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Aims. The proportion of patients with upper gastrointestinal cancers that received chemotherapy varies widely in Australia and internationally, indicating a need for a benchmark rate of chemotherapy utilisation. We developed evidence-based models for upper gastrointestinal cancers to estimate the optimal chemotherapy utilisation rates that can serve as useful benchmarks for measuring and improving the quality of care. Materials and Methods. Optimal chemotherapy utilisation models for cancers of the oesophagus, stomach, pancreas, gallbladder, and primary liver were constructed using indications for chemotherapy identified from evidence-based guidelines. Results. Based on the best available evidence, the optimal proportion of upper gastrointestinal cancers that should receive chemotherapy at least once during the course of the patients' illness was estimated to be 79% for oesophageal cancer, 83% for gastric cancer, 35% for pancreatic cancer, 80% for gallbladder cancer, and 27% for primary liver cancer. Conclusions. The reported chemotherapy utilisation rates for upper gastrointestinal cancers (with the exception of primary liver cancer) appear to be substantially lower than the estimated optimal rates suggesting that chemotherapy may be underutilised. Further studies to elucidate the reasons for the potential underutilisation of chemotherapy in upper gastrointestinal tumours are required to bridge the gap between the ideal and actual practice identified.

Background: No benchmarks exist in the screened breast cancer population to establish the optimal proportions of newly detected cancer patients who should receive the ideal treatment. The aim of the study was to estimate the optimal proportion of cases diagnosed in a breast-screening program who should receive treatment according to evidence-based cancer treatment guidelines and to compare these optimal rates with actual treatment rates. METHOD.: Optimal surgery, radiotherapy, chemotherapy, and hormone therapy utilization trees were constructed based on indications from evidence-based treatment guidelines. The proportions with clinical attributes that indicated a possible benefit from a particular treatment were obtained from epidemiologic data from BreastScreen Victoria. The optimal proportions of screen-detected breast cancer patients who should receive various therapies were then calculated using TreeAge software and compared with the actual proportions obtained from the epidemiologic data., Results: According to the best available evidence, the proportion of screen-detected breast cancer patients who have attributes suitable for various treatments are: breast-conserving surgery (BCS) 85%, mastectomy 15%, radiotherapy 87%, chemotherapy 34%, and hormonal therapy 68%. The actual BCS utilization rate in Victoria was similar to the optimal rate (79% vs 85%), whereas there appeared to be underuse of radiotherapy (62% vs 87%), chemotherapy (19% vs 34%), and hormonal therapy (49% vs 68%) when compared with guideline recommendations., Conclusions: This research provided optimal treatment utilization rates for screen-detected breast cancer and a comparison of best practice evidence and actual treatment. The results showed comparable rates for surgery but suggested underutilization of radiotherapy, chemotherapy, and hormone therapy.

Background: Brachytherapy (BT) is an integral part of cervical carcinoma treatment. There have been no attempts to estimate the optimal proportion of new cervical carcinoma cases that should be treated with BT, that is, the optimal rate of brachytherapy utilization (BTU)., Methods: Evidence-based guidelines and primary evidence were used to construct a BTU tree for carcinoma of the uterine cervix. Searches were performed of the epidemiological literature to ascertain the proportion of patients who fulfilled criteria for BT. The robustness of the model was tested by sensitivity analyses and by peer review. A patterns of care study of BT in New South Wales for 2003 was conducted, and actual BTU for cervical carcinoma determined. The differences between optimal and actual rates of BTU were assessed., Results: The optimal cervical carcinoma BTU was 49% (range, 42% to 50%). In New South Wales in 2003, actual BTU was only 30% of 256 cervical carcinoma patients. The major discrepancy was for FIGO stage IB-IIA disease, where there was an underutilization of BT, estimated to be 15% actual use compared with 47% optimal use. In Surveillance, Epidemiology, and End Results (SEER) areas, there was underutilization for stage IB-IIA (22% actual BTU versus 47% optimal BTU) and for stage IIB-IVA (54% actual BTU versus 100% optimal BTU)., Conclusions: BT for cervical carcinoma is underutilized in New South Wales and in SEER areas. The authors' model of optimal BTU can be used as a quality assurance tool to provide an evidence-based benchmark against which actual patterns of practice can be measured. The model can also be used to help determine adequacy of BT resource allocation., (Copyright 2006 American Cancer Society.)

