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Aggarwal A, Nossiter J, Parry M, Sujenthiran A, Zietman A, Clarke N, Payne H, van der Meulen J. Public reporting of outcomes in radiation oncology: the National Prostate Cancer Audit. Lancet Oncol 2021; 22:e207-e215. [DOI: 10.1016/s1470-2045(20)30558-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/10/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
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Utilization of Prostate Cancer Quality Metrics for Research and Quality Improvement: A Structured Review. Jt Comm J Qual Patient Saf 2018; 45:217-226. [PMID: 30236510 DOI: 10.1016/j.jcjq.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/21/2018] [Accepted: 06/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The shift toward value-based care in the United States emphasizes the role of quality measures in payment models. Many diseases, such as prostate cancer, have a proliferation of quality measures, resulting in resource burden and physician burnout. This study aimed to identify and summarize proposed prostate cancer quality measures and describe their frequency and use in peer-reviewed literature. METHODS The PubMed database was used to identify quality measures relevant to prostate cancer care, and included articles in English through April 2018. A gray literature search for other documents was also conducted. After the selection process of the pertinent articles, measure characteristics were abstracted, and uses were summarized for the 10 most frequently utilized measures in the literature. RESULTS A total of 26 articles were identified for review. Of the 71 proposed prostate cancer quality measures, only 47 were used, and less than 10% of these were endorsed by the National Quality Forum. Process measures were most frequently reported (84.5%). Only 6 outcome measures (8.5%) were proposed-none of which were among the most frequently utilized. CONCLUSION Although a high number of proposed prostate cancer quality measures are reported in the literature, few were assessed, and the majority of these were non-endorsed process measures. Process measures were most commonly assessed; outcome measures were rarely evaluated. In a step to close the quality chasm, a "top 5" core set of quality measures for prostate cancer care, including structure, process, and outcomes measures, is suggested. Future studies should consider this comprehensive set of quality measures.
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Assessing the information and support needs of radical prostate cancer patients and acceptability of a group-based treatment review: a questionnaire and qualitative interview study. JOURNAL OF RADIOTHERAPY IN PRACTICE 2018. [DOI: 10.1017/s1460396917000644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractAimsCurrent literature suggests the information and support needs of oncology patients undergoing radical radiotherapy to the prostate often remain unmet and can impact quality of life. We aimed to explore the effectiveness of delivery and opportunities for service improvement, including a group-based treatment review.MethodsA total of 60 prostate patients completing radical radiotherapy (mean age 70, range 47–79) in a UK cancer-centre completed a self-designed questionnaire assessing information and support. To explore views on a group-based treatment review, 11% took part in a semi-structured interview. Descriptive data were computed and interviews transcribed and analysed thematically.ResultsIn all, 87% were satisfied with information and support when delivered by radiographers. However, 26% were only ‘sometimes’ able to complete bladder-filling, suggesting information regarding treatment delays would improve this. In total, 49% preferred both Doctor and Urology nurse reviews whereas 26% preferred nurse only; 70% stated their ‘concerns were always addressed’ by a nurse and 49% by a Doctor. Interviews revealed that a group review was generally acceptable with peer support an influencing factor.FindingsOverall patients felt their needs were being met. Suggestions for improvement (more information on preparation, side effects and delays) will be implemented locally. Future work will explore the feasibility of group reviews in patients undergoing radical radiotherapy to the prostate.
