INTRODUCTION:Optimal radiotherapy utilisation (RTU) modelling estimates the proportion of people with cancer who would benefit from radiotherapy. Assessment of comorbidities is an important component of the assessment of suitability for radiotherapy in addition to chronological age and life expectancy. Comorbidities have not been considered in previous optimal RTU models. We aimed to develop an age- and comorbidity- adjusted optimal RTU model for patients with lung, rectal, prostate, and cervical cancer, and compare them to actual RTU rates, with a particular focus on those aged 80+ years, METHODS: New South Wales (NSW) Cancer Registry data (2010-2014) linked to radiotherapy data (2010-2015) and hospitalisation data (2008-2015) were used to determine the number of patients diagnosed with lung, rectal, prostate and cervical cancer. The Cancer Specific C3 'all sites' comorbidity index was calculated from hospital diagnosis data for each patient to determine suitability for radiotherapy. The index was then incorporated into a tumour site-specific decision tree model. The actual RTU was also calculated using the linked datasets. RESULTS:14,696 patients were diagnosed with non-small cell lung cancer (NSCLC), 1839 with small cell lung cancer (SCLC), 5551 with rectal cancer, 30,935 with prostate cancer and 1216 with cervical cancer in New South Wales from 2010-2014. The proportion of patients aged 80+ years at cancer diagnosis was 25% (3603 patients), 15% (279 patients), 17% (943 patients), 12% (3745 patients), and 7% (88 patients) respectively. The age- and comorbidity- adjusted optimal RTU rates for patients aged 80+ years using the C3 index were 49% (NSCLC), 49% (SCLC), 43% (rectal), 51% (prostate) and 40% (cervical). The corresponding actual RTU rates for patients aged 80+ years were 25%, 32%, 27%, 16%, and 56%. CONCLUSION:Even after adjusting for age and comorbidities, the actual radiotherapy utilisation rates were lower than optimal radiotherapy utilisation rates in patients aged 80+ years except for patients with cervical cancer. This warrants further assessment and research into reasons and solutions.

INTRODUCTION:There is an increasing incidence of cancer in older people, but limited data on radiotherapy uptake, and in particular, radiotherapy utilisation (RTU) rates. The RTU rate for older adults with cancer may be lower than recommended due to lower tolerance for radiotherapy as well as additional comorbidities, reduced life expectancy and travel for treatment. Radiotherapy use must be aligned with best available, age-specific evidence to ensure older adults with cancer receive optimal benefit without harms.MATERIALS AND METHODS:A systematic review was conducted to synthesise the published data on the actual RTU rate for patients with cancer as a function of age. MEDLINE and EMBASE were systematically searched to identify relevant population-based and hospital-based cohort studies on radiotherapy utilisation for all age groups, published in English, from 1 January 1990 to 1 July 2020. We focused on the following common cancers in older adults for which radiotherapy is recommended: breast, prostate, lung, rectal cancer, glioblastoma multiforme (GBM), and cervical cancer. Age-specific radiotherapy utilisation data were extracted and analysed as a narrative synthesis.RESULTS:From 2606 studies screened, 75 cohort and population-based studies were identified with age-specific radiotherapy utilisation data. The total number of patients in the 75 studies was 4,792,138. The RTU rate decreased with increasing age for all tumour sites analysed, except for patients receiving curative radiotherapy as definitive treatment for prostate or cervical cancer. This reduction with increasing age was demonstrated in both palliative and curative settings.DISCUSSION:There is a global reduction in radiotherapy utilisation with increasing age for most tumour sites. The reduction in delivery of radiotherapy warrants further examination and evidence-based guidelines specific to this population.

