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84 Survey: practice patterns of Canadian urologists in the management of stage 1 seminoma of the testis
CARO 2003
dress casual attire (with pants or skirt), nor departmental sweatshirt with white dress pants. There was no clinically significant trend to a change in perception over the time interval tested. Patients felt that wearing a lab coat and name badges positively influenced the perception of professionalism. Patients, overall preference was for uniform scrubs. Patients demonstrated a preference for the attire of radiation therapists. Wearing lab coats and name badges positively influenced patients perceptions of professionalism, satisfaction, and comfort. 82
Boosts for breast cancer patterns of practice in Ontario D. Danko 1, J. Sussman 2 1Michener Institute Radiation Therapy School, Toronto, Ontario, Canada 2Hamilton Regional Cancer Centre, McMaster Unive(sity, Hamilton, Ontario, Canada Backround: Recent studies suggest there may be improvements in outcome using boost radiotherapy in some patients with early stage breast cancer. Most often electrons are used. This has implications regarding patient care and treatment resources. Objective: To determine the current breast boost practices in the province of Ontario. Methods: Self-completed mailed survey of all radiation oncologists treating breast cancer in Ontario. A modified Dilman procedure was used. Results: An unadjusted response rate of 81% was achieved (39/48). 84% of respondents offer a boost in situations with a negative lumpectomy margin. Of these, 69% offer boost based on age, 65% based on surgical margin distance with 50% offering boost for margins <2 mm (40% offer boost for margin >l<2mm). 76% of physicians reported having local guidelines for boost indications. 70% of respondents routinely attempt to cover the surgical scar in their volume. Tools used to plan the lateral extent of the boost volume include: Mammogram (71%); operative reports (59%); clinical palpation (59%); surgical clips in tumour cavity (56%). Tools used to plan the boost treatment depth include: mammogram films (44%); clinical palpation (39%); CT (39%); surgical clips (32%); Tangent Films (29%); Operative Reports (29%); Ultrasound (24%). Several dose fractionation schedules are reported. The most common schedule is 10Gy/5 (46%) followed by 12.5Gy/5 (20%); 60% of respondents reported local guidelines for breast boost planning and prescription. Conclusions: We found variation in the self-reported practices for electron boosts for breast cancer in Ontario. Most physicians identified local guidelines for treatment indications and planning. Provincial evidence based guidelines may help address treatment variations to optimize resource utilization and patient care. 83
Patterns of practice and outcome for patients with stage III non-small cell lung cancer in British Columbia 1991-2000 E. Wai, F. Sheehan British Columbia Cancer Agency, Vancouver Island Centre, Victoria, British Columbia, Canada Backaround: This study documents the pattern of practice and survival in a population-based cohort of Stage III NSCLC patients in British Columbia between 1991-2000. Methods: Electronic records of all patients diagnosed with clinical Stage Ill NSCLC between January 1, 1991 and December 31, 2000 referred to the British Columbia Cancer Agency were analyzed. Descriptors of radiotherapy use in this population were determined. The proportions of patients receiving combined modality therapy with chemotherapy and radiotherapy (CMT), radical radiotherapy (RRT), and palliative treatment (PT) were compared for the years 1991-2000. Overall survival was determined for patients based on their initial treatment. Results: Among 2268 patients,1856 received radiotherapy to the lung during their illness, 1520 within the first 90 days. There was no significant change in the radiotherapy dose prescriptions used between 1991-2000. The most commonly used dose/fractionation schedule was 2000 cGy/5 fractions (n=839). 110 patients received lung brachytherapy, and 193 patients received more than one course of external beam radiotherapy to the lung. Overall, 5% (n = 124), 11% (n = 241), and 84% (n = 1903) received radical CMT, RRT, and PT respectively. Between 1991-2000, an increasing number of patients were treated with radical CMT (Chi-square trend test, p=0.015), particularly after 1996 (range 1-11%). In all years, most patients were treated palliatively (range 82-90%). Controlling for important prognostic factors, the hazard ratio for mortality in comparison to the CMT group was 1.30 (95% Cl: 0.98, 1.7) for RRT group and 2.21 (95% Cl: 1.7, 2.8) for PT group. Cox modelling showed that mortality was also related to
