Cancer statistics for African American and Black people, 2025

African American and other Black individuals (referred to as Black people in this article) have a disproportionate cancer burden, including the lowest survival of any racial or ethnic group for most cancers. Every 3 years, the American Cancer Society estimates the number of new cancer cases and deaths for Black people in the United States and compiles the most recent data on cancer incidence (herein through 2021), mortality (through 2022), survival, screening, and risk factors using population-based data from the National Cancer Institute and the Centers for Disease Control and Prevention. In 2025, there will be approximately 248,470 new cancer cases and 73,240 cancer deaths among Black people in the United States. Black men have experienced the largest relative decline in cancer mortality from 1991 to 2022 overall (49%) and in almost every 10-year age group, by as much as 65%-67% in the group aged 40-59 years. This progress largely reflects historical reductions in smoking initiation among Black teens, advances in treatment, and earlier detections for some cancers. Nevertheless, during the most recent 5 years, Black men had 16% higher mortality than White men despite just 4% higher incidence, and Black women had 10% higher mortality than White women despite 9% lower incidence. Larger inequalities for mortality than for incidence reflect two-fold higher death rates for prostate, uterine corpus, and stomach cancers and for myeloma, and 40%-50% higher rates for colorectal, breast, cervical, and liver cancers. The causes of ongoing disparities are multifactorial, but largely stem from inequalities in the social determinants of health that trace back to structural racism. Increasing diversity in clinical trials, enhancing provider education, and implementing financial incentives to ensure equitable care across the cancer care continuum would help close these gaps.

Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals

BACKGROUND

Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups.

METHODS

A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level.

RESULTS

A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data.

CONCLUSION

Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.

Biomarker-Directed Therapy in Black and White Men With Metastatic Castration-Resistant Prostate Cancer

Importance

Black men have higher incidence and mortality from prostate cancer. Whether precision oncology disparities affect Black men with metastatic castration-resistant prostate cancer (mCRPC) is unknown.

Objective

To compare precision medicine data and outcomes between Black and White men with mCRPC.

Design, Setting, and Participants

This retrospective cohort study used data collected by the Prostate Cancer Precision Medicine Multi-Institutional Collaborative Effort (PROMISE) consortium, a multi-institutional registry with linked clinicogenomic data, from April 2020 to December 2021. Participants included Black and White patients with mCRPC with molecular data. Data were analyzed from December 2021 to May 2023.

Exposures

Database-reported race and ethnicity.

Main Outcomes and Measures

The primary outcome was the frequency of actionable molecular data, defined as the presence of mismatch repair deficiency (MMRD) or high microsatellite instability (MSI-H), homologous recombination repair deficiency, or tumor mutational burden of 10 mutations per megabase or greater. Secondary outcomes included the frequency of other alterations, the type and timing of genomic testing performed, and use of targeted therapy. Efficacy outcomes were prostate-specific antigen response rate, site-reported radiographic response, and overall survival.

Results

A total of 962 eligible patients with mCRPC were identified, including 204 Black patients (21.2%; median [IQR] age at diagnosis, 61 [55-67] years; 131 patients [64.2%] with Gleason scores 8-10; 92 patients [45.1%] with de novo metastatic disease) and 758 White patients (78.8%; median [IQR] age, 63 [57-69] years; 445 patients [58.7%] with Gleason scores 8-10; 310 patients [40.9%] with de novo metastatic disease). Median (IQR) follow-up from mCRPC was 26.6 (14.2-44.7) months. Blood-based molecular testing was more common in Black men (111 men [48.7%]) than White men (317 men [36.4%]; P < .001). Rates of actionable alterations were similar between groups (65 Black men [32.8%]; 215 White men [29.1%]; P = .35), but MMRD or MSI-H was more common in Black men (18 men [9.1]) than White men (36 men [4.9%]; P = .04). PTEN alterations were less frequent in Black men than White men (31 men [15.7%] vs 194 men [26.3%]; P = .003), as were TMPRSS alterations (14 men [7.1%] vs 155 men [21.0%]; P < .001). No other differences were seen in the 15 most frequently altered genes, including TP53, AR, CDK12, RB1, and PIK3CA. Matched targeted therapy was given less frequently in Black men than White men (22 men [33.5%] vs 115 men [53.5%]; P = .008). There were no differences in response to targeted therapy or survival between the two cohorts.

Conclusions and Relevance

This cohort study of men with mCRPC found higher frequency of MMRD or MSI-H and lower frequency of PTEN and TMPRSS alterations in Black men compared with White men. Although Black men received targeted therapy less frequently than White men, no differences were observed in clinical outcomes.

Variations in Clinical Practice: Assessing Clinical Care Processes According to Clinical Guidelines in a National Cohort of Hospice Patients

Background: National clinical guidelines have been developed internationally to reduce variations in clinical practices and promote the quality of palliative care. In The Netherlands, there is considerable variability in the organisation and care processes of inpatient palliative care, with three types of hospices - Volunteer-Driven Hospices (VDH), Stand-Alone Hospices (SAH), and nursing home Hospice Units (HU). Aim: This study aims to examine clinical practices in palliative care through different hospice types and identify variations in care. Methods: Retrospective cohort study utilising clinical documentation review, including patients who received inpatient palliative care at 51 different hospices and died in 2017 or 2018. Care provision for each patient for the management of pain, delirium and palliative sedation were analysed according to the Dutch national guidelines. Results: 412 patients were included: 112 patients who received treatment for pain, 53 for delirium, and 116 patients underwent palliative sedation therapy. Care was provided in accordance with guidelines for pain in 32%, 61% and 47% (P = .047), delirium in 29%, 78% and 79% (P = .0016), and palliative sedation in 35%, 63% and 42% (P = .067) of patients who received care in VDHs, SAHs and HUs respectively. When all clinical practices were considered, patient care was conducted according to the guidelines for 33% of patients in VDHs, 65% in SAHs, and 50% in HUs (P < .001). Conclusions: The data demonstrate that care practices are not standardised throughout Dutch hospices and exhibit significant variations between type of hospice.

Cancer statistics for African American/Black People 2022

African American/Black individuals have a disproportionate cancer burden, including the highest mortality and the lowest survival of any racial/ethnic group for most cancers. Every 3 years, the American Cancer Society estimates the number of new cancer cases and deaths for Black people in the United States and compiles the most recent data on cancer incidence (herein through 2018), mortality (through 2019), survival, screening, and risk factors using population-based data from the National Cancer Institute and the Centers for Disease Control and Prevention. In 2022, there will be approximately 224,080 new cancer cases and 73,680 cancer deaths among Black people in the United States. During the most recent 5-year period, Black men had a 6% higher incidence rate but 19% higher mortality than White men overall, including an approximately 2-fold higher risk of death from myeloma, stomach cancer, and prostate cancer. The overall cancer mortality disparity is narrowing between Black and White men because of a steeper drop in Black men for lung and prostate cancers. However, the decline in prostate cancer mortality in Black men slowed from 5% annually during 2010 through 2014 to 1.3% during 2015 through 2019, likely reflecting the 5% annual increase in advanced-stage diagnoses since 2012. Black women have an 8% lower incidence rate than White women but a 12% higher mortality; further, mortality rates are 2-fold higher for endometrial cancer and 41% higher for breast cancer despite similar or lower incidence rates. The wide breast cancer disparity reflects both later stage diagnosis (57% localized stage vs 67% in White women) and lower 5-year survival overall (82% vs 92%, respectively) and for every stage of disease (eg, 20% vs 30%, respectively, for distant stage). Breast cancer surpassed lung cancer as the leading cause of cancer death among Black women in 2019. Targeted interventions are needed to reduce stark cancer inequalities in the Black community.

Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists

BACKGROUND

Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists' recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting.

METHODS

We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention.

RESULTS

Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient's ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation.

CONCLUSIONS

Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.

Intraoperative and early postoperative complications in postchemotherapy retroperitoneal lymphadenectomy among patients with germ cell tumors using validated grading classifications

BACKGROUND

Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) is an essential, yet potentially morbid, therapy for the management of patients with advanced germ cell tumors. In the current study, the authors sought to define the complication profile of PC-RPLND using validated grading systems for intraoperative adverse events (iAEs) and early postoperative complications.

