Decision making in lung cancer : how applicable are the guidelines?

Modelling demand for radiotherapy is contingent on the uniform application of clinical practice guidelines. However, decision making in lung cancer is a complex process requiring the integration of multimodality treatment in patients who frequently have underlying comorbidities. Population studies have shown that guideline adherence in lung cancer is modest, ranging from 44 to 52%. The application of guideline treatment decreases with increasing age and the presence of comorbidities. Patient and clinician attitudes also impact on this. In some regions, sociodemographic factors, such as lower income and non-White race, have been associated with a lack of guideline treatment. One of the major barriers in treating lung cancer patients according to guidelines is the mismatch between the clinic population and those enrolled in clinical trials from which evidence is derived. The lung cancer clinic population often consists of patients who are older, have multiple comorbidities and are of borderline performance status, all characteristics that are usually exclusion criteria for clinical trials. Hence, there is uncertainty not only about the magnitude of benefit, but also potential toxicities of guideline treatment. Further research is necessary in order to define the best treatment in these patients and thus increase the applicability of guidelines to the general lung cancer population. Lung cancer is an extreme example of the difficulties in translating evidence into clinical practice. The applicability of guidelines to specific cancer populations will affect the modelling of demand for radiotherapy and other treatment modalities

Radiotherapy in lung cancer

Radiotherapy is an important modality in the treatment of lung cancer. In Australia, up to 76% of patients have an indication for radiotherapy at diagnosis. This includes curative radiotherapy for patients with inoperable stage I and II non-small cell lung cancer, and in combination with chemotherapy, for patients with stage III non-small cell lung cancer and limited stage small cell lung cancer. There are challenges in delivering curative radiotherapy to this group of patients, many of whom have smoking-related comorbidities. However, newer technologies allow selection of appropriate patients for treatment, improve identification of the tumour, individualise radiotherapy treatment according to patient specific motion and reduce normal tissue toxicities. Image guided radiotherapy is increasingly becoming the standard of care, whereby the tumour position is confirmed on cone-beam CT performed on the linear accelerator prior to treatment. Intensity modulated radiotherapy is improving dose conformality and avoidance of normal tissue structures. Stereotactic ablative radiotherapy is currently being evaluated as a treatment option for patients with inoperable stage I non-small cell lung cancer. Radiotherapy is also an important palliative treatment for lung cancer, with well-established indications for palliation of thoracic symptoms such as airway obstruction, chest pain, cough and haemoptysis. Bone and brain metastases are common in lung cancer and radiotherapy remains the prime modality for alleviating symptoms from these. Multidisciplinary discussion of lung cancer patients is essential to ensure that appropriate patients receive the evidence-based benefits of radiotherapy

A decade of community-based outcomes of patients treated with curative radiotherapy with or without chemotherapy for non-small cell lung cancer

Aim: Clinical trials have reported good outcomes for non-small cell lung cancer (NSCLC) patients treated with curative radiotherapy. These populations are highly selected and may not be representative of lung cancer population. We aim to evaluate the outcomes of NSCLC patients treated with radiotherapy ± chemotherapy in Australian community setting and to assess the effect of comorbidity on outcomes. Method: Oncology records at Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia, were queried to retrieve patient, tumor and treatment data for stage I–III NSCLC patients who were treated with radiotherapy (minimum dose 60 Gy) between 1 January 2000 and 31 December 2010. Simplified comorbidity score (SCS) was used to score comorbidity. Kaplan–Meier and Cox hazards models were used for survival analysis. Results: A total of 160 patients were identified with median follow-up of 22 months. Median age was 69 years (range 36–89); 76 patients received radiotherapy alone, 25 received sequential chemoradiation and 59 received concurrent chemoradiation. Median overall survivals for stages I, II and III were 29, 26 and 18 months, respectively. On multivariate analysis, stage II or III and weight loss > 5% were predictive of cancer-specific survival with hazard ratios of 4.47 (1.08–18.55, P = 0.04) and 2.23 (1.13–4.39, P = 0.02), respectively. Toxicities were grade ≥ 3 pneumonitis in 2% of patients, grade ≥ 3 esophagitis in 6% and grade ≥ 3 febrile neutropenia in 2%. There were no treatment-related deaths. SCS was neither prognostic nor predictive of toxicity or survival. Conclusion: Curative radiotherapy ± chemotherapy is a well-tolerated and effective treatment for inoperable or locally advanced NSCLC. Patients should not be excluded from radiotherapy on basis of comorbidity since higher SCS was not correlated with worse survival

