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Chee LYS, Sia J, Milne RL, Foroudi F, Millar JL, Ong WL. Variations in whole brain radiation therapy fractionation for brain metastases in Victoria. J Med Imaging Radiat Oncol 2022; 66:1106-1114. [PMID: 35726760 PMCID: PMC10084193 DOI: 10.1111/1754-9485.13447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We aim to evaluate the use of different whole brain radiation therapy (WBRT) fractionation schedules for brain metastases (BM) in Victoria, and the factors associated with it. METHODS This is a population-based cohort of patients who received radiation therapy for BM between 2012 and 2017, as captured in the Victorian Radiotherapy Minimum Dataset. We excluded patients with primary brain tumour and those who had 'prophylactic' intent treatment. The Cochran-Armitage test was used to evaluate changing trend in WBRT fractionation. Multivariate multinomial logistic regressions were used to evaluate factors associated with WBRT fractionation. RESULTS Of the 3111 patients who had WBRT, 1048 (45%), 1291 (42%) and 312 (13%) had ≤5, 6-10 and >10 fractions WBRT respectively. There was progressive increase in ≤5 fractions WBRT use over time, from 37% in 2012 to 50% in 2017 (P-trend < 0.001). In multivariate analyses, increasing age, patients with gastrointestinal cancer, patients living in remote/regional areas and more recent treatment were associated with the use of shorter WBRT fractionation (≤5 fractions), while patients who had WBRT plus stereotactic radiosurgery, and those treated in private institutions were associated with the use of prolonged WBRT fractionation (≥6 fractions). Three hundred eighty-nine (13%) patients died within 30 days of WBRT, of which 241 (64%), 119 (32%) and 17 (5%) had ≤5, 6-10 and > 10 fractions WBRT respectively. CONCLUSION We observed large variations in WBRT fractionation that are associated with patient, tumour, treatment and institutional factors. It is important to continuously monitor and benchmark our practice in order to reduce potentially unwarranted variations.
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Affiliation(s)
- Lessandra Yan Shan Chee
- Alfred Health Radiation Oncology, Melbourne, Victoria, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Joseph Sia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Roger L Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Precision Medicine, School of Clinical Sciences, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Victoria, Australia
| | - Jeremy L Millar
- Alfred Health Radiation Oncology, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Chand CP, Greenley S, Macleod U, Lind M, Barton R, Kelly C. Geographical distance and reduced access to palliative radiotherapy: systematic review and meta-analysis. BMJ Support Palliat Care 2022:bmjspcare-2021-003356. [PMID: 35292512 DOI: 10.1136/bmjspcare-2021-003356] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/12/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Palliative radiotherapy (PRT) is an effective way of reducing symptoms caused by advanced incurable cancer. Several studies have investigated factors that contribute to inequalities in access to PRT; distance to a radiotherapy centre has been identified as one potential barrier. AIM To assess whether there is an association between distance to a radiotherapy centre and utilisation rates of PRT in adults with cancer. METHODS A systematic review and meta-analysis protocol was registered in the PROSPERO database (CRD42020190772). MEDLINE, EMBASE, CINAHL and APA-PsycINFO were searched for relevant papers up to 28 February 2021. RESULTS Twenty-one studies were included. Twelve studies focused on whether patients with incurable cancer received PRT, as part of their treatment package. Pooled results reported that living ≥50 km vs <50 km from the radiotherapy centre was associated with a reduced likelihood of receiving PRT (OR 0.84 (95%CI 0.80, 0.88)). Nine focused on distance from the radiotherapy centre and compared single-fraction (SF) versus multiple-fraction PRT, indicating that patients living further away were more likely to receive SF. Pooled results comparing ≥50 km versus <50 km showed increased odds of receiving SF for those living ≥50 km (OR 1.48 (95%CI 1.26,1.75)). CONCLUSION Patients living further away from radiotherapy centres were less likely to receive PRT and those who received PRT were more likely to receive SF PRT, providing some evidence of inequalities in access to PRT treatment based on proximity to centres providing radiotherapy. Further research is needed to understand whether these inequalities are influenced by clinical referral patterns or by patients unwilling or unable to travel longer distances. PROSPERO REGISTRATION NUMBER CRD42020190772.