METHODS

Between 2000 and 2018, all patients who underwent PC-RPLND were analyzed for iAEs and early postoperative complications using the Kaafarani and Clavien-Dindo classifications, respectively. Logistic regression models were conducted to assess patient and tumor factors associated with iAEs and postoperative complications.

RESULTS

Of the 453 patients identified, 115 patients (25%) and 252 patients (56%), respectively, experienced an iAE and postoperative complication. Major iAEs (grade ≥3) were observed in 15 patients (3%) and major postoperative complications (grade ≥3) were noted in 80 patients (18%). The most common iAE was vascular injury (112 of 132 events; 85%), which occurred in 92 patients (20%), and the most frequent postoperative complication was ileus, which occurred in 121 patients (27%). Original and postchemotherapy retroperitoneal mass size, nonretroperitoneal metastases, intermediate and/or poor International Germ Cell Cancer Collaborative Group classification, previous RPLND, elevated tumor markers at the time of RPLND, and anticipated adjuvant surgical procedures increased the risk of both iAEs and postoperative complications. Patients who experienced an iAE were significantly more likely to experience a postoperative complication (odds ratio, 2.50; 95% confidence interval, 1.58-3.97 [P < .001]).

CONCLUSIONS

In what to the authors' knowledge is the first analysis of PC-RPLND using validated classifications for both iAEs and postoperative complications, advanced disease and surgical complexity significantly increased the risks of major iAEs and postoperative complications. Standardized reporting of adverse perioperative events allows providers and patients to appreciate the consequences of PC-RPLND during counseling and decision making.

Hospital-level Effects Contribute to Variations in Prostate Cancer Quality of Care

A paucity of real-world data exists highlighting whether variations in prostate cancer quality of care occur at a hospital level, independent of differences in case mix. To overcome this knowledge gap, we benchmarked hospital-level quality (n = 1245 hospitals) across a broad multidisciplinary panel of previously reported disease-specific, expert-defined quality indicators (QIs), adjusting for differences in patient case mix by indirect standardization. A composite measure of prostate cancer quality-the prostate cancer quality score (PC-QS)-was derived, and associations between PC-QS and hospital volume, academic status, and location as well as patient all-cause mortality were determined. After adjusting for the case mix, of the total of 1245 hospitals evaluated, 2-37% were identified as those performing significantly below the national average for a given QI. Hospitals with a higher PC-QS displayed larger patient volumes, were more commonly academic affiliated, and had lower overall mortality. Collectively, our data-driven benchmarking analysis reveals that widespread hospital-level variations exist in prostate cancer quality of care after adjusting for differences in case mix, with the PC-QS serving as a novel, validated, quality benchmarking tool. PATIENT SUMMARY: Our statistical benchmarking method shows that the quality of prostate cancer care varies between hospitals, after accounting for differences in patient characteristics. The prostate cancer quality score is a novel, validated, quality benchmarking tool.

Exploration of Surgeon Motivations in Management of Abdominal Wall Hernias: A Qualitative Study

IMPORTANCE

Although evidence-based guidelines designed to minimize health care variation and promote effective care are widely accepted, creating guidelines alone does not often lead to the desired practice change. Such knowledge-to-practice gaps are well-recognized in the management of patients with abdominal wall hernia, where wide variation in patient selection and operative approach likely contributes to suboptimal patient outcomes. To create sustainable, scalable, and widespread adherence to evidence-based guidelines, it is imperative to better understand individual surgeon motivations and behaviors associated with surgical decision-making.

OBJECTIVE

To evaluate the systematic application of the Theoretical Domains Framework (TDF) to explore motivations and behaviors associated with surgical decision-making in abdominal wall hernia practice to help inform the future design of theory-based interventions for desired practice and behavior change.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used purposive sampling to recruit 21 practicing surgeons at community and academic hospitals from 5 health regions across Michigan. It used interviews consisting of clinical vignettes for highly controversial situations in abdominal wall hernia repair, followed by semistructured interview questions based on the domains of the TDF to gain nuance into motivating factors associated with surgical practice. Patterns within the data were located, analyzed, and identified through thematic analysis using software. All data were collected between May and July 2018, and data analysis was performed from August 2018 to July 2019.

MAIN OUTCOMES AND MEASURES

Factors associated with decisions on the surgical approach to abdominal wall hernia repair were assessed using TDF.

RESULTS

Seventeen (81%) of the 21 participants were men, with a median (interquartile range) age of 47 (45-54) years. Of the 14 TDF domains, 5 were found to be most associated with decisions on the surgical approach to abdominal wall hernia repair for surgeons in Michigan: knowledge, beliefs about consequences, social or professional role and identity, environmental context and resources, and social influences. Mapping of the findings to the sources of behavior identified the potential intervention functions and policy categories that could be targeted for intervention. The intervention functions found to be most relevant included education, persuasion, modeling, incentivization, and environmental restructuring.

CONCLUSIONS AND RELEVANCE

Using the TDF, this study found that the primary factors associated with individual practice were opinion leaders, practice conformity, and reputational concerns. These findings are important because they challenge traditional dogma, which relies mainly on dissemination of published evidence, education, and technical skills acquisition to achieve evidence-based practice. Such knowledge allows for the development of sustainable, theory-based interventions for adherence to evidence-based guidelines.

How to implement the requirements of a quality assurance system for prostate cancer

PURPOSE

In 2003, the German Cancer Society (Deutsche Krebsgesellschaft, DKG) launched a certification program aimed at improving the quality of cancer care. The purpose of this article is to describe the experience of the Prostate Cancer Unit (PCU) at Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, in the process towards DKG certification.

METHODS

In 2018, PCU decided to apply for certification by adopting DKG catalogue of requirements (CoR) and quality indicators. A multiprofessional working group was established with the aim of acting the necessary steps to meet DKG standards.

RESULTS

Our organizational setting (procedures, personnel) and activities were accurately analyzed, thus outlining strengths and weaknesses, and modified to comply with DKG CoR and indicators. As examples, (1) a quality management plan was developed; (2) measures were taken to strengthen the surgical expertise; (3) cases evaluated in weekly tumor boards were expanded to include surgical cases with pathological risk factors, metastatic, relapsed and castration-resistant patients; (4) a survey was added to the patient-dedicated initiatives already scheduled; (5) the TuDoc software became the tool to register all new cases of prostate cancer patients referred to PCU.

CONCLUSIONS

The process of certification requires many efforts but represents a unique opportunity of improving quality of care of prostate cancer patients, making it comparable on an international scale.

Is it possible to automatically assess pretreatment digital rectal examination documentation using natural language processing? A single-centre retrospective study

OBJECTIVES

To develop and test a method for automatic assessment of a quality metric, provider-documented pretreatment digital rectal examination (DRE), using the outputs of a natural language processing (NLP) framework.

SETTING

An electronic health records (EHR)-based prostate cancer data warehouse was used to identify patients and associated clinical notes from 1 January 2005 to 31 December 2017. Using a previously developed natural language processing pipeline, we classified DRE assessment as documented (currently or historically performed), deferred (or suggested as a future examination) and refused.

PRIMARY AND SECONDARY OUTCOME MEASURES

We investigated the quality metric performance, documentation 6 months before treatment and identified patient and clinical factors associated with metric performance.

RESULTS

The cohort included 7215 patients with prostate cancer and 426 227 unique clinical notes associated with pretreatment encounters. DREs of 5958 (82.6%) patients were documented and 1257 (17.4%) of patients did not have a DRE documented in the EHR. A total of 3742 (51.9%) patient DREs were documented within 6 months prior to treatment, meeting the quality metric. Patients with private insurance had a higher rate of DRE 6 months prior to starting treatment as compared with Medicaid-based or Medicare-based payors (77.3%vs69.5%, p=0.001). Patients undergoing chemotherapy, radiation therapy or surgery as the first line of treatment were more likely to have a documented DRE 6 months prior to treatment.

CONCLUSION

EHRs contain valuable unstructured information and with NLP, it is feasible to accurately and efficiently identify quality metrics with current documentation clinician workflow.

The European Prostate Cancer Centres of Excellence: A Novel Proposal from the European Association of Urology Prostate Cancer Centre Consensus Meeting

BACKGROUND

High-quality management of prostate cancer is needed in the fields of clinics, research, and education.