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Treatment-related determinants of survival in early-stage (T1-2N0M0) oral cavity cancer: A population-based study. Head Neck 2017; 39:876-880. [DOI: 10.1002/hed.24679] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2016] [Indexed: 01/22/2023] Open
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Scott E. Androgen Deprivation With or Without Radiation Therapy for Clinically Node-Positive Prostate Cancer. ACTA ACUST UNITED AC 2015; 107:djv119. [PMID: 28159496 DOI: 10.1093/jnci/djv119] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 04/03/2015] [Indexed: 12/16/2022]
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Berrington de Gonzalez A, Wong J, Kleinerman R, Kim C, Morton L, Bekelman JE. Risk of second cancers according to radiation therapy technique and modality in prostate cancer survivors. Int J Radiat Oncol Biol Phys 2015; 91:295-302. [PMID: 25636756 DOI: 10.1016/j.ijrobp.2014.10.040] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 10/17/2014] [Accepted: 10/21/2014] [Indexed: 12/01/2022]
Abstract
PURPOSE Radiation therapy (RT) techniques for prostate cancer are evolving rapidly, but the impact of these changes on risk of second cancers, which are an uncommon but serious consequence of RT, are uncertain. We conducted a comprehensive assessment of risks of second cancer according to RT technique (>10 MV vs ≤10 MV and 3-dimensional [3D] vs 2D RT) and modality (external beam RT, brachytherapy, and combined modes) in a large cohort of prostate cancer patients. METHODS AND MATERIALS The cohort was constructed using the Surveillance Epidemiology and End Results-Medicare database. We included cases of prostate cancer diagnosed in patients 66 to 84 years of age from 1992 to 2004 and followed through 2009. We used Poisson regression analysis to compare rates of second cancer across RT groups with adjustment for age, follow-up, chemotherapy, hormone therapy, and comorbidities. Analyses of second solid cancers were based on the number of 5-year survivors (n=38,733), and analyses of leukemia were based on number of 2-year survivors (n=52,515) to account for the minimum latency period for radiation-related cancer. RESULTS During an average of 4.4 years' follow-up among 5-year prostate cancer survivors (2DRT = 5.5 years; 3DRT = 3.9 years; and brachytherapy = 2.7 years), 2933 second solid cancers were diagnosed. There were no significant differences in second solid cancer rates overall between 3DRT and 2DRT patients (relative risk [RR] = 1.00, 95% confidence interval [CI]: 0.91-1.09), but second rectal cancer rates were significantly lower after 3DRT (RR = 0.59, 95% CI: 0.40-0.88). Rates of second solid cancers for higher- and lower-energy RT were similar overall (RR = 0.97, 95% CI: 0.89-1.06), as were rates for site-specific cancers. There were significant reductions in colon cancer and leukemia rates in the first decade after brachytherapy compared to those after external beam RT. CONCLUSIONS Advanced treatment planning may have reduced rectal cancer risks in prostate cancer survivors by approximately 3 cases per 1000 after 15 years. Despite concerns about the neutron doses, we did not find evidence that higher energy therapy was associated with increased second cancer risks.
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Affiliation(s)
- Amy Berrington de Gonzalez
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Jeannette Wong
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ruth Kleinerman
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Clara Kim
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lindsay Morton
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Justin E Bekelman
- Department of Radiation Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Evan Pollack C, Wang H, Bekelman JE, Weissman G, Epstein AJ, Liao K, Dugoff EH, Armstrong K. Physician social networks and variation in rates of complications after radical prostatectomy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2014; 17:611-8. [PMID: 25128055 PMCID: PMC4135395 DOI: 10.1016/j.jval.2014.04.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 04/01/2014] [Accepted: 04/22/2014] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy. METHODS In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. RESULTS Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications. CONCLUSIONS Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.
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Affiliation(s)
- Craig Evan Pollack
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Hao Wang
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Justin E Bekelman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Gary Weissman
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Andrew J Epstein
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kaijun Liao
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Eva H Dugoff
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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DuGoff EH, Bekelman JE, Stuart EA, Armstrong K, Pollack CE. Surgical quality is more than volume: the association between changing urologists and complications for patients with localized prostate cancer. Health Serv Res 2014; 49:1165-83. [PMID: 24461049 DOI: 10.1111/1475-6773.12148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To examine the association of changing urologists on surgical complications in men with prostate cancer. DATA SOURCES/STUDY SETTING Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005. STUDY DESIGN A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy. METHODS Subjects were classified as having "changed urologists" if they had a different urologist who diagnosed their cancer from the one who performed their surgery. "Doubly robust" propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence. PRINCIPAL FINDINGS Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76-0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment. CONCLUSIONS Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.
