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Y.C. Ung



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    P2.09 - Poster Session 2 - Combined Modality (ID 213)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Combined Modality
    • Presentations: 1
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      P2.09-010 - Variation in the Uptake of the Combined Modality Practice Guideline for Surgically Unresectable Stage III NSCLC in Ontario (ID 1887)

      09:30 - 09:30  |  Author(s): Y.C. Ung

      • Abstract

      Background
      Cancer Care Ontario’s (CCO) Program in Evidence-based Care has been developing lung cancer practice guidelines since 1997. Based on randomized clinical trials and published meta-analyses, a modest but clinically significant benefit for the use of concurrent chemo-radiotherapy treatment (CCRT) in selected inoperable stage III NSCLC (good performance status, limited weight loss), was recommended in a guideline published in 2005 and revised in 2006.

      Methods
      In 2008, CCO began to measure concordance with guidelines and to publically report regional results through the Cancer System Quality Index (CSQI),a web-based public reporting tool released annually by the Cancer Quality Council of Ontario (CQCO), Guideline concordance is a measure within the Effective quality domain of CSQI and is used to track the consistency of cancer treatment services across Ontario. This measure links data within Cancer Care Ontario’s Activity Level Reporting Enterprise Data Warehouse and the Ontario Cancer Registry with information from the Canadian Institute for Health Information’s Discharge Abstract Data and National Ambulatory Care Reporting System.

      Results
      Of 1312 patients with unresected stage III disease diagnosed in 2010 and 1259 in 2011, only 30.3% and 31.8% respectively received CCRT defined as radiation and chemotherapy given within 180 days of diagnosis. An additional 33.9% received an alternative form of treatment in 2011: 83.6% of these patients were treated only with radiation, 66% of whom had palliative radiotherapy while 33.4% had radical (curative) radiotherapy. In 2010, a similar pattern of treatment was observed with 33.5% of cases receiving alternate treatment: 81.3% of whom received only radiation; 70% of these patients received palliative treatment while 27.5% received radical radiotherapy. In 2011, 34.2% received no treatment, a decrease of 2% from 2010. Variation in guideline concordant practice was evident between the 14 health service regions of the province (range from 23.3% to 44.5%) but only one was significantly greater than the Ontario rate (95% Confidence Interval (CI); effect size (d =0.56). Six of 14 regions had a decline in the concordance rate between 2010 and 2011. There was no difference in the rate of CCRT use by gender (28.4%) but there was a sharp decline in CCRT after age 65 (45% < 65 yr vs. 25% > 65 yr), (95% CI, 21.5-28.5; p=0001). Less CCRT was given to the lowest income quintile (Q)(22.9% vs. 29.9% for Q4, 95% CI 23.9-35.9; p=0.0001), to urban vs. rural populations (22.9% vs. 34.8%; 95% CI, 28.6-40.9; p=0.0001) and in those areas of the province with higher populations of immigrants (lowest tercile 28.4% vs. 18.6% for middle and 19.0% for the highest tercile, p=0.0001).

      Conclusion
      Concordance with the CCO guideline on CCRT in Stage III unresectable NSCLC is particularly low in older, lower income, urban and immigrant populations. The absence of weight loss and performance status data makes interpretation of this data difficult. Further study of the reasons for these variations in practice will be necessary to inform appropriate strategies to reduce these inequities.

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    P2.24 - Poster Session 2 - Supportive Care (ID 157)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P2.24-022 - Implementing Dyspnea Management: A quality improvement project for patients with lung cancer in Ontario, Canada (ID 1439)

      09:30 - 09:30  |  Author(s): Y.C. Ung

      • Abstract

      Background
      Dyspnea is a distressing symptom that occurs in up to 75% of patients with lung cancer as measured by the Edmonton Symptom Assessment System (ESAS). Appropriate dyspnea management (DM) can improve the patient’s quality of life, performance status and emotional well-being. However DM is not uniform or standard across Regional Cancer Centers (RCC). A quality improvement intiative on DM was implemented through the Disease Pathway Management (DPM) of Cancer Care Ontario (CCO). DPM is a unifying approach to quality improvement that integrates program activity across the cancer continuum in order to advance system-wide improvements. This initiative provided advice on various delivery models and strategies for DM.

