The objectives of this study were 1) to describe patterns of use of computed tomography (CT) in laryngeal carcinoma, and 2) to characterize the contribution of CT to the T classification of laryngeal carcinoma.The study population comprised 1195 patients with laryngeal carcinoma diagnosed from 1982 through 1995 chosen randomly from the Ontario provincial cancer registry. A chart review was conducted to obtain data on each case. Patient-related, tumor-related, and health-system-related factors were analyzed to identify factors associated with the use of CT. Descriptions of clinical exams and CT reports were reviewed to see how CT information modified T classification. Actuarial local control and cause specific survival curves were plotted by clinical T classification without and with CT to evaluate stage migration. The percentage of the variance in outcome explained by T classification in a Cox analysis was used to evaluate whether the prognostic accuracy of T classification was improved with the use of information from CT.Patients with glottic (20.1%) and supraglottic (41.7%) carcinoma underwent CT. The use of CT increased over time in glottic and supraglottic carcinoma combined from 17.2% in 1982-5 to 33.9% in 1991-5. Computed tomography was used less often in older patients with a 16% (95% confidence interval, 5-27%) decrease in the odds of having CT with each 10-year age increment. Computed tomography use varied considerably across the cancer center regions in Ontario. Computed tomography altered the T classification in 20.2% of those patients who had CT, with most being "upstages." Stage migration due to CT was demonstrated. Using information from CT in the assignment of T classification for 27.8% of this study population did not make a significant contribution to the ability of T classification to predict outcome over the entire group.There is large variation in the use of CT among different age groups and regions. The ability to compare outcomes by stage across geographic areas is compromised when the use of CT varies.
1583 Background: ACT for NSCLC is associated with improved survival in the general population but may be underutilized. Underutilization may relate to lack of referral from surgeon to MO, MO not offering ACT, or patient declining ACT. Here we explore factors associated with referral to MO and use of ACT among patients with resected NSCLC in Ontario Canada. Methods: The Ontario Cancer Registry was used to identify all incident cases of NSCLC diagnosed in Ontario 2004-2006. We linked electronic records of treatment to identify surgery, ACT, and MO consultation. Co-morbidity was classified using the Charlson Comorbidity Index modified for administrative data. A multivariate logistic regression model was used to evaluate factors associated with referral to MO and use of ACT. Results: 3354 cases of NSCLC were resected in Ontario 2004-2006, 1830 (55%) were seen post-operatively by MO and 1032 (31%) were treated with ACT. Cases younger than 70 were more likely to have MO consultation (age 60-69 OR 1.6; 50-59 OR 2.3; 20-49 OR 2.2, p<0.001) as were cases with stage II/III (ORs 2.7 and 2.0, p<0.01) compared to stage I disease. There was substantial geographic variation in the proportion of surgical cases referred to MO (range 32-88%, p<0.001). Among cases seen by MO, patients younger than 70 were more likely to have ACT (age 60-69 OR 3.1; 50-59 OR 4.7; 20-49 OR 6.7, p<0.001) as were cases with stage II/III (ORs 2.7 and 3.0, p<0.001) compared to stage I disease. Less co-morbidity (OR 2.1, p=0.02) and shorter post-operative stay (OR 1.4, p=0.001) were also associated with use of ACT. Among cases seen by MO, there was some geographic variation (range 46-63%, p<0.001) in rates of ACT utilization. Conclusions: The upstream decision to refer to MO is associated with age and stage of disease and these factors have an even greater effect on ACT utilization once patients are seen by MO. While co-morbidity and post-operative length of stay are not associated with referral to MO, they are associated with use of ACT among cases seen by MO. There is substantial geographic variation in referral patterns to MO and less variation in ACT utilization once patients are seen by MO.
