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Purpose: Increasing the survival of patients with metastatic prostate cancer (PCa) may affect the demand for palliative radiation to bone (PRTB). Our aim was to characterize the use of PRTB in patients who died of PCa in British Columbia between 2003 and 2015., Methods and Materials: All patients with a diagnosis of PCa who died during the study period (n = 23,260) were identified from a population-based provincial registry. Patient and treatment characteristics were analyzed. PRTB utilization rate was calculated by year and location. Survival was calculated from the first and the last course of PRTB., Results: A total of 5701 patients died of PCa, with a median survival from diagnosis of 5.2 years. The overall PRTB utilization rate was 38.6%, with an increasing trend over time. Multiple courses of PRTB were frequent, with 51% of patients receiving ≥2 courses of PRTB. Of the patients who died of PCa (15.2% of the PRTB cohort), 5.4% received PRTB within the last 4 weeks of life, 60% of whom received multiple fractions. Rural areas had a lower referral rate and lower use of PRTB. Patients with longer survival tended to receive multiple courses of treatment. The median survival after the first course of PRTB increased from 8.2 months in 2003 to 2004 to 9.4 months in 2013 to 2014 (P = .04)., Conclusions: PRTB is only used in a minority of patients dying of PCa. The majority who die of PCa after PRTB do so within a year of their first course. The use of multifractionation was common in the last 4 weeks of life. Survival after first PRTB increased minimally over time, and additional research is required to identify its association with recent changes in practice. The referral rate and PRTB utilization rate differ between rural and nonrural locations, underlying the importance of accessibility and referral for utilization of PRTB. Investigating other barriers and ensuring equitable access to radiation are needed., (Copyright © 2019 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Aims: To compare the existing model estimates of the appropriate rates of radiotherapy for lung, breast and prostate cancers with actual radiotherapy rates in rural, semi-urban and urban areas, and in areas with short and long drive distances to cancer clinics in British Columbia., Materials and Methods: All registered cases of lung, breast and prostate cancer diagnosed in British Columbia between 1997 and 2007 were identified. The proportion of cancers treated within 1 (RT1Y) and 5 years (RT5Y) of diagnosis were calculated according to rural, semi-urban and urban area, and areas associated with short and long drive distances to cancer clinics in British Columbia., Results: RT1Y for lung, breast and prostate in urban and rural areas were 47/45%, 57/46% and 31/30%, and for short and long drive times were 47/44%, 56/50% and 31/31% compared with model estimates for initial radiotherapy needs of 41-45%, 57-61% and 32-37%, respectively. RT5Y for lung, breast and prostate in urban and rural areas were 52/47%, 59/48% and 42/39%, and for short and long drive times were 51/47%, 57/50% and 42/42% compared with model estimates for overall radiotherapy needs of 66-83%, 57-61% and 60-61%, respectively., Conclusions: Radiotherapy rates vary between and within urban and rural areas in British Columbia. Radiotherapy rates for breast and lung cancer patients are higher, and closer to model estimates of need, in urban areas and short drive time areas. Radiotherapy rates do not vary with drive time or rural versus urban classification for patients with prostate cancer., (Copyright (c) 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Purpose: Current estimates of the proportion of cancer patients who will require radiotherapy (RT) are based almost entirely on expert opinion. The objective of this study was to use an evidence-based approach to estimate the proportion of incident cases of prostate cancer that should receive RT at any point in the evolution of the illness., Methods and Materials: A systematic review of the literature was undertaken to identify indications for RT for prostate cancer and to ascertain the level of evidence that supported each indication. An epidemiologic approach was then used to estimate the incidence of each indication for RT in a typical North American population of prostate cancer patients. The effect of sampling error on the estimated appropriate rate of RT was calculated mathematically, and the effect of systematic error using alternative sources of information was estimated by sensitivity analysis., Results: It was estimated that 61.2% +/- 5.6% of prostate cancer cases develop one or more indications for RT at some point in the course of the illness. The plausible range for this rate was 57.3%-69.8% on sensitivity analysis. Of all prostate cancer patients, 32.2% +/- 3.8% should receive RT in their initial treatment and 29.0% +/- 4.1% later for recurrence or progression. The proportion of cases that ever require RT is risk grouping dependent; 43.9% +/- 2.2% in low-risk disease, 68.7% +/- 3.5% in intermediate-risk disease; and 79.0% +/- 3.8% in high-risk locoregional disease. For metastatic disease, the predicted rate was 66.4% +/- 0.3%., Conclusion: This method provides a rational starting point for the long-term planning of radiation services and for the audit of access to RT at the population level. By completing such evaluations in major cancer sites, it will be possible to estimate the appropriate RT rate for the cancer population as a whole.