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Affiliation(s)
- Eva H DuGoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Albert JM, Das P. Quality indicators in radiation oncology. Int J Radiat Oncol Biol Phys 2012; 85:904-11. [PMID: 23040217 DOI: 10.1016/j.ijrobp.2012.08.038] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 08/28/2012] [Accepted: 08/29/2012] [Indexed: 11/28/2022]
Abstract
Oncologic specialty societies and multidisciplinary collaborative groups have dedicated considerable effort to developing evidence-based quality indicators (QIs) to facilitate quality improvement, accreditation, benchmarking, reimbursement, maintenance of certification, and regulatory reporting. In particular, the field of radiation oncology has a long history of organized quality assessment efforts and continues to work toward developing consensus quality standards in the face of continually evolving technologies and standards of care. This report provides a comprehensive review of the current state of quality assessment in radiation oncology. Specifically, this report highlights implications of the healthcare quality movement for radiation oncology and reviews existing efforts to define and measure quality in the field, with focus on dimensions of quality specific to radiation oncology within the "big picture" of oncologic quality assessment efforts.
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Affiliation(s)
- Jeffrey M Albert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Bujold A, Craig T, Jaffray D, Dawson LA. Image-guided radiotherapy: has it influenced patient outcomes? Semin Radiat Oncol 2012; 22:50-61. [PMID: 22177878 DOI: 10.1016/j.semradonc.2011.09.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cancer control and toxicity outcomes are the mainstay of evidence-based medicine in radiation oncology. However, radiotherapy is an intricate therapy involving numerous processes that need to be executed appropriately in order for the therapy to be delivered successfully. The use of image-guided radiation therapy (IGRT), referring to imaging occurring in the radiation therapy room with per-patient adjustments, can increase the agreement between the planned and the actual dose delivered. However, the absence of direct evidence regarding the clinical benefit of IGRT has been a criticism. Here, we dissect the role of IGRT in the radiotherapy (RT) process and emphasize its role in improving the quality of the intervention. The literature is reviewed to collect evidence that supports that higher-quality dose delivery enabled by IGRT results in higher clinical control rates, reduced toxicity, and new treatment options for patients that previously were without viable options.
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Affiliation(s)
- Alexis Bujold
- Département de Radio-Oncologie Clinique-Enseignement-Recherche, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Canada.
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Palta JR, Efstathiou JA, Bekelman JE, Mutic S, Bogardus CR, McNutt TR, Gabriel PE, Lawton CA, Zietman AL, Rose CM. Developing a national radiation oncology registry: From acorns to oaks. Pract Radiat Oncol 2012; 2:10-7. [DOI: 10.1016/j.prro.2011.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 06/06/2011] [Indexed: 11/26/2022]
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Pollack CE, Bekelman JE, Epstein AJ, Liao K, Wong YN, Armstrong K. Racial disparities in changing to a high-volume urologist among men with localized prostate cancer. Med Care 2011; 49:999-1006. [PMID: 22005606 PMCID: PMC3298812 DOI: 10.1097/mlr.0b013e3182364019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients who receive surgery from high-volume surgeons tend to have better outcomes. Black patients, however, are less likely to receive surgery from high-volume surgeons. OBJECTIVE Among men with localized prostate cancer, we examined whether disparities in use of high-volume urologists resulted from racial differences in patients being diagnosed by high-volume urologists and/or changing to high-volume urologists for surgery. RESEARCH DESIGN Retrospective cohort study from Surveillance, Epidemiology, and End Results-Medicare data. SUBJECTS A total of 26,058 black and white men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 that underwent prostatectomy. Patients were linked to their diagnosing urologist and a treating urologist (who performed the surgery). MEASURES Diagnosis and receipt of prostatectomy by a high-volume urologist, and changing between diagnosing and treating urologist RESULTS After adjustment for confounders, black men were as likely as white men to be diagnosed by a high-volume urologist; however, they were significantly less likely than white men to be treated by a high-volume urologist [odds ratio 0.76; 95% confidence interval (CI), 0.67-0.87]. For men diagnosed by a low-volume urologist, 46.0% changed urologists for their surgery. Black men were significantly less likely to change to a high-volume urologist (relative risk ratio 0.61; 95% CI, 0.47-0.79). Racial differences appeared to reflect black and white patients being diagnosed by different urologists and having different rates of changing after being diagnosed by the same urologists. CONCLUSIONS Lower rates of changing to high-volume urologists for surgery among black men contribute to racial disparities in treatment by high-volume surgeons.
