an organized breast cancer screening programme, compared with opportunistic breast and cervical cancer screening activities. Methods Two cross-sectional health interview surveys conducted in 1994 and 2006 in Catalonia (Spain), with 6382 and 7653 women participating in both surveys. The main outcome measures were having undergone regular mammography, and regular cytology. Age-standardized prevalence rates for both screening tests were computed using the direct method. The relative inequality index was computed to measure changes over time in inequality on screening utilization. Results Participation among women aged 50-69 has increased after the introduction of the organized breast screening programme; the greatest impact has been observed among those women with lower educational levels (from 17% in 1994 to 79% in 2006). Equity of access by education was particularly increased in the target group for breast cancer screening. Conclusion This study indicates that an organized screening programme could improve participation and equity of access.

Assessing the effectiveness of a guideline recommendation for pre-operative radiochemotherapy in rectal cancer

AIM To ascertain the degree of adherence to the guideline recommendation on pre-operative RT/ChT for stage-II and -III patients in Catalonian public hospitals, and its impact on local recurrence among rectal cancer patients. METHODS Data were derived from a multicentre retrospective cohort study of patients who underwent curative-intent surgery for primary rectal cancer at Catalonian public hospitals in 2005 and 2007. RESULTS The study covered 1229 patients with TNM stage-II or -III primary rectal cancer. Of these patients, 54.5% underwent pre-operative RT/ChT; 14.9% underwent post-operative RT (± chemotherapy); and 30.6% did not undergo any RT. The crude local recurrence rate at 2years was 4.1% and the crude distant recurrence rate at 2years was 6.5%. The results of the univariate analyses showed a local-recurrence hazard ratio of 1.84 for the group of patients that received no RT versus the group that received pre-operative RT/ChT (p<0.01). CONCLUSIONS This is the first population-based study in Catalonia to support the use of pre-operative RT/ChT in rectal cancer patients because, in line with the results of population-based studies reported from other countries, its application, compared to non-application of RT, was found to lead to a clear reduction in the probability of local recurrence.

Clinical relevance of histologic subtypes in locally advanced esophageal carcinoma treated with pre-operative chemoradiotherapy: Experience of a monographic oncologic centre

Background Locally advanced esophageal carcinoma (LAEC) represents less than 30% of all diagnosed esophageal carcinoma worldwide. The standard of care for resectable tumours consists of preoperative chemoradiotherapy (CRT) followed by surgery. Despite the curative intent, the prognosis is still poor mainly due to relapse. A multidisciplinary approach is required in order to optimize the therapeutic strategy and follow-up. Differences in outcomes between the two main histological subtypes, adenocarcinoma (ADC) and squamous cell carcinoma (SCC), have been reported. Nevertheless, the heterogeneity in trials design and data available have hampered the achievement of clear conclusions. The purpose of this study is to report the outcomes from a cohort of patients with LAEC treated with a multidisciplinary approach and to remark the differences observed between the two main histologic subtypes and their clinical implications. Methods We retrospectively reviewed 100 patients diagnosed with LAEC that were treated with preoperative CRT at our institution and integrated centres. Histopathological characteristics and toxicities during treatment were recorded. Patterns of recurrence at the first relapse were analysed. Survival curves were plotted using the Kaplan Meier method and multivariate Cox proportional hazards models were used. Results Among the patients who received preoperative CRT, 83% underwent surgery. The median overall survival (mOS) was 31.7 months, 26.9 months for ADC and 45.5 for SCC (p-value = 0.33). In the multivariate Cox regression analysis, ypN+ was the only factor that negatively influenced in OS (OR = 4.1, p-value = 0.022). Patterns of recurrence differed according to histologic subtype. Distant relapse was more frequent in ADC (62%), whereas locoregional relapse was higher in SCC (50%) (p-value = 0.027). Second line therapeutic strategies could be offered to 50% of those patients who relapsed. Conclusions Differences in outcomes and recurrence pattern could be observed between the two main histologic subtypes of LAEC. A better molecular characterization, adapted therapeutic regimens and follow up strategies should be adopted in order to improve survival of these patients.

603PIMPROVING CLINICAL OUTCOMES IN CANCER CARE THROUGH CENTRALISATION OF TREATMENT AND CLINICAL AUDIT: THE RECTAL CANCER CASE

ABSTRACT Aim: Using the clinical audit as a quality improvement tool with evidence of better results in high-volume centres in Catalonia (Spain), a re-organisation of specialized surgical procedures and rare tumour distribution among reference hospitals was implemented. Using rectal cancer as a case study, we assess the impact of centralization of high-complexity cancer care services. Methods: Mixed methods combining quantitative and qualitative data were used. Quality of cancer care in rectal cancer was audited in accordance with the clinical practice guideline (CPG), and outcomes in all patients surgically treated for the first time in public hospitals in Catalonia in two-time periods (2005/7 and 2011/12) were assessed. Indicators of the quality of rectal cancer care and its results, comparing both periods, were analysed in order to measure the impact of centralization. In addition, key informant semi-structured interviews (n = 15) were undertaken with the managers and the lead clinicians involved in the process, to obtain their perception of this re-organisation. Results: From 2005/7 to 2011/12 the number of hospitals performing rectal cancer surgery decreased from 51 to 29 centres. A better quality of TME (36.2% vs 79.6%), more preoperative radio-chemotherapy (51% vs 65.8%) and more lymph node extractions (median: 10 vs 14 n.) were observed comparing both periods. Also, the rate of LR during the first year after surgery fell from 3.49 to 2.75/100.000. Qualitative assessment showed a favourable stance towards centralisation among the stakeholders involved, although critical views arose in regard to a surgery-centred concentration, the takeover of the diagnostic process by the referring center including the associated costs, and the lack of policy guidance in respect of continuity of care. Conclusions: Health policy approach combining assessment from the clinical audit with reorganisation of the delivery of complex treatments has been associated with better outcomes. A model of care based on the centralisation of high-complexity cancer treatments should be reinforced by managed regional networks and improved referral of patients. Disclosure: All authors have declared no conflicts of interest.

P64– Clinical practice guidelines in cancer in Catalonia assessing adherence to recommendations on rectal cancer

development of multiple interfaces for varying professionals. Content management is streamlined from a centralized location, also ensuring consistency of guidelines between medical practitioners and case managers and claims adjustors. DISCUSSION (CONCLUSION): This study demonstrates that delivery of treatment guideline recommendations in a decision support system is an effective dissemination strategy that can be tailored to the needs of users not necessarily trained in the interpretation and use of medical evidence. Combining this with an interface for physicians provides a mechanism that can improve the alignment between physician clinical decision-making and that of insurance professionals. TARGET AUDIENCE(S): 1. Guideline developer 2. Guideline implementer 3. Developer of guideline-based products 4. Health care policy analyst/policy-maker 5. Health insurance payers and purchasers