INTRODUCTIONFluoropyrimidine and oxaliplatin-based adjuvant chemotherapy delivered as 5-fluorouracil, leucovorin and oxaliplatin (FOLFOX), or capecitabine and oxaliplatin (CAPOX) is the standard of care for resected stage III colon cancer. Without randomized trial data, we compared real-world dose intensity, survival outcomes, and tolerability of these regimens.METHODSRecords of patients treated with FOLFOX or CAPOX in the adjuvant setting for stage III colon cancer across four institutions in Sydney during 2006-2016 were reviewed. The relative dose intensity (RDI) of fluoropyrimidine and oxaliplatin of each regimen, disease-free survival (DFS), overall survival (OS), and incidence of grade ≥2 toxicities were compared.RESULTSCharacteristics of patients receiving FOLFOX (n = 195) and CAPOX (n = 62) were evenly matched. FOLFOX patients had a higher mean RDI for both fluoropyrimidine (85% vs. 78%, p < 0.01) and oxaliplatin (72% vs. 66%, p = 0.06). In spite of a lower RDI, CAPOX patients trended toward a better 5-year DFS (84% vs. 78%, HR = 0.53, p = 0.068) and similar OS (89% vs. 89%, HR = 0.53, p = 0.21) compared to the FOLFOX group. This difference was most pronounced in the high-risk (T4 or N2) group where 5-year DFS was 78% versus 67% (HR = 0.41, p = 0.042). Patients receiving CAPOX experienced more grade ≥2 diarrhea (p = 0.017) and hand-foot syndrome (p < 0.001) but not peripheral neuropathy or myelosuppression.CONCLUSIONIn a real-world setting, patients who received CAPOX had similar OS rates when compared to those receiving FOLFOX in the adjuvant setting in spite of lower RDI. In the high-risk population, CAPOX appears to demonstrate a superior 5-year DFS over FOLFOX.

Asia-Pacific Journal of Clinical OncologyEarly View REPLY Response from Batumalai V et al. Vikneswary Batumalai, Corresponding Author Vikneswary Batumalai v.batumalai@unsw.edu.au orcid.org/0000-0003-2021-2599 Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia GenesisCare, Alexandria, New South Wales, Australia Correspondence Vikneswary Batumalai, GenesisCare, Buildings 1 & 11, The Mill, 41-43 Bourke Road, Alexandria, NSW 2015, Australia. Email: v.batumalai@unsw.edu.auSearch for more papers by this authorJoseph Descallar, Joseph Descallar Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorGabriel Gabriel, Gabriel Gabriel Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorGeoff P. Delaney, Geoff P. Delaney Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, AustraliaSearch for more papers by this authorAndrew Oar, Andrew Oar Icon Cancer Centre, Gold Coast University Hospital, Gold Coast, AustraliaSearch for more papers by this authorMichael B. Barton, Michael B. Barton Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, AustraliaSearch for more papers by this authorShalini K. Vinod, Shalini K. Vinod Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, AustraliaSearch for more papers by this author Vikneswary Batumalai, Corresponding Author Vikneswary Batumalai v.batumalai@unsw.edu.au orcid.org/0000-0003-2021-2599 Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia GenesisCare, Alexandria, New South Wales, Australia Correspondence Vikneswary Batumalai, GenesisCare, Buildings 1 & 11, The Mill, 41-43 Bourke Road, Alexandria, NSW 2015, Australia. Email: v.batumalai@unsw.edu.auSearch for more papers by this authorJoseph Descallar, Joseph Descallar Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorGabriel Gabriel, Gabriel Gabriel Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorGeoff P. Delaney, Geoff P. Delaney Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, AustraliaSearch for more papers by this authorAndrew Oar, Andrew Oar Icon Cancer Centre, Gold Coast University Hospital, Gold Coast, AustraliaSearch for more papers by this authorMichael B. Barton, Michael B. Barton Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, AustraliaSearch for more papers by this authorShalini K. Vinod, Shalini K. Vinod Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, New South Wales, Australia Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, AustraliaSearch for more papers by this author First published: 27 October 2022 https://doi.org/10.1111/ajco.13891Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. 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INTRODUCTION:There is a lack of large population-based studies examining patterns of curative treatment for non-small cell lung cancer (NSCLC) in Australia. This study aimed to evaluate the utilization of curative treatment for NCSLC at a population level and identify factors associated with its use in New South Wales (NSW), Australia.METHODS:Patients diagnosed with localized or locoregional NSCLC between 2009 and 2014 were identified from the NSW Central Cancer Registry. Curative treatment was defined as surgery or radiotherapy with a 45 Gy minimum dose. Univariate and multivariable analyses were performed to investigate factors associated with the receipt of curative treatment. A Cox proportional-hazards regression model was used to analyze the factors associated with 2-year overall survival (OS).RESULTS:Of the 5722 patients diagnosed with NSCLC in the study period, 3355 (59%) patients received curative treatment and 2367 (41%) patients did not receive curative treatment. The receipt of curative treatment was significantly associated with younger patients, female gender, localized disease, and Charlson Comorbidity Index (CCI) = 0. The use of curative treatment increased significantly over time from 2009 (55%) to 2014 (63%) and varied significantly from 24% to 70% between local health districts (LHDs) of residence. Younger age, female gender, localized disease, CCI = 0, and overseas country of birth were significantly associated with 2-year OS. The 2-year OS significantly improved from 70% in 2009 to 77% in 2014 for patients who received curative treatment.CONCLUSION:The use of curative treatment for patients with potentially curable NSCLC was low at 59%. However, the use of curative treatment and survival have increased over time. Significant variation was noted in the use of curative treatment between LHDs.