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Affiliation(s)
- Craig Evan Pollack
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD 21287, USA.
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Pollack CE, Weissman G, Bekelman J, Liao K, Armstrong K. Physician social networks and variation in prostate cancer treatment in three cities. Health Serv Res 2011; 47:380-403. [PMID: 22092259 DOI: 10.1111/j.1475-6773.2011.01331.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine whether physician social networks are associated with variation in treatment for men with localized prostate cancer. DATA SOURCE 2004-2005 Surveillance, Epidemiology and End Results-Medicare data from three cities. STUDY DESIGN We identified the physicians who care for patients with prostate cancer and created physician networks for each city based on shared patients. Subgroups of urologists were defined as physicians with dense connections with one another via shared patients. PRINCIPAL FINDINGS Subgroups varied widely in their unadjusted rates of prostatectomy and the racial/ethnic and socioeconomic composition of their patients. There was an association between urologist subgroup and receipt of prostatectomy. In city A, four subgroups had significantly lower odds of prostatectomy compared with the subgroup with the highest rates of prostatectomy after adjusting for patient clinical and sociodemographic characteristics. Similarly, in cities B and C, subgroups had significantly lower odds of prostatectomy compared with the baseline. CONCLUSIONS Using claims data to identify physician networks may provide an insight into the observed variation in treatment patterns for men with prostate cancer.
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Affiliation(s)
- Craig Evan Pollack
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA
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Pollack CE, Bekelman JE, Liao KJ, Armstrong K. Hospital racial composition and the treatment of localized prostate cancer. Cancer 2011; 117:5569-78. [PMID: 21692067 DOI: 10.1002/cncr.26232] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 03/10/2011] [Accepted: 04/12/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Racial differences in the treatment of men with localized prostate cancer remain poorly understood. This study examines whether hospital racial composition is associated with the type of treatment black and white men receive. METHODS The authors performed a retrospective cohort study of men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 linked to hospital and census data. A total of 134,291 men were assigned to the hospital where they received care. Generalized estimating equations were used to determine whether hospital racial composition was associated with the receipt of definitive therapy and type of treatment. RESULTS Black men were less likely to receive radiation and/or prostatectomy compared with white men (55.5% vs 63.7%, P < .001) and, among those who received definitive therapy, were less likely to undergo prostatectomy (27.5% vs 31.9%, P < .001). The percentage of black men who received their care at hospitals with a high proportion of black patients was 48.0%, compared with only 5.2% of white patients who received care in this subset of hospitals. Men were significantly less likely to receive definitive treatment (odds ratio, 0.81; 95% confidence interval, 0.74-0.90) in hospitals with a high proportion of black patients compared with men seen at hospitals with fewer black patients. The association between hospital racial composition and treatment did not significantly differ by patient race. CONCLUSIONS Hospital racial composition is consistently associated with the care that men receive for localized prostate cancer. Better understanding of the factors that determine where men receive care is an important component in reducing variation in treatment.