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the dose of radiotherapy given. Conclusion: A small proportion of Stage III NSCLC patients in British Columbia were treated with CMT. This increased mostly after 1996, most likely related to a new provincial guideline produced in 1995. Radiotherapy practice did not significantly change in other ways during this time period. 84
Survey: practice patterns of Canadian urologists in the management of stage 1 seminoma of the testis R. Choo, S. Bagnell, L. Klotz Toronto Sunnybrook Regional Cancer Centre, University of Toronto, Toronto, Ontario, Canada Obiective: To evaluate the practice patterns of Canadian urologists in the management of stage 1 seminoma of the testis. Methods: Survey of Canadian urologists between July and November 2002, using 3-page questionnaire. Results: Response rate: 42% (212/498). I. Practice profile: 118 (55%) as university affiliated teaching centre, 94 (46%) as community/private practice. 12 (5.7%), 186 (87.7%), 11 (5.2%), and 3 (1.4%) urologists reported to manage 0, 1-5, 6-10, and >10 new seminoma cases per year, respectively. I1. Radiological investigations as staging work-up: Percentages of responders ordering the following tests: lymphangiograms: 0.9%, chest x-ray: 82.1%, CT abdomen/pelvis: 100%, CT chest: 53.1%. II1. Management approaches: 34.2% of the responders did not offer an option of surveillance to patients with stage 1 seminoma in their practice. When asked to rank among 3 management options (1. Surveillance, 2. Adjuvant radiotherapy, 3. Adjuvant single-cycle chemotherapy) for a patient with low relapse risk and desire to preserve fertility, the order of first preference was option 1 (73.8%), 2 (19.5%), and 3 (0.9%). For a high-risk patient wishing to preserve fertility, it was option 2 (70.2%), 1 (15.2%), and 3 (14.6%). If fertility was not of concern to the patient, the order of preference for a low-risk patient was option 2 (57.6%), 1 (41.4%), and 3 (10.0%). For a high-risk patient without fertility concern, it was option 2 (77.8%), 3 (17.2%) and 1 (5.0%). There were no significant differences in management options chosen between academic and community urologists. Conclusion: There is some variation among Canadian urologists in the management of stage 1 seminoma of the testis. The issue of fertility preservation and perceived relapse risk were important factors influencing management decision. Urologists at academic centres were not more likely to offer surveillance as an option, compared to community urologists. 85
The McMaster HNRQ demonstrates clinically important change in patients with head and neck cancer and xerostomia J. Ringash, P. Warde, G. Lockwood, H. Hu Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada Purpose: To determine the responsiveness of the McMaster Head and Neck Radiotherapy Questionnaire (HNRQ) to change in QOL over time for patients undergoing radiotherapy for head and neck (H&N) cancer in a clinical xerostomia trial. We also examined the relationship between QOL and xerostomia scores. Methods: Patients with mixed H&N diagnoses were randomized to pilocarpine (n=65) vs. placebo (n=65) during radiotherapy. No differences were observed between arms in xerostomia score, toxicity or QOL scores, so all 130 patients were analyzed together to assess change over time. Results: Baseline QOL data was obtained on 98.5% of participants. The baseline HNRQ score of 5.7 (n=I28) declined to 4.0 in the 6th week of radiation (n=65) and returned to baseline (5.8) by 6 months post-treatment (n=90). Using Student's t-test, a statistically significant difference was observed between QOL scores at baseline and week 6 (p < 0.0001). By estimating clinically meaningful change at 5 to 10% of total instrument score, this represents a large, clinically important change of 1.7/7 (24%). Using effect size (ES) criteria, the calculated ES of 1.34 represents a large change. The decline in QOL during radiotherapy parallels the onset of xerostomia as measured on a xerostomia questionnaire. The correlation of the HNRQ score with a linear analogue xerostomia score at 1 month was 0.36. However, the post-treatment recovery of QOL scores occurs without any improvement in xerostomia. Xerostomia score was 79.1 at baseline, 38.4 at 11 weeks and 33.0 at 6 months. The trajectory of the xerostomia score was very similar to that of the HNRQ's question #9, which also measures xerostomia (r=0.75 at 1 month). Conclusion: These data demonstrate the McMaster HNRQ's high degree of sensitivity to change in QOL in this population, and suggest either response shift, or that xerostomia has a relatively small influence on overall QOL.
