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INTRODUCTION: Randomized controlled trials (rcts) are the "gold standard" for establishing treatment efficacy; however, efficacy does not automatically translate to a comparable level of effectiveness in routine practice. Our objectives were to □ describe outcomes of palliative platinum-doublet chemotherapy (ppdc) in non-small-cell lung cancer (nsclc) in routine practice, in terms of survival and well-being; and□ compare the effectiveness of ppdc in routine practice with its efficacy in rcts. METHODS: Electronic treatment records were linked to the Ontario Cancer Registry to identify patients who underwent ppdc for nsclc at Ontario's regional cancer centres between April 2008 and December 2011. At each visit to the cancer centre, a patient's symptoms are recorded using the Edmonton Symptom Assessment System (esas). Score on the esas "well-being" item was used here as a proxy for quality of life (qol). Survival in the cohort was compared with survival in rcts, adjusting for differences in case mix. Changes in the esas score were measured 2 months after treatment start. The proportion of patients having improved or stable well-being was compared with the proportion having improved or stable qol in relevant rcts. RESULTS: We identified 906 patients with pre-ppdcesas records. Median survival was 31 weeks compared with 28-48 weeks in rcts. After accounting for deaths and cases lost to follow-up, we estimated that, at 2 months, 62% of the cohort had improved or stable well-being compared with 55%-63% who had improved or stable qol in rcts. CONCLUSIONS: The effectiveness of ppdc for nsclc in routine practice in Ontario is consistent with its efficacy in rcts, both in terms of survival and improvement in well-being.

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AIMS: To describe the use of adjuvant radiotherapy for endometrial cancer in Ontario, and identify factors associated with its use, and to determine whether variation in the use of radiation is associated with differences in survival. MATERIALS AND METHODS: This was a retrospective, population-based, cohort study of all patients who had a hysterectomy for endometrial cancer in Ontario between 1992 and 2003. We used multiple logistic regression to identify health system-related factors associated with the use of radiotherapy, while controlling for disease- and patient-related factors. Survival and cancer cause-specific survival were compared among regions of the province with higher and lower rates of use of radiotherapy. RESULTS: The study population included a total of 9411 women with a median age of 63 years. Overall, 26.2% received adjuvant radiotherapy. Patients living further from regional cancer centres were slightly less likely to receive radiation (P = 0.02). Patients who had their surgery during longer prevailing waiting times for radiotherapy were less likely to receive radiation (P = 0.04). The use of radiotherapy varied widely from 18.0 to 34.3% among the catchment areas of provincial radiotherapy centres (P < 0.0001). In the overall population, there was no difference in survival among regions with higher and lower rates of use of radiotherapy. However, in the subgroup of cases with clear cell and serous carcinomas, both overall survival and cancer cause-specific survival were significantly lower in regions with lower rates of use of radiotherapy (P < 0.05). This difference remained significant after controlling for other factors (P < 0.05; hazard ratio 1.43; 95% confidence limits 1.06-1.93). CONCLUSIONS: Health system-related factors unrelated to patients' needs affect the use of adjuvant radiotherapy in Ontario. Lower rates of use of adjuvant radiotherapy are associated with lower rates of survival in patients with serous and clear cell carcinomas.

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AIMS: Determining the appropriate rate of radiotherapy is important for ensuring optimal radiotherapy utilisation and accessibility. A criterion-based benchmark (CBB) approach was developed as an alternative to evidence-based methods of determining the need for radiotherapy in prostate cancer. Our primary objective was to determine the initial/lifetime CBB radiotherapy rates in prostate cancer and to compare results with evidence-based estimates. Secondary objectives were to compare observed radiotherapy rates in Ontario, Canada and the USA with the estimated rates. MATERIALS AND METHODS: Benchmarks were defined in Ontario as communities in proximity to cancer centres and without long waiting lists. Surgical and radiotherapy data, encompassing both external beam radiation and brachytherapy, for 1997-2001 were collected for Ontario cancer patients. The Surveillance, Epidemiology and End Results (SEER) public use file described treatment in the USA. RESULTS: In total, 35 379 cases of prostate cancer were diagnosed in Ontario and 93 275 in SEER. CBB estimates of the initial/lifetime need for radiotherapy were 37.2% (95% confidence interval: 35.8-38.7) and 59.1% (54.3-63.9). Our group's evidence-based estimate (Ebest) rates were 32.3% (28.5-36.1) and 61.2% (55.6-66.8). Observed initial radiotherapy rates were 28.0% (27.5-28.4) in Ontario and 37.0% (36.7-37.3) in SEER. In Ontario, the estimated lifetime rate was 42.6% (41.2-44.0). CONCLUSIONS: CBB provides a reasonable estimate of the need for radiotherapy in prostate cancer. Observed initial radiotherapy rates in the USA were concordant with the CBB estimate. The CBB suggests a shortfall in radiotherapy utilisation for prostate cancer in Ontario.