      Methods
      Seven RCCs received funding from CCO to undertake one year pilot projects in DM. These projects had to have potential for significant impact, be innovative and be cost effective. Each RCC project was required to address the physical and psychological aspects of dyspnea that affect the patient, their families and/or caregivers. The precise methodology was left to each RCC to develop and initiate within the specified criteria. Approaches included educational sessions for patients and family members, individual counseling and treatment plans, and symptom management clinics. Four measures were tracked: ESAS for patient-reported symptom severity, Palliative Performance Status (PPS) for evaluation of functional status, European Organization for Research and Treatment Quality of Life Questionnaire (EORTC-QOL) to measure quality of life and a Patient Survey to evaluate the patient’s knowledge of dyspnea, preparedness for self-management and overall satisfaction with the DM initiative.

      Results
      188 patients were evaluable. 45% of patients with an initial severe dyspnea score on ESAS reported a shift to either a moderate or mild score by the last visit. 32% of patients with an initial moderate dyspnea score on ESAS reported a shift to a mild score. Patient satisfaction was high, with feelings of empowerment to carry on daily activities as a result of the interventions offered; caregivers reported a better understanding of dyspnea and better ability to support their loved ones; clinicians noted a difference in patients attending the dyspnea care initiative and valued the helpful resource for their patients. Challenges encountered during the project were lower than expected recruitment due to lack of clinical engagement from busy clinicians, multiple additional visits that sometimes conflicted with other scheduled patient visits to the RCC, and declining performance status of the patients precluding in-person attendance for training in DM techniques.

      Conclusion
      DM can be effectively implemented and tailored to local needs of a RCC or program. Key factors for success included a clinical champion and a multidisciplinary team approach in order to build the necessary knowledge and expertise for DM. The lessons learned as a result of these pilot projects have led to a new initiative to improve the quality and consistency of DM across the province of Ontario. This new initiative will incorporate novel approaches for knowledge transference with the possibility of engaging healthcare providers beyond the RCC.

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    P3.12 - Poster Session 3 - NSCLC Early Stage (ID 206)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P3.12-008 - Variations in the Uptake of Practice Guideline Recommendations on Adjuvant Chemotherapy Use Following Surgical Resection in Ontario (ID 1921)

      09:30 - 09:30  |  Author(s): Y.C. Ung

      • Abstract

      Background
      Since 1997, lung cancer practice guidelines have been developed through Cancer Care Ontario’s Program in Evidence-based Care. A 2006 CCO guideline (EBS 7-1-2) recommends adjuvant chemotherapy (AC) in selected patients with resected lung cancer.

      Methods
      In 2008, CQCO began to measure concordance with guidelines and to publically report regional results through the Cancer System Quality Index (CSQI),a web-based public reporting tool released annually by the Cancer Quality Council of Ontario (CQCO). Guideline concordance is a measure within the Effective quality domain of CSQI and is used to track the consistency of cancer treatment services across Ontario. This measure links data within Cancer Care Ontario’s Activity Level Reporting Enterprise Data Warehouse and the Ontario Cancer Registry with information from the Canadian Institute for Health Information’s Discharge Abstract Data and National Ambulatory Care Reporting System. Two cohorts of patients who were diagnosed with Stage II or IIIa NSCLC between January and December 2008 to 2009 (cohort 1; n=685) and 2010 to 2011 (cohort 2; n=626) and resected within 270 days of diagnosis and who received cisplatin-based chemotherapy within 120 days of surgery are included in this analysis.

