Impact of sociodemographic factors on the radiotherapeutic management of lung cancer: Results of a Quality Research in Radiation Oncology Survey

Practical Radiation Oncology (2014) 4, e167–e179

www.practicalradonc.org

Original Report

Impact of sociodemographic factors on the radiotherapeutic management of lung cancer: Results of a Quality Research in Radiation Oncology Survey Ramesh Rengan MD, PhD a,⁎, Alex Ho MS, MA b , Jean B. Owen PhD b , R. Komaki c , Najma Khalid MS b , J. Frank Wilson MD d , Benjamin Movsas MD e a

Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA American College of Radiology, Philadelphia, PA c University of Texas MD Anderson Cancer Center, Houston, TX d Medical College of Wisconsin, Milwaukee, WI e Department of Radiation Oncology, Henry Ford Hospital, Dearborn, MI b

Received 3 April 2013; revised 5 July 2013; accepted 16 July 2013

Abstract Purpose: The objective of this study is to describe the impact of sociodemographic (SOC) factors on the management of lung cancer patients treated at radiation therapy facilities participating in the Quality Research in Radiation Oncology survey. Methods and materials: A 2-stage stratified random sample of lung cancer patients treated in 2006 to 2007 at 45 facilities yielded 340 stage I-III non-small cell lung cancer (NSCLC) and 144 limitedstage small cell lung cancer (LS-SCLC) cases. Five SOC variables based on data from the 2000 US Census were analyzed for association with the following clinical factors: patients living in urban versus rural settings (U/R); median household income (AHI); % below poverty level (PPV); % unemployed (PUE); and % with college education (PCE). Results: The 340 NSCLC patients were stage I, 16%; stage II, 11%; stage III, 62%; stage unknown, 11%. Histologic subtypes were adenocarcinoma, 31.8%; squamous cell carcinoma, 35.3%; large cell carcinoma, 3.2%; and NSCLC NOS, 27.7%. The median age was 66 years. Median Karnofsky performance status (KPS) was 80. The 144 LS-SCLC had a median age of 63; 73 were male (50.7%). Median KPS was 80. Stereotactic body radiation therapy (SBRT) and modern imaging utilization was associated with treatment at facilities located in higher SOC regions. SBRT was employed in 46.8% stage I NSCLC patients treated in centers where %PUE was below median versus 14.8% in centers where %PUE was above median (P = .02). Four-dimensional computed tomography was utilized in 14.2% of patients treated in centers located in regions with %PPV below median versus 3.7% in centers located in regions with %PPV above median (P b .01). SCLC patients were more likely to receive all of their planned RT when treated at centers located in regions with lower PPV (95.0% vs 79.1%; P = .04). Sources of support: This study was supported by the Pennsylvania Department of Health, Tobacco Settlement Act 77-201, CURE [Continuing Umbrella for Research Experience] program (This project is funded, in part, under a grant with the Pennsylvania Department of Health. The Department specifically declaims responsibility for any analyses, interpretations or conclusions), and NCI [National Cancer Institute] Grant CA065435. Conflicts of interest: None. ⁎ Corresponding author (current affiliation). Department of Radiation Oncology, University of Washington, 1959 Pacific Ave, Seattle, WA 98195. E-mail address: [email protected] (R. Rengan). 1879-8500/$ – see front matter © 2014 Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. http://dx.doi.org/10.1016/j.prro.2013.07.012

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Conclusions: SOC factors may impact use of modern treatment planning and delivery and multidisciplinary management of NSCLC and SCLC. These results may suggest an impact of these SOC factors on access to health care. © 2014 Published by Elsevier Inc. on behalf of American Society for Radiation Oncology.

Introduction Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) together accounted for approximately 160,000 deaths in 2012. 1 Although these poor outcomes are primarily attributable to the virulence of the disease itself, there is level 1 evidence that early detection and treatment can improve survival. 2 As lung cancer is largely asymptomatic in early stage disease, detection relies heavily upon imaging and physical examination. Consequently, socioeconomic factors and access to health care can have a significant impact on diagnosis and clinical outcome in this disease. Low socioeconomic status has been linked to poorer overall survival in cancer. 3 Recently, Erhunmwunsee et al 4 reported on the impact of socioeconomic status on clinical outcome in NSCLC in the southeastern United States and found that low socioeconomic status was an independent prognostic factor for poor survival in patients with both early and advanced stage NSCLC. They also found that patients who lived in areas with high poverty levels, low median incomes, and low education levels had worse mortality. The Quality Research in Radiation Oncology (QRRO, formerly known as the Patterns of Care Study) focuses on process measures that correlate with differences in outcome, as indicated by evidence from randomized clinical trials or other high level-of-evidence research. 5 During the past 4 decades, QRRO has conducted scientifically rigorous surveys of radiation oncology facilities in a variety of different practice settings and locations to assess aspects of radiation oncology structures, processes, and outcomes for the purpose of establishing benchmarks and as a basis for quality improvement. 6 Prior reports have documented the patterns of care for lung cancer patients about a decade ago, 7-9 and more recently in 2006 to 2007. 10 The focus of this report is to examine the impact of sociodemographic factors on adoption of new technologies and modern radiation therapeutic techniques across the QRRO survey facilities. Additionally, this report examines the impact of sociodemographic factors on adherence to established standards of care for the diagnosis, treatment, and quality of radiation treatment of lung cancer.

survey design utilized a 2-stage stratified random sampling of radiation oncology facilities in the United States (first stage) and further random selection of patients (second stage) within the selected facility. Patient inclusion criteria were as follows: (1) limited stage small cell lung cancer (LSSCLC) or (2) stage I, II, and III NSCLC; (3) patients received their treatment from 2006 through 2007; (4) Karnofsky performance status (KPS) ≥ 60; (5) no distant metastases or malignant pleural effusion; (6) no prior thoracic radiation therapy; and (7) no concurrent or prior malignancy within 5 years (excluding in situ or non-melanoma skin cancers). Two separate study cohorts surveyed a total of 340 NSCLC and 144 LS-SCLC patients who received radiation therapy selected from 45 institutions that participated out of 106 invited facilities. A patient who had both NSCLC and SCLC was included in the SCLC study. Data were extracted on site at each of the facilities by highly trained QRRO research associates. All medical records, and radiation therapy charts and records, were carefully reviewed. Data collected included patient demographics and characteristics, clinical and pathologic factors, and treatment details including dosimetric information. To identify the relationship between sociodemographic factors and the consequential disparities in the care provided to lung cancer patients, surrogates for sociodemographic information (college education, median household income, poverty, unemployment status, and urban or rural area) of patients was obtained by linking patient’s zip code in the Process Survey to the data from the United States Census of 2000, specifically data from Census 2000 Summary File 3 according to previously published methods. 11-15 Percent of population who had college education, median household income, income below poverty level, and unemployed was first calculated from the census data and then dichotomized into 2 categories using the median. Patient's residence was categorized into 100% urban area, 100% rural area, and urban and rural mix area according to previously published methods. 14 This census information was used in addition to the patient-specific data elements in the survey to identify the relationship between sociodemographic factors and the consequential disparities in the care provided to patients. 16,17 This project was performed with institutional approval from the American College of Radiology—Quality Research in Radiation Oncology group (QRRO).

