External-beam radiation therapy for clinically localized prostate cancer: patterns of care studies in the United States

Data are presented from the Patterns of Care Study and other sources that define the role of external-beam irradiation in the management of localized prostate cancer as practiced in the United States as a whole. Patients must be treated with complex treatment techniques and high-energy linear accelerators and careful adjustment of radiation dose. Transurethral resection of the prostate should be avoided in the intermediate and poorly differentiated subgroup of stage C patients. The excellent 5- and 10-year survival for patients treated by radiation therapy is demonstrated for all stages of prostate cancer and for T1 or early stage B patients. It is noted that the national averages for survival have improved between 1973 and 1978. Stages A2 and B patients with negative lymph node dissections show freedom from recurrence that is equal to patient reports for radical surgery. Complications resulting from radiation therapy were modest, and potency was maintained in 73% of the patients. Adjuvant irradiation is necessary for pathologic stage C patients after recovery from surgery. Radiation therapy is equally effective though less costly than surgery for early prostate cancer. A particular need of future research is the study of the patterns of care in the United States regarding the surgical management of prostate cancer so that health professionals can determine if this care is generally available throughout the United States and if good outcome and acceptable morbidity result after it is given.     

Radiation therapy facilities in the United States

PURPOSE: About half of all cancer patients in the United States receive radiation therapy as a part of their cancer treatment. Little is known, however, about the facilities that currently deliver external beam radiation. Our goal was to construct a comprehensive database of all radiation therapy facilities in the United States that can be used for future health services research in radiation oncology. METHODS AND MATERIALS: From each state's health department we obtained a list of all facilities that have a linear accelerator or provide radiation therapy. We merged these state lists with information from the American Hospital Association (AHA), as well as 2 organizations that audit the accuracy of radiation machines: the Radiologic Physics Center (RPC) and the Radiation Dosimetry Services (RDS). The comprehensive database included all unique facilities listed in 1 or more of the 4 sources. RESULTS: We identified 2,246 radiation therapy facilities operating in the United States as of 2004-2005. Of these, 448 (20%) facilities were identified through state health department records alone and were not listed in any other data source. CONCLUSIONS: Determining the location of the 2,246 radiation facilities in the United States is a first step in providing important information to radiation oncologists and policymakers concerned with access to radiation therapy services, the distribution of health care resources, and the quality of cancer care.     

Status of postmastectomy radiotherapy in the United States: a patterns of care study

PURPOSE: The Patterns of Care Study performed this first known practice survey to establish a national profile of the delivery of postmastectomy radiotherapy (RT) in operable breast cancer. METHODS AND MATERIALS: A Patterns of Care Study research associate collected data from 55 randomly selected institutions. The survey data included 132 items describing the patient, pathologic features, and treatment course for patients with clinical Stage I, II, and IIIA breast cancer undergoing postmastectomy RT in 1998 and 1999. A multivariate analysis was performed to determine the impact of tumor factors and type of treatment facility on the radiation fields used. RESULTS: A weighted sample size of 13,720 was obtained from a sampling of 405 patient records. The mean tumor size was 3.5 cm, and the mean number of axillary nodal metastases was 4.55. Lymphatic vascular invasion was noted in 34%, microscopic skin or dermal lymphatic invasion in 16%, positive or close margins in 36%, and extracapsular nodal extension in 23%. Radiotherapy included the chest wall in all cases and the regional nodes in 78%. When nodal RT was delivered, it included a supraclavicular field, supplemental axillary field, and/or an internal mammary field in 98%, 46%, and 23% of cases, respectively. Chest wall and supraclavicular RT was delivered in >90% of instances with 6-MV photons to doses between 45 and 50 Gy. More variation was seen in the delivery of the axillary and internal mammary RT. On multivariate analysis, the presence of four or more positive nodes and treatment at a large-volume facility were the factors most frequently associated with the use of regional radiation fields. CONCLUSION: This Patterns of Care Study survey has demonstrated that breast cancer patients undergoing postmastectomy RT in 1998 and 1999 had a high proportion of factors associated with an increased risk of locoregional failure. The practice patterns established in this study provide a baseline for comparison with future survey results.     