dress casual attire (with pants or skirt), nor departmental sweatshirt with white dress pants. There was no clinically significant trend to a change in perception over the time interval tested. Patients felt that wearing a lab coat and name badges positively influenced the perception of professionalism. Patients, overall preference was for uniform scrubs. Patients demonstrated a preference for the attire of radiation therapists. Wearing lab coats and name badges positively influenced patients perceptions of professionalism, satisfaction, and comfort. 82
Boosts for breast cancer patterns of practice in Ontario D. Danko 1, J. Sussman 2 1Michener Institute Radiation Therapy School, Toronto, Ontario, Canada 2Hamilton Regional Cancer Centre, McMaster Unive(sity, Hamilton, Ontario, Canada Backround: Recent studies suggest there may be improvements in outcome using boost radiotherapy in some patients with early stage breast cancer. Most often electrons are used. This has implications regarding patient care and treatment resources. Objective: To determine the current breast boost practices in the province of Ontario. Methods: Self-completed mailed survey of all radiation oncologists treating breast cancer in Ontario. A modified Dilman procedure was used. Results: An unadjusted response rate of 81% was achieved (39/48). 84% of respondents offer a boost in situations with a negative lumpectomy margin. Of these, 69% offer boost based on age, 65% based on surgical margin distance with 50% offering boost for margins <2 mm (40% offer boost for margin >l<2mm). 76% of physicians reported having local guidelines for boost indications. 70% of respondents routinely attempt to cover the surgical scar in their volume. Tools used to plan the lateral extent of the boost volume include: Mammogram (71%); operative reports (59%); clinical palpation (59%); surgical clips in tumour cavity (56%). Tools used to plan the boost treatment depth include: mammogram films (44%); clinical palpation (39%); CT (39%); surgical clips (32%); Tangent Films (29%); Operative Reports (29%); Ultrasound (24%). Several dose fractionation schedules are reported. The most common schedule is 10Gy/5 (46%) followed by 12.5Gy/5 (20%); 60% of respondents reported local guidelines for breast boost planning and prescription. Conclusions: We found variation in the self-reported practices for electron boosts for breast cancer in Ontario. Most physicians identified local guidelines for treatment indications and planning. Provincial evidence based guidelines may help address treatment variations to optimize resource utilization and patient care. 83
Patterns of practice and outcome for patients with stage III non-small cell lung cancer in British Columbia 1991-2000 E. Wai, F. Sheehan British Columbia Cancer Agency, Vancouver Island Centre, Victoria, British Columbia, Canada Backaround: This study documents the pattern of practice and survival in a population-based cohort of Stage III NSCLC patients in British Columbia between 1991-2000. Methods: Electronic records of all patients diagnosed with clinical Stage Ill NSCLC between January 1, 1991 and December 31, 2000 referred to the British Columbia Cancer Agency were analyzed. Descriptors of radiotherapy use in this population were determined. The proportions of patients receiving combined modality therapy with chemotherapy and radiotherapy (CMT), radical radiotherapy (RRT), and palliative treatment (PT) were compared for the years 1991-2000. Overall survival was determined for patients based on their initial treatment. Results: Among 2268 patients,1856 received radiotherapy to the lung during their illness, 1520 within the first 90 days. There was no significant change in the radiotherapy dose prescriptions used between 1991-2000. The most commonly used dose/fractionation schedule was 2000 cGy/5 fractions (n=839). 110 patients received lung brachytherapy, and 193 patients received more than one course of external beam radiotherapy to the lung. Overall, 5% (n = 124), 11% (n = 241), and 84% (n = 1903) received radical CMT, RRT, and PT respectively. Between 1991-2000, an increasing number of patients were treated with radical CMT (Chi-square trend test, p=0.015), particularly after 1996 (range 1-11%). In all years, most patients were treated palliatively (range 82-90%). Controlling for important prognostic factors, the hazard ratio for mortality in comparison to the CMT group was 1.30 (95% Cl: 0.98, 1.7) for RRT group and 2.21 (95% Cl: 1.7, 2.8) for PT group. Cox modelling showed that mortality was also related to
3-5 October 2003
$21