Methods and materials Statistical analysis A National Process Survey was developed for lung cancer to collect data on patient demographics, diagnosis, staging, history, geographic region, practice setting, insurance status, comorbidities, treatment, and toxicities. The

Statistical analysis was conducted using Statistical Analysis System (SAS, version 9.2, SAS Institute, Cary, NC) for data management and initial unweighted

Practical Radiation Oncology: May-June 2014 Table 1

Sociodemographic factors and radiation in lung cancer

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Characteristics of patients included in the Quality Research in Radiation Oncology (QRRO) survey

Variable

Non-small cell lung cancer

No.

340

Median age (IQ range)

%

Small cell lung cancer

%

144

66

59-75

63

59-66

Sex Male Female

179 161

52.65 47.35

73 71

50.69 49.31

Karnofsky performance status 60 70 80 90 100 Unknown

18 54 108 111 48 1

5.29 15.88 31.76 32.65 14.12 0.29

4 19 49 55 17

2.78 13.19 34.03 38.19 11.81

Race White Black/African-American Asian Other

261 59 7 13

76.76 17.35 2.06 3.82

121 18 0 5

84.03 12.50 0.00 3.47

Ethnicity Hispanic Not Hispanic/unspecified

18 322

5.29 94.71

5 139

3.47 96.53

Marital status Married Single Not specified/unknown

174 111 55

51.18 32.65 16.18

84 46 14

58.33 31.94 9.72

Primary payment method Medicare Private insurance Health maintenance organization Medicaid Government insurance Self-pay Not specified

173 68 35 22 24 5 13

50.88 20.00 10.29 6.47 7.06 1.47 3.82

45 55 16 14 11 3

31.25 38.19 11.11 9.72 7.64 2.08

Stratum Academic Large nonacademic (≥ 3 linacs) Medium nonacademic (2 linacs) Small nonacademic (1 linac)

112 104 52 72

32.94 30.59 15.29 21.18

52 46 25 21

36.11 31.94 17.36 14.58

Census region Northeast Midwest South West

48 92 125 75

14.12 27.06 36.76 22.06

17 49 46 32

11.81 34.03 31.94 22.22

Smoking status Never smoked Current smoker Former smoker (quit ≤ 1 y ago) Former smoker (quit N 1 y and ≤ 10 y ago) Former smoker (quit N 10 y ago) Former smoker (quit period unknown) Unknown smoking status

16 149 41 50 73 7 4

4.71 43.82 12.06 14.71 21.47 2.06 1.18

1 0.69 76 52.78 27 18.75 23 15.97 14 9.72 0 0.00 3 2.08 (continued on next page)

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Table 1 (continued) Variable Tumor histology Squamous cell Adenocarcinoma Large cell NSCLC, NOS+ Other Unknown Small cell/oat cell Mixed histology (SCLC and NSCLC) Stage I II III Unknown Staging of patients with stage III receiving combined modality therapy or SCLC receiving EBRT Brain MRI or CT and PET or bone scan Brain MRI/CT scan Brain MRI Brain CT scan PET/bone scan PET only PET only or PET/CT Bone scan

Non-small cell lung cancer

%

120 108 11 94 5 2

35.29 31.76 3.24 27.65 1.47 0.59

53 39 211 37

15.59 11.47 62.06 10.88

181 120 126 73 69 168 38 160 45

Small cell lung cancer

%

141 3

97.92 2.08

NA NA NA NA 144

66.30 69.61 40.33 38.12 92.82 20.99 88.40 24.86

121 137 94 61 126 20 82 72

84.03 95.14 65.28 42.36 87.50 13.89 56.94 50.00

CT, computed tomography; EBRT, external beam radiation therapy; MRI, magnetic resonance imaging; NOS, not otherwise specified; NSCLC, nonsmall cell lung cancer; PET, positron emission tomography.

analysis. Weights were calculated for each patient record on the basis of the relative sample and population size of each institution and patient. Stratum-specific weighted percentages were calculated to reflect the distribution in the population as a whole. These weighted percentages were used to estimate national averages and make statistically valid inferences for national process measures. To account for the sampling design of the survey and weighting, as well as to calculate the national estimates, analysis was performed using SUDAAN (version 10, Research Triangle Institute, Cary, NC). Descriptive statistics was used to describe the general distribution of the study population of the variables that are of interest in this report. The χ 2 test was employed to examine the association between categoric variables. For continuous variables, Student t test and analysis of variance were performed to evaluate the mean differences between 2 and 3 groups accordingly. Statistical significance was set at 5% level.

Results Patient characteristics A sample of 340 NSCLC and 144 SCLC patients from those who received radiation therapy at 45 institutions

between January 1, 2006 and December 31, 2007, participated in the QRRO survey. The patient demographic and disease characteristics are detailed in Table 1 (shown are survey sample size and percent). For NSCLC patients, the median age was 66, 31.8% had adenocarcinoma histology, and 320 (94.1%) were current or former smokers. For SCLC patients, the median age was 63 and 97.2% were current or former smokers.

Patient characteristics as analyzed by sociodemographic variables For NSCLC patients, the patient characteristics as analyzed by sociodemographic (SOC) variables are given in Table 2. There was a greater percentage of nonHispanic white patients in the lower PPV (85.2% vs 66.3%; P b .01), lower PUE (85.5% vs 65.6%; P b .01), and rural versus urban areas (88.9% vs 54.2%; P b .01). There was no statistically significant difference in age, gender, smoking status, weight loss, or KPS in more than 1 SOC variable. For SCLC patients, the patient characteristics as analyzed by SOC variables are given in Table 3. Similar to NSCLC, there was no significant difference in age, gender, smoking status, baseline weight loss, or performance status between SOC categories in more than 1 SOC variable.

