Population Analysis of SABR/SRS for the Treatment of Metastatic Cancer in a Jurisdiction of 15 Million People

PURPOSE/OBJECTIVE(S)

Stereotactic Ablative Radiotherapy (SABR) or Stereotactic Radiosurgery (SRS) for oligometastatic cancer or oligoprogression of metastatic cancer is supported by an expanding body of evidence in the literature. The degree of uptake of these techniques, supplanting traditional and potentially less resource-intensive techniques in this patient population, would be of interest to clinicians and administrators alike.

MATERIALS/METHODS

A review of provincial date for Ontario, Canada (population ∼ 15 million) was performed to quantify the use of SABR/SRS to metastases either in the brain or elsewhere in the body. Data was obtained from a new (April 2022) activity-based hospital funding model, responsible for ALL radiation treatment remuneration at all facilities across the province (i.e., single payer system). Funding is triggered when a patient is treated as per 1 or more of the ∼270 provincial radiation protocols, defined as a "protocol instance". Protocols were developed by clinicians across Ontario according to a consensus-based iterative process, considering provincial, national and international guidelines and/or evidence-based practice. Prerequisite information for remuneration included (but was not limited to): patient demographics, identification of whether a primary tumor or metastasis(es) was treated, protocol, radiation technique, dose/fractionation, and encounter dates. Submission of data was performed by the 17 hospitals who provide radiation services and logic checked centrally by the provincial cancer agency following submission. Validation of data is performed by ongoing iterative processes.

RESULTS

From April 1 to November 30, 2022, a total of 31,916 radiation protocol instances were funded for 27,298 patients. Of these, 4,156 (13%) were SABR/SRS protocols. When only treatment to metastases were considered, the total number of SABR/SRS protocol instances was 3,024 (9.5% of total) and 29.4% of the total number of protocol instances delivered to metastases (10,271). The 29.4% was split further as 1567 protocol instances (15.3%) to brain metastases and 1457 protocol instances elsewhere in the body, most often to lung (3.9%), spine (3.4%), non-spine bone (2.2%) and liver (1.7%), with a further 2.9% to unspecified extra-cranial metastases. Data for all 17 Ontario treatment facilities revealed a range of SABR/SRS usage for metastases from 1.8 to 59.8% (median 23.2%, IQ range 16.9%).

CONCLUSION

On review of recently submitted data, nearly 1/3 of all radiation treatments to metastases in Ontario are delivered using a SABR/SRS technique. There is wide regional variation in the use of these techniques. Reasons for this variation require further investigation.

Implementing a one-day testing model improves timeliness of workup for patients with lung cancer

Background

Patients with lung cancer often experience stressful delays throughout the diagnostic phase of care. To address that situation, our multidisciplinary team created a "Navigation Day," during which patients partake in a single-day visit that comprises nurse-led teaching, social work, smoking cessation counselling, symptom control, and dedicated test slots for integrated positron-emission tomography and computed tomography (pet/ct), pulmonary function tests (pfts), and magnetic resonance imaging (mri) of the brain. We evaluated the effects of that program on wait times and patient satisfaction.

Methods

Patients with a suspicion of lung cancer on chest ct imaging referred during 3 time periods were reviewed: 1 year before launch of the Navigation Day, 1 year post-launch, and 2 years post-launch. Patients were further stratified according to concordance of their test date with a Navigation Day date. Mean wait times for pet/ct, pfts, and mri brain were calculated for each group. Patient satisfaction was measured using a standardized provincial survey. The Student t-test and analysis of variance were used to assess for significance.

Results

After implementation, mean wait times in the first year improved to 9.2 days from 15.5 days for pet/ct (p < 0.0001), to 9.6 days from 15.7 days for pfts (p < 0.0001), and to 10.2 days from 16.0 days for mri brain (p < 0.0001). Patients who used a dedicated test slot experienced the shortest wait times, at 5.8 days for pet/ct, 5.8 days for pfts, and 6.3 days for mri brain (p < 0.0001). Those improvements were sustained at 2 years post-launch. Patient satisfaction in the categories of assistance, emotional support, and clarity remained high post-launch.