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Affiliation(s)
| | | | - Una Macleod
- Hull York Medical School, University of Hull, Hull, UK
| | - Mike Lind
- Hull York Medical School, University of Hull, Hull, UK
- Oncology, Hull University Teaching Hospital, Hull, UK
| | - Rachel Barton
- Oncology, Hull University Teaching Hospital, Hull, UK
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Batumalai V, Descallar J, Delaney GP, Gabriel G, Wong K, Shafiq J, Vinod SK, Barton MB. Patterns of palliative radiotherapy fractionation for brain metastases patients in New South Wales, Australia. Radiother Oncol 2020; 156:174-180. [PMID: 33359268 DOI: 10.1016/j.radonc.2020.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE There is a paucity of studies examining variation in the use of palliative radiation therapy (RT) fractionation for brain metastases. The aim of this study is to assess variation in palliative RT fractionation given for brain metastases in New South Wales (NSW), Australia, and identify factors associated with variation. MATERIALS AND METHODS This is a population-based cohort of patients who received whole brain RT (WBRT) for brain metastases (2009-2014), as captured in the NSW Central Cancer Registry. A logistic regression model was used to identify factors associated with fractionation type. RESULTS Of the 2,698 patients that received WBRT, 1,389 courses (51%) were < 6 fractions, 1,050 courses (39%) were 6-10 fractions, and 259 courses (10%) were > 10 fractions. Older patients were more likely to be treated with shorter courses (P < 0.0001). Patients with primary lung cancers were more likely to receive shorter courses compared with other primary cancers (P < 0.0001). Patients without surgical excision were more likely to receive < 6 fractions compared to those who underwent surgical excision. Shorter courses were more likely to be delivered to patients with the most disadvantaged socioeconomic status (SES) compared with patients with the least disadvantaged SES (P < 0.0001). There were significant fluctuations in the proportion of courses using lower number of fractions over time from 2009 to 2014, but no apparent trend (P = 0.02). There was wide variation in the proportion of shorter courses across residence local health districts, ranging from 24% to 69% for < 6 fractions, 21% to 72% for 6-10 fractions, and 4% to 20% for > 10 fractions (P < 0.0001). CONCLUSION This study has identified significant unwarranted variations in fractionation for WBRT in NSW. Accelerating the uptake of shorter fractionation regimens, if warranted through evidence, should be prioritised to enhance evidence-based care.
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Affiliation(s)
- V Batumalai
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia.
| | - J Descallar
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - G P Delaney
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - G Gabriel
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - K Wong
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - J Shafiq
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - S K Vinod
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - M B Barton
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
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Barton M, Batumalai V, Spencer K. Health Economic and Health Service Issues of Palliative Radiotherapy. Clin Oncol (R Coll Radiol) 2020; 32:775-780. [DOI: 10.1016/j.clon.2020.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/19/2020] [Accepted: 06/18/2020] [Indexed: 01/31/2023]
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Dennis K, Harris G, Kamel R, Barnes T, Balboni T, Fenton P, Rembielak A. Rapid Access Palliative Radiotherapy Programmes. Clin Oncol (R Coll Radiol) 2020; 32:704-712. [DOI: 10.1016/j.clon.2020.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
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Karim S, Mackillop WJ, Brennan K, Peng Y, Siemens DR, Krzyzanowska MK, Booth CM. Estimating the optimal perioperative chemotherapy utilization rate for muscle-invasive bladder cancer. Cancer Med 2019; 8:6258-6271. [PMID: 31472011 PMCID: PMC6797575 DOI: 10.1002/cam4.2449] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 11/24/2022] Open
Abstract
Background Identifying optimal chemotherapy (CT) utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of perioperative CT for muscle‐invasive bladder cancer (MIBC). Methods The Ontario Cancer Registry and linked treated records were used to identify neoadjuvant and adjuvant CT rates among patients with MIBC during 2004‐2013. Monte Carlo simulation was used to estimate the proportion of observed rate variation that could be due to chance alone. The criterion‐based benchmarking approach was used to explore whether social and health‐system factors were associated with CT rates. We also used the “pared‐mean” approach to identify a benchmark population of hospitals with the highest treatment rates. Hospital CT rates were adjusted for case mix and simulated using a multi‐level multivariable model and a parametric bootstrapping approach. Results The study population included 2581 patients; perioperative CT was delivered to 31% (798/2581). Multivariate analysis showed that treatment was strongly associated with patient socioeconomic status and hospital teaching status. The benchmark rate was 36%. Unadjusted CT rates were significantly different across hospitals (range 0%‐52%, P < .001). The unadjusted benchmark perioperative CT rate was 45% (95% CI 40%‐50%); utilization rate in nonbenchmark hospitals was 28% (95% CI 26%‐30%). When using simulated CT rates adjusted for case mix, the benchmark CT rate was 41% (95% CI 35%‐47%) and the nonbenchmark hospital CT rate was 30% (95% CI 28%‐32%). The simulation analysis suggested that the observed component of variation (38%) was outside the 95% CI (22%‐28%) of what could be expected due to chance alone. Conclusions There is significant systematic variation in perioperative CT rates for MIBC across hospitals in routine practice. The benchmark perioperative CT rate for MIBC is 36%‐41%.