INTRODUCTION:Trends in the use of short-course radiation therapy (RT) for rectal cancer in Australia are unknown. The purpose of this study was to compare short-course RT and long-course chemoradiation (CRT) utilisation in the neoadjuvant treatment of rectal cancer in New South Wales (NSW).METHODS:Patients who received neoadjuvant RT (2009-2014) for rectal cancer were identified from the NSW Central Cancer Registry. Univariate and multivariable analyses were performed to investigate factors associated with receipt of short-course RT.RESULTS:A total of 1196 (81%) patients received long-course CRT, and 274 (19%) patients received short-course RT. Receipt of short-course RT was associated with older age: 54% in patients ≥80 years, and 11% in patients <50 years (P < 0.0001). Patients with T2 disease (30%) were more likely to receive short-course RT, compared with T3 (19%) or T4 (8%) disease (P = 0.002). Patients with N0 (23%) disease were more likely to be treated with short-course RT, compared with N+ (16%) (P = 0.03). The proportion of short-course RT delivered to patients with Charlson Comorbidity Index (CCI) ≥ 2 (28%) was higher than patients with CCI = 0 (17%) (P = 0.002). There was wide variation in the proportion of short-course RT used across residence local health districts (5-29%) (P < 0.0001).CONCLUSION:In rectal cancer patients treated with neoadjuvant RT in NSW, 19% received short-course RT. The use of short-course RT was associated with older age, comorbidities and less advanced disease. Wide variation across NSW was identified and future research investigating factors for the variation will be useful.

BACKGROUND AND PURPOSE:Large non-age-specific radiotherapy utilisation rate (RTU) studies have demonstrated that actual RTU is below the optimal recommended utilisation rate for both curative and palliative intent radiotherapy indications. The optimal utilisation rate for the geriatric oncology cohort of patients has not yet been determined. The purpose of this research was to examine the actual RTU for patients treated in New South Wales (NSW), Australia as a function of increasing age, and the relationship between RTU and tumour site, travelling distance and socio-economic status. MATERIALS & METHODS:NSW Central Cancer Registry data (2009-2011) were linked to the NSW Radiotherapy Dataset (2009-2012). RTU was calculated for patients aged <80 years and ≥80 years. RTU was defined as the proportion of patients receiving at least a single course of radiotherapy within 12 months of a cancer diagnosis. RESULTS:110,645 patients were diagnosed with cancer, of whom 27,721 received at least one course of radiotherapy. The overall RTU was 25%. RTU for patients aged <80 years was 28% compared to 14% for patients aged 80+ years (p < 0.001). On both univariate and multivariate analysis, increasing age, residential address in disadvantaged socioeconomic areas and increasing distance to the nearest radiotherapy department were associated with a reduction in RTU. CONCLUSION:Geriatric oncology patients are less likely to receive radiotherapy than their younger counterparts. Some of the reduction in RTU may be justifiable on the basis of limited life expectancy and co-morbidity. Further research is required to determine the co-morbidity adjusted optimal RTU in older patients.