To facilitate treatment decision‐making, one aims to provide information, present it in a way that makes it as easy as possible to understand, and to help the decision‐maker through the cognitive processes that result in a treatment decision. Decision aids aim to accomplish just these goals and this paper identifies practical issues that we have encountered in creating a decision aid for men with early stage prostate cancer. We highlight the results of studies we carried out to provide an empirical basis for the decision aid that we were developing. Several of the studies were designed to identify what information key players (health professionals, patients and family members) thought was important for the decision‐making process. Another investigation studied methodological considerations in identifying important information. The final study focused on presentation issues. These studies, designed to explore what information was considered important, found great variability among both health care professionals involved in treating patients with prostate cancer (urologists, radiation oncologists, nurses in cancer clinics, and radiation technologists) and among the patients, themselves. The studies also showed that not all information contained within a typical category is of equal importance. A methodological study showed that the information that patients deem to be important to their decision depends on whether they are rating the information that could be provided, or questions that could be answered. Finally, presentation studies showed that the various formats used in presenting quantitative information are processed with differing degrees of accuracy and ease. Each of the above results has implications for those creating decision aids; these implications are highlighted.
Purpose To describe the structure and use of a decision aid for patients with locally advanced non‐small cell lung cancer (LA‐NSCLC) who are eligible for combined‐modality treatment (CMT) or for radiotherapy alone (RT). Methods The aid included a structured description of the treatment options and trade‐off exercises designed to help clarify the patient’s values for the relevant outcomes by determining the patient’s survival advantage threshold (the increase in survival conferred by CMT over RT that the patient deemed necessary for choosing CMT). Additional outcome measures included each patient’s strength of treatment preference, decisional conflict, objective understanding of survival information, decisional role preference, and evaluation of the aid itself. Results Twenty‐five patients met the eligibility criteria for study. Of these, seven declined the decision aid because they had a clear treatment preference (four chose CMT and three chose RT). The remaining 18 participants completed the decision aid; 16 chose CMT and two chose RT. All 18 patients wished to participate in the decision to some extent. All patients reported that using the decision support was useful to them and recommended its use for others. No patient or physician reported that the aid interfered with the physician‐patient relationship. Patients’ 3‐year survival advantage thresholds, and their median survival advantage thresholds, were each strongly correlated with their strengths of treatment preference ( ρ =0.80, P < 0.001 and ρ =0.77, P < 0.001, respectively). For all but one patient, either their 3‐year or median survival threshold was consistent with their final treatment choice. Eight patients reported a stronger treatment preference after using the decision aid. Conclusions We conclude that a treatment trade‐off based decision aid for patients with locally advanced non‐small cell lung cancer is feasible, that it demonstrates internal consistency and convergent validity, and that it is favourably evaluated by patients and their physicians. The aid seems to help patients understand the benefits and risks of treatment and to choose the treatment that is most consistent with their values.
Abstract Background Identifying optimal chemotherapy utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of adjuvant chemotherapy (ACT) for stage III colon cancer. Methods The Ontario Cancer Registry and linked treated records were used to identify ACT utilization. Monte Carlo simulation was used to estimate the proportion of ACT rate variation that could be due to chance alone. The criterion‐based benchmarking approach was used to explore whether socioeconomic or system‐level factors were associated with ACT. We also used the “pared‐mean” approach to identify a benchmark population of hospitals with the highest ACT rates. Results The study population included 2801 patients; ACT was delivered to 66% (1861/2801). Monte Carlo simulation suggested that the observed component of variation (15.6%) in ACT rates was within the 95% CI (11.5%‐17.3%) of what could be expected due to chance alone; the nonrandom component of ACT rate variation across hospitals was only 1.5%. There was no difference in hospital ACT rate by teaching status ( P = .107), cancer center status ( P = .362), or having medical oncology on site ( P = .840). Unadjusted ACT rates varied across hospitals (range 44%‐91%, P = .017). The unadjusted benchmark ACT rate was 81% (95%CI 76%‐86%); utilization rate in non‐benchmark hospitals was 65% (95%CI 63%‐66%). However, after adjusting for case mix, the difference in ACT utilization between benchmark and non‐benchmark populations was significantly smaller. Conclusions We did not find any system‐level factors associated with the utilization of ACT. Our results suggest that the observed variation in hospital ACT rate is not significantly different from variation due to chance alone. Using the “pared‐mean” approach may significantly overestimate optimal treatment rates if case mix is not considered.