Practical Radiation Oncology: May-June 2014 Table 2

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Patient characteristics by census sociodemographic factors in non-small cell lung cancer Census sociodemographic factors PCE≤m

Total b Nuw %uw %w

162 49.5 51.6

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban

Rural Mix

165 50.5 48.4

165 50.5 50.8

42 12.8 15.3

162 49.5 49.2

164 50.2 50.4

163 49.8 49.6

165 50.5 51.3

162 49.5 48.7

124 37.9 29.5

66.8 39-90 (%wc)

pt= .23 68.0 39-90 (%wc)

161 49.2 55.2

66.3 37-91 (%wc)

pt= .22 68.0 39-90 (%wc)

66.3 37-91 (%wc)

pF= .44 d 66.3 68.9 67.1 37-90 43-87 45-91 (%wc) (%wc) (%wc)

Age (y) Mean Range

pt= .74 c 67.4 42-91 (%wc) e

66.9 37-90 (%wc)

pt= .64 67.5 37-91 (%wc)

Sex Male Female

pc= .87 f 50.5 49.5

49.5 50.5

pc= .28 53.5 46.5

46.6 53.4

pc= .47 47.8 52.2

52.4 47.6

pc= .04 43.6 56.4

56.8 43.2

pc= .80 49.6 50.4

55.2 44.8

48.9 51.1

Race-ethnicity Non-Hispanic White Non-Hispanic Black Hispanic/other

pc= .63 73.3 17.9 8.8

78.4 14.6 7.0

pc= .93 75.9 16.7 7.4

75.7 15.8 8.5

pcb .01 85.2 8.6 6.2

66.3 24.1 9.6

pcb .01 85.5 8.5 6.0

65.6 24.4 10.0

pcb .01 54.2 30.3 15.5

88.9 7.3 3.8

83.7 11.3 5.0

Smoking status Never smoked Current smoker Former smoker (quit ≤10 y) Former smoker (quit N10 y)

pc= .71 4.0 45.4 26.4 24.2

7.7 43.9 25.7 22.7

pc= .36 4.7 47.4 21.9 26.0

7.0 41.9 30.2 20.9

pc= .30 7.6 39.9 29.6 22.9

4.0 49.4 22.5 24.1

pc= .69 7.2 42.5 25.1 25.2

4.3 46.9 27.1 21.7

pc= .01 6.8 51.5 25.5 16.2

0.0 30.9 26.7 42.4

6.8 44.7 26.2 22.3

60.7 39.3

61.8 38.2

Weight loss (WL) ≤6 months pc= .27 prior to treatment No 61.7 Yes 38.3

pc= .07 55.0 45.0

53.0 47.0

pcb .01

pc= .12 64.2 35.8

pc= .41

63.2 36.8

53.7 46.3

pc= .97

67.5 32.5

pc= .26 49.0 51.0

pc= .13

51.1 48.9

Karnofsky performance status (KPS) KPS b80 KPS ≥80

pc= .76

pc= .11

20.6 79.4

22.2 77.8

23.5 76.5

19.2 80.8

21.5 78.5

21.3 78.7

17.5 82.5

25.4 74.6

14.3 85.7

27.7 72.3

23.4 76.6

Piccirillo index No/unknown Mild Moderate Severe

pc= .57 11.8 37.3 26.8 24.1

9.9 32.9 25.5 31.7

pc= .20 11.0 29.0 28.4 31.6

10.7 41.5 23.9 23.9

pc= .33 7.7 36.7 25.4 30.3

14.1 33.6 27.0 25.3

pc= .95 10.0 36.1 25.3 28.6

11.8 34.2 27.0 27.0

pc= .08 19.0 34.3 19.4 27.3

4.8 25.7 31.3 38.2

8.2 38.3 28.4 25.1

FEV1 in mean liters

pt= .49 c 1.7

1.8

pt= .72 1.7

1.8

pt= .79 1.7

1.7

pt= .70 1.7

1.8

pF= .22 d 1.9 1.7

1.6

AHI, % with median annual household income; FEV1, forced expiratory volume in the first second of expiration; PCE, % with college education; PPV, % of population below poverty level; PUE, % of population with unemployment. a Median of the % of population. b Nuw, unweighted sample size = 340 with 13 without census sociodemographic information; % uw, unweighted row % of patients; %w, weighted row % of patients. c pt = P value (t test for comparison between 2 median categories). d pF = P value (analysis of variance, F-test). e %wc = weighted column percentages based on weighted number of patients. f pc = P value (χ2 test to measure of association between patient’s characteristics and sociodemographics.

Diagnostic workup as analyzed by SOC variables For NSCLC patients, the diagnostic workup as analyzed by SOC variables is given in Table 4. There was no significant difference between categories of SOC variables in baseline chest CT, positron emission tomography (PET)

or bone scan, brain imaging (computed tomographic or magnetic resonance imaging), invasive mediastinal staging (mediastinoscopy, endoscopic ultrasound, or endobronchial ultrasound) as part of initial staging. For SCLC patients, the diagnostic workup as analyzed by SOC variables is given in Table 5. The percentage of patients undergoing baseline

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Table 3

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Patient characteristics by census sociodemographic factors in small cell lung cancer (SCLC) Census sociodemographic factors

Characteristic Total Nuw %uw %w

PCE≤m

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban

Rural Mix

67 48.9 43.7

69 50.4 58.6

14 10.2 14.7

b

70 51.1 56.3

68 49.6 41.4

68 49.6 46.8

69 50.4 53.2

71 51.8 45.0

66 48.2 55.0

50 36.5 27.4

60.5 28-83 (%wc)

pt= .16 61.3 28-83 (%wc)

73 53.3 57.9

63.7 35-82 (%wc)

pt= .22 61.5 28-83 (%wc)

63.6 43-78 (%wc)

pF= .16 d 60.7 64.7 63.0 28-83 54-76 43-82 (%wc) (%wc) (%wc)

Age (y) Mean Range

pt= .03 c 64.1 43-83 (%wc) e

60.7 28-82 (%wc)

pt= .03 64.1 35-82 (%wc)

Sex Male Female

pc= .50 f 44.6 55.4

51.8 48.2

pt= .84 46.8 53.2

49.1 50.9

pc= .81 46.4 53.6

49.0 51.0

pc= .51 51.8 48.2

44.5 55.5

pc= .16 38.3 61.7

30.9 69.1

56.6 43.4

Race-ethnicity Non-Hispanic White Non-Hispanic Black Hispanic/Other

pc= .07 84.7 6.9 8.4

79.7 19.3 1.0

pt= .37 82.7 10.0 7.3

82.3 15.6 2.1

pc= .96 82.7 12.8 4.5

82.4 11.9 5.7

pc= .07 90.2 9.8 0.0

76.2 14.4 9.4

pcb .01 64.5 30.0 5.5

78.1 0.0 21.9

92.2 7.1 0.7

Smoking status pc= .07 Never smoked (excluded, n=1) Current smoker 57.8 Former smoker 27.2 (quit ≤10 y) Former smoker 15.0 (quit N10 y) Weight loss (WL) ≤6 months pc= .58 prior to treatment No 63.8 Yes 36.2