Background and purpose: Substantial variation in the adoption of hypofractionation for breast radiation therapy has been observed, despite the availability of consensus guidelines. This study aimed to investigate the variation in radiation therapy fractionation in breast cancer patients in New South Wales (NSW), Australia, and to estimate survival outcome and cost implications. Materials and methods: This is a population-based cohort of patients who received radiation therapy for breast cancer (2009-2013), as captured in the NSW Central Cancer Registry. A logistic regression model was used to identify factors associated with fractionation type. Survival outcome was estimated using multivariable Cox proportional hazards model. Cost per treatment and potential cost saving associated with evidence-based fractionation was estimated. Results: A total of 10,482 patients were available for analysis, divided into 3 cohorts (breast alone: N = 7000; breast + nodes: N = 1119; all chestwall: N = 2363). In multivariable analysis, increasing age, laterality (right), year of treatment (2013), early stage, lower socioeconomic status, and regional area of residence were independent predictors of hypofractionation for breast alone radiation therapy. For the breast + nodes and chest wall cohorts, common factors that predicted the use of hypofractionation were increasing age. In multivariable survival analysis, there was no difference between the fractionation regimens at 5 years. Estimated radiation therapy cost of this cohort approximated $52.1 million, compared with $38.5 million had these patients been treated with evidence-based fractionation. This demonstrated a potential saving of $13.6 million. Conclusion: Hypofractionation appears underused for breast radiation therapy in NSW over time. This study highlights that evidence-based practice will translate to reduced health care treatment costs. Crown Copyright (C) 2020 Published by Elsevier B.V. All rights reserved.

Background and purposeThis study aimed to identify the actual radiotherapy utilisation rate (A-RUR) in New South Wales (NSW) Australia for 2009–2011 and compare that to the published evidence-based optimal radiotherapy utilisation rate (O-RUR) and to previously reported A-RUR in NSW in 2004–2006. It also aimed to estimate the effect of underutilisation on 5-year local control (LC) and overall survival (OS) and identify factors that predict for underutilisation.Materials and methodsAll cases of registered cancer diagnosed in NSW between 2009 and 2011 were identified from the NSW Central Cancer Registry and linked with data from all radiotherapy departments. The A-RUR was calculated and compared with O-RURs for all cancers. The difference for each indication was used to estimate 5-year OS and LC shortfall. Univariate and multivariate analyses were performed to identify factors that correlated with reduced radiotherapy utilisation.Results110,645 cancer cases were identified. 25% received radiotherapy within one year of diagnosis compared to an estimated optimal rate of 45%. This has marginally improved from previously reported rate of 22% in NSW in 2004–2006. We estimated that 5-year OS and LC were compromised in 1162 and 5062 patients respectively. Factors that predicted for underuse of radiotherapy were older age, male gender, lower socioeconomic status, increasing distance to nearest radiotherapy centre and localised disease.ConclusionThe identified deficit in radiotherapy use has a significant negative impact on patient outcomes. Strategies to overcome such shortfalls need to be developed to improve radiotherapy use and patient outcomes.

Background and purpose Escalating health care costs have led to greater efforts directed at measuring the cost and benefits of medical treatments. The aim of this study was to estimate the costs of 5-year local control and overall survival benefits of radiotherapy for the cancer population in Australia. Materials and Methods The local control and overall survival benefits of radiotherapy at 5-years and optimal number of fractions per course have been estimated for 26 tumour sites for which radiotherapy is indicated. For this study, a hybrid approach that merges features from activity based costing (ABC) and relative value units costing (RVU) were used to provide cost estimates. ABC methodology was used to allocate costs to all radiotherapy activities associated with each patient's treatment course, while the RVUs represent the cost of each radiotherapy activity relative to the average cost of all activities and were used to achieve a weighted cost allocation. A patient's journey for the financial year was constructed by consolidating all the radiotherapy activities and their associated costs, and the average cost per activity (fraction) was determined. The cost of radiotherapy per 5-year overall survival and local control was then estimated. Results The estimated population 5-year local control and overall survival benefits of radiotherapy for all cancer were 23% and 6%, respectively. The optimal number of fractions per treatment course if guidelines were followed was 19.4 fractions. The average cost per fraction for all cancer was AU$276. The estimated cost of radiotherapy was AU$23,585 per 5-year local control and AU$86,480 per 5-year overall survival (equivalent to 5 life years) for all cancer. Conclusion The cost of AU$86,480 per 5-year overall survival would translate to AU$17,296 1-year overall survival. Therefore, the cost of radiotherapy is inexpensive if delivered optimally. Policy implications from this study include knowledge about cost to deliver radiotherapy to allow one to quantify the expected benefit at a population level.