Purpose: Current estimates of the proportion of cancer patients who will require radiotherapy (RT) are based almost entirely on expert opinion. We sought to use an evidence-based approach to estimate the proportion of incident cases of breast cancer that will require RT at any point in the evolution of the illness., Methods and Materials: We undertook a systematic review of the literature to identify indications for RT for breast cancer and to ascertain the level of evidence that supported each indication. An epidemiologic approach was then used to estimate the incidence of each indication for RT in a typical North American population of breast cancer patients. The effect of sampling error on the estimated appropriate rate of RT was calculated mathematically, and the effect of systematic error was estimated by sensitivity analysis., Results: It was estimated that 66.4% +/- 4.8% of breast cancer patients develop one or more indications for RT at some point in the course of the illness. The plausible range for this rate was 56.3%-72.4% on sensitivity analysis. Of all breast cancer patients, 57.3% +/- 4.7% require RT in their initial treatment and 9.1% +/- 1.0% do so later for recurrence or progression. The proportion of patients who ever require RT is stage dependent: 39.8% +/- 1.1% in ductal carcinoma in situ; 68.6% +/- 4.1% in Stage I invasive carcinoma; 81.5% +/- 2.3% in Stage II; 95.3% +/- 0.3% in Stage III; and 63.7% +/- 0.3% in Stage IV., Conclusion: This method provides a rational starting point for the long-term planning of RT services and for the audit of access to RT at the population level. By completing such evaluations in the major cancer sites, it will be possible to estimate the appropriate RT treatment rate for the cancer population as a whole.

Background The Spinal Instability Neoplastic Score (sins) was developed to identify patients with spinal metastases who may benefit from surgical consultation. We aimed to assess the distribution of sins in a population-based cohort of patients undergoing palliative spine radiotherapy (rt) and referral rates to spinal surgery pre-rt. Secondary outcomes included referral to a spine surgeon post-rt, overall survival, maintenance of ambulation, need for re-intervention, and presence of spinal adverse events. Methods We retrospectively reviewed ct simulation scans and charts of consecutive patients receiving palliative spine rt between 2012 and 2013. Data were analyzed using Student's t-test, Chi-squared, Fisher's exact, and Kaplan- Meier log-rank tests. Patients were stratified into low (<7) and high (≥7) sins groups. Results We included 195 patients with a follow-up of 6.1 months. The median sins was 7. The score was 0 to 6 (low, no referral recommended), 7 to 12 (intermediate, consider referral), and 13 to 18 (high, referral suggested) in 34%, 59%, and 7% of patients, respectively. Eleven patients had pre-rt referral to spine surgery, with a surgery performed in 0 of 1 patient with sins 0 to 6, 1 of 7 with sins 7 to 12, and 1 of 3 with sins 13 to 18. Seven patients were referred to a surgeon post-rt with salvage surgery performed in two of those patients. Primary and secondary outcomes did not differ between low and high sins groups. Conclusion Higher sins was associated with pre-rt referral to a spine surgeon, but most patients with high sins were not referred. Higher sins was not associated with shorter survival or worse outcome following rt. [ABSTRACT FROM AUTHOR]

Background The use of neoadjuvant systemic therapy (NAST) in the treatment of breast cancer is increasing, and the role of adjuvant radiation therapy (RT) in that setting is uncertain. We sought to review and report the use of NAST, its trends over time, and its relationship with the prescribing patterns of locoregional RT in a provincial cancer system. Methods Patients with stages I-III breast cancer diagnosed during 2007-2012 were identified using a provincial database. Patient, tumour, and treatment characteristics were extracted. Multivariable logistic regression analyses were used to assess associations with the use of NAST. Kaplan-Meier and Cox regression were used for survival analyses. Results Of the 11,658 patients who met the inclusion criteria, 602 (5%) had received NAST. Use of NAST was more frequent in stage III patients (53%) than in stages I and II patients (2%). In clinically lymph-node positive patients, a pathology assessment was made approximately 50% of the time. Higher clinical tumour stage and increasing clinical nodal stage predicted for increasing use of NAST and of nodal RT after NAST, but pathologic nodal status after NAST was not associated with use of nodal RT. A statistically significant survival difference was observed between patients in the NAST and no- NAST groups, but that significance disappeared in a multivariable Cox regression analysis. Conclusions This population-based study demonstrated 5% use of NAST for breast cancer. Most patients received nodal RT after NAST, and nodal RT was not associated with pathologic stage after NAST. Findings likely reflect the realities of clinical practice and show that reliance on clinical nodal staging results in outcomes similar to those reported in the literature. [ABSTRACT FROM AUTHOR]