pt= .29

pc= .63

pc= .55

pc= .13

56.7 40.7

53.9 32.9

62.4 33.2

62.8 29.6

52.7 35.9

63.6 27.1

52.4 37.7

56.8 42.3

70.7 24.8

54.1 30.8

2.6

13.2

4.4

7.6

11.4

6.3

9.9

0.9

4.5

15.1

67.3 32.7

59.2 40.8

pt= .80 58.0 42.0

60.1 39.9

pc= .95 62.8 37.2

pt= .94

61.6 38.4

pc= .89 60.9 39.1

pc= .91

62.0 38.0

pc= .87 60.6 39.4

pc= .42

62.3 37.7

Karnofsky performance status (KPS) KPS b80 KPS ≥80

pc= .37

pc= .22

13.6 86.4

21.5 78.5

16.8 83.2

17.4 82.6

17.6 82.4

16.5 83.5

13.3 86.7

20.1 79.9

11.4 88.6

42.8 57.2

13.2 86.8

Piccirillo index No/unknown Mild Moderate Severe

pc= .66 9.8 48.5 21.8 19.9

13.2 35.0 25.8 26.0

pt= .14 9.0 50.3 25.7 15.0

14.6 31.7 20.5 33.2

pc= .37 15.0 40.3 17.2 27.5

8.1 44.6 29.1 18.2

pc= .02 14.3 24.8 30.7 30.2

8.8 57.1 17.7 16.4

pc= .27 13.1 48.8 21.2 16.8

1.6 46.7 36.8 14.9

12.9 38.6 21.3 27.2

FEV1 in mean liters

pt= .15 c 2.1

1.8

pt= .81 c 1.9 2.0

pt= .43 2.0

1.8

pt= .65 2.0

1.9

pFb .01 d 1.6 1.5

2.2

AHI, % with median annual household income; FEV1, forced expiratory volume in the first second of expiration; PCE, % with college education; PPV, % of population below poverty level; PUE, % of population with unemployment. a Median of the % of population. b Nuw, unweighted sample size = 137 with 7 without census sociodemographic information; % uw, unweighted row % of patients; % w, weighted row % of patients. c pt = P value (t test for comparison between 2 median categories). d pF = P value (analysis of variance, F-test). e %wc = weighted column percentages based on weighted number of patients. f pc = P value (χ2 test to measure of association between patient’s characteristics and sociodemographics).

Practical Radiation Oncology: May-June 2014 Table 4

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Diagnostic and workup by census sociodemographic factors in non-small cell lung cancer (NSCLC) Census sociodemographic factors

Variable

PCE≤m (%wc) b

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban Rural Mix (%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc) (%wc)

4.0 96.0

pc= .89 3.3 96.7

3.0 97.0

pc= .71 2.7 97.3

3.6 96.4

pc= .59 3.8 96.2

2.5 97.5

pc= .77 4.3 95.7

3.8 2.4 96.2 97.6

c

Chest CT scan No Yes

pc= .50 2.4 97.6

Upper abdominal CT scan No Yes

pc= .96 13.6 86.4

13.9 86.1

pc= .02 18.3 81.7

8.9 91.1

pc= .95 13.6 86.4

13.9 86.1

pc= .49 12.3 87.7

15.3 84.7

pc= .20 12.4 87.6

25.7 11.0 74.3 89.0

Bone scan No Yes

pc= .27 69.4 30.6

75.8 24.2

pc= .70 73.7 26.3

71.4 28.6

pc= .36 75.2 24.8

69.9 30.1

pc= .34 75.2 24.8

69.7 30.3

pc= .67 74.6 25.4

76.6 70.3 23.4 29.7

PET scan No Yes

pc= .42 16.3 83.7

12.7 87.3

pc= .66 13.6 86.4

15.5 84.5

pc= .08 10.7 89.3

18.5 81.5

pc= .06 10.5 89.5

18.9 81.1

pc= .34 13.2 86.8

8.6 17.0 91.4 83.0

Brain CT No Yes

pc= .14 61.3 38.7

70.3 29.7

pc= .27 69.0 31.0

62.3 37.7

pc= .26 69.0 31.0

62.3 37.7

pc= .79 66.5 33.5

64.9 35.1

pc= .96 66.8 33.2

65.8 65.1 34.2 34.9

Brain MRI No Yes

pc= .36 67.7 32.3

62.2 37.8

pc= .49 67.0 33.0

62.9 37.1

pc= .05 59.1 40.9

71.1 28.9

pc= .70 63.9 36.1

66.2 33.8

pc= .46 62.5 37.5

73.5 64.0 26.5 36.0

Brain CT or MRI No Yes

pc= .43 48.6 51.4

53.7 46.3

pc= .29 54.4 45.6

47.7 52.3

pc= .44 53.6 46.4

48.6 51.4

pc= .92 51.4 48.6

50.8 49.2

pc= .78 50.1 49.9

56.6 50.1 43.4 49.9

TBNA No Yes

pc= .13 9.6 90.4

18.6 81.4

pc= .06 8.4 91.6

19.3 80.7

pc= .15 17.7 82.3

9.5 90.5

pc= .23 17.2 82.8

10.2 89.8

pc= .01 7.2 92.8

2.2 20.3 97.8 79.7

Transesophageal ultrasound pc= .22 guided biopsy/EUS No 99.4 Yes 0.6

97.6 2.4

98.8 1.2

98.3 1.7

98.4 1.6

98.7 1.3

98.4 1.6

98.8 1.2

99.1 0.9

Mediastinoscopy No Yes

pc= .52 73.7 26.3

68.5 31.5

pc= .42 74.5 25.5

68.0 32.0

pc= .65 69.6 30.4

73.2 26.8

pc= .49 68.6 31.4

74.1 25.9

pc= .59 75.3 24.7

Mediastinoscopy/ TBNA/EUS No Yes

pc= .16 1.4 98.6

pc= .73

pc= .80

pc= .16 0.0 100.0

1.4 98.6

pc= .78

pc= .16 0.0 100.0

0.0 100.0

pc= .20

pc= .84 1.5 98.5

0.8 99.2

100.0 97.9 0.0 2.1 59.9 71.7 40.1 28.3

pc= .37 0.6 99.4

0.0 100.0

2.2 0.8 97.8 99.2

AHI, % with median annual household income; CT, computed tomography; EUS, endoscopic ultrasound; MRI, magnetic resonance imaging; PCE, % with college education; PET, positron emission tomography; PPV, % of population below poverty level; PUE, % of population with unemployment; TBNA, transbronchial needle aspiration. a Median of the % of population. b %wc = weighted column percentages based on weighted number of patients. c pc = P value (χ2 test to measure of association between patient’s characteristics and sociodemographics).

brain imaging (computed tomographic or magnetic resonance imaging) was more often obtained in higher median household income (79.9% vs 59.7%; P = .04) and lower PPV areas (84.2% vs 53.9%; P b .01). There were no other significant differences.