Background: In this one in a series of articles, the objective was to estimate the ideal proportion of patients with cancer who should receive radiotherapy at least once during the course of their illness based on the best available evidence. This estimate should be useful in planning for future radiotherapy facilities. Optimal rates of radiotherapy for patients with central nervous system (CNS) carcinoma, thyroid carcinoma, or carcinoma of unknown primary site (CUP) have not been studied previously., Methods: A systematic review of evidence-based treatment guidelines for the treatment of CNS carcinoma, CUP, and thyroid carcinoma was undertaken. An optimal radiotherapy utilization tree was constructed for each of these malignancies depicting the indications for radiotherapy at various stages of disease. The proportion of patients who had clinical attributes that indicated a possible benefit from radiotherapy was calculated by adding epidemiological data to the radiotherapy utilization tree. The optimal proportion of patients who should receive radiotherapy was then calculated using specialized decision-analysis software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed., Results: The optimal rates of radiotherapy utilization for carcinoma of the CNS, thyroid carcinoma, and CUP were 92%, 10%, and 61%, respectively. Comparison with actual rates of utilization in South Australia, Sweden, and the U.S. suggested an under-utilization of radiotherapy for CNS carcinoma and CUP. However, the actual rates of radiotherapy for thyroid carcinoma exceeded the optimal rate for some jurisdictions, although some data may have included radioactive iodine, which was not included in the current project., Conclusions: It was possible to estimate optimal radiotherapy utilization rates based on evidence. This methodology allowed a comparison of optimal rates with actual rates to identify areas in which improvements in the evidence-based use of radiotherapy can be made, and it may provide valuable data for future radiotherapy service planning.

Radiotherapy utilization rates for cancer vary widely internationally. It has previously been suggested that approximately 50% of all cancer patients should receive radiation. However, this estimate was not evidence-based. The aim of this study was to estimate the ideal proportion of new cases of cancer that should receive radiotherapy at least once during the course of their illness based on the best available evidence. An optimal radiotherapy utilization tree was constructed for each cancer based upon indications for radiotherapy taken from evidence-based treatment guidelines. The proportion of patients with clinical attributes that indicated a possible benefit from radiotherapy was obtained by adding epidemiologic data to the radiotherapy utilization tree. The optimal proportion of patients with cancer that should receive radiotherapy was then calculated using TreeAge (TreeAge Software, Williamstown, MA) software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed. The proportion of patients with cancer in whom external beam radiotherapy is indicated according to the best available evidence was calculated to be 52%. Monte Carlo analysis indicated that the 95% confidence limits were from 51.7% to 53.1%. The tightness of the confidence interval suggests that the overall estimate is robust. Comparison with actual radiotherapy utilization data suggests a shortfall in actual radiotherapy delivery. This methodology allows comparison of optimal rates with actual rates to identify areas where improvements in the evidence-based use of radiotherapy can be made. It provides valuable data for radiotherapy service planning. Actual rates need to be addressed to ensure better radiotherapy utilization., (Copyright 2005 American Cancer Society.)

Background: Radiotherapy is used commonly in the treatment of patients with head and neck carcinoma. The benchmark radiotherapy utilization rates for head and neck carcinoma largely are unknown. The objective of the current study was to determine the optimal radiotherapy utilization rate for patients with head and neck carcinoma and to compare this optimal rate with actual utilization rates where actual utilization data were available., Methods: An optimal radiotherapy utilization tree was constructed that depicted all patients with head and neck carcinoma in whom radiotherapy was indicated according to evidence-based treatment guidelines. The proportions of patients with clinical attributes that indicated possible benefit from radiotherapy were obtained from epidemiological data and were inserted into the utilization tree. The optimal proportion of patients with carcinoma of the head and neck who should receive radiotherapy was calculated by merging the evidence-based recommendations with the epidemiological data in the tree. Optimal rates of radiotherapy utilization were compared with actual rates obtained from population-based studies., Results: Radiotherapy was indicated at some point during their illness in 74% of all patients with head and neck carcinoma. By subsite, the optimal radiotherapy utilization rates were oral cavity, 74%; lip, 20%; larynx, 100%; oropharynx, 100%; salivary gland, 87%; hypopharynx, 100%; nasopharynx, 100%; paranasal sinuses, 100%; and unknown squamous cell carcinoma of the head and neck, 90%. All treatment recommendations were based on Level III or IV evidence. Assessment of actual radiotherapy utilization rates indicated an increased use of radiotherapy over time for head and neck carcinoma. However, there also were some decreases in the use of radiotherapy for some carcinoma subsites over the past 20 years, despite the lower actual rates compared with the optimal rates. The reasons for these reductions in use were not identified., Conclusions: The actual radiotherapy utilization rate for patients with head and neck carcinoma corresponded reasonably closely to the optimal rate for some populations but also identified some shortfalls for other patient groups. The results of this study provide a way of assessing shortfalls in radiotherapy.