OBJECTIVE

The objective of this project was to develop the concept of "European Prostate Cancer Centres of Excellence" (EPCCE), with the specific aim of identifying European centres characterised by high-quality cancer care, research, and education.

DESIGN, SETTING, AND PARTICIPANTS

A task force of experts aimed at identifying the general criteria to define the EPCCE. Discussion took place in conference calls and by e-mail from March 2017 to November 2017, and the final consensus meeting named "European Association of Urology (EAU) Prostate Cancer Centre Consensus Meeting" was held in Barcelona on November 16, 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The required criteria were grouped into three main steps: (1) clinics, (2) research, and (3) education. A quality control approach for the three steps was defined.

RESULTS AND LIMITATIONS

The definition of EPCCE consisted of the following steps: (1) clinical step-five items were identified and classified as core team, associated services, multidisciplinary approach, diagnostic pathway, and therapeutic pathway; (2) research step-internal monitoring of outcomes was required; clinical data had to be collected through a prespecified database, clinical outcomes had to be periodically assessed, and prospective trials had to be conducted; (3) educational step-it consists of structured fellowship programmes of 1yr, including 6mo of research and 6mo of clinics; and (4) quality assurance and quality control procedures, related to the quality assessment of the previous three steps. A limitation of this project was that the definition of standards and items was mainly based on a consensus among experts rather than being an evidence-based process.

CONCLUSIONS

The EAU Prostate Cancer Centre Consensus Meeting defined the criteria for the identification of the EPCCE in the fields of clinics, research, and education. The inclusion of a quality control approach represents the novelty that supports the excellence of these centres.

PATIENT SUMMARY

A task force of experts defined the criteria for the identification of European Prostate Cancer Centres of Excellence, in order to certify the high-quality centres for prostate cancer management.

Contemporary prostate cancer radiation therapy in the United States: Patterns of care and compliance with quality measures

PURPOSE

Quality measures represent the standards of appropriate treatment agreed upon by experts in the field and often supported by data. The extent to which providers in the community adhere to quality measures in radiation therapy (RT) is unknown.

METHODS AND MATERIALS

The Comparative Effectiveness Analysis of Surgery and Radiation study enrolled men with clinically localized prostate cancer in 2011 and 2012. Patients completed surveys and medical records were reviewed. Patients were risk-stratified according to D'Amico classification criteria. Patterns of care and compliance with 8 quality measures as endorsed by national consortia as of 2011 were assessed.

RESULTS

Overall, 926 men underwent definitive RT (69% external beam radiation therapy [EBRT]), 17% brachytherapy (BT), and 14% combined EBRT and BT with considerable variation in radiation techniques across risk groups. Most men who received EBRT had dose-escalated EBRT (>75 Gy; 93%) delivered with conventional fractionation (<2 Gy; 95%), intensity modulated RT (76%), and image guided RT (85%). Most men treated with BT received I125 (77%). Overall, 73% of the men received EBRT that was compliant with the quality measures (dose-escalation, image-guidance, appropriate use of androgen deprivation therapy, and appropriate treatment target) but only 60% of men received BT that was compliant with quality measures (postimplant dosimetry and appropriate dose). African-American men (64%) and other minorities (62%) were less likely than white men (77%) to receive EBRT that was compliant with quality measures.

CONCLUSIONS

Most men who received RT for localized prostate cancer were treated with an appropriately high dose and received image guidance and intensity modulated RT. However, compliance with some nationally recognized quality measures was relatively low and varied by race. There are significant opportunities to improve the delivery of RT and especially for men of a minority race.

The Role of Provider Characteristics in the Selection of Surgery or Radiation for Localized Prostate Cancer and Association With Quality of Care Indicators

INTRODUCTION

We sought to identify the role of provider and facility characteristics in receipt of radical prostatectomy (RP) or external beam radiation therapy (EBRT) and adherence to quality of care measures in men with localized prostate cancer (PCa).

MATERIALS AND METHODS

Subjects included 2861 and 1630 men treated with RP or EBRT, respectively, for localized PCa whose records were reabstracted as part of the Centers for Disease Control and Prevention Breast and Prostate Patterns of Care Study. We utilized multivariable generalized estimating equation regression analysis to assess patient, clinical, and provider (year of graduation, urologist density) and facility (group vs. solo, academic/teaching status, for-profit status, distance to treatment facility) characteristics that predicted use of RP versus EBRT as well as quality of care outcomes.

RESULTS

Multivariable analysis revealed that group (vs. solo) practice was associated with a decreased risk of RP (odds ratio, 0.47; 95% confidence interval, 0.25-0.91). Among RP patients with low-risk disease, receipt of a bone scan that was not recommended was significantly predicted by race and insurance status. Surgical quality of care measures were associated with physician's year of graduation and receiving care at a teaching facility.

CONCLUSIONS

In addition to demographic factors, we found that provider and facility characteristics were associated with treatment choice and specific quality of care measures. Long-term follow-up is required to determine whether quality of care indicators are related to PCa outcomes.

A narrative synthesis of the quality of cancer care and development of an integrated conceptual framework

The general paradigms that exist to guide measures in quality of care do not sufficiently deal with the changing needs of cancer management. The aim of this study was to review the literature regarding the quality of cancer care and develop a conceptual framework relevant to current practice. A textual narrative review of the literature was conducted by searching electronic databases from the last 10 years. Articles were then screened and included if they were both relevant to the management of cancer and standards in quality of care. Thematic analysis of the included articles was performed. Eighty-three articles were included and 12 domains identified and integrated with current models to develop a conceptual framework. These included: healthcare delivery system; timeliness; access; appropriateness of care; multidisciplinary and coordinated care; patient experience; technical aspects; safety; patient-centred outcomes; disease-specific outcomes; innovation and improvement and value. We propose a conceptual framework for the quality of cancer care based on relevant and current oncology practice. This presents a more practical and comprehensive approach than general models, and can be used by healthcare providers, managers and policy makers to guide and identify the need for metrics for quality improvements.

Quality indicators of clinical cancer care for prostate cancer: a population-based study in southern Switzerland

Background

Quality of cancer care (QoCC) has become an important item for providers, regulators and purchasers of care worldwide. Aim of this study is to present the results of some evidence-based quality indicators (QI) for prostate cancer (PC) at the population-based level and to compare the outcomes with data available in the literature.

Methods

The study included all PC diagnosed on a three years period analysis (01.01.2011–31.12.2013) in the population of Canton Ticino (Southern Switzerland) extracted from the Ticino Cancer Registry database. 13 QI, approved through the validated Delphi methodology, were calculated using the “available case” approach: 2 for diagnosis, 4 for pathology, 6 for treatment and 1 for outcome. The selection of the computed QI was based on the availability of medical documentation. QI are presented as proportion (%) with the corresponding 95% confidence interval.

Results

700 PC were detected during the three-year period 2011–2013: 78.3% of them were diagnosed through a prostatic biopsy and for 72.5% 8 or more biopsy cores were taken. 46.5% of the low risk PC patients underwent active surveillance, while 69.2% of high risk PC underwent a radical treatment (radical prostatectomy, radiotherapy or brachytherapy) and 73.5% of patients with metastatic PC were treated with hormonal therapy. The overall 30-day postoperative mortality was 0.5%.

Conclusions

Results emerging from this study on the QoCC for PC in Canton Ticino are encouraging: the choice of treatment modalities seems to respect the international guidelines and our results are comparable to the scarce number of available international studies. Additional national and international standardisation of the QI and further QI population-based studies are needed in order to get a real picture of the PC diagnostic-therapeutic process progress through the definition of thresholds of minimal standard of care.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4604-2) contains supplementary material, which is available to authorized users.

Development of quality indicators to monitor radiotherapy care for men with prostate cancer: A modified Delphi method

BACKGROUND AND PURPOSE

Quality indicators (QIs) have been developed for many aspects of prostate cancer care, but are under-developed with regard to radiotherapy treatment. We aimed to develop a valid, relevant and feasible set of core QIs to measure quality of radiotherapy care in men with prostate cancer.

MATERIALS AND METHODS

We used a RAND-modified Delphi process to select QIs that were regarded as both important and feasible measures of quality radiotherapy care. This involved two phases: (1) a literature review to identify a list of proposed QIs; and (2) a QI selection process by an expert panel (n = 12) conducted in a series of three rounds: two online questionnaires' and one face-to-face meeting. The RAND criterion identified variation in ratings and determined the level of agreement after each round of voting.