Staging and histology as analyzed by SOC variables in NSCLC patients The stage distribution and tumor histologies of the NSCLC patients are given in Table 6. Both stage distribution

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Table 5

Practical Radiation Oncology: May-June 2014

Diagnostic and workup by census sociodemographic factors in small cell lung cancer (SCLC) Census sociodemographic factors

Variable

PCE≤m (%wc) b

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban Rural Mix (%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

1.0 99.0

pc= .32 0.0 100.0

1.0 99.0

pc= .32 0.9 99.1

0.0 100.0

pc= .32 0.0 100.0

0.8 99.2

pc= .61 0.0 0.0 0.7 100.0 100.0 99.3

Upper abdominal CT scan pc= .97 No 5.7 Yes, separate abdominal CT 94.3

5.5 94.5

pc= .91 5.4 94.6

5.8 94.2

pc= .63 4.6 95.4

6.6 93.4

pc= .84 6.0 94.0

5.2 94.8

pc= .45 9.3 90.7

1.9 4.5 98.1 95.5

Bone scan No Yes

pc= .93 44.8 55.2

43.7 56.3

pc= .40 48.2 51.8

39.0 61.0

pc= .02 31.6 68.4

56.1 43.9

pc= .60 41.1 58.9

47.0 53.0

pc= .06 63.9 36.1

28.0 39.2 72.0 60.8

PET scan No Yes

pc= .51 46.4 53.6

39.3 60.7

pc= .75 41.8 58.2

45.4 54.6

pc= .66 45.9 54.1

41.1 58.9

pc= .95 43.7 56.3

43.0 57.0

pc= .24 50.6 49.4

21.0 45.0 79.0 55.0

Bone and/or PET scan No Yes

pc= .96 7.3 92.7

7.6 92.4

pc= .63 6.2 93.8

9.1 90.9

pc= .91 7.1 92.9

7.7 92.3

pc= .54 5.5 94.5

9.1 90.9

pc= .22 17.4 82.6

1.8 4.2 98.2 95.8

Brain CT No Yes

pc= .38 54.0 46.0

63.7 36.3

pc= .74 59.7 40.3

56.0 44.0

pc= .24 51.2 48.8

64.3 35.7

pc= .27 51.4 48.6

63.7 36.3

pc= .61 55.7 44.3

46.0 32.5 54.0 37.5

Brain MRI No Yes

pc= .66 35.3 64.7

30.6 69.4

pc= .71 31.5 68.5

35.6 64.4

pc= .17 40.9 59.1

26.3 73.7

pc= .04 45.2 54.8

23.2 76.8

pc= .81 36.1 63.9

39.5 30.4 60.5 69.6

Brain CT or MRI No Yes

pc= .33 36.4 63.6

26.3 73.7

pc= .04 40.3 59.7

20.1 79.9

pcb .01 15.8 84.2

46.1 53.9

pc= .25 25.6 74.4

37.2 62.8

pc= .60 39.4 60.6

23.5 30.7 76.5 69.3

Chest CT scan No Yes

pc= .32 0.0 100.0

c

(%wc) (%wc)

AHI, % with median annual household income; CT, computed tomography; MRI, magnetic resonance imaging; PCE, % with college education; PET, positron emission tomography; PPV, % of population below poverty level; PUE, % of population with unemployment. a Median of the % of population. b %wc = weighted column percentages based on weighted number of patients. c pc= P value (χ2 test to measure of association between patient’s characteristics and sociodemographics).

and tumor histologies were similar between SOC categories across all SOC variables.

Radiation treatment approach as analyzed by SOC variables For NSCLC patients, the radiation treatment as analyzed by SOC variables is given in Table 7. For stage I NSCLC, stereotactic body RT (SBRT) was used more often in PPV [lower % of the population below the poverty level] (46.8% vs 14.8%; P = .02), and lower PUE [% of population with unemployment] areas (57.6% vs 8.6%; P b .01). There was no significant difference in enrollment on clinical protocols across all SOC variables. For stage IIIII patients with KPS ≥ 70 and no baseline weight loss, there was greater use of concurrent chemoradiation therapy in lower PCE [% with college education] (30.3% vs 25.5%, P = .82), higher AHI (31.1% vs 24.2%, P = .67), lower PPV (36.7% vs 17.3%, P = .08), lower PUE

(33.2% vs 20.8%, P = .38), and rural vs urban (40.3% vs 34.0%, P = .57); however, not statistically significant. For SCLC patients, the radiation treatment as analyzed by SOC variables is given in Table 8. There was greater enrollment of patients onto clinical trials in higher PCE (2.7% vs 0.4%; P = .07), higher AHI (3.4% vs 0%; P = .01), lower PPV (3.0% vs 0%; P = .01), lower PUE (3.2% vs 0%; P = .01), and urban or rural mix versus urban or rural areas (2.5% vs 0% vs 0%, P = .05). There was no significant difference in use of hyperfractionated radiation therapy, delivery of prophylactic cranial irradiation, or use of concurrent chemoradiation therapy across all SOC variables.

Radiation treatment planning and delivery techniques as analyzed by SOC variables For NSCLC patients, the radiation treatment planning and delivery techniques as analyzed by SOC variables are given in Table 9. Four-dimensional computed tomography

Practical Radiation Oncology: May-June 2014 Table 6

Sociodemographic factors and radiation in lung cancer

e175

Staging by census sociodemographic factors in non-small cell lung cancer (NSCLC) Census sociodemographic factors

Variable

PCE≤m (%wc) b

Clinical stage I II, III Unknown

pc= .99 15.0 74.3 10.7

Histology Squamous cell Adenocarcinoma Large cell NSCLC, NOS NSCLC - neuroendocrine Alveolar or bronchoalveolar Adenocarcinoma with bronchioloalveolar carcinoma (BAC) features

pc= .15 37.9 27.2 2.2 32.7 0.0 0.0 0.0

Mixed histology (NSCLC)

0.0

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban Rural Mix (%wc)

(%wc)