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Affiliation(s)
- Craig Evan Pollack
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Bekelman JE, Mitra N, Efstathiou J, Liao K, Sunderland R, Yeboa DN, Armstrong K. Outcomes after intensity-modulated versus conformal radiotherapy in older men with nonmetastatic prostate cancer. Int J Radiat Oncol Biol Phys 2011; 81:e325-34. [PMID: 21498008 DOI: 10.1016/j.ijrobp.2011.02.006] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 01/19/2011] [Accepted: 02/03/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE There is little evidence comparing complications after intensity-modulated (IMRT) vs. three-dimensional conformal radiotherapy (CRT) for prostate cancer. The study objective was to test the hypothesis that IMRT, compared with CRT, is associated with a reduction in bowel, urinary, and erectile complications in elderly men with nonmetastatic prostate cancer. METHODS AND MATERIALS We undertook an observational cohort study using registry and administrative claims data from the SEER-Medicare database. We identified men aged 65 years or older diagnosed with nonmetastatic prostate cancer in the United States between 2002 and 2004 who received IMRT (n = 5,845) or CRT (n = 6,753). The primary outcome was a composite measure of bowel complications. Secondary outcomes were composite measures of urinary and erectile complications. We also examined specific subsets of bowel (proctitis/hemorrhage) and urinary (cystitis/hematuria) events within the composite complication measures. RESULTS IMRT was associated with reductions in composite bowel complications (24-month cumulative incidence 18.8% vs. 22.5%; hazard ratio [HR] 0.86; 95% confidence interval [CI], 0.79-0.93) and proctitis/hemorrhage (HR 0.78; 95% CI, 0.64-0.95). IMRT was not associated with rates of composite urinary complications (HR 0.93; 95% CI, 0.83-1.04) or cystitis/hematuria (HR 0.94; 95% CI, 0.83-1.07). The incidence of erectile complications involving invasive procedures was low and did not differ significantly between groups, although IMRT was associated with an increase in new diagnoses of impotence (HR 1.27, 95% CI, 1.14-1.42). CONCLUSION IMRT is associated with a small reduction in composite bowel complications and proctitis/hemorrhage compared with CRT in elderly men with nonmetastatic prostate cancer.
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Affiliation(s)
- Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Implications of comparative effectiveness research for radiation oncology. Pract Radiat Oncol 2011; 1:72-80. [PMID: 24673918 DOI: 10.1016/j.prro.2011.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Accepted: 02/13/2011] [Indexed: 11/23/2022]
Abstract
PURPOSE The essence of comparative effectiveness research (CER) is to understand what health interventions work, for which patients, and under what conditions. The objective of this article is to introduce the relative strengths and weaknesses of several forms of evidence to illustrate the potential for CER evidence generation within radiation oncology. METHODS We introduce the underlying concepts of effectiveness and efficacy. We describe the design of traditional explanatory randomized trials (RCTs). We introduce the rationale, strengths, and weaknesses of several alternative study designs for comparative effectiveness, including pragmatic clinical trials, adaptive trials, and observational (nonrandomized) studies. RESULTS Explanatory RCTs are designed to assess the efficacy of an intervention while achieving a high degree of internal validity. Pragmatic clinical trials (PCTs) are prospective studies performed in typical, real-world clinical practice settings. The emphasis of PCTs is to maintain a degree of internal validity while also maximizing external validity. Adaptive trials can be modified at interim stages using existing or evolving evidence in the course of a trial, which may allow trials to maintain clinical relevance by studying current treatments. Observational data are becoming increasingly important, given substantial funding for clinical registries and greater availability of electronic medical records and claims databases, but need to address well-known limitations such as selection bias. CONCLUSION With the rapid proliferation of new and evolving radiotherapy technologies, it is incumbent upon our field to invest in building the evidence base for radiotherapy CER and to actively participate in current initiatives for generating comparative evidence.
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