BACKGROUND AND PURPOSE:Despite evidence of the benefits of radiotherapy (RT) in the treatment of cancer patients, its underutilisation has been reported for various tumour sites. The aim of this study was to estimate survival shortfall, 'years of potential life lost' (YPLL) and 'disability-adjusted life years lost' (DALY) to demonstrate the impact of radiotherapy underutilisation in Australia. MATERIALS AND METHODS:Optimal and actual RT utilisation (RTU) was compared to assess RT underutilisation to estimate 5-year overall survival shortfall using 2006 data from New South Wales (NSW) for 26 common tumour sites. 5-year overall survival shortfall is defined as number of people not surviving for 5-years due to RT underutilisation [=benefit proportion × shortfall [(optimal-actual RTU)/optimal RTU] proportion × No. of new cases]. YPLL = survival shortfall × estimated years of life lost per person (overall life expectancy - median age at death for specific cancer). DALY = (Years lived with disability + Years of life lost) × survival shortfall. RESULTS:The total number of new cases with cancer in 2006 in NSW was 20,741. Optimal RTU was 48% while actual RTU was 26%, resulting in estimated of 411 deaths due to underutilisation. Each death resulted in an average of 10.4 YPLL and 17.5 DALY. It was estimated RT underutilisation resulted in a total of 4,289 YPLL and 7,192 DALY overall. CONCLUSION:This study illustrates the value of considering different mortality statistics, which include measures of the burden of cancer deaths on both the population and patients.

Chemotherapy is underutilised in patients over the age of 70 and good arguments exist to support active treatment in this group. We examined patient and disease factors in colorectal cancer patients aged <70 years and 75 years or older that might influence treatment choices independently of age. The data were obtained from LANTIS, the electronic medical record system used at Liverpool and Campbelltown Hospitals. Variables collected included patient demographics and treatment-related factors. It was hypothesised that the difference in utilisation between older and younger patients could be ascribed to confounding factors being more common in the older population. There were 445 patients with colorectal cancer in the years 2005 and 2006. Of these, 267 (60%) were under 70 years of age, 278 (63%) were males and 308 (69%) were married. Two hundred and ninety four patients (66%) had colon cancer, 137 (31%) had rectal cancer and 14 (3%) had rectosigmoid cancer. Three hundred patients received chemotherapy, whereas out of the 137 (31%) who did not, 83 (61%) were in the older age group (75 years or older). Data were missing for eight patients. There was a trend for elderly patients to receive less chemotherapy as compared to the younger cohort. Multivariate regression analyses showed no statistically significant differences for gender, ECOG performance status, socioeconomic status or site of disease. Age was the strongest discriminating factor in chemotherapy decisions of older patients with colorectal cancer. (author abstract)

Background and purpose: Despite evidence for the efficacy of radiotherapy in stages II and III rectal cancer, utilization rates remain low. The aim of this study is to examine patient, provider and service factors affecting utilization of radiotherapy in rectal cancer patients.Materials and methods: Patients with a diagnosis of curable rectal cancer were identified from the colorectal tumor databases of three Sydney Area Health Services between 1994 and 2001. Data were collected on tumor characteristics such as site and stage, provider factors such as type of surgery and surgeon caseload, and patient factors including socioeconomic status and access to radiotherapy.Results: Thirty-five percent of stage II and 57% of stage III rectal cancer patients received radiotherapy. Independent determinants of utilization were age less than 70 years (odds ratio, 2.96; 95% confidence interval, 1.75-5.03), high-volume surgeons (OR, 1.95; 95% CI, 1.17-3.24), stage III disease (OR, 2.06; 95% CI, 1.25-3.41) and abdominoperineal resections (OR, 3.67; 95% CI, 1.94-6.94).Conclusion: Radiotherapy utilization rates remain low. Age, and being referred to a surgeon with a high caseload, has a greater impact on radiotherapy utilization than other provider, socioeconomic or service factors.