14.6 74.1 11.3 32.4 38.4 3.8 22.1 1.5 0.3 0.5

c

1.0

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc) (%wc) (%wc)

pc= .07 19.7 9.8 69.3 79.3 11.0 10.9

pc= .54 12.6 77.1 10.3

17.0 71.3 11.7

pc= .30 11.8 78.0 10.2

18.0 70.2 11.8

pc= .27 17.8 16.0 74.1 59.7 8.1 24.3

12.9 78.3 8.8

pc= .55 37.3 33.1 30.6 34.6 1.7 4.3 28.8 26.4 1.2 0.3 0.0 0.3 0.4 0.0

pc= .23 33.3 36.9 4.6 23.9 0.3 0.0 0.0

37.2 28.2 1.3 31.4 1.2 0.3 0.4

pc= .59 32.1 35.8 3.6 27.0 0.3 0.3 0.0

38.6 29.2 2.3 28.3 1.2 0.0 0.4

pc= .46 32.3 33.4 0.7 29.9 2.5 0.5 0.7

41.3 35.4 6.0 17.3 0.0 0.0 0.0

35.2 31.4 3.3 29.2 0.0 0.0 0.0

0.0

1.0

0.0

0.9

1.0

0.0

0.9

0.0

0.0

AHI, % with median annual household income; NOS, not otherwise specified; PCE, % with college education; PPV, % of population below poverty level; PUE, % of population with unemployment. a Median of the % of population. b %wc = weighted column percentages based on weighted number of patients. c pc = P value (χ2 test to measure of association between patient’s characteristics and sociodemographics).

was used more often in lower PPV (14.2% vs 3.7%; P b .01) and lower PUE categories (13.6% vs 4.1%; P b .01). Respiratory gating was also used more often in lower PPV (19.2% vs 5.7%; P b .01), and lower PUE (18.9% vs 5.8%; P b .01). Similarly, image guided RT was also used more often in lower PPV (19.9% vs 3.6%; P b .01) and lower PUE categories (20.3% vs 2.9%; P b .01). There was no difference in utilization of PET for treatment planning, intensity modulated RT, or percentage of patients receiving their full planned RT course across all SOC variables. For SCLC patients, the radiation treatment planning and delivery techniques as analyzed by SOC variables are given in Table 10. Comparing between lower and higher categories of SOC, there was no significant difference in use of PET for treatment planning, intensity modulated RT (except in urban and rural areas), 4D-CT, respiratory gating, or image guided RT in more than 1 SOC variable analyzed. SCLC patients were more likely to receive all of their planned RT in lower PPV (95.0% vs 79.1%; P = .04), higher PCE (97.5% vs 77.9%, P = .06, trend) and higher AHI (94.3% vs 81.1%; P = .09, trend).

Discussion In this study, we report a descriptive analysis of the impact of sociodemographic variables on the diagnosis, treatment, and management of 340 NSCLC (stage I-III)

and 144 LS-SCLC patients treated at 45 radiation therapy centers participating in the QRRO survey in 2006-2007. We identified greater utilization of emerging radiation therapy treatment approaches (SBRT in stage I NSCLC), treatment planning (4D-CT and respiratory gating in all NSCLC), and treatment delivery (image guided RT) in patients living in areas where a smaller percentage of the population were below the poverty line and in areas where unemployment rates were lower. This may be a reflection of the greater cost of early adoption of these new modalities that may affect access to care. The impact of utilization of emerging radiation therapy treatment approaches on clinical outcome is unclear. It should be noted that it is not possible to separate the adoption of new technologies from the socioeconomic indicators that were examined in this study. These indicators were chosen as they have been shown to be independent predictors of inferior clinical outcome. 18 Additionally, in SCLC patients we observed greater utilization of standard-of-care brain imaging as part of the diagnostic workup and a greater percentage of patients receiving all of their planned radiation therapy in areas where a smaller percentage of the population were below the poverty line and there was lower unemployment. There are several limitations to this study. This study is retrospective in nature, and therefore subject to selection bias. Additionally, although 45 radiation therapy centers from both academic and non-academic centers representing diverse geographic, socioeconomic, and demographic

e176 Table 7

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Treatment of non-small cell lung cancer (NSCLC) by census sociodemographic factors Census sociodemographic factors

Variable

Investigational protocol No Yes Stage I External beam RT No Yes Mean total dose (cGy) Stereotactic body RT No Yes Mean total dose (cGy) Brachytherapy No Yes Stage II, III (no weight loss, KPS ≥70) RT (n = 118) Concurrent CT Sequential (pre-/post-RT) CT RT alone Criteria for lung toxicity, V20 (%) Mean lung dose (cGy) Mean max dose to spinal cord (cGy)

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban

Rural Mix

(%wc) b

(%wc)

(%wc)

pc= .26 c 96.6 3.4

94.7 5.3

PCE≤m

pc= .41 22.1 77.9 pt= .72 6257 pc= .30 77.9 22.1 pt= .03 5362 pc = NA 100.0 0.0

32.5 67.5 6390 64.5 35.5 5842 100.0 0.0

pc= .82

30.3 60.0 9.7 pt= .30 d 27.5 pt= .17 1737 pt= .23 3820

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc) (%wc)

pc= .98 95.7 95.7 4.3 4.3

pc= .51 96.3 3.7

95.2 4.8

pc= .74 95.4 4.6

96.0 4.0

pc= .43 93.9 6.1

97.0 3.0

96.3 3.7

pc= .66 25.2 74.8 pt= .40 6214 pc= .48 74.8 25.2 pt= .47 5708 pc = NA 100.0 0.0

pc= .03 43.3 56.7 pt= .76 6395 pc= .02 53.3 46.8 pt= .97 5641 pc = NA 100.0 0.0

30.0 70.0

20.9 79.1

30.9 69.1 6543 64.7 35.3 5519 100.0 0.0

pc= .67

25.5 61.9 12.6 25.2 1505 3486

24.2 62.6 13.2 pt= .25 27.8 ptb .01 1849 pt= .57 3740

14.8 85.2 6277 85.2 14.8 5630 100.0 0.0

pc= .08

31.1 59.6 9.3 25.2 1392 3586

36.7 51.4 11.9 pt= .09 24.7 pt= .07 1492 pt= .15 3501

pcb .01 54.0 46.0 pt= .77 6195 pcb .01 42.4 57.6 pt= .26 5702 pc = NA 100.0 0.0

8.6 91.4 6358 91.4 8.6 5360 100.0 0.0

pc= .38

17.3 72.8 9.9 28.5 1803 3875

33.2 56.4 10.4 pt= .13 24.8 pt= .58 1577 pt= .80 3629

pc= .64 34.0 66.0 pF= .84 6285 pc= .50 61.8 38.2 pF= .06 5898 pc = NA 100.0 0.0

6650 6234 70.0 30.0

79.1 20.9

5458 5415 100.0 100.0 0.0 0.0

pc= .57

20.8 67.3 11.9 28.5 1676 3700

34.0 56.5 9.5 pF = .76 e 26.8 pF = .78 1545 pF b .01 4179

40.3 41.4 18.3

22.9 66.8 10.3

28.5

25.6

1655 1656 3496 3452

AHI, % with median annual household income; CT, computed tomography; KPS, Karnofsky performance status; NA, not applicable; PCE, % with college education; PPV, % of population below poverty level; PUE, % of population with unemployment; RT, radiation therapy. a Median of the % of population. b %wc = weighted column percentages based on weighted number of patients. c pc = P value (χ2 test to measure of association between patient’s characteristics and college education). d pt = P value (t test for comparison between 2 median categories). e pF = P value (analysis of variance, F-test).