Fast neutron beam radiation therapy in the United States

Following a 30-year hiatus after Dr. Stone's work in the 1930's and 1940's, clinical trials with fast neutrons were restarted in the United States in 1972. Approximately 2500 patients have been treated with neutrons since that time. Three hundred and seven patients with squamous cell carcinomas of the head and neck were entered on an RTOG-coordinated randomized study comparing standard photon irradiation with mixed beam radiation therapy. No significant differences were noted in the local control, survival or complication rates. One hundred and sixty patients were entered on a randomized glioblastoma study. Although there were no significant differences in median survival, autopsy results showed greater tumor effect on the neutron-treated tumors. Twenty-six patients were treated for transitional cell carcinomas of the bladder with either preoperative mixed beam irradiation or mixed beam irradiation alone. Both the local control rates and survival rates compare favorably with photon radiation therapy. The future of fast neutron beam radiation therapy in the United States is discussed.     

Contemporary prostate cancer radiation therapy in the United States: Patterns of care and compliance with quality measures

Purpose

Quality measures represent the standards of appropriate treatment agreed upon by experts in the field and often supported by data. The extent to which providers in the community adhere to quality measures in radiation therapy (RT) is unknown.

A survey of intensity-modulated radiation therapy use in the United States

BACKGROUND: The objective of this study was to assess the current level of intensity-modulated radiation therapy (IMRT) use in the United States. METHODS: Three-hundred thirty-three randomly selected radiation oncologists were sent a 13-question survey regarding IMRT use. IMRT users were asked about the number of patients and sites treated, their reasons for adopting IMRT, and future plans for its use. Physicians who did not use IMRT were asked about their reasons for not using IMRT; whether they intended to adopt it in the future; and, if so, their reasons. RESULTS: One-hundred sixty-eight responses (50.5%) were received. Fifty-four respondents (32.1%) stated that they currently used IMRT. Most IMRT users (79.6%) had adopted IMRT since 2000. Academic physicians were more likely to use IMRT (P = 0.003) compared with private practitioners. The percent of physicians using IMRT in practices comprised of 1 physician, 2-4 physicians, or > 4 physicians were 15.4%, 28.4%, and 44.2%, respectively (P = 0.02). The most common sites treated were head and neck malignancies and genitourinary tumors. Of the 114 IMRT nonusers, 96.5% planned to use IMRT in the future, with 91.8% planning to use IMRT within 3 years. Among IMRT nonusers, the most common reason cited for not using IMRT was lack of necessary equipment. The most common reasons for adopting IMRT (users) or wanting to adopt IMRT (nonusers) were to improve delivery of conventional doses and to escalate dose. CONCLUSIONS: Approximately one-third of radiation oncologists in the United States use IMRT. However, this number appears to be growing rapidly. Efforts to ensure the safe and appropriate application of this new technology are warranted.     

The crisis in health care cost in the United States: some implications for radiation oncology.

This communication reviews the increasing cost of medical care in the USA (13% of GNP in 1995) and the associated lack of access to care for 35 million citizens. Factors affecting cost and access are presented, including where the increases are seen. The resulting effects on the Federal government, private industry, the patient, and the physician are noted. The failure of a current mechanism of control of cost is illustrated as are the views of patients and physicians. The portion of radiation oncology devoted to palliative care is discussed for its potential to reduce costs by $150-$250 million through the elimination of excessive treatments and thereby contribute to the solution of excessive cost of care.     

Omission of radiation therapy after breast-conserving surgery in the United States: a population-based analysis of clinicopathologic factors

BACKGROUND:

Radiation therapy (RT) after breast‐conserving surgery (BCS) is associated with a significant reduction in ipsilateral breast tumor recurrence and breast cancer mortality rates in patients with early stage breast cancer. The authors of this report sought to determine which patients with breast cancer do not receive RT after BCS in the United States.

METHODS:

The Surveillance, Epidemiology, and End Results registry was used to determine the rates of RT after BCS for women with stage I through III breast cancer in the United States from 1992 through 2007. A multivariate analysis was performed to identify independent predictors of omission of RT.