RESULTS

A total of 144 candidate QIs, which included measures from pre-treatment to post-treatment and survivorship care were identified. After three rounds of voting, the panel approved a comprehensive set of 17 QIs, with most assessing a process of care (n = 16, 94.1%) and the remaining assessing a health outcome.

CONCLUSION

This study developed a core set of 17 QIs which will be used to report from the Prostate Cancer Outcomes Registry-Australia & New Zealand, to monitor the quality of radiotherapy care prostate cancer patients receive.

Quality of care and economic considerations of active surveillance of men with prostate cancer

The current health care climate mandates the delivery of high-value care for patients considering active surveillance for newly-diagnosed prostate cancer. Value is defined by increasing benefits (e.g., quality) for acceptable costs. This review discusses quality of care considerations for men contemplating active surveillance, and highlights cost implications at the patient, health-system, and societal level related to pursuit of non-interventional management of men diagnosed with localized prostate cancer. In general, most quality measures are focused on prostate cancer care in general, rather that active surveillance patients specifically. However, most prostate cancer quality measures are pertinent to men seeking close observation of their prostate tumors with active surveillance. These include accurate documentation of clinical stage, informed discussion of all treatment options, and appropriate use of imaging for less-aggressive prostate cancer. Furthermore, interventions that may help improve the quality of care for active surveillance patients are reviewed (e.g., quality collaboratives, judicious antibiotic use, etc.). Finally, the potential economic impact and benefits of broad acceptance of active surveillance strategies are highlighted.

Improving Long-Term Outcomes for Patients with Extra-Abdominal Soft Tissue Sarcoma Regionalization to High-Volume Centers, Improved Compliance with Guidelines or Both?

Introduction

Optimization of outcomes of extra-abdominal STS is not clearly understood. We sought to determine whether hospital surgical volume and adherence to NCCN guidelines, or both, are associated with outcomes in the treatment of extra-abdominal soft tissue sarcoma (STS).

Methods

The National Cancer Database (NCDB) was queried for patients undergoing surgery for extra-abdominal STS diagnosed from 2003 to 2007. Mean annual hospital volume for STS surgery was divided into volume terciles (1T ≤3, 2T 4–10, and 3T ≥11 cases/year). Adherence to NCCN guidelines was determined. Primary outcome was overall survival.

Results

Our study population consisted of 13,684 patients with a median age of 56 years. 3T hospitals were more likely to adhere to NCCN guidelines for stage III patients (63% versus 47%; p ≤ 0.001) than 1T hospitals. On multivariable analysis, adherence to NCCN guidelines was associated with improved survival (HR = 0.79, CI 0.73–0.87; p < 0.001), but hospital volume was not (3T versus 1T: HR = 0.92, CI 0.82–1.02; p=0.12). Five-year overall survival was comparable for compliant groups at 1T, 2T, and 3T hospitals (72%, 72.4%, and 72.6%, resp.). 3T hospitals were not associated with a lower risk of 30-day mortality (OR 0.70, 95% CI 0.44–1.11) compared to 1T hospitals but did have a higher R0 resection rate (OR 1.43, 95% CI 1.32–1.54).

Conclusions

Adherence to NCCN guidelines, irrespective of hospital volume, is associated with improved overall survival for patients with extra-abdominal STS. High-volume hospitals more often adhere to guidelines, but low-volume hospitals that follow national guidelines may achieve comparable outcomes.

Concordance between patient-reported and physician-reported sexual function after radical prostatectomy

PURPOSE

Accurately tracking health-related quality-of-life after radical prostatectomy is critical to counseling patients and improving technique. Physicians consistently overestimate functional recovery. We measured concordance between surgeon-assessed and patient-reported outcomes and evaluated a novel method to provide feedback to surgeons.

MATERIALS AND METHODS

Men treated with radical prostatectomy self-completed the International Index of Erectile Function-6 questionnaire at each postoperative visit. Separately, physicians graded sexual function on a 5-point scale. International Index of Erectile Function -6 score<22 and grade ≥3 defined patient-reported and physician-assessed erectile dysfunction (ED), respectively. Feedback on concordance was given to physicians starting in May 2013 with the implementation of the Amplio feedback system. Chi-square tests were used to assess agreement proportions and linear regression to evaluate changes in agreement after implementation.

RESULTS

From 2009 to 2015, 3,053 men completed at least 1 postprostatectomy questionnaire and had a concurrent independent physician-reported outcome. Prior to implementation of feedback in 2013, patients and physicians were consistent as to ED 83% of the time; in 10% of cases, physicians overestimated function; in 7% of cases, physicians, but not patients reported ED. Agreement increased after implementation of feedback but this was not statistically significant, likely owing to a ceiling effect. Supporting this hypothesis, increase in agreement postfeedback was greater during late follow-up (≥12mo), where baseline agreement was lower compared to earlier follow-up.

CONCLUSIONS

Agreement was higher than expected at baseline; implementation of feedback regarding discrepancies between patient-reported and physician-assessed outcomes did not further improve agreement significantly. Our observed high rate of agreement may be partly attributed to our institutional practice of systematically capturing patient-reported outcomes as part of normal clinical care.

Racial Disparities in Clinically Significant Prostate Cancer Treatment: The Potential Health Information Technology Offers

PURPOSE

Black men are more likely to die as a result of prostate cancer than white men, despite effective treatments that improve survival for clinically significant prostate cancer. We undertook this study to identify gaps in prostate cancer care quality, racial disparities in care, and underlying reasons for poorer quality care.

METHODS

We identified all black men and random age-matched white men with Gleason scores ≥ 7 diagnosed between 2006 and 2013 at two urban hospitals to determine rates of treatment underuse. Underuse was defined as not receiving primary surgery, cryotherapy, or radiotherapy. We then interviewed treating physicians about the reasons for underuse.

RESULTS

Of 359 black and 282 white men, only 25 (4%) experienced treatment underuse, and 23 (92%) of these were black. Most (78%) cases of underuse were due to system failures, where treatment was recommended but not received; 38% of these men continued receiving care at the hospitals. All men with treatment underuse due to system failures were black.

CONCLUSION

Treatment rates of prostate cancer are high. Yet, racial disparities in rates and causes of underuse remain. Only black men experienced system failures, a type of underuse amenable to health information technology-based solutions. Institutions are missing opportunities to use their health information technology capabilities to reduce disparities in cancer care.

Cohort profile: the TrueNTH Global Registry - an international registry to monitor and improve localised prostate cancer health outcomes

PURPOSE

Globally, prostate cancer treatment and outcomes for men vary according to where they live, their race and the care they receive. The TrueNTH Global Registry project was established as an international registry monitoring care provided to men with localised prostate cancer (CaP).

PARTICIPANTS

Sites with existing CaP databases in Movember fundraising countries were invited to participate in the international registry. In total, 25 Local Data Centres (LDCs) representing 113 participating sites across 13 countries have nominated to contribute to the project. It will collect a dataset based on the International Consortium for Health Outcome Measures (ICHOM) standardised dataset for localised CaP.

FINDINGS TO DATE

A governance strategy has been developed to oversee registry operation, including transmission of reversibly anonymised data. LDCs are represented on the Project Steering Committee, reporting to an Executive Committee. A Project Coordination Centre and Data Coordination Centre (DCC) have been established. A project was undertaken to compare existing datasets, understand capacity at project commencement (baseline) to collect the ICHOM dataset and assist in determining the final data dictionary. 21/25 LDCs provided data dictionaries for review. Some ICHOM data fields were well collected (diagnosis, treatment start dates) and others poorly collected (complications, comorbidities). 17/94 (18%) ICHOM data fields were relegated to non-mandatory fields due to poor capture by most existing registries. Participating sites will transmit data through a web interface biannually to the DCC.

FUTURE PLANS

Recruitment to the TrueNTH Global Registry-PCOR project will commence in late 2017 with sites progressively contributing reversibly anonymised data following ethical review in local regions. Researchers will have capacity to source deidentified data after the establishment phase. Quality indicators are to be established through a modified Delphi approach in later 2017, and it is anticipated that reports on performance against quality indicators will be provided to LDCs.

