The COVID-19 pandemic has been unprecedented and has led to drastic reductions in non-urgent medical visits. Deferral of these visits may have critical health impact, including delayed diagnosis for ...melanoma and other skin cancers. We examined the influence of the pandemic on skin biopsy rates in a large population-based cohort.
Using a universal health care claims dataset from Ontario, we examined skin biopsies from January 6, 2020 to September 27, 2020, and compared these to the same period for 2019. Those diagnosed with anogenital cancers, younger than 20 years, residing out-of-province and with lapses in coverage were excluded. The sensitivity and specificity of claims diagnoses compared to a validated algorithm to identify keratinocyte carcinoma (KC), or to the cancer registry for melanoma was evaluated. Factors associated with biopsy during the early pandemic were investigated with modified Poisson regression.
A precipitous drop in total skin biopsies (15% of expected), biopsies for KC (18%) and melanoma (27%) was seen with the onset of COVID-19 cases (p<0.01). Claims diagnoses were of high specificity for KC (99%), and for melanoma (98%), though sensitivity was less (61%, 28% respectively). In adjusted analysis, the elderly (80+ years), females and residents of certain regions were less likely to be biopsied during the pandemic. Subsequently, there were substantial improvements in biopsy rates over 10 weeks. However, compared to 2019, a large backlog of expected cases still remained 28 weeks after lockdown (45,710 all biopsy, 9,104 KC, 595 melanoma).
A drastic reduction in skin biopsies is noted early in the COVID-19 pandemic; this disproportionately affected the elderly, females and certain geographic regions. Though biopsies subsequently increased, a large backlog of cases remained after almost half a year. This will have implications for downstream care of skin cancer. Efforts should be made to limit diagnostic delay.
To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways.
Systematic review and meta-analysis.
Published studies in ...Medline from 1 January 2000 to 10 April 2020.
Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models.
The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings.
Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.
Abstract Background and Purpose In 2003 we estimated that 52.3% of new cases of cancer in Australia had an indication for external beam radiotherapy at least once at some time during the course of ...their illness. This update reviews the contemporary evidence to define the optimal proportion of new cancers that would benefit from radiotherapy as part of their treatment and estimates the changes to the optimal radiotherapy utilisation rate from 2003 to 2012. Materials and Methods National and international guidelines were reviewed for external beam radiotherapy indications in the management of cancers. Epidemiological data on the proportion of new cases of cancer with each indication for radiotherapy were identified. Indications and epidemiological data were merged to develop an optimal radiotherapy utilisation tree. Univariate and Monte Carlo simulations were used in sensitivity analysis. Results The overall optimal radiotherapy utilisation rate (external beam radiotherapy) for all registered cancers in Australia changed from 52.3% in 2003 to 48.3% in 2012. Overall 8.9% of all cancer patients in Australia have at least one indication for concurrent chemo-radiotherapy during the course of their illness. Conclusions The reduction in the radiotherapy utilisation rate was due to changes in epidemiological data, changes to radiotherapy indications and refinements of the model structure.
Expanding global access to radiotherapy Atun, Rifat, Prof; Jaffray, David A, Prof; Barton, Michael B, Prof ...
The lancet oncology,
09/2015, Letnik:
16, Številka:
10
Journal Article
Recenzirano
Summary Radiotherapy is a critical and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low-income and middle-income countries, radiotherapy is ...essential for effective treatment. In high-income countries, radiotherapy is used in more than half of all cases of cancer to cure localised disease, palliate symptoms, and control disease in incurable cancers. Yet, in planning and building treatment capacity for cancer, radiotherapy is frequently the last resource to be considered. Consequently, worldwide access to radiotherapy is unacceptably low. We present a new body of evidence that quantifies the worldwide coverage of radiotherapy services by country. We show the shortfall in access to radiotherapy by country and globally for 2015–35 based on current and projected need, and show substantial health and economic benefits to investing in radiotherapy. The cost of scaling up radiotherapy in the nominal model in 2015–35 is US$26·6 billion in low-income countries, $62·6 billion in lower-middle-income countries, and $94·8 billion in upper-middle-income countries, which amounts to $184·0 billion across all low-income and middle-income countries. In the efficiency model the costs were lower: $14·1 billion in low-income, $33·3 billion in lower-middle-income, and $49·4 billion in upper-middle-income countries—a total of $96·8 billion. Scale-up of radiotherapy capacity in 2015–35 from current levels could lead to saving of 26·9 million life-years in low-income and middle-income countries over the lifetime of the patients who received treatment. The economic benefits of investment in radiotherapy are very substantial. Using the nominal cost model could produce a net benefit of $278·1 billion in 2015–35 ($265·2 million in low-income countries, $38·5 billion in lower-middle-income countries, and $239·3 billion in upper-middle-income countries). Investment in the efficiency model would produce in the same period an even greater total benefit of $365·4 billion ($12·8 billion in low-income countries, $67·7 billion in lower-middle-income countries, and $284·7 billion in upper-middle-income countries). The returns, by the human-capital approach, are projected to be less with the nominal cost model, amounting to $16·9 billion in 2015–35 (–$14·9 billion in low-income countries; –$18·7 billion in lower-middle-income countries, and $50·5 billion in upper-middle-income countries). The returns with the efficiency model were projected to be greater, however, amounting to $104·2 billion (–$2·4 billion in low-income countries, $10·7 billion in lower-middle-income countries, and $95·9 billion in upper-middle-income countries). Our results provide compelling evidence that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits.