RESULTS:

In total, 294,254 patients with invasive, nonmetastatic breast cancer were identified who underwent surgery from 1992 through 2007. Most patients (57%) underwent BCS; among those, 21.1% did not receive RT after BCS. The omission of RT increased significantly from 1992 (15.5%) to 2007 (25%). The receipt of RT also decreased significantly for patients with increased cancer stage, age <55 years, high‐grade tumors, large tumors, positive or untested lymph node status, African American or Hispanic race, and negative or unknown estrogen receptor status. Significant geographic variation was observed in the rates of RT after BCS.

CONCLUSIONS:

The omission of RT after BCS was more common in recent years, especially among women who had an increased risk of breast cancer recurrence. This trend represents a serious health care concern because of the potential increased risk of local recurrence and breast cancer mortality. Cancer 2012. © 2011 American Cancer Society.     

Geographic patterns of bladder cancer in the United States.

Age-adjusted rates of mortality during 1950-69 from bladder cancer were correlated with demographic and industrial indexes for the 3,056 counties of the contiguous United States. Rates among whites and nonwhites of both sexes rose sharply with urbanization. A small but positive socioeconomic gradient was observed, and mortality was slightly higher among males in counties with high percentages of British and German residents. Even after controlling for demographic variables, the Northeastern excess of bladder cancer among whites was sizable, whereas the regional differences among nonwhites were small. The high rates in the Northeast were seen in both sexes and in rural as well as urban areas, with mortality in small counties in upstate New York and New England equaling or exceeding those in large metropolitan centers elsewhere in the country. Outside the Northeast, high rates were generally limited to urban areas, but clusters of elevated mortality occurred among white males along the Illinois-Wisconsin border, in parts of lower Michigan, and in southern Louisiana. Industrial factors may explain at least part of the geographic clustering, inasmuch as rates among males were significantly higher in U.S. counties where the chemical industry is heavily concentrated. Increases were also associated with the printing industry, but correlations with 16 other major manufacturing industries were near or below expected levels.     

Geographic patterns of renal cancer in the United States.

Mapping of the geographic distribution of renal cancer mortality for groupings of U.S. counties revealed clustering of elevated rates among white males and females in the upper north-central part of the country. Throughout the United States, mortality increased with urbanization for males only, whereas rates for both sexes showed positive correlations with socioeconomic status. The major correlate of the cancer rates was ethnicity. Mortality was elevated in counties with high percentages of residents of German, Scandinavian, and especially Russian descent. Ethnic susceptibility appears to account, at least partly, for the regional clustering of kidney cancer and may provide leads to environmental determinants.     

Geographic patterns of prostate cancer in the United States.

Age-adjusted rates of mortality from prostate cancer during 1950-69 were correlated by race with demographic, industrial, and agricultural data from 3,056 U.S. countries. Mortality among nonwhites was 50% higher than that among whites in all parts of the country where blacks comprise most of the nonwhite population. The rising rate associated with population density among nonwhites, but not whites, suggested that environmental exposures related to urban living may account for the predisposition of American blacks to prostate cancer. Despite a clustering of counties with elevated mortality in certain North Central and Northeastern States, the geographic variation among whites with prostate tumors was considerably less than that among whites with other tumors. Mortality was elevated in counties with a high percentage of residents of Scandinavian descent, in counties with metal-using and textile industries, and in regions with high consumption of high-fat foods.     