Racial Disparity in Delivering Definitive Therapy for Intermediate/High-risk Localized Prostate Cancer: The Impact of Facility Features and Socioeconomic Characteristics

BACKGROUND

The gap in prostate cancer (PCa) survival between Blacks and Whites has widened over the past decade. Investigators hypothesize that this disparity may be partially attributable to differences in rates of definitive therapy between races.

OBJECTIVE

To examine facility level variation in the use of definitive therapy among Black and White men for localized PCa.

DESIGN, SETTING, AND PARTICIPANTS

Using data from the National Cancer Data Base, we identified 223 873 White and 59 262 Black men ≥40 yr of age receiving care within the USA with biopsy confirmed localized intermediate/high-risk PCa diagnosed between January 2004 and December 2013.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multilevel logistic regression was fitted to predict the odds of receiving definitive therapy for PCa. Sensitivity and subgroup analyses were performed to adjust for inherent patient and facility-level differences when appropriate.

RESULTS AND LIMITATIONS

Eighty-three percent (n=185 647) of White men received definitive therapy compared with 74% (n=43 662) of Black men between 2004 and 2013. Overall rates of definitive therapy during that time increased for both White (81% vs 83%, p<0.001) and Black (73% vs 75%, p=0.001) men. However, 39% of treating facilities demonstrated significantly higher rates of definitive therapy in White men, compared with just 1% favoring Black men. Our study is limited by potential selection bias and effect modification.

CONCLUSIONS

After adjusting for sociodemographic and clinical factors, we found that most facilities favored definitive therapy in Whites. Health care providers should be aware of these inherit biases when counseling patients on treatment options for localized PCa. Our study is limited by the retrospective nature of the cohort.

PATIENT SUMMARY

We found significant differences in rates of radiation and surgical treatment for prostate cancer among White and Black men, with most facilities favoring Whites. Nonclinical factors such as treatment facility type and location influenced rates of therapy.

Decision Support with the Personal Patient Profile-Prostate: A Multicenter Randomized Trial

PURPOSE

We evaluated the efficacy of the web based P3P (Personal Patient Profile-Prostate) decision aid vs usual care with regard to decisional conflict in men with localized prostate cancer.

MATERIALS AND METHODS

A randomized (1:1), controlled, parallel group, nonblinded trial was performed in 4 regions of the United States. Eligible men had clinically localized prostate cancer and an upcoming consultation, and they spoke and read English or Spanish. Participants answered questionnaires to report decision making stage, personal characteristics, concerns and preferences plus baseline symptoms and decisional conflict. A randomization algorithm allocated participants to receive tailored education and communication coaching, generic teaching sheets and external websites plus a 1-page summary to clinicians (intervention) or the links plus materials provided in clinic (usual care). Conflict outcomes and the number of consultations were measured at 1 month. Univariate and multivariable models were used to analyze outcomes.

RESULTS

A total of 392 men were randomized, including 198 to intervention and 194 to usual care, of whom 152 and 153, respectively, returned 1-month outcomes. The mean ± SD 1-month decisional conflict scale (score range 0 to 100) was 10.9 ± 16.7 for intervention and 9.9 ± 18.0 for usual care. The multivariable model revealed significantly reduced conflict in the intervention group (-5.00, 95% CI -9.40--0.59). Other predictors of conflict included income, marital or partner status, decision status, number of consultations, clinical site and D'Amico risk classification.

CONCLUSIONS

In this multicenter trial the decision aid significantly reduced decisional conflict. Other variables impacted conflict and modified the effect of the decision aid, notably risk classification, consultations and resources. P3P is an effective adjunct for shared decision making in men with localized prostate cancer.

Brachytherapy improves outcomes in young men (≤60 years) with prostate cancer: A SEER analysis

PURPOSE

The aim of the study was to compare prostate cancer-specific mortality (PCSM) in young men with clinically localized prostate cancer treated by either external beam radiation (EBRT) alone or brachytherapy with or without external beam radiation.

METHODS AND MATERIALS

Utilizing the Surveillance, Epidemiology and End Results database, 15,505 patients ≤60 years of age diagnosed with prostate cancer between 2004 and 2009 and treated with radiation therapy alone were identified. Incidence of PCSM was determined for both groups and compared using competing risk models.

RESULTS

The overall 8-year PCSM for the study population was 1.9% (95% confidence interval [CI]: 1.6-2.2). For patients treated with EBRT or brachytherapy with or without external beam, the 8-year PCSM was found to be 2.8% (CI: 2.2-3.4) and 1.2% (CI: 0.9-1.6), respectively (p < 0.001). Univariable analysis demonstrated that brachytherapy was associated with lower PCSM risk (hazard ratio = 0.40; CI: 0.30-0.54; p < 0.001). High Gleason risk category, black race, higher Tumor (T) stage, and higher grade were all associated with greater mortality risk (p < 0.01). On multivariable analysis, brachytherapy continued to be associated with a significantly lower mortality risk (hazard ratio = 0.65; CI: 0.47-0.89; p = 0.008). Subgroup analyses found that among those with Gleason score ≥8, younger patients had increased risk of PCSM (p = 0.001).

CONCLUSIONS

In men ≤60 years of age with prostate cancer, radiation therapy continues to offer excellent outcomes. After adjusting for relevant variables, the use of brachytherapy was associated with reduced PCSM compared to treatment with EBRT alone.

Navigating Treatment of Metastatic Castration- Resistant Prostate Cancer: Nursing Perspectives

BACKGROUND

Treatment of metastatic castration-resistant prostate cancer (mCRPC) has evolved rapidly. In particular, five new treatments that extend survival in mCRPC have been approved since 2010, including the chemotherapy cabazitaxel (Jevtana®), hormonal agents abiraterone (Zytiga®) and enzalutamide (Xtandi®), vaccine sipuleucel-T (Provenge®), and radiopharmaceutical radium-223 (Xofigo®); all have different indications and toxicity profiles.

OBJECTIVES

This review discusses treatment advances in mCRPC, including considerations for side-effect management and treatment sequencing. Studies relating to quality of care in prostate cancer are also discussed.

METHODS

Nonsystematic searches were performed on published manuscripts and abstracts from major oncology or urology congresses, focusing on practical characteristics of the previously mentioned new treatments that extend survival in mCRPC, as well as studies relating to quality of care and the role of nurses in prostate cancer management.

FINDINGS

To ensure that patients derive optimal clinical benefit, assessing overall health and proactively managing expected side effects are essential. Treatment sequencing in mCRPC is an important consideration, but clinical data in this area are limited. Despite medical advances in mCRPC, studies have identified other aspects of care in which improvement is needed. Nurses can make major contributions to addressing supportive care needs, which has been shown to improve patient care and outcomes in prostate cancer. Although patient navigation programs have improved coordination of care, inconsistent implementation among centers has been identified for prostate cancer. Greater use of outcome measures can help to identify unmet patient needs.

Health Care Integration and Quality among Men with Prostate Cancer

PURPOSE

The delivery of high quality prostate cancer care is increasingly important for health systems, physicians and patients. Integrated delivery systems may have the greatest ability to deliver high quality, efficient care. We sought to understand the association between health care integration and quality of prostate cancer care.

MATERIALS AND METHODS

We used SEER-Medicare data to perform a retrospective cohort study of men older than age 65 with prostate cancer diagnosed between 2007 and 2011. We defined integration within a health care market based on the number of discharges from a top 100 integrated delivery system, and compared rates of adherence to well accepted prostate cancer quality measures in markets with no integration vs full integration (greater than 90% of discharges from an integrated system).

RESULTS

The average man treated in a fully integrated market was more likely to receive pretreatment counseling by a urologist and radiation oncologist (62.6% vs 60.3%, p=0.03), avoid inappropriate imaging (72.2% avoided vs 60.6%, p <0.001), avoid treatment when life expectancy was less than 10 years (23.7% vs 17.3%, p <0.001) and avoid multiple hospitalizations in the last 30 days of life (50.2% vs 43.6%, p=0.001) than when treated in markets with no integration. Additionally, patients treated in fully integrated markets were more likely to have complete adherence to all eligible quality measures (OR 1.38, 95% CI 1.27-1.50).

CONCLUSIONS

Integrated systems are associated with improved adherence to several prostate cancer quality measures. Expansion of the integrated health care model may facilitate greater delivery of high quality prostate cancer care.