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Affiliation(s)
- Safiya Karim
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
| | - William J Mackillop
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
| | - Kelly Brennan
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
| | - Yingwei Peng
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
| | | | - Monika K Krzyzanowska
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
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Karim S, Booth CM, Brennan K, Peng Y, Siemens DR, Krzyzanowska MK, Mackillop WJ. Estimating the optimal rate of adjuvant chemotherapy utilization for stage III colon cancer. Cancer Med 2019; 8:5590-5599. [PMID: 31407518 PMCID: PMC6745837 DOI: 10.1002/cam4.2456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 01/22/2023] Open
Abstract
Background Identifying optimal chemotherapy utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of adjuvant chemotherapy (ACT) for stage III colon cancer. Methods The Ontario Cancer Registry and linked treated records were used to identify ACT utilization. Monte Carlo simulation was used to estimate the proportion of ACT rate variation that could be due to chance alone. The criterion‐based benchmarking approach was used to explore whether socioeconomic or system‐level factors were associated with ACT. We also used the “pared‐mean” approach to identify a benchmark population of hospitals with the highest ACT rates. Results The study population included 2801 patients; ACT was delivered to 66% (1861/2801). Monte Carlo simulation suggested that the observed component of variation (15.6%) in ACT rates was within the 95% CI (11.5%‐17.3%) of what could be expected due to chance alone; the nonrandom component of ACT rate variation across hospitals was only 1.5%. There was no difference in hospital ACT rate by teaching status (P = .107), cancer center status (P = .362), or having medical oncology on site (P = .840). Unadjusted ACT rates varied across hospitals (range 44%‐91%, P = .017). The unadjusted benchmark ACT rate was 81% (95%CI 76%‐86%); utilization rate in non‐benchmark hospitals was 65% (95%CI 63%‐66%). However, after adjusting for case mix, the difference in ACT utilization between benchmark and non‐benchmark populations was significantly smaller. Conclusions We did not find any system‐level factors associated with the utilization of ACT. Our results suggest that the observed variation in hospital ACT rate is not significantly different from variation due to chance alone. Using the “pared‐mean” approach may significantly overestimate optimal treatment rates if case mix is not considered.
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Affiliation(s)
- Safiya Karim
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Christopher M Booth
- Departments of Oncology, Queen's University, Kingston, ON, Canada.,Departments of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - Kelly Brennan
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - Yingwei Peng
- Departments of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - D Robert Siemens
- Departments of Urology, Queen's University, Kingston, ON, Canada
| | - Monika K Krzyzanowska
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, OV, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - William J Mackillop
- Departments of Oncology, Queen's University, Kingston, ON, Canada.,Departments of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
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Abstract
The past decade has witnessed impressive advances in cancer treatment ushered in by targeted and immunotherapies. However, with significantly prolonged survival, upon recurrence, more patients become inflicted by brain metastasis, which is mostly refractory to all currently available therapeutic regimens. Historically, brain metastasis is an understudied area in cancer research, partly due to the dearth of appropriate experimental models that closely simulate the special biological features of metastasis in the unique brain environment and to the sophistication of techniques required to perform in-depth studies of the extremely complex and challenging brain metastasis. Yet, with increasing clinical demand for more effective treatment options, brain metastasis research has rapidly advanced in recent years. The present review spotlights the recent major progresses in basic and translational studies of brain metastasis with focuses on new animal models, novel imaging technologies, omics "big data" resources, and some new and exciting biological insights on brain metastasis.
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Mackillop WJ, Kong W. Estimating the Need for Palliative Radiation Therapy: A Benchmarking Approach. Int J Radiat Oncol Biol Phys 2016; 94:51-59. [DOI: 10.1016/j.ijrobp.2015.09.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/24/2015] [Accepted: 09/18/2015] [Indexed: 12/25/2022]
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