Background: Benchmark radiotherapy utilization rates for genitourinary malignancies are largely unknown, despite the finding that genitourinary cancers comprise approximately 19% of all registered malignancies in Australia., Methods: To develop an evidence-based benchmark of the optimal proportion of patients with genitourinary malignancies who should receive at least one course of radiotherapy at some time during their illness, the authors studied treatment guidelines and treatment reviews regarding genitourinary malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes that indicated possible benefit from radiotherapy based on evidence. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with genitourinary cancer for whom radiotherapy was considered appropriate., Results: The proportion of patients with genitourinary malignancies for whom radiotherapy was indicated at some point in their illness, according to the best available evidence, was estimated to be 27% of patients with renal cancer, 58% of patients with bladder cancer, 60% of patients with prostate cancer, and 49% of patients with testicular cancer. The occurrence of ureteric and penile cancers among patients was too rare, and, therefore, these patients were not included in the current study., Conclusions: There was a large discrepancy between actual radiotherapy utilization and the evidence-based optimal rate. The authors recommended strategies to implement the evidence-based guidelines. Evidence-based benchmarks for radiotherapy utilization rates such as the ones described in the current study were important in the evaluation of the appropriate use of radiotherapy., ((c) 2004 American Cancer Society)

Background: The objective of this study was to estimate the ideal proportion of new patients with leukemia and myeloma who should receive radiotherapy at some time during the course of their illness based on the best evidence., Methods: Available evidence of the efficacy of radiotherapy in most clinical situations for leukemia and myeloma was identified through extensive literature reviews and treatment guideline searches. Epidemiologic data concerning the distribution of types, disease stages, and other factors that influence the use of radiotherapy were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiological data to calculate the optimal proportion of patients who should receive radiotherapy according to the best available evidence. Actual radiotherapy utilization rates also were identified., Results: The proportion of patients diagnosed with myeloma in Australia who should receive radiotherapy based on the evidence was 38%. There was wide variation in the proportion of patients who actually received radiotherapy for myeloma from 24% up to 55%. The recommended proportion of patients diagnosed with myeloma in Australia who, according to the best available evidence, should receive at least a single course of radiotherapy was 38%. The proportion of patients diagnosed in Australia with leukemia who should receive radiotherapy at some point in their management, according to the best available evidence, was calculated at 4%, which corresponded with actual practice., Conclusions: Further research will be required to determine why more patients who are diagnosed with myeloma are not treated with radiotherapy., ((c) 2004 American Cancer Society.)

Background: Radiotherapy utilization rates for cancer vary widely, both within and between countries. Current estimates of the proportion of cancer patients who should optimally receive radiotherapy are based either on expert opinion or on the measurement of actual utilization rates, rather than on the best scientific evidence., Methods: Evidence-based treatment guidelines regarding endometrial carcinoma were reviewed to develop an evidence-based benchmark for radiotherapy utilization. An optimal radiotherapy utilization tree was constructed and the proportions of endometrial carcinoma patients with clinical indications for radiotherapy were obtained from epidemiologic data. The ideal utilization rates were compared with actual radiotherapy utilization rates for endometrial carcinoma both in Australia and internationally., Results: According to the best available evidence, radiotherapy is indicated at least once in 46% of all patients with endometrial carcinoma. A review of the limited data available concerning actual radiotherapy utilization rates revealed that the actual rates are approximately 10% lower than the optimal rates., Conclusions: Further research into the patterns of actual treatment and the development of optimal chemotherapy and surgery utilization rates for endometrial carcinoma is recommended. The difference between the optimal and the actual utilization rates warrants investigation into the reasons for the low radiotherapy utilization rates encountered in clinical practice., (Copyright 2004 American Cancer Society.)