Practice patterns of palliative care for the United States 1984-1985

This study reports the national averages for patterns of palliative radiation therapy observed in the United States for patients treated in 1984-1985 and compares those patterns to the pertinent literature. The data were collected in 1984-1985 by the Patterns of Care Study Survey of Palliative Care conducted in 49 institutions selected to provide valid national averages for the practice patterns reported. Data were collected from 784 patient records selected from five "strata" of practice. Demographic data and process data were tabulated and national averages were calculated from the data. Four metastatic sites were selected, weight bearing bones (401), non-weight bearing bones (102), brain metastasis (224), and lung-mediastinum (57). The median patient age was 63 years, equally divided by sex. In 52% of patients this was the first metastasis. Common Karnofsky performance scores ranged from 40 to 80%. Lung, breast, and prostate were the most common primaries. Two-thirds of the patients were treated by linear accelerators, one-third by cobalt. The median number of fractions was 10, median dose 3000 cGy, median fraction size 300 cGy, and median treatment duration 15 days. The goal of treatment was relief of pain (98%) and return of function (30%) for weight bearing bones, for brain metastasis it was preservation of function (68%), pain relief (33%), and relief of compression (25%). All sites showed TDF values that ranged from 33-85, and a TDF of approximately 65 was most common for weight bearing bones and brain metastasis with no consistent pattern of TDF selection for the other sites. Compliance by strata of practice with work-up criteria was excellent with isolated poor compliance seen in several strata.     

Geographic patterns of prostate cancer mortality and variations in access to medical care in the United States.

BACKGROUND: Striking geographic variation in prostate cancer death rates have been observed in the United States since at least the 1950s; reasons for these variations are unknown. Here we examine the association between geographic variations in prostate cancer mortality and regional variations in access to medical care, as reflected by the incidence of late-stage disease, prostate-specific antigen (PSA) utilization, and residence in rural counties. METHODS: We analyzed mortality data from the National Center for Health Statistics, 1996 to 2000, and incidence data from 30 population-based central cancer registries from the North American Association of Central Cancer Registries, 1995 to 2000. Ecological data on the rate of PSA screening by registry area were obtained from the 2001 Behavioral Risk Factor Surveillance System. Counties were grouped into metro and nonmetro areas according to Beale codes from the Department of Agriculture. Pearson correlation analyses were used to examine associations. RESULTS: Significant correlations were observed between the incidence of late-stage prostate cancer and death rates for Whites (r = 0.38, P = 0.04) and Blacks (r = 0.53, P = 0.03). The variation in late-stage disease corresponded to about 14% of the variation in prostate cancer death rates in White men and 28% in Black men. PSA screening rate was positively associated with total prostate cancer incidence (r = 0.42, P = 0.02) but inversely associated with the incidence of late-stage disease (r = -0.58, P = 0.009) among White men. Nonmetro counties generally had higher death rates and incidence of late-stage disease and lower prevalence of PSA screening (53%) than metro areas (58%), despite lower overall incidence rates. CONCLUSION: These ecological data suggest that 10% to 30% of the geographic variation in mortality rates may relate to variations in access to medical care.     

A survey of image‐guided radiation therapy use in the United States

BACKGROUND:

Image‐guided radiation therapy (IGRT) is a novel array of in‐room imaging modalities that are used for tumor localization and patient setup in radiation oncology. The prevalence of IGRT use among US radiation oncologists is unknown.

METHODS:

A random sample of 1600 radiation oncologists was surveyed by Internet, e‐mail and fax regarding the frequency of IGRT use, clinical applications, and future plans for use. The definition of IGRT included imaging technologies that are used for setup verification or tumor localization during treatment.

RESULTS:

Of 1089 evaluable respondents, 393 responses (36.1%) were received. The proportion of radiation oncologists using IGRT was 93.5%. When the use of megavoltage (MV) portal imaging was excluded from the definition of IGRT, the proportion using IGRT was 82.3%. The majority used IGRT rarely (in <25% of their patients; 28.9%) or infrequently (in 25%‐50% of their patients; 33.1%). The percentages using ultrasound, video, MV‐planar, kilovoltage (kV)‐planar, and volumetric technologies were 22.3%, 3.2%, 62.7%, 57.7%, and 58.8%, respectively. Among IGRT users, the most common disease sites treated were genitourinary (91.1%), head and neck (74.2%), central nervous system (71.9%), and lung (66.9%). Overall, 59.1% of IGRT users planned to increase use, and 71.4% of nonusers planned to adopt IGRT in the future.

CONCLUSIONS:

IGRT is widely used among radiation oncologists. On the basis of prospective plans of responders, its use is expected to increase. Further research will be required to determine the safety, cost efficacy, and optimal applications of these technologies. Cancer 2010. © 2010 American Cancer Society.