Multisource feedback for radiation oncologists

Introduction Multisource feedback (MSF) is an assessment of performance through evaluation of an individual's competence from multiple perspectives. It is mandated in many specialist training schemes in medicine. The aim of this study was to test the feasibility of implementing MSF for consultant radiation oncologists. Methods A validated tool consisting of a self-assessment questionnaire, medical colleague questionnaire, co-worker questionnaire and patient questionnaire was used for MSF. Statements were rated on a 5-point Likert scale with 1 being a low rating and 5 a high rating. Seven radiation oncologists volunteered to undergo MSF. They each nominated 10 medical colleagues, 10 co-workers and 10 patients to be surveyed. Clinician feedback was provided as an individual report with a mean score and range for each data item. Results Two hundred ten surveys were mailed out and seven self-assessments were completed. The response rate was 87% for medical colleagues, 89% for co-workers and 79% for patients. The mean feedback scores averaged for the radiation oncologists ranged from 4.4 to 4.9, significantly higher than self-assessments scores which ranged from 3.2 to 3.7. MSF identified areas for potential improvement including communication and collaboration with co-workers and accessibility to and adequacy of clinic space for patients. All radiation oncologists found the MSF a positive experience, and five planned to make changes in their practice in response to this. Conclusions The high response rate to the surveys has shown that it is feasible to implement MSF for radiation oncologists. This could potentially be used as a method for ongoing revalidation

Application of guideline recommended treatment in routine clinical practice : a population-based study of stage I-IIIB non-small cell lung cancer

Aims: The application of guideline recommended treatment (GRT) in routine clinical practice can be difficult due to differences between the clinic population and the clinical trial populations on which evidence is based. The study aims were to measure receipt of GRT in stage I-IIIB non-small cell lung cancer (NSCLC) patients, identify factors associated with GRT and its impact on survival. Materials and methods: New diagnoses of stage I-IIIB NSCLC from 1 January 2006 to 31 December 2011 in South West Sydney residents were identified from the district Clinical Cancer Registry. Treatment received was assigned as GRT or not based on Australian guidelines (using Eastern Cooperative Oncology Group [ECOG] performance status and TNM stage). Multivariate Poisson regression models with robust variance identified predictors of GRT receipt. Cox regression models identified multivariate predictors of patient survival. Results: In total, 592 eligible cases were identified, of whom 66% (n = 389) received GRT. This ranged from 81% of stage I to 39% of stage IIIB (relative risk 0.48, 0.38-0.60, P < 0.0001). Stage I-IIIA patients who were ECOG 2 and stage III patients aged 70 years and older were less likely to receive GRT. The median survival was 30 months in the GRT group and 16 months in the non-GRT group (P < 0.001). GRT receipt was associated with improved survival in stage I-II disease only (hazard ratio 0.41, P < 0.001; and hazard ratio 0.43, P = 0.006). Conclusion: One-third of NSCLC patients did not receive GRT. Stage and performance status were key predictors for GRT receipt. Patients with early stage NSCLC were associated with improved survival with the receipt of GRT

Incorporating a radiologist in a Radiation Oncology Department : a new model of care?

Aims: Increasingly complex imaging techniques, such as computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography scans are being used by radiation oncologists to improve the accuracy of their radiotherapy planning contours, despite limited formal training in diagnostic imaging. This study aimed to assess whether the availability of an 'in-house' radiologist would be beneficial in enhancing the interpretation of oncological imaging and accuracy of contouring. Materials and methods: A radiology/oncology fellow was based in the oncology department, providing radiological advice on diagnostic and planning images, for two sessions per week over a 9 month period. Oncology staff were able to book a time slot with the radiologist on a MOSAIQ cancer database and record the reason for the consultation and its outcome. The radiologist also reviewed the accuracy of the patient's contours for the weekly quality assurance audit meetings. Results: The radiologist reviewed 56 scans during the 49 consultation sessions. Advice over diagnostic images and target volume delineation were the main reasons for the consultations, which resulted in a change of practice in 45% of cases, ranging from changing target volumes (25%) to carrying out further imaging (20%). For the quality assurance audit meetings, the radiologist's review of 99 patients' planning contours resulted in a significant change in management in 6% of cases. Conclusions: This is the first study to attempt to formally quantify the clinical benefit of having a dedicated 'in-house' radiologist within a radiation oncology department, clearly showing the valuable impact of such a role