the dose of radiotherapy given. Conclusion: A small proportion of Stage III NSCLC patients in British Columbia were treated with CMT. This increased mostly after 1996, most likely related to a new provincial guideline produced in 1995. Radiotherapy practice did not significantly change in other ways during this time period. 84
Survey: practice patterns of Canadian urologists in the management of stage 1 seminoma of the testis R. Choo, S. Bagnell, L. Klotz Toronto Sunnybrook Regional Cancer Centre, University of Toronto, Toronto, Ontario, Canada Obiective: To evaluate the practice patterns of Canadian urologists in the management of stage 1 seminoma of the testis. Methods: Survey of Canadian urologists between July and November 2002, using 3-page questionnaire. Results: Response rate: 42% (212/498). I. Practice profile: 118 (55%) as university affiliated teaching centre, 94 (46%) as community/private practice. 12 (5.7%), 186 (87.7%), 11 (5.2%), and 3 (1.4%) urologists reported to manage 0, 1-5, 6-10, and >10 new seminoma cases per year, respectively. I1. Radiological investigations as staging work-up: Percentages of responders ordering the following tests: lymphangiograms: 0.9%, chest x-ray: 82.1%, CT abdomen/pelvis: 100%, CT chest: 53.1%. II1. Management approaches: 34.2% of the responders did not offer an option of surveillance to patients with stage 1 seminoma in their practice. When asked to rank among 3 management options (1. Surveillance, 2. Adjuvant radiotherapy, 3. Adjuvant single-cycle chemotherapy) for a patient with low relapse risk and desire to preserve fertility, the order of first preference was option 1 (73.8%), 2 (19.5%), and 3 (0.9%). For a high-risk patient wishing to preserve fertility, it was option 2 (70.2%), 1 (15.2%), and 3 (14.6%). If fertility was not of concern to the patient, the order of preference for a low-risk patient was option 2 (57.6%), 1 (41.4%), and 3 (10.0%). For a high-risk patient without fertility concern, it was option 2 (77.8%), 3 (17.2%) and 1 (5.0%). There were no significant differences in management options chosen between academic and community urologists. Conclusion: There is some variation among Canadian urologists in the management of stage 1 seminoma of the testis. The issue of fertility preservation and perceived relapse risk were important factors influencing management decision. Urologists at academic centres were not more likely to offer surveillance as an option, compared to community urologists. 85
The McMaster HNRQ demonstrates clinically important change in patients with head and neck cancer and xerostomia J. Ringash, P. Warde, G. Lockwood, H. Hu Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada Purpose: To determine the responsiveness of the McMaster Head and Neck Radiotherapy Questionnaire (HNRQ) to change in QOL over time for patients undergoing radiotherapy for head and neck (H&N) cancer in a clinical xerostomia trial. We also examined the relationship between QOL and xerostomia scores. Methods: Patients with mixed H&N diagnoses were randomized to pilocarpine (n=65) vs. placebo (n=65) during radiotherapy. No differences were observed between arms in xerostomia score, toxicity or QOL scores, so all 130 patients were analyzed together to assess change over time. Results: Baseline QOL data was obtained on 98.5% of participants. The baseline HNRQ score of 5.7 (n=I28) declined to 4.0 in the 6th week of radiation (n=65) and returned to baseline (5.8) by 6 months post-treatment (n=90). Using Student's t-test, a statistically significant difference was observed between QOL scores at baseline and week 6 (p < 0.0001). By estimating clinically meaningful change at 5 to 10% of total instrument score, this represents a large, clinically important change of 1.7/7 (24%). Using effect size (ES) criteria, the calculated ES of 1.34 represents a large change. The decline in QOL during radiotherapy parallels the onset of xerostomia as measured on a xerostomia questionnaire. The correlation of the HNRQ score with a linear analogue xerostomia score at 1 month was 0.36. However, the post-treatment recovery of QOL scores occurs without any improvement in xerostomia. Xerostomia score was 79.1 at baseline, 38.4 at 11 weeks and 33.0 at 6 months. The trajectory of the xerostomia score was very similar to that of the HNRQ's question #9, which also measures xerostomia (r=0.75 at 1 month). Conclusion: These data demonstrate the McMaster HNRQ's high degree of sensitivity to change in QOL in this population, and suggest either response shift, or that xerostomia has a relatively small influence on overall QOL.