•This population-based study describes the management of stage I NSCLC, 2010–2019.•The utilization of SABR increased, while surgery and observation decreased.•Substantial practice variation was ...observed amongst the 14 Ontario health regions.•From 2010 to 2019, 2 yr-OS and CSS over time improved for all stage I and surgically managed patients.
Stereotactic Ablative Body Radiotherapy (SABR) is the standard of care for medically inoperable patients with Stage I NSCLC. The adoption of SABR and its association with cancer outcomes requires characterization.
We described the management of biopsy-proven Stage I NSCLC with SABR, surgery, non-SABR curative radiotherapy (RT) and observation in Ontario, Canada, between 2010 and 2019. Temporal and geographic trends in practice and survival outcomes were analyzed.
This was a retrospective population-based cohort study conducted by linking electronic radiotherapy (RT) records to a population-based cancer registry.
A total of 12,065 patients were identified, 61.7 % underwent surgery, 17.9 % received SABR, 8.6 % received non-SABR curative RT and 11.7 % were observed. Between 2010 and 2019, the utilization of surgery decreased (63.8 % to 49.9 %, p < 0.0001), while SABR use increased (7.5 % to 24.4 %, p < 0.0001), non-SABR curative RT use increased (6.7 % to 9.6 %, p < 0.0014) and patients observed decreased (14.4 % to 12.0 %, p < 0.0001). Substantial variation in practice exists across Ontario. Two- yr CSS improved for the entire cohort (81.9 % to 85.0 %, p < 0.0001). While there was improvement in 2 yr CSS for surgical patients (92.1 %% to 95.7 %, p < 0.001), survival for patients who received SABR, Non-SABR curative RT and observation remained stable.
There has been an increase in SABR utilization and a reduction in surgical utilization with a corresponding increased survival of stage I patients in Ontario between 2010 and 2019. Substantial differences in practice patterns exist across health regions, suggesting the need for strategies to improve access to SABR in many jurisdictions.
Continuous quality improvement is important for cancer systems. However, collecting and compiling quality indicator data can be time-consuming and resource-intensive. Here we explore the utility and ...feasibility of linked routinely collected health data to capture key elements of quality of care for melanoma in a single-payer, universal health care setting.
This pilot study utilized a retrospective population-based cohort from a previously developed linked administrative data set, with a 65% random sample of all invasive cutaneous melanoma cases diagnosed 2007-2012 in the province of Ontario. Data from the Ontario Cancer Registry was utilized, supplemented with linked pathology report data from Cancer Care Ontario, and other linked administrative data describing health care utilization. Quality indicators identified through provincial guidelines and international consensus were evaluated for potential collection with administrative data and measured where possible.
A total of 7,654 cases of melanoma were evaluated. Ten of 25 (40%) candidate quality indicators were feasible to be collected with the available administrative data. Many indicators (8/25) could not be measured due to unavailable clinical information (e.g. width of clinical margins). Insufficient pathology information (6/25) or health structure information (1/25) were less common reasons. Reporting of recommended variables in pathology reports varied from 65.2% (satellitosis) to 99.6% (body location). For stage IB-II or T1b-T4a melanoma patients where SLNB should be discussed, approximately two-thirds met with a surgeon experienced in SLNB. Of patients undergoing full lymph node dissection, 76.2% had adequate evaluation of the basin.
We found that use of linked administrative data sources is feasible for measurement of melanoma quality in some cases. In those cases, findings suggest opportunities for quality improvement. Consultation with surgeons offering SLNB was limited, and pathology report completeness was sub-optimal, but was prior to routine synoptic reporting. However, to measure more quality indicators, text-based data sources will require alternative approaches to manual collection such as natural language processing or standardized collection. We recommend development of robust data platforms to support continuous re-evaluation of melanoma quality indicators, with the goal of optimizing quality of care for melanoma patients on an ongoing basis.