Conclusions

Navigation Day significantly improved the timeliness of diagnostic testing services in patients with suspected lung cancer.

Time to Diagnosis and Treatment with Palliative Radiotherapy among Inuit Patients with Cancer from the Arctic Territory of Nunavut, Canada

AIMS

The cancer burden among Circumpolar Inuit is high. Palliative radiotherapy is a mainstay treatment for controlling symptoms of advanced cancers, but Inuit are required to travel far distances to access this service. Access to palliative radiotherapy and time away from home communities have not been explored among this population. We sought to describe the time intervals from symptom onset to the start of palliative radiotherapy among Canadian Inuit patients treated at The Ottawa Hospital (TOH).

MATERIALS AND METHODS

A retrospective review of Inuit patients from Nunavut treated with radiotherapy between 2005 and 2014 at TOH.

RESULTS

Of a total of 152 radiotherapy patients, 88 (58%) were treated palliatively. Of these, 61 (70%) had stage IV disease at diagnosis and 63 (72%) had lung cancer. The median time from referral for specialist care to the patient's first flight to Ottawa was 4 days (range 0-97). The median length of treatment was 7 days (range 0-27), but patients spent a median of 64.5 days (range 14-633) in Ottawa. The median survival from the date of pathological diagnosis was 5.2 months.

CONCLUSIONS

Most Inuit radiotherapy patients at TOH were treated palliatively. Patients were brought from Nunavut relatively quickly for specialist care, which is encouraging. However, patients spent over 2 months away from home, in the context of a median survival of less than 6 months. Opportunities for improvement include both provider and system-level changes, which may be applicable to other Circumpolar Inuit regions across Europe and North America.

Regional process redesign of lung cancer care: a learning health system pilot project

Background

The Ottawa Hospital (toh) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, toh used a learning health system (lhs) vision to redesign regional diagnostic processes. A lhs is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a lhs is a collaborative platform that provides connectivity across silos, organizations, and professions.

Methods

To operationalize a lhs, we developed the Ottawa Health Transformation Model (ohtm) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (cop) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation.

Results

The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days.

Conclusions

The initiative optimized regional integration from referral to initial treatment. Use of a lhs lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations.

Identifying barriers to accrual in radiation oncology randomized trials

Background

Data about factors driving accrual to radiation oncology trials are limited. In oncology, 30%-40% of trials are considered unsuccessful, many because of poor accrual. The goal of the present study was to inform the design of future trials by evaluating the effects of institutional, clinician, and patient factors on accrual rates to a randomized radiation oncology trial.

Methods

Investigators participating in sabr-comet (NCT01446744), a randomized phase ii trial open in Canada, Europe, and Australia that is evaluating the role of stereotactic ablative radiotherapy (sabr) in oligometastatic disease, were invited to complete a survey about factors affecting accrual. Institutional ethics approval was obtained. The primary endpoint was the annual accrual rate per institution. Univariable and multivariable linear regression analyses were used to identify factors predictive of annual accrual rates.

Results

On univariable linear regression analysis, off-trial availability of sabr (p = 0.014) and equipoise of the referring physician (p = 0.014) were found to be predictive of annual accrual rates. The annual accrual rates were lower when centres offered sabr for oligometastases off-trial (median: 3.7 patients vs. 8.4 patients enrolled) and when referring physicians felt that, compared with having equipoise, sabr was beneficial (median: 4.8 patients vs. 8.4 patients enrolled). Multivariable analysis identified perceived level of equipoise of the referring physician to be predictive of the annual accrual rate (p = 0.023).

Conclusions

The level of equipoise of referring physicians might play a key role in accrual to radiation oncology randomized controlled trials. Efforts to communicate with and educate referring physicians might therefore be beneficial for improving trial accrual rates.