Abstract: Background: Different jurisdictions report different breast cancer treatment rates. Evidence-based utilization models may be specific to derived populations. We compared predicted optimal with actual radiotherapy utilization in British Columbia, Canada; Dundee, Scotland; and Perth, Western Australia. Design: Data were analyzed for differences in demography, tumor, and treatment. Epidemiological data were fitted to published Australian optimal radiotherapy utilization trees and region-specific optimal treatment rates were calculated. Optimal and actual surgery/radiotherapy rates from 2 population-based and 1 institution-based registries were compared for patients diagnosed with breast cancer between 2000 and 2004, and 2002 for British Columbia. Results: Mastectomy rates differed between British Columbia (40%), Western Australia (44%), and Dundee (47%, p <0.01). Radiotherapy rates differed between British Columbia (60%), Western Australia (52%), and Dundee (49%, p <0.01). Actual radiotherapy utilization rates were lower than optimal estimates. Region-specific optimal utilization rates at diagnosis varied from 57% to 71% for radiotherapy and 62% to 64% when taking into account patient preference. Variation was attributed to local differences in demography and tumor stage. Conclusions: Actual treatment rates varied, and were associated with patterns of care and guideline differences. Actual radiotherapy rates were lower than optimal rates. Differences between optimal and actual utilization may be due to access shortfalls, and patient preference. [Copyright &y& Elsevier]

The European Organisation for Research and Treatment of Cancer (EORTC) 22,881–10,882 trial showed significant benefit of a radiotherapy boost (RTB) in women ≤40 years in a pre-hormone therapy (HT) era. We determined how the use of HT and RTB changed in response to clinical guidelines and whether the benefit of routine RTB was still observed in the HT era. Between 1996 and 2004, a provincial database identified all women ≤40 years with breast cancer who met the inclusion criteria of the EORTC trial. In total, 411 patients were classified into three eras defined by the guidelines: era 1 (discretionary HT, discretionary RTB); era 2 (routine HT, discretionary RTB); era 3 (routine HT, routine RTB). HT use, RTB use and cumulative incidence of local recurrence were calculated and compared across eras. HT use increased after the first policy change from 13% to 75% for oestrogen receptor-positive patients (P < 0.01). RTB use also increased from 33% to 76% following the second policy change (P < 0.01). At 10 years, the cumulative incidence of local recurrence was 12% in era 1, 6% in era 2 and 6% in era 3 (era 2 versus era 3, P = 0.92). For patients in the routine HT era (eras 2 and 3 combined) there was no significant difference in local recurrence between RTB and 'no RTB' patients (6% versus 7%, P = 0.81). The routine use of HT and RTB increased significantly after new practice guidelines. Introduction of the HT guideline was associated with a 6% improvement in local recurrence at 10 years. No improvement in local recurrence was associated with the introduction of the RTB guideline in the HT era. The routine use of a boost in unselected young women with negative margins should be re-evaluated in the current HT era. • Prior to routine hormone therapy (HT) use, a boost (RTB) reduced breast cancer local recurrence in women ≤ 40 years. • The use of HT and RTB increased significantly after the introduction of new practice guidelines. • Local recurrence was halved after introduction of the HT guideline. • No improvement in local recurrence was associated with the introduction of the RTB guideline in the HT era. • The routine use of RTB in unselected young women with negative margins should be re-evaluated in the current HT era. [ABSTRACT FROM AUTHOR]