Differences in practice patterns between urologists and radiation oncologists in the management of localized prostate cancer: a cross-sectional survey

INTRODUCTION

Through a cross-sectional survey, we tried to assess whether practices of urologists and radiation oncologists are uniform when faced with similar clinical situations.

MATERIALS AND METHODS

A self-administered questionnaire was mailed to all French urologists and radiation oncologists. Respondents were asked about their practices through 11 case scenarios. The scenarios cover most of localized prostate cancer situations and were gradually organized depending on prostate cancer progression risk and the age of the patient. The eight first scenarios address the situation of treatment-naive patients, and the last cases were about the management of patients after radical prostatectomy. Physicians were asked to choose a treatment modality for each case. The responses were first stratified according to the intention to treat: either curative-intent treatment or palliative. The curative-treatment modality chosen were afterward assessed. The responses to clinical scenarios were compared between the two specialties.

RESULTS

Concerning the intention to treat, practice patterns were overall consistent except in one case. Indeed, a higher rate of radiation oncologists prefer curative-intent treatment for intermediate-risk prostate cancer in aged patients: 57.4 versus 14.6 % (p < 0.001). Each medical specialist prefers the treatment that he himself delivers (p < 0.005). For intermediate-risk prostate cancer in 65-year-old patient: 96.5 % of urologists chose radical prostatectomy versus 37.7 % of radiation oncologists (p < 0.001). Fewer urologists (almost 14 %) compared to radiation oncologists (47.5 %) would prescribe adjuvant treatment after radical prostatectomy for T3a R0 prostate cancer with post-operative PSA undetectable (p < 0.001).

CONCLUSION

Significant differences were found in therapeutic approach between the two main specialties that deal with localized prostate cancer.

'Act on oncology' as a new comprehensive approach to assess prostate cancer centres--method description and results of a pilot study

Background

Multidisciplinary care of prostate cancer is increasingly offered in specialised cancer centres. It requires the optimisation of medical and operational processes and the integration of the different medical and non-medical stakeholders.

Objective

To develop a standardised operational process assessment tool basing on the capability maturity model integration (CMMI) able to implement multidisciplinary care and improve process quality and efficiency.

Design, Setting, and Participants

Information for model development was derived from medical experts, clinical guidelines, best practice elements of renowned cancer centres, and scientific literature. Data were organised in a hierarchically structured model, consisting of 5 categories, 30 key process areas, 172 requirements, and more than 1500 criteria. Compliance with requirements was assessed through structured on-site surveys covering all relevant clinical and management processes. Comparison with best practice standards allowed to recommend improvements. ‘Act On Oncology’(AoO) was applied in a pilot study on a prostate cancer unit in Europe.

Results and Limitations

Several best practice elements such as multidisciplinary clinics or advanced organisational measures for patient scheduling were observed. Substantial opportunities were found in other areas such as centre management and infrastructure. As first improvements the evaluated centre administration described and formalised the organisation of the prostate cancer unit with defined personnel assignments and clinical activities and a formal agreement is being worked on to have structured access to First-Aid Posts.

Conclusions

In the pilot study, the AoO approach was feasible to identify opportunities for process improvements. Measures were derived that might increase the operational process quality and efficiency.

Establishment and characterization of a highly tumorigenic African American prostate cancer cell line, E006AA-hT

Genuine racial differences in prostate cancer (PCa) biology have been considered among the potential reasons to explain PCa disparities. There is no animal model to represent all aspects of human PCa and, more specifically, to be used for PCa disparity research. The lack of a spontaneously transformed in vitro cell-based model system has been a significant impediment to investigating and understanding potential molecular mechanisms, and the hormonal, genetic, and epigenetic factors underlying the biological and clinical aggressiveness of PCa in African American (AA) men.

In this study, we established and characterized the E006AA-hT cell line as a highly tumorigenic subline of the previously characterized primary AA-PCa cell line, E006AA. Extensive characterization of the E006AA-hT cell line was accomplished using cytodifferentiation and prostate-specific markers, spectral karyotyping, cell line authentication assays, cell proliferation and migration assays, and in vitro tumorigenesis assays.

Spectral karyotyping of E006AA-hT showed a hypertriploid chromosome complement and shared cytogenetic changes similar to its parental cells such as diploid X, absence of Y-chromosomes, numerical gains in chromosomes 5,6,8,10,17,20,21, and marker chromosomes of unknown origin. In addition, E006AA-hT also presented numerous clonal and structural aberrations such as insertion, deletion, duplication, and translocations in chromosomes 1-5, 8, 9, 11, 13, 14, 17, and 18. The E006AA-hT cell line was shown to be highly tumorigenic and produced tumors at an accelerated growth rate in both athymic nude and triple-deficient SCID mice.

Silencing the mutated androgen receptor (AR-599 Ser>Gly) did not affect proliferation (loss-of-function), but decreased migration (gain-of-function) in E006AA-hT and its parental cell type. These data support that AR-point mutations may lead simultaneously to different “loss-of-function” and “gain-of-function” phenotypes in PCa cells. E006AA-Par and its subline as the only available spontaneously transformed low- and highly-tumorigenic primary AA-PCa cell lines could be used for basic and translational research aimed in supporting prostate cancer disparity research.

Using a population-based observational cohort study to address difficult comparative effectiveness research questions: the CEASAR study

BACKGROUND

While randomized controlled trials represent the highest level of evidence we can generate in comparative effectiveness research, there are clinical scenarios where this type of study design is not feasible. The Comparative Effectiveness Analyses of Surgery and Radiation in localized prostate cancer (CEASAR) study is an observational study designed to compare the effectiveness and harms of different treatments for localized prostate cancer, a clinical scenario in which randomized controlled trials have been difficult to execute and, when completed, have been difficult to generalize to the population at large.

METHODS

CEASAR employs a population-based, prospective cohort study design, using tumor registries as cohort inception tools. The primary outcome is quality of life after treatment, measured by validated instruments. Risk adjustment is facilitated by capture of traditional and nontraditional confounders before treatment and by propensity score analysis.

RESULTS

We have accrued a diverse, representative cohort of 3691 men in the USA with clinically localized prostate cancer. Half of the men invited to participate enrolled, and 86% of patients who enrolled have completed the 6-month survey.

CONCLUSION

Challenging comparative effectiveness research questions can be addressed using well-designed observational studies. The CEASAR study provides an opportunity to determine what treatments work best, for which patients, and in whose hands.

Optimal management of gastric cancer: results from an international RAND/UCLA expert panel

OBJECTIVE

Defining processes of care, which are appropriate and necessary for management of gastric cancer (GC), is an important step toward improving outcomes.

METHODS

Using a RAND/UCLA Appropriateness Method, an international multidisciplinary expert panel created 22 statements reflecting optimal management. All statements were scored for appropriateness and necessity.

RESULTS

The following tenets were scored appropriate and necessary: (1) preoperative staging by computed tomography of abdomen/pelvis; (2) positron-emission tomographic scans not routinely indicated; (3) consideration for adjuvant therapy; (4) further clinical trials; (5) multidisciplinary decision making; (6) sufficient support at hospitals; (7) assessment of 16 or more lymph nodes (LNs); (8) in metastatic disease, surgery only for palliation of major symptoms; (9) surgeons experienced in GC management; (10) and surgeons experienced in both GC management and advanced laparoscopic surgery for laparoscopic resection. The following were scored appropriate, but of indeterminate necessity: (1) diagnostic laparoscopy before treatment; (2) a multidisciplinary approach to linitis plastica; (3) genetic assessment for diffuse GC and family history, or age less than 45 years; (4) endoscopic removal of select T1aN0 lesions; (5) D2 LN dissection in curative intent cases; (6) D1 LN dissection for early GC or patients with comorbidities; (7) frozen section analysis of margins; (8) nonemergent cases performed in a hospital with a volume of more than 15 resections per year; and (9) by a surgeon with more than 6 resection per year.

CONCLUSIONS

The expert panel has created 22 statements for the perioperative management of GC patients, to provide guidance to clinicians and improve the care received by patients.

Adherence to performance measures and outcomes among men treated for prostate cancer

PURPOSE

We assessed the relationship between health care system performance on nationally endorsed prostate cancer quality of care measures and prostate cancer treatment outcomes.