Timeliness of management for nonsmall cell lung cancer patients in South Western Sydney

Introduction: Timeliness of management is important for patients diagnosed with nonsmall cell lung cancer (NSCLC). Delays in management increase the risk of disease progression and potentially impact on survival

Uncertainties in volume delineation in radiation oncology : a systematic review and recommendations for future studies

Background and purpose: Volume delineation is a well-recognised potential source of error in radiotherapy. Whilst it is important to quantify the degree of interobserver variability (IOV) in volume delineation, the resulting impact on dosimetry and clinical outcomes is a more relevant endpoint. We performed a literature review of studies evaluating IOV in target volume and organ-at-risk (OAR) delineation in order to analyse these with respect to the metrics used, reporting of dosimetric consequences, and use of statistical tests. Methods and materials: Medline and Pubmed databases were queried for relevant articles using keywords. We included studies published in English between 2000 and 2014 with more than two observers. Results: 119 studies were identified covering all major tumour sites. CTV (n=47) and GTV (n=38) were most commonly contoured. Median number of participants and data sets were 7 (3-50) and 9 (1-132) respectively. There was considerable heterogeneity in the use of metrics and methods of analysis. Statistical analysis of results was reported in 68% (n=81) and dosimetric consequences in 21% (n=25) of studies. Conclusion: There is a lack of consistency in conducting and reporting analyses from IOV studies. We suggest a framework to use for future studies evaluating IOV

Do patients discussed at a lung cancer multidisciplinary team meeting receive guideline-recommended treatment?

Aim: Clinical guidelines provide evidence-based management recommendations to guide practice. This study aimed to evaluate whether patients discussed at a lung cancer multidisciplinary team meeting received guideline-recommended treatment and determine reasons for not receiving guideline-recommended treatment. Methods: All new lung cancer patients discussed at the Liverpool/Macarthur lung cancer multidisciplinary team meeting between 1 December 2005 and 31 December 2010 were included. Guideline-recommended treatment was assigned according to pathology, stage and ECOG (Eastern Co-operative Oncology Group) performance status as per the 2004 Australian Lung Cancer Guidelines. This was compared with actual treatment received to determine adherence to guidelines. For those patients who did not receive guideline-recommended treatment, the medical record was reviewed to determine the reason(s) for this. Survival was compared between those who did and did not receive guideline-recommended treatment. Results: 808 new patients were discussed at the multidisciplinary team meeting. Guideline-recommended treatment could not be assigned in 2% of patients due to missing data. 435 patients (54%) received guideline-recommended treatment, and 356 (44%) did not. The most common reasons for not receiving guideline-recommended treatment were a decline in ECOG performance status (24%), large tumor volume precluding radical radiotherapy (17%), comorbidities (15%) and patient preference (13%). Patients less than 70 years who received guideline-recommended treatment had improved survival compared with those who did not. Conclusions: A significant proportion of lung cancer patients did not receive guideline-recommended treatment due to legitimate reasons. Alternative guidelines are needed for patients not suitable for current best practice. Treatment according to guidelines was a predictor for survival

Assessing guideline adherence and patient outcomes in cervical cancer

Aim: To investigate adherence to clinical practice guidelines (CPGs) in cervical cancer and the correlation with clinical outcomes. Methods: A retrospective analysis was conducted using patient information from a population-based cancer registry (2005-2011, n = 208). Compliance to 10 widely accepted CPGs was assessed. Univariate and multivariate analyses were performed to assess sociodemographic factors associated with CPG adherence. Multivariate Cox regression was performed to assess the relationship between CPG adherence and 5-year survival. Results: Adherence to individual CPGs ranged from 47% to 100%. Compliance to all applicable CPGs was seen in 54% (n = 72) of patients, 62% of stage I and II patients and 22% of stage III and IV patients. Poorest adherence was seen with those with locally advanced disease receiving chemoradiotherapy. Patients who lived within 5 km of the treatment facility were more likely to be compliant. No difference was found for either age, country of birth or socioeconomic status group. Five-year survival was greater for stage I and II patients who received guideline adherent care (93.7% vs 69.7%, P = 0.002), and they had a significant lower risk of death on multivariate analysis (HR = 0.22, P = 0.015). There was no significant difference for those with stage III or IV disease. Conclusions: In this study, CPG adherence is variable between treatment modalities and only half complied to all applicable CPGs. There was better adherence in those with early-stage disease and this was associated with improved patient outcomes. CPG adherence may be a useful surrogate for quality of care