To identify inequalities in cancer survival rates for patients with a history of severe psychiatric illness (SPI) compared to those with no history of mental illness and explore differences in the ...provision of recommended cancer treatment as a potential explanation. The universal healthcare system in Ontario, Canada. Colorectal cancer (CRC) patients diagnosed between April 1st, 2007 and December 31st, 2012. SPI history (schizophrenia, schizoaffective disorders, other psychotic disorders, bipolar disorders or major depressive disorders) was determined using hospitalization, emergency department, and psychiatrist visit data and categorized as 'no history of mental illness, 'outpatient SPI history', and 'inpatient SPI history'. Cancer-specific survival, non-receipt of surgical resection, and non-receipt of adjuvant chemotherapy or radiation. 24,507 CRC patients were included; 482 (2.0%) had an outpatient SPI history and 258 (1.0%) had an inpatient SPI history. Individuals with an SPI history had significantly lower survival rates and were significantly less likely to receive guideline recommended treatment than CRC patients with no history of mental illness. The adjusted HR for cancer-specific death was 1.69 times higher for individuals with an inpatient SPI (95% CI 1.36-2.09) and 1.24 times higher for individuals with an outpatient SPI history (95% CI 1.04-1.48). Stage II and III CRC patients with an inpatient SPI history were 2.15 times less likely (95% CI 1.07-4.33) to receive potentially curative surgical resection and 2.07 times less likely (95% CI 1.72-2.50) to receive adjuvant radiation or chemotherapy. These findings were consistent across multiple sensitivity analyses. Individuals with an SPI history experience inequalities in colorectal cancer care and survival within a universal healthcare system. Increasing advocacy and the availability of resources to support individuals with an SPI within the cancer system are warranted to reduce the potential for unnecessary harm.
The efficacy‐effectiveness (EE) gap describes the differences in survival seen in clinical trials and routine clinical practice, where patients in real‐world practice often have inferior outcomes ...compared to trial populations. However, EE gaps may exist beyond survival outcomes, including gaps in quality of life, toxicity, cost‐effectiveness, and patient time, and these EE gaps should also influence patient and clinician treatment decisions. Failure to clearly acknowledge these EE gaps may cause patients, clinicians, and health care systems to have unrealistic expectations of the benefits of therapy across a range of important clinical and economic domains. In this commentary, the authors review the evidence supporting the existence of EE gaps in quality of life, time toxicity, cost and toxicities, and urge for further research into this important topic.
Efficacy‐effectiveness (EE) gaps are typically associated with survival outcomes. In this commentary, the authors review potential EE gaps in quality of life, toxicity, cost‐effectiveness, and patient time and how these EE gaps may cause patients, clinicians, and health care systems to have unrealistic expectations of the benefits of therapy across a range of clinical and economic domains.
Population-based datasets are often used to estimate changes in utilization or outcomes of novel therapies. Inclusion or exclusion of unstaged patients may impact on interpretation of these studies.
...A large population-based dataset in Ontario, Canada of non-small cell lung cancer patients was examined to evaluate the characteristics and outcomes of unstaged patients compared to staged patients. Multivariable Poisson regression was used to evaluate differences in patient-level characteristics between groups. Kaplan-Meier estimates of survival and log-rank statistics were utilized.
In our Ontario cohort of 51,152 patients with NSCLC, 11.2% (n=5,707) were unstaged, and there was evidence that stage data was not missing completely at random. Those without assigned stage were more likely than staged patients to be older (RR 95%CI), (70-79 vs. 20-59: 1.51 1.38-1.66; 80+ vs. 20-59: 2.87 2.62-3.15), have a higher comorbidity index (Score 1-2 vs 0: 1.19 1.12-1.27; 3 vs. 0: 1.49 1.38-1.60), and have a lower socioeconomic class (4 vs. 1 (lowest): 0.91 0.84-0.98; 5 vs. 1 (lowest): 0.89 0.83-0.97). Overall survival of unstaged patients suggested a mixture of early and advanced stage, but with a large proportion that are probably stage IV patients with more rapid death than those with reported stage IV disease.
In this case study, evaluation of stage-specific health care utilization and outcomes for staged patients with stage IV disease at the population level may have a bias as a distinct subset of stage IV patients with rapid death are likely among those without a documented stage in administrative data.
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