Abstract Aims To evaluate the prevalence, patterns of care and outcome of pathologically node-positive (pN+) prostate cancer (P-Ca) after radical prostatectomy from a provincial population database. Patients and methods Patients were identified from a provincial cancer registry and a genitourinary cancer outcomes unit (2005–2014). Of a total of 4723 patients who underwent radical prostatectomy, 167 patients with pN+ P-Ca were identified (28/2181 from 2005–2007 and 139/2542 from 2010–2014). Persistently elevated postoperative prostate-specific antigen (PSA) ≥ 0.2 ng/ml was noted in 52 (31%) patients, 23 (44.2%) of whom had salvage androgen deprivation therapy plus radiotherapy (ADT + RT), 25 (48%) were managed with ADT alone and four (7.8%) had no treatment. Of 115 patients with postoperative PSA <0.2 ng/ml, 47 (41%) had ADT alone and 50 (43.5%) had ADT + RT. Survival estimation was carried out using the Kaplan–Meier method. The association of prognostic factors with survival was evaluated using univariate and multivariate analysis and was limited to the newer cohort (2010–2014). Results The median age was 64 years; the median baseline PSA was 12.5 ng/mL (range 2.5–108.4). After a median follow-up of 48 months, overall survival at 5 and 10 years for the entire cohort were 89% and 81%, respectively, and distant metastasis-free survival (DMFS) at the same time points were 77% and 58%, respectively. For the newer cohort, 5-year overall survival and DMFS were 91.5% and 76%, respectively. On univariate analysis, persistently elevated postoperative PSA ≥0.2 ng/ml (P = 0.0003), seminal vesicle involvement (P = 0.027), ≥2 nodes (P = 0.035) and ADT alone (P = 0.054) had a poor prognostic impact on DMFS, whereas margin involvement had a marginally negative influence on overall survival (P = 0.06). On multivariate analysis, postoperative PSA ≥0.2 ng/ml (hazard ratio 4.4, 95% confidence interval 1.7–11.4; P = 0.002) continued to have a significant association with DMFS. On a sensitivity analysis, postoperative PSA ≥0.1 also had a significant association with DMFS on univariate and multivariate analysis (hazard ratio 3.69, 95% confidence interval 1.32–10.29; P = 0.01). Similarly, postoperative PSA ≥0.4 ng/ml had a significant association with DMFS (hazard ratio 3.87, 95% confidence interval 1.58–9.46, P = 0.003). Conclusion This study showed a notable difference in the proportion of pN+ P-Ca patients between two different time cohorts. A significant association of persistently elevated postoperative PSA with DMFS was noted in our study. This must be accounted for while tailoring postoperative treatment in pN+ P-Ca. Highlights • The study shows rising incidence of pathologically node-positive prostate cancer. • Persistently elevated postoperative PSA >0.2 ng/ml is predictive of poor prognosis. • No additional benefit of ADT + RT over ADT alone was noted in pN+ prostate cancer. [ABSTRACT FROM AUTHOR]

While SABR is known for its overall low toxicity and safety, there remains a research gap regarding its combined use with specific systemic therapies. This study aims to evaluate the toxicity of SABR in combination with various systemic therapies. The hypothesis is that certain systemic therapies would significantly increase the risk of Grade 2+ and Grade 3+ radiation therapy-related toxicities when used concurrently with Stereotactic Ablative Radiotherapy (SABR). A secondary analysis of the SABR-5 trial compared grade 2+ and 3+ toxicities associated with SABR until the last follow-up in patients receiving high-risk or non-high-risk systemic therapy at intervals of 3 months, 2 weeks, 1 week, and concurrently with SABR. High-risk systemic therapy was a priori defined, based on previous literature, as drugs that, when given close to SABR, may increase treatment toxicity. This category encompasses cytotoxic chemotherapy drugs, multi-targeted tyrosine kinase inhibitors, cyclin-dependent kinase 4/6 inhibitors, epidermal growth factor receptor inhibitors, anti-vascular endothelial growth factor agents, and anti-cytotoxic T-lymphocyte-associated protein 4 agents. Among the 381 patients, the actuarial rates of grade 2+ and 3+ toxic effects were as follows: for patients not on systemic therapy 3 months prior to SABR (n = 202), the rates were 17.3% and 3.5%, respectively; for patients on non-high-risk systemic therapy concurrent with SABR (n = 102), the rates were 18.6% and 3.9%, respectively; and for patients on high-risk systemic therapy concurrent with SABR (n = 5), the rates were notably higher at 60% and 40%, respectively. On multivariable analysis, concurrent use of high-risk systemic therapy was associated with a higher risk of grade 2+ (OR = 7.15, P = 0.043) or 3+ toxic effects (OR = 13.9, P = 0.015). Significance was not observed when high-risk drugs were used only within 1 week, 2 weeks, or 3 months of SABR, nor with the use of any non-high-risk drugs. A second adverse factor included increased tumor diameter (per 1 cm increment; G2+ OR = 1.25, P < 0.001; G3+ OR = 1.27, P = 0.015). High-risk drugs have demonstrated a potential of increased SABR-related toxicity, warranting caution in their concurrent use with SABR. In contrast, the combination of non-high-risk drugs with SABR may be safe. Ongoing efforts are essential to identify potential risks and uncertainties associated with this therapeutic combination. [ABSTRACT FROM AUTHOR]