regions were included this still may introduce the possibility of selection bias. However, to minimize these effects, the survey design utilized a 2-stage stratified random sampling of radiation oncology facilities in the United States (first stage) and further random selection of patients (second stage) within the selected facility. Weights were calculated for each patient record on the basis of the relative sample and population size of each institution and patient. Stratum-specific weighted percentages were calculated to reflect the distribution in the population as a whole. These weighted percentages were used to estimate national averages in order to make statistically valid inferences for national process measures. 6 Finally, we used zip codes as an identifier and linkage to the surrogate indices for sociodemo-

graphic status. Although this approach provides an index of the “neighborhood socioeconomic status” in which the patient resides, the individual patient socioeconomic status may be different. This approach of examining the neighborhood socioeconomic status has been used by other investigators to examine local variance in access to care and cancer-related outcomes. 19-22 It has been shown recently that socioeconomic status is an independent predictor of survival in NSCLC. 4 In a retrospective cohort study examining 4820 patients with NSCLC treated at Duke Medical Center between 1995 and 2007, Erhunmwunsee et al 4 examined the impact of socioeconomic status as identified by the individual census tract based upon data from the 2000 census. They found that individuals who resided in areas with a larger number

Practical Radiation Oncology: May-June 2014 Table 8

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e177

Treatment of small cell lung cancer (SCLC) by census sociodemographic factors Census sociodemographic factors a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban

Rural

(%wc) b

(%wc)

(%wc)

(%wc)

(%wc)

(%wc) (%wc)

Investigational protocol No Yes

pc= .07 c 99.6 0.4

97.3 2.7

pc= .01 100.0 0.0

96.6 3.4

pc= .01 97.0 3.0

Hyperfractionation No Yes Fractional dose (cGy)

pc= .11 93.9 6.1 pt = 79 d 152 pt = .99 6 pt = NA d 2 pt = .44 5331

Variable

Interval between fraction (hours) No. fractions per day Total EB dose, cGy (for those who did not have hyperfractionation) Prophylactic cranial irradiation No Yes RT with concurrent CT No Yes Mean max dose to spinal cord (cGy)

PCE≤m

88.0 12.0 152 6 2 5499

pc= .65 57.9 42.1 pc = NA 0.0 100.0 pt = .64 4057

pc= .27 93.0 7.0 pt = .97 152 pt = .76 6 pt = NA 2 pt = .79 5378

88.9 11.1 152 6 2 5436

pc= .86 52.9 47.1 0.0 100.0 4107

56.5 43.5 pc = NA 0.0 100.0 pt = .92 4085

54.6 45.4 0.0 100.0 4075

(%wc)

(%wc)

pc= .01 100.0 96.8 0.0 3.2

(%wc)

(%wc)

pc= .05 100.0 100.0 0.0 0.0

100.0 0.0

Mix

97.5 2.5

pc= .72 90.6 91.9 9.4 8.1 pt = .97 152 152 pt = .70 6 6 pt = NA 2 2 pt = .72 5446 5363

pc= .22 88.8 93.3 11.2 6.7 pt = .78 151 152 pt = .99 6 6 pt = NA 2 2 pt = .77 5439 5372

pc= .23 88.9 97.1 90.9 11.1 2.9 9.1 pF = .35 e 153 150 152 pF b .01 6 7 6 pF = NA 2 2 2 pF = .46 5150 5585 5468

pc= .29

pc= .91

pc= .90

49.4 61.3 60.6 38.7 pc = NA 0.0 0.0 100.0 100.0 pt = .85 4090 4070

56.4 55.1 43.6 44.9 pc = NA 0.0 0.0 100.0 100.0 pt = .46 4042 4121

59.3 51.5 55.1 40.7 48.5 44.9 pc = NA 0.0 0.0 0.0 100.0 100.0 100.0 pF = .53 3989 4186 4090

AHI, % with median annual household income; CT, computed tomography; EB, external beam; NA, not applicable; PCE, % with college education; PPV, % of population below poverty level; PUE, % of population with unemployment; RT, radiation therapy. a Median of the % of population. b %wc = Weighted column percentages based on weighted number of patients. c pc= P value (χ2 test to measure of association between patient’s characteristics and college education). d pt = P value (t test for comparison between 2 median categories). e pF = P value (analysis of variance, F-test).

of individuals living below the poverty line or a lower annual median household income had a poorer 6-year cancer specific survival. As these patients were all treated at Duke Medical Center, this study did not comment on the impact socioeconomic status had on access to care or adherence to treatment standards. However, these data reflect that neighborhood socioeconomic status can have a significant impact on outcome in lung cancer. Universal health care has been proposed as a possible solution to mitigate the effects of socioeconomic status on individual health. To address this question, Chang et al 3 recently examined 20,488 cancer patients in Taiwan, where a universal health care system is in place. In this retrospective report, they found that lung cancer patients with low socioeconomic status carried the highest risk of mortality. Additionally, they found that across a number of cancer subtypes, a low socioeconomic status was an independent predictor of mortality risk. Taken together, these studies show that socioeconomic status can impact oncologic outcome and that tracking socioeconomic factors

and developing mitigation strategies for these factors is critical to improving quality of care in lung cancer. The QRRO program has the key strength with the overall goal of improving the quality of care delivered in radiation oncology facilities in the United States. Through carefully designed surveys that investigate process, structure, and outcomes of care in radiation therapy facilities that span a variety of different practice settings and geographic locations, this program has helped the radiation oncology field to identify and report critical “gaps” in patient care. Importantly, the QRRO program has then tracked progress in addressing these deficiencies. As noted by Earle and Emmanuel, 23 these efforts have served to create a vital “environment of watchful concern.” Indeed, Komaki et al 10 recently showed in a comparative analysis of quality indicators in 2006 to 2007 that care had improved across most indices when compared with 1998 to 1999. The current study extends this analysis to assess the impact of socioeconomic and demographic factors on the quality of care. Our study shows that these factors may

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Practical Radiation Oncology: May-June 2014

Table 9 Radiation therapy delivery technique by census sociodemographic factors in non-small cell lung cancer (NSCLC) treatment Census sociodemographic factors Variable

PCE≤m (%wc)

b

PET for treatment planning pc= .23 No 79.8 Yes 20.2

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban Rural Mix (%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

85.7 14.3

pc= .69 83.6 16.4

81.6 18.4

pc= .16 79.3 20.7

86.1 14.0

pc= .10 78.9 21.1

86.5 13.5

pc= .16 87.8 71.1 12.2 28.9

83.1 16.9

c

(%wc) (%wc)