      Results
      In 2011, 60% of stage I, 64% of stage II and 15% of stage III NSCLC underwent surgical resection. On average, AC use increased in those resected from 54.3% in cohort 1 to 56.7% in cohort 2 but with significant variation amongst the 14 health service regions of the province (range 42.9 to 72.1%). 3 regions were moderately different from the Ontario rate based on Cohen’s d effect test at 95% CI, (d = 0.53-0.65). The variation between regions was greater in cohort 1 (31.4% to 66.9%; Δ 35.5%) than in cohort 2 (42.9% to 72.1%; Δ 29.2%) suggesting that public reporting may have driven some modest change. However, although the rate of use of AC increased for 10 regions, it actually decreased in 4. Men were significantly less likely to be treated with AC (38.2%) compared to women (52.7%) (95% CI, 44.6-60.8, p=.0001), as were patients over age 65 (65% < 65 yr vs. 34% % > 65 yr), (95% CI, 27.5-41.2; p=0001). Patients from areas with the highest tercile of immigrant population were also significantly less likely to be treated 14.3% (95% CI, p=.023) vs 46.0% for the middle; and 51.0% (p=.0001) for the lowest tercile. There were no differences based on quintiles (Q) of income (lowest Q 48.3% vs Q4, 48.3%; Q5, 40.8%) or rural versus urban residence.

      Conclusion
      Overall guideline uptake appears low for a therapy with the potential to improve long term survivorship and there is wide variance between regions only partially explained by factors such as age, gender and immigrant status. Further study is necessary to understand the factors driving this variation in practice and the best strategies to ensure that patients receive guideline recommended therapy.

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    P3.20 - Poster Session 3 - Early Detection and Screening (ID 174)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Imaging, Staging & Screening
    • Presentations: 1
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      P3.20-003 - A Practice Guideline for Low Dose CT Screening for Lung Cancer: Evidence Based Recommendations Before Implementation. (ID 1197)

      09:30 - 09:30  |  Author(s): Y.C. Ung

      • Abstract

      Background
      The National Lung Screening Trial (NLST) compared low dose CT (LDCT) with chest radiography (CXR) in high-risk populations and found a 20% reduction in lung cancer mortality at 6 years with LDCT after an initial scan and two annual rounds of screening. This is the first randomized controlled trial (RCT) to show a mortality benefit with lung cancer screening. LDCT screening is not yet part of the standard of care and no formal process currently exists in Ontario, Canada for lung cancer screening. Injudicious use of LDCT can potentially cause more harm than benefit, including exposure of healthy persons to ionizing radiation and subsequent invasive procedures for ultimately benign lesions. When used correctly, however, LDCT screening has the potential to save lives. A practice guideline was developed to guide clinicians and healthcare policy makers with evidence-based recommendations for screening high-risk populations for lung cancer.

      Methods
      The guideline was developed using the methods of Cancer Care Ontario’s Program in Evidence-Based Care (PEBC). The core methodology of the PEBC’s guideline development process is a systematic review. A systematic review had recently been completed by a collaboration of the American Cancer Society, the American College of Chest Physicians, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. The evidence from that systematic review formed the basis of the current recommendations, which were reviewed, and amended where necessary, by clinical experts in the fields of medical, radiation, and thoracic oncology; diagnostic radiology; pulmonary disease; and population health. The recommendations were reviewed by the Provincial Lung Cancer Disease Site Group and underwent both internal review by an expert panel and external review by clinicians with expertise in the topic to achieve consensus.

      Results
      The systematic review included three RCTs comparing LDCT screening with CXR (including the NLST), 5 RCTs comparing LDCT screening with usual care (no screening), and 13 single-arm studies of LDCT in patients at risk for lung cancer. One large RCT reported a statistically significant reduction in lung cancer mortality with low-dose computed tomography at six years compared with CXR. The practice guideline recommendations generally align with the parameters of the NLST. Deviations were described and justified by the guideline working group. The recommendations support screening persons at high-risk for lung cancer with advice for defining a positive result on LDCT, appropriate follow-up, and optimal screening interval.

      Conclusion
      The benefits of screening high-risk populations for lung cancer with LDCT outweigh the harms if screening is implemented in a strictly controlled manner targeting the high risk population. This practice guideline forms the basis for the rationale for a screening program. An economic impact analysis will need to be done to design an appropriate cost effective lung cancer screening program prior to implementation.