Clinical Audit and feedback (CA&F) is a demonstrated successful knowledge translation (KT) method that positively impacts change in practice in numerous clinical scenarios. However, there has been low implementation of CA&F in oncology, and specifically in radiotherapy (RT) prescribing practices. We sought to identify the impact of a simple CA&F intervention on prescribing practices across six BC Cancer Centers by investigating four clinical scenarios: (1) women <50 years old with invasive breast cancer post partial mastectomy who receive surgical cavity RT boost vs not; (2) patients with 1-3 positive lymph nodes receiving regional RT vs not; (3) women >70 years old with T1N0 breast cancer omitting whole breast RT vs not; (4) all women who received local or locoregional radiotherapy who are prescribed 16 versus 25 fractions of RT. Thirty-five radiation oncologists were randomized to receive CA&F intervention vs not and stratified by BC Cancer center. Patient data was obtained retrospectively for patients treated before and after intervention. The study measured one of two possible prescriptions per clinical scenario, with prescription 1 containing the most evidence in favor of its use. A logistic fixed effect regression model was used to measure odds ratio of prescription 1 before and after intervention. This model captured the difference in prescription use within and between control and intervention groups pre and post CA&F, while adjusting for the number of patients seen by each physician. Time as a potential confounding variable that could impact prescription rates from pre to post intervention was also adjusted for. A total of 5215 unique cases were identified. The change in odds of using prescription 1 after CA&F in cohorts 1, 2, 3 and 4 was 0.45 (p=0.12), 0.59 (p=0.34), 2.23 × 10−9 (p=0.98, unstable model), and 0.77 (p=0.11) respectively. There was no significant change in odds of utilizing the more evidence-based prescription across any of the four clinical scenarios, suggesting our simple CA&F intervention was not effective in changing prescribing practices. Further, radiation oncologists may have been optimally informed of prescribing patterns prior to intervention. A more complex CA&F intervention may be necessary in future quality assurance efforts to achieve a greater impact on radiotherapy prescribing practices. [ABSTRACT FROM AUTHOR]

PURPOSE: Equivalent long-term outcomes have been demonstrated between conventional whole breast radiotherapy (CWBRT) and accelerated hypofractionated whole breast radiotherapy (AWBRT) for early-stage breast cancer. However, there is ongoing concern regarding the long-term risk of cardiac injury with AWBRT in women with left-sided breast cancer. The primary goal of this population-based study was to determine whether there was an increase in cardiac morbidity with AWBRT versus CWBRT based on hospital administrative data. MATERIALS AND METHODS: Between 1990 and 1998, 2706 women, aged less than 80 years with left-sided early-stage breast cancer were treated with post-operative radiotherapy (RT) to the breast or chest wall alone. Baseline patient, tumour and treatment factors were recorded in a provincial outcomes database, linked to hospital administrative databases and de-identified. Data from hospitalization records two years prior to RT were used to identify baseline cardiac risk factors (including hypertension (HTN), diabetes, hypercholesterolemia and prior cardiac events) and other comorbidities. There was a policy of using CWBRT for women with breast and chest wall radiotherapy planning separations of >23cm, so a propensity-score model was developed to balance cardiac and breast cancer risk factors between women who received AWBRT (42.5-44 Gy/16 fractions) versus CWBRT (45-50 Gy/25 fractions). The first event of a hospital admission for cardiac causes after RT was determined from hospitalization records. Cumulative incidence of cardiac morbidity was estimated at 10 years after RT for AWBRT versus CWBRT groups. Gray's test was used to test for differences in the cumulative incidence curves between the AWBRT and CWBRT groups. RESULTS: The median follow-up [range] was 13.2 [10-28] years. 485 women were treated with CWBRT and 2221 women were treated with AWBRT. The CWBRT group had a higher prevalence of diabetes, with a trend towards higher prevalence of HTN and other cardiac risk factors. Age, year of diagnosis, stage, grade, ER status, hormone and chemotherapy use were not statistically different between the RT groups. There was no statistically significant difference at 10 years in the incidence rate (as measured by first hospitalisation for cardiac morbidity) between the RT groups. The 10-year cumulative incidence of these hospitalization events for cardiac morbidity (95% CI) was 20.8% (19.1-22.5) with AWBRT and 22.1% (18.5-25.9) with CWBRT. This difference was not significant between raw unadjusted values (p = 0.07) or after propensity score adjustment with Gray's test (p = 0.2). Differences were also not statistically different at 15 years follow-up. These values are comparable with published long- term cardiac morbidity rates with CWBRT. Mortality due to cardiac cause was not statistically different between the two groups at 15 years follow-up. CONCLUSION: Hospitalization for a primary or contributing cardiac cause at 15 years follow- up was not significantly different between women with left-sided early-stage breast cancer treated with AWBRT versus CWBRT even after correcting for pretreatment cardiac risk factors and events. [ABSTRACT FROM AUTHOR]