MATERIALS AND METHODS

This retrospective cohort study included 48,050 men from SEER-Medicare linked data diagnosed with localized prostate cancer between 2004 and 2009, and followed through 2010. Based on a composite quality measure we categorized the health care systems in which these men were treated into 1-star (bottom 20%), 2-star (middle 60%) and 3-star (top 20%) systems. We then examined the association of health care system level quality of care with outcomes using multivariable logistic and Cox regression.

RESULTS

Patients who underwent prostatectomy in 3-star vs 1-star health care systems were at lower risk for perioperative complications (OR 0.80, 95% CI 0.64-1.00). However, they were more likely to undergo a procedure addressing treatment related morbidity, eg for sexual morbidity (11.3% vs 7.8%, p = 0.043). In patients who received radiotherapy star ranking was not associated with treatment related morbidity. In all patients star ranking was not significantly associated with all-cause mortality (HR 0.99, 95% CI 0.84-1.15) or secondary cancer therapy (HR 1.04, 95% CI 0.91-1.20).

CONCLUSIONS

We found no consistent association between health care system quality and outcomes, which questions how meaningful these measures ultimately are for patients. Thus, future studies should focus on developing more discriminative quality measures.

Regional variation in quality of prostate cancer care

PURPOSE

Despite the endorsement of several quality measures for prostate cancer by the National Quality Forum and the Physician Consortium for Performance Improvement, how consistently physicians adhere to these measures has not been examined. We evaluated regional variation in adherence to these quality measures to identify targets for future quality improvement.

MATERIALS AND METHODS

For this retrospective cohort study we used SEER (Surveillance, Epidemiology, and End Results)-Medicare data for 2001 to 2007 to identify 53,614 patients with newly diagnosed prostate cancer. Patients were assigned to 661 regions (Hospital Service Areas). Hierarchical generalized linear models were used to examine reliability adjusted regional adherence to the endorsed quality measures.

RESULTS

Adherence at the patient level was highly variable, ranging from 33% for treatment by a high volume provider to 76% for receipt of adjuvant androgen deprivation therapy while undergoing radiotherapy for high risk cancer. In addition, there was considerable regional variation in adherence to several measures, including pretreatment counseling by a urologist and radiation oncologist (range 9% to 89%, p <0.001), avoiding overuse of bone scans in low risk cancer (range 16% to 96%, p <0.001), treatment by a high volume provider (range 1% to 90%, p <0.001) and followup with radiation oncologists (range 14% to 86%, p <0.001).

CONCLUSIONS

We found low adherence rates for most established prostate cancer quality of care measures. Within most measures regional variation in adherence was pronounced. Measures with low adherence and a large amount of regional variation may be important low hanging targets for quality improvement.

A criterion-based audit of the technical quality of external beam radiotherapy for prostate cancer

PURPOSE

To evaluate the technical quality of external beam radiotherapy for prostate cancer in Canada.

METHODS

This was a multi-institution, retrospective study of a random sample of patients undergoing radiotherapy (RT) for prostate cancer in Canada. Patterns of care were determined by abstracting details of the patients' management from original records. The quality of patient's technical care was measured against a previously published, comprehensive suite of quality indicators.

RESULTS

32 of the 37 RT centres participated. The total study population of 810 patients included 25% low-risk, 44% intermediate-risk, and 28% high-risk cases. 649 received external beam RT (EBRT) only, for whom compliance with 12 indicators of the quality of pre-treatment assessment ranged from 56% (sexual function documented) to 96% (staging bone scan obtained in high-risk patients). Compliance with treatment-related indicators ranged from 78% (dose to prostate ≥74 Gy in intermediate risk patients not receiving hormone therapy) to 100% (3DCRT or IMRT plan). Compliance varied among centres; no centre demonstrated 100% compliance on all indicators and every centre was 100% compliant on at least some indicators. The number of assessment-related indicators (n=13) with which a given centre was 100% compliant ranged from 4 to 11 (median 7) and the number of the treatment-specific indicators (n=8) with which a given centre was 100% compliant ranged from 6 to 8 (median 8). ADT therapy was utilised in most high-risk cases (191, 92.3%).

CONCLUSIONS

While patterns of prostate cancer care in Canada vary somewhat, compliance on the majority of quality indicators is very high. However, all centres showed room for improvement on several indicators and few individual patients received care that met target benchmarks on all quality measures. This variation is particularly important for indicators such as delivered dose where impact on disease outcome is known to exist, and suggests that quality improvement programmes have the potential to further improve quality of care.

Impact of a prostate multidisciplinary clinic program on patient treatment decisions and on adherence to NCCN guidelines: the William Beaumont Hospital experience

OBJECTIVES

In order to demonstrate the impact of multidisciplinary care in the community oncology setting, we evaluated treatment decisions after the initiation of a dedicated prostate and genitourinary (GU) multidisciplinary clinic (MDC).

METHODS

In March 2010, a GU MDC was created at William Beaumont Hospital with the goal of providing patients with a comprehensive multidisciplinary evaluation and consensus treatment recommendations in a single visit. Urologists, radiation, and medical oncologists along with ancillary support staff participated in this comprehensive initial evaluation. The impact of this experience on patient treatment decisions was analyzed.

RESULTS

During the first year, a total of 182 patients were seen. Compared with previous years, low-risk MDC patients more frequently chose external beam radiation therapy (41.1% vs. 26.6%, P=0.02), and active surveillance (14.3% vs. 6.1%, P=0.02) and less frequently prostatectomy (30.4% vs. 44.0%, P=0.03). Similar increases in external beam were seen in intermediate and high-risk patients. Increased use of hormonal therapy was found in high-risk patients compared with the years before the initiation of the MDC (76.2% vs. 51.1%, P=0.03). Increased adherence to National Comprehensive Cancer Network (NCCN) guidelines was seen with intermediate-risk patients (89.8% vs. 75.9%, P=0.01), whereas nonsignificant increases were seen in low-risk (100% vs. 98.9%, P=0.43) and high-risk patients (100% vs. 94.2%, P=0.26).

CONCLUSIONS

The establishment of a GU MDC improved the quality of care for cancer patients as demonstrated by improved adherence to National Comprehensive Cancer Network guidelines, and a broadening of treatment choices made available.

Receipt of National Comprehensive Cancer Network guideline-concordant prostate cancer care among African American and Caucasian American men in North Carolina

BACKGROUND

African Americans have a higher incidence of prostate cancer and experience poorer outcomes compared with Caucasian Americans. Racial differences in care are well documented; however, few studies have characterized patients based on their prostate cancer risk category, which is required to differentiate appropriate from inappropriate guideline application.

METHODS

The medical records of a population-based sample of 777 North Carolina men with newly diagnosed prostate cancer were studied to assess the association among patient race, clinical factors, and National Comprehensive Cancer Network (NCCN) guideline-concordant prostate cancer care.

RESULTS

African Americans presented with significantly higher Gleason scores (P = .025) and prostate-specific antigen levels (P = .008) than did Caucasian Americans. However, when clinical T stage was considered as well, difference in overall risk category only approached statistical significance (P = .055). Across risk categories, African Americans were less likely to have surgery (58.1% versus 68.0%, P = .004) and more likely to have radiation (39.0% versus 27.4%, P = .001) compared with Caucasian Americans. However, 83.5% of men received guideline-concordant care within 1 year of diagnosis, which did not differ by race in multivariable analysis (odds ratio = 0.83; 95% confidence interval  = 0.54-1.25). Greater patient-perceived access to care was associated with greater odds of receiving guideline-concordant care (odds ratio = 1.06; 95% confidence interval = 1.01-1.12).

CONCLUSIONS

After controlling for NCCN risk category, there were no racial differences in receipt of guideline-concordant care. Efforts to improve prostate cancer treatment outcomes should focus on improving access to the health care system.