Intensity modulated RT No Yes

pc= .17 81.6 18.4

88.0 12.0

pc= .31 82.4 17.6

87.1 12.9

pc= .79 84.1 15.9

85.3 14.7

pc= .27 82.2 17.8

87.3 12.7

pc= .81 85.4 80.5 14.6 19.5

85.5 14.5

4-dimensional CT No Yes

pc= .59 92.0 8.0

90.0 10.0

pc= .19 93.4 6.6

88.6 11.4

pcb .01 85.8 14.2

96.3 3.7

pcb .01 86.4 13.6

95.9 4.1

pc= .32 92.1 81.7 7.9 18.3

93.0 7.0

Gating No Yes Unknown

pc= .11 86.6 12.2 1.2

83.4 12.8 3.8

pc= .27 87.8 9.5 2.7

82.2 15.6 2.2

pcb .01 78.1 19.2 2.7

92.1 5.7 2.2

pcb .01 79.0 18.9 2.1

91.4 5.8 2.8

pc= .34 83.5 77.8 13.4 21.2 3.1 1.0

87.9 9.6 2.5

Image guided RT No Yes

pc= .93 88.0 12.0

88.4 11.6

pc= .59 89.3 10.7

87.1 12.9

pcb .01 80.1 19.9

96.4 3.6

pcb .01 79.7 20.3

97.1 2.9

pc= .10 84.9 79.5 15.1 20.5

92.3 7.7

Planned RT completed No Yes

pc= .51 7.0 93.0

9.1 90.9

pc= .90 7.8 92.2

8.2 91.8

pc= .54 7.1 92.9

9.0 91.0

pc= .85 8.3 91.7

7.7 92.3

pc= .88 8.6 9.4 91.4 90.6

7.3 92.7

AHI, % with median annual household income; CT, computed tomography; PCE, % with college education; PET, positron emission tomography; PPV, % of population below poverty level; PUE, % of population with unemployment; RT, radiation therapy. a Median of the % of population. b %wc = weighted column percentages based on weighted number of patients. c pc = P value (χ2 test to measure of association between patient’s characteristics and sociodemographics.

impact not only adoption of emerging technologies across radiation therapy facilities but also adherence to therapeutic standards.

Conclusions This report shows greater penetration of emerging and advanced radiation treatment approach and delivery techniques for patients with higher SOC. Additionally, in small cell lung cancer there was an observation of stricter adherence to standard-of-care diagnostic imaging and delivery of all planned radiation therapy for patients with higher SOC. Further research is needed to analyze the underlying causes of these findings, which may suggest an impact of these SOC factors on access to health care.

Acknowledgments The authors thank the radiation oncologists, physicists, and staff at participating facilities for their support and cooperation, which is essential to the QRRO Process Survey. They also thank Lisa Morabito for administrative support

and Cheryl Crozier, RN, and Joanne Sorich, RN, for data design, data management, and quality management.

References 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10-29. 2. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409. 3. Chang CM, Su YC, Lai NS, et al. The combined effect of individual and neighborhood socioeconomic status on cancer survival rates. PLoS One. 2012;7:e44325. 4. Erhunmwunsee L, Joshi MB, Conlon DH, Harpole Jr DH. Neighborhood-level socioeconomic determinants impact outcomes in nonsmall cell lung cancer patients in the Southeastern United States. Cancer. 2012;118:5117-5123. 5. Crozier C, Erickson-Wittmann B, Movsas B, et al. Shifting the focus to practice quality improvement in radiation oncology. J Healthc Qual. 2011;33:49-57. 6. Owen JB, White JR, Zelefsky MJ, Wilson JF. Using QRRO survey data to assess compliance with quality indicators for breast and prostate cancer. J Am Coll Radiol. 2009;6:442-447. 7. Chang JY, Moughan J, Johnstone DW, et al. Surgical patterns of care in operable lung carcinoma treated with radiation. J Thorac Oncol. 2006;1:526-531.

Practical Radiation Oncology: May-June 2014 Table 10

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Radiation therapy delivery technique by census sociodemographic factors in small cell lung cancer (SCLC) treatment Census sociodemographic factors

Variable

PCE≤m (%wc) b

PET for treatment planning pc= .12 No 91.3 Yes 8.7

a

PCENm AHI≤m AHINm PPV≤m PPVNm PUE≤m PUENm Urban Rural Mix (%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

(%wc)

98.4 1.6

pc= .20 92.1 7.9

97.7 2.3

pc= .15 98.0 2.0

91.3 8.7

pc= .43 96.4 3.6

92.8 7.2

pc= .37 98.3 85.4 1.7 14.6

94.7 5.3

c

(%wc) (%wc)

Intensity modulated RT No Yes

pc= .24 79.1 20.9

89.3 10.7

pc= .32 80.0 20.0

88.6 11.4

pc= .56 86.4 13.6

81.1 18.9

pc= .28 78.3 21.7

88.1 11.9

pc= .03 96.0 74.4 4.0 25.6

79.8 20.2

4-dimensional CT No Yes

pc= .98 89.9 10.1

90.1 9.9

pc= .98 89.9 10.1

90.1 9.9

pc= .74 91.3 8.7

88.8 11.2

pc= .08 82.9 17.1

96.0 4.0

pc= .24 96.5 87.2 3.5 12.8

87.5 12.5

Gating No Yes Unknown

pc= .79 84.9 10.3 4.8

86.4 10.9 2.7

pc= .81 85.9 9.4 4.6

85.1 12.0 2.9

pc= .72 87.3 10.2 2.5

84.0 10.9 5.1

pc= .17 78.1 18.2 3.7

91.6 4.3 4.1

pc= .46 92.4 78.1 4.2 11.5 3.5 10.4

84.3 13.3 2.5

Image guided RT No Yes

pc= .55 85.6 14.4

90.3 9.7

pc= .65 86.1 13.9

89.8 10.2

pc= .44 91.0 9.0

84.7 15.3

pc= .30 83.1 16.9

91.4 8.6

pc= .99 87.2 88.5 12.8 11.5

87.6 12.4

Planned RT completed No Yes

pc= .06 22.1 77.9

2.5 97.5

pc= .09 18.9 81.1

5.7 94.3

pc= .04 5.0 95.0

20.9 79.1

pc= .33 9.0 91.0

17.0 83.0

pc= .77 9.5 11.5 90.6 88.5

15.8 84.3

AHI, % with median annual household income; CT, computed tomography; PCE, % with college education; PPV, % of population below poverty level; PUE, % of population with unemployment; RT, radiation therapy. a Median of the % of population. b %wc = weighted column percentages based on weighted number of patients. c pc = P value (χ2 test to measure of association between patient’s characteristics and sociodemographics).

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