The changing cancer care landscape, the need for “quality benchmarks” and the role of the Clinical Oncology Society of Australia (COSA) by Sandro V Porceddu, Immediate past-President of COSA.
By 2020, 150,000 new cancer cases (excluding skin cancer) will be diagnosed each year in Australia.
Australia has one of the highest cancer survival rates in the world. In the 1980’s the 5-year cancer survival rate was around 40%.This rate has improved to be in excess of 60%.
While early detection through screening has played a major role, other factors such as better diagnostic imaging and treatments have obviously contributed. Underpinning this has been the acknowledgement of the importance of multidisciplinary care, which promotes evidence-based care and enrolment onto clinical trials. For over 40 years the Clinical Oncology Society of Australia (COSA) has championed this movement and continues to do so.
However this survival improvement has not been universal, with those from lower socioeconomic (SEG) groups, rural and remote regions and indigenous communities having inferior outcomes compared with those from urban areas and higher SEGs. There has also been an inequity of access to cancer care for patients from rural and remote regions. Groups such as COSA, the Cancer Councils and Cancer Australia have successfully promoted and lobbied for better access to cancer care through the development of regional cancer centres throughout Australia.
The community’s expectations are, however, that the quality of treatment received in these new regional centres are equivalent to that received by their city-folk counterparts, and rightly so. In addition, over the past 5 years we have also seen an increase in the number of smaller and single radiation therapy units, not necessarily attached to large tertiary institutions. One of the issues it highlights however relates to concerns about the quality of care for less common or complex cases, such as head and neck cancer and sarcomas, where resources and expertise may be limited in these centres.
Further, it raises the concept of what is “quality cancer care”, how do we measure it and what are the benchmarks that should be set to provide the community the confidence that the treatments they are receiving are of the highest quality. This issue is obviously not just limited to regional and smaller centres.
Over the next decade determining the benchmarks for quality cancer care is going to be one of our greatest challenges. Currently “low hanging” surrogates of quality such as waiting times, enrolment onto clinical trials and throughputs, are important measures, but how well do these actually measure quality treatment. Measure of complication rates is important but may be misleading as this can reflect the selection of cases being treated.
Emerging, is the appreciation of outcomes as a function of volume of cases treated. Surgical data has demonstrated improved outcomes relating to volume.
This issue has only begun to be recognised in my specialty of radiation oncology. With the development of highly conformal radiation therapy, such as intensity-modulated radiation therapy, which delivers a high dose to the target area and lower doses to normal structures, its effective delivery is highly dependent on the level of expertise of the treating radiation oncologists, radiation therapy planning staff and the nursing and allied health team supporting these patients.
In a pivotal study conducted by the Trans Tasman Radiation Oncology Group (TROG) known as the HeadSTART study, the quality of the radiation therapy planning had a significant impact on survival1. The study was designed to demonstrate whether the hypoxic cytotoxin, tirapazamine, improved outcomes when added to standard chemoradiotherapy in advanced head and neck cancer. The study was powered to demonstrate a 20% benefit in survival with the addition of tirapazamine. The study did not show a benefit with the addition of the drug. However, in this study radiotherapy plans were evaluated against the protocol in real-time allowing for adjustments if the plan did not comply with the study protocol. Where the RT planning was non-compliant and not altered during treatment, a 20% detriment in survival was observed, equivalent to what was the anticipated expected benefit from the drug.
In a recent publication by Wuthrick and colleagues in the Journal of Clinical Oncology (2015) the impact of institutional experience on overall survival in patients with advanced head and neck cancer was investigated within a randomised trial of the Radiation Therapy Oncology Group (RTOG 0129), which compared cisplatin concurrent with standard versus accelerated fractionation radiotherapy2. As a surrogate for experience, institutions were classified as historically low- (HLACs) or high-accruing centers (HHACs) based on accrual to 21 RTOG head and neck trials (1997 to 2002). They observed significantly worse overall survival and progression free survival among patients with head and neck cancer treated at institutions with historically low- as compared with historically high-volume accrual to RTOG trials. Risk of death or progression was 90% greater for patients at HLACs. There were also higher locoregional recurrence rates at HLACs compared with HHACs. Deviations from protocol therapy were more common at HLACs than HHACs and independently increased risk of death. However, the survival difference was not entirely explained by the deviation from treatment protocol. These findings suggested that experienced providers were more likely to deliver superior treatment plans and better patient support throughout treatment.
While it is a monumental undertaking, an organisation such as COSA, is well placed to begin to promote the importance of assessment of quality care through its various groups and broad cancer-related health professionals representation. This topic is not new, and attempts are being made to address it. However, COSA and other cancer-related organisations in Australia now need to begin this important discussion within the broader cancer community to ensure a collaborative and universal approach amongst disciplines.
1. Leters LJ, O’Sullivan B, Giralt J, et al: Critical impact of radiotherapy protocol compliance and quality in the treatment of advanced head and neck cancer: Results from TROG 02.02. J Clin Oncol 28:2996-3001, 2010
2. Wuthrick EJ, Zhang Q, Machtay M, et al: Institutional clinical trial accrual volume and survival of patients with head and neck cancer. J Clin Oncol doi: 10.1200/JCO.2014.56.5218[hr]