Understanding variation in the quality of the surgical treatment of prostate cancer

More than 80% of men with prostate cancer undergo active treatment, which can be associated with significant morbidity. Outcomes of surgical treatment vary widely depending on who treated the patient and where the patient was treated, implying that there is room for improvement. Factors influencing outcomes include patient characteristics as well as some measure of procedure volume. Although relationships between volume and outcomes for prostatectomy can most likely be explained by differences between surgeons (e.g., experience, technical skill), the hospital environment (e.g., team communication, safety culture) has the potential to either amplify or dampen the effects. Although most patient factors are immutable, these other aspects of surgical care and the delivery environment provide opportunities for quality improvement. Collaborative quality improvement initiatives may prove to be an important vehicle for achieving better prostate cancer care. These grass roots organizations, driven largely by urologists dedicated to providing prostate cancer care, have had initial successes in improving some aspects of quality in prostate cancer care, including reducing unwarranted use of imaging and perioperative morbidity. However, much of the variation in functional outcomes after prostate cancer surgery arises from differences in technical skill. Evaluating and improving intraoperative surgeon performance will inevitably be challenging, as they require acquisition and interpretation of data collected in the operating room. To this end, several methods have been described to objectively assess what happens in the operating room.

Clinical implementation of quality of life instruments and prediction tools for localized prostate cancer: results from a national survey of radiation oncologists and urologists

PURPOSE

Although clinical guidelines recommend assessing quality of life, cancer aggressiveness and life expectancy for making localized prostate cancer treatment decisions, it is unknown whether instruments that objectively measure such outcomes have disseminated into clinical practice. In this context we determined whether quality of life and prediction instruments for prostate cancer have been adopted by radiation oncologists and urologists in the United States.

MATERIALS AND METHODS

Using a nationally representative mail survey of 1,422 prostate cancer specialists in the United States, we queried about self-reported clinical implementation of quality of life instruments, prostate cancer nomograms and life expectancy prediction tools in late 2011. The Pearson chi-square test and multivariate logistic regression were used to determine differences in the use of each instrument by physician characteristics.

RESULTS

A total of 313 radiation oncologists and 328 urologists completed the survey for a 45% response rate. Although 55% of respondents reported using prostate cancer nomograms, only 27% and 23% reported using quality of life and life expectancy prediction instruments, respectively. On multivariate analysis urologists were less likely to use quality of life instruments than radiation oncologists (OR 0.40, p <0.001). Physicians who spent 30 minutes or more counseling patients were consistently more likely to use quality of life instruments (OR 2.57, p <0.001), prostate cancer nomograms (OR 1.83, p = 0.009) and life expectancy prediction tools (OR 1.85, p = 0.02) than those who spent less than 15 minutes.

CONCLUSIONS

Although prostate cancer nomograms have been implemented into clinical practice to some degree, the use of quality of life and life expectancy tools has been more limited. Increased attention to implementing validated instruments into clinical practice may facilitate shared decision making for patients with prostate cancer.

Growth of high-cost intensity-modulated radiotherapy for prostate cancer raises concerns about overuse

To study the impact of new, expensive, and unproven therapies to treat prostate cancer, we investigated the dissemination of intensity-modulated radiotherapy (IMRT). IMRT is an innovative treatment for prostate cancer that delivers higher doses of radiation with improved precision compared to alternative radiotherapies. We observed rapid adoption of this new treatment among men diagnosed with prostate cancer from 2001 through 2007, despite uncertainty about its relative effectiveness. We compared patient and disease characteristics of those receiving IMRT and the previous radiation standard of care, three-dimensional conformal therapy; assessed intermediate-term outcomes; and examined potential factors associated with the increased use of IMRT. We found that in the early period of IMRT adoption (2001-03) men with high-risk disease were more likely to receive IMRT, whereas after IMRT's initial dissemination (2004-07) men with low-risk disease had fairly similar likelihoods of receiving IMRT as men with high-risk disease. This raises concerns about overtreatment, as well as considerable health care costs, because treatment with IMRT costs $15,000-$20,000 more than other standard therapies. As health care delivery reforms gain traction, policy makers must balance the promotion of new, yet unproven, technology with the risk of overuse.

The Prostate Cancer Registry: monitoring patterns and quality of care for men diagnosed with prostate cancer

OBJECTIVE

To establish a pilot population-based clinical registry with the aim of monitoring the quality of care provided to men diagnosed with prostate cancer.

PATIENTS AND METHODS

All men aged >18 years from the contributing hospitals in Victoria, Australia, who have a diagnosis of prostate cancer confirmed by histopathology report notified to the Victorian Cancer Registry are eligible for inclusion in the Prostate Cancer Registry (PCR). A literature review was undertaken aiming to identify existing quality indicators and source evidence-based guidelines from both Australia and internationally.

RESULTS

A Steering Committee was established to determine the minimum dataset, select quality indicators to be reported back to clinicians, identify the most effective recruitment strategy, and provide a governance structure for data requests; collection, analysis and reporting of data; and managing outliers. A minimum dataset comprising 72 data items is collected by the PCR, enabling ten quality indicators to be collected and reported. Outcome measures are risk adjusted according to the established National Comprehensive Cancer Network and Cancer of the Prostate Risk Assessment Score (surgery only) risk stratification model. Recruitment to the PCR occurs concurrently with mandatory notification to the state-based Cancer Registry. The PCR adopts an opt-out consent process to maximize recruitment. The data collection approach is standardized, using a hybrid of data linkage and manual collection, and data collection forms are electronically scanned into the PCR. A data access policy and escalation policy for mortality outliers has been developed.

CONCLUSIONS

The PCR provides potential for high-quality population-based data to be collected and managed within a clinician-led governance framework. This approach satisfies the requirement for health services to establish quality assessment, at the same time as providing clinically credible data to clinicians to drive practice improvement.

Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes

INTRODUCTION

There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes.

METHODS

The California Cancer Registry was used to identify patients treated for PC from 2001 to 2006. Only hospitals with ≥ 400 beds were included to limit evaluation to centres possessing resources to provide multimodality care (n= 50). Risk-adjusted multivariable models evaluated predictors of adherence to stage-specific NCCN guidelines for PC and mortality.

RESULTS

In all, 3706 patients were treated for PC in large hospitals during the study period. Compliance with NCCN guidelines was only 34.5%. Patients were less likely to get recommended therapy with advanced age and low socioeconomic status (SES). Using multilevel analysis, controlling for patient factors (including demographics and comorbidities), hospital factors (e.g. size, academic affiliation and case volume), compliance with NCCN guidelines was associated with a reduced risk of mortality [odds ratio (OR) for death 0.64 (0.53-0.77, P < 0.0001)].

CONCLUSIONS

There is relatively poor overall compliance with the NCCN PC guidelines in California's large hospitals. Higher compliance rates are correlated with improved survival. Compliance is an important potential measure of the quality of care.

Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample

BACKGROUND

Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates.

OBJECTIVE

Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique.

DESIGN, SETTING, AND PARTICIPANTS

As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n=11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n=7389).

INTERVENTION

All patients underwent RARP or ORP.

MEASUREMENTS

We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score-matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors.

RESULTS AND LIMITATIONS

Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score-matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28-0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31-0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77-0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26-0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up.

CONCLUSIONS

RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.

Racial/ethnic differences in receipt of pelvic lymph node dissection among men with localized/regional prostate cancer

BACKGROUND

Black and Hispanic men have a lower prostate cancer (PCa) survival rate than white men. This racial/ethnic survival gap has been explained in part by differences in tumor characteristics, stage at diagnosis, and disparities in receipt of definitive treatment. Another potential contributing factor is racial/ethnic differences in the timely and accurate detection of lymph node metastases. The current study was conducted to examine the association between race/ethnicity and the receipt of pelvic lymph node dissection (PLND) among men with localized/regional PCa.

METHODS

Logistic regression was used to estimate the adjusted odds of undergoing PLND among men who were diagnosed during 2000 to 2002 with PCa, who underwent radical prostatectomy or PLND without radical prostatectomy, and who were diagnosed in regions covered by the Surveillance, Epidemiology, and End Results database (n = 40,848).

RESULTS

Black men were less likely to undergo PLND than white men (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84-0.98). When the analysis was stratified by PCa grade, black men with well differentiated PCa (OR, 0.48; 95% CI, 0.27-0.84) and poorly differentiated PCa (OR, 0.73; 95% CI, 0.60-0.89) were less likely to undergo PLND than their white counterparts, but racial differences were not observed among men with moderately differentiated PCa (OR, 0.96; 95% CI, 0.88-1.05).

CONCLUSIONS

Among men with poorly differentiated PCa, failure to undergo PLND was associated with worse survival. Racial disparities in the receipt of PLND, especially among men with poorly differentiated PCa, may contribute to racial differences in prostate cancer survival.

Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations

This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required.