Background: Radiotherapy usage rates exhibit wide variations both within and between countries. Current estimates of the proportion of cancer patients who should optimally receive radiotherapy are based either on expert opinion or on the measurement of actual usage rates rather than on the best available scientific evidence., Methods: With the goal of developing an evidence-based benchmark for radiotherapy use in the treatment of malignancies of the cervix, vagina, vulva, and ovary (endometrial malignancies are covered in a separate article), the authors reviewed international evidence-based treatment guidelines. Optimal radiotherapy usage trees were constructed, and proportions of patients with clinical indications for radiotherapy were obtained from epidemiologic data. These ideal usage rates were compared with actual radiotherapy utilization rates recorded in Australia and elsewhere., Results: According to the best available evidence, radiotherapy is indicated at least once for 58% of patients with cervical carcinoma, 4% of patients with ovarian carcinoma, 100% of patients with vaginal carcinoma, and 34% of patients with vulvar carcinoma. A review of the limited data available suggests that actual radiotherapy usage rates for patients with gynecologic malignancies are comparable to optimal usage rates., Conclusions: Actual practice appears to approximate the authors' model of optimal radiotherapy use. This finding reflects the high level of agreement among treatment guidelines as well as the existence of high-quality evidence related to the management of gynecologic malignancies, and it may also be indicative of the fact that a large proportion of patients are treated in specialist units. The management of gynecologic malignancies may serve as a good example in the development of management strategies for other types of cancer., (Copyright 2004 American Cancer Society.)

Background: Radiotherapy utilization rates for cancer vary widely, both within and between countries. The optimal proportion of patients with gastrointestinal malignancies who should receive at least one course of radiotherapy at some time during their illness is an important benchmark., Methods: The authors studied treatment guidelines and treatment reviews to identify the indications for radiotherapy for patients with gastrointestinal malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes of patients with gastrointestinal carcinomas who will benefit from radiotherapy. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with gastrointestinal malignancies for whom radiotherapy was considered appropriate. Optimal rates of radiotherapy use were compared with actual rates in population-based studies to assess any discrepancies between actual and optimal radiotherapy utilization rates., Results: Radiotherapy was indicated in 80% of patients with esophageal carcinoma, 68% of patients with gastric carcinoma, 57% of patients with pancreatic carcinoma, 13% of patients with carcinoma of the gallbladder, 0% of patients with hepatic carcinoma, 14% of patients with colon carcinoma, and 61% of patients with rectal carcinoma. The actual radiotherapy utilization rates for most of these gastrointestinal malignancies fell well short of optimal rates, which were derived from evidence-based treatment guidelines., Conclusions: It is possible to model optimal radiotherapy utilization using published treatment guidelines and existing incidence data. There was a discrepancy between the optimal and actual rates of radiotherapy utilization for patients with carcinomas of the esophagus, stomach, pancreas, and rectum. Strategies to implement evidence-based clinical guidelines are recommended., (Copyright 2004 American Cancer Society.)

Background: Radiotherapy is not used commonly in the treatment of patients with malignant melanoma. The benchmark optimal radiotherapy utilization rates for melanoma are largely unknown, despite the fact that melanoma is a very common cancer., Methods: To develop an evidence-based benchmark for the optimal proportion of patients with melanoma who should receive radiotherapy, the authors reviewed major treatment guidelines for melanoma. A radiotherapy decision tree was constructed showing the clinical features of melanoma patients for whom radiotherapy was indicated based on evidence. The proportions of melanoma patients with indications for radiotherapy were obtained from epidemiologic data and were used to calculate the optimal proportion of melanoma patients who should receive radiotherapy., Results: The proportion of patients with melanoma for whom radiotherapy is indicated at some point in their illness, according to the best available evidence, was calculated at 23% of all melanoma patients. The utilization rates of radiotherapy for melanoma recorded in actual practice were 13% in New South Wales, 6% in data from the American College of Surgeons, and 1% according to Surveillance, Epidemiology, and End Results data., Conclusions: Strategies for implementing the evidence-based guidelines are recommended to overcome the shortfall in the use of radiotherapy in the treatment of patients with melanoma., (Copyright 2004 American Cancer Society.)

