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A. Chyjek



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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): A. Chyjek

      • 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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    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): A. Chyjek

      • 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.