Background: Radiotherapy utilization rates for breast carcinoma vary widely, both within and between countries. Current estimates of the proportion of patients with carcinoma who optimally should receive radiotherapy are based either on expert opinion or on the measurement of actual utilization rates, and not on the best scientific evidence., Methods: To develop an evidence-based benchmark for radiotherapy utilization in patients with breast carcinoma, the authors undertook a systematic review of treatment guidelines on the use of radiotherapy for breast carcinoma. A decision tree was constructed, and the proportions of patients with clinical features that lead to a decision for radiotherapy were obtained from epidemiological data. This ideal utilization rate was compared with the utilization rates of radiotherapy over the last decade for breast carcinoma in Australia and internationally., Results: The proportion of patients with breast carcinoma in whom radiotherapy would be recommended according to the best available evidence was calculated at 83% (95% confidence interval, 82-85%) of all patients with breast carcinoma. A review of actual radiotherapy utilization rates for breast carcinoma revealed that, in clinical practice, actual utilization rates varied between 24% and 71%., Conclusions: A substantial difference was found between the recommended optimal utilization of radiotherapy based on evidence and the actual rates reported in clinical practice. The reasons for these differences need to be examined, and a plan for addressing the suboptimal use of radiotherapy needs to be implemented. Cancer 2003., (Copyright 2003 American Cancer Society.)

Background: Management of patients with ductal carcinoma in situ (DCIS) is a dilemma, as mastectomy provides nearly a 100% cure rate but at the expense of physical and psychologic morbidity. It would be helpful if we could predict which patients with DCIS are at sufficiently high risk of local recurrence after conservative surgery (CS) alone to warrant postoperative radiotherapy (RT) and which patients are at sufficient risk of local recurrence after CS + RT to warrant mastectomy. The authors reviewed the published studies and identified the factors that may be predictive of local recurrence after management by mastectomy, CS alone, or CS + RT., Methods: The authors examined patient, tumor, and treatment factors as potential predictors for local recurrence and estimated the risks of recurrence based on a review of published studies. They examined the effects of patient factors (age at diagnosis and family history), tumor factors (sub-type of DCIS, grade, tumor size, necrosis, and margins), and treatment (mastectomy, CS alone, and CS + RT). The 95% confidence intervals (CI) of the recurrence rates for each of the studies were calculated for subtype, grade, and necrosis, using the exact binomial; the summary recurrence rate and 95% CI for each treatment category were calculated by quantitative meta-analysis using the fixed and random effects models applied to proportions., Results: Meta-analysis yielded a summary recurrence rate of 22.5% (95% CI = 16.9-28.2) for studies employing CS alone, 8.9% (95% CI = 6.8-11.0) for CS + RT, and 1.4% (95% CI = 0.7-2.1) for studies involving mastectomy alone. These summary figures indicate a clear and statistically significant separation, and therefore outcome, between the recurrence rates of each treatment category, despite the likelihood that the patients who underwent CS alone were likely to have had smaller, possibly low grade lesions with clear margins. The patients with risk factors of presence of necrosis, high grade cytologic features, or comedo subtype were found to derive the greatest improvement in local control with the addition of RT to CS. Local recurrence among patients treated by CS alone is approximately 20%, and one-half of the recurrences are invasive cancers. For most patients, RT reduces the risk of recurrence after CS alone by at least 50%. The differences in local recurrence between CS alone and CS + RT are most apparent for those patients with high grade tumors or DCIS with necrosis, or of the "comedo" subtype, or DCIS with close or positive surgical margins., Conclusions: The authors recommend that radiation be added to CS if patients with DCIS who also have the risk factors for local recurrence choose breast conservation over mastectomy. The patients who may be suitable for CS alone outside of a clinical trial may be those who have low grade lesions with little or no necrosis, and with clear surgical margins. Use of the summary statistics when discussing outcomes with patients may help the patient make treatment decisions.