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AIMS: Determining the appropriate rate of radiotherapy is important for ensuring optimal radiotherapy utilisation and accessibility. A criterion-based benchmark (CBB) was developed for estimating the need for radiotherapy in incident breast cancer cases. Our primary objective was to compare an evidence-based estimate (Ebest) of need against the CBB. These estimates were then compared with radiotherapy rates in Ontario, Canada and the USA. Surgical rates were also examined. MATERIALS AND METHODS: Benchmarks were defined in Ontario as communities in proximity to cancer centres and without long waiting lists. Patient data from 1997 to 2001 were prospectively collected from radiotherapy cancer centres. Surgical data were obtained from the Canadian Institute for Health Information database. The public use file of Surveillance, Epidemiology and End Results (SEER) described treatment in the USA. RESULTS: In total, 4241 cases of breast cancer were diagnosed in benchmark communities. The overall radiotherapy rate by Ebest was 64.0% (95% confidence interval: 58.1-69.8%) compared with the CBB of 60.7% (59.3-62.1%). In comparison, Ontario's overall radiotherapy rate was 55.6% (55.0-56.1%) and in SEER it was 49.3% (48.9-49.6%). Adjuvant radiotherapy rates after lumpectomy were 100% in Ebest and 83.6% (82.0-85.1%) by the CBB. The Ebest and CBB post-mastectomy rates were 21.9% (20.6-23.3%) and 34.6% (32.5-36.7%), respectively. Observed post-lumpectomy radiotherapy rates were 75.1% in Ontario and 65.3% in SEER. Post-mastectomy radiotherapy rates were 29.5% in Ontario and 17.0% in SEER. CONCLUSIONS: CBB provides a reasonable estimate of the overall need for radiotherapy in breast cancer. Observed radiotherapy rates in Ontario and the USA suggest an age-related decrease in the use of radiotherapy. The benchmark estimate suggests a shortfall of adjuvant breast radiotherapy utilisation in Ontario.

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AIM: To examine changes in radiotherapy (RT) use, cause-specific survival (CSS), and overall survival (OS) in a population-based cohort of Hodgkin's disease (HD) patients diagnosed from 1982 to 1996. MATERIALS AND METHODS: Adult patients with HD diagnosed from 1 January 1982 to 31 December 1996 (n = 3957) were identified from the Ontario Cancer Registry. The cohort was divided into three consecutive 5-year periods: 1982-1986, 1987-1991, and 1992-1996. RT use, CSS and OS in each of these three periods were compared. For the entire cohort, the cumulative incidence of different causes of death was calculated. RESULTS: The proportion of patients receiving RT within 11 weeks of diagnosis declined over the three consecutive periods (25.1%, 15.6%, 11.7%, P < 0.001), as did the proportion receiving RT within 45 weeks (57.0%, 51.0%, 48.1%; P < 0.001). There was a significant increase in 5-year CSS over time (81%, 87%, 89%; P < 0.001), and OS (72%, 77%, 82%; P < 0.001), which remained significant in multivariable analyses. The cumulative incidence of death from causes other than HD was equal to the incidence of HD-related death within 12 years of diagnosis. CONCLUSIONS: There was a significant decline in the use of RT as the primary treatment modality and as part of the initial management of HD from 1982-1996 in Ontario. A greater proportion of patients received their RT after a delay consistent with the receipt of prior chemotherapy. There was also a significant increase in the CSS and OS over this period. These findings are in keeping with the adoption of effective chemotherapy in the treatment of HD.

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PURPOSE: To describe hospital bed utilization in the final 6 months of life in patients dying of cancer in Ontario, Canada. PATIENTS AND METHODS: Hospital separation records were linked to a population-based cancer registry to identify factors associated with hospitalization in the 203,713 patients who died of cancer in Ontario between 1986 and 1998. RESULTS: Between 1986 and 1998, 5.3% of all acute care beds in Ontario were devoted to the care of cancer patients in the last 6 months of life. The mean time spent in hospital in the last 6 months of life decreased from 34.3 days in 1986 to 22.7 days in 1998. Hospitalization rates increased exponentially during the last month of life. Patients younger than 50 years of age, women, and residents of poorer communities spent significantly longer in hospital than others. Hospitalization rates differed very little among the common solid tumors, but patients with CNS malignancies, the lymphomas, and the leukemias spent significantly longer in hospital than the other groups. There was significant interregional variations in hospitalization that were not explained by differences in case mix. There was a statistically significant inverse correlation between the rate of use of palliative radiotherapy and the hospital bed use in the county in which the patient resided. CONCLUSION: The total time spent in hospital in the last 6 months of life has decreased over the last decade, but acute care hospitals continue to play a large role in the care of patients who are dying of cancer.

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BACKGROUND: Associations between socioeconomic status (SES) and the incidence of cancer have been reported previously in the U.S. Canada has more comprehensive health care and social programs than the U.S. The purpose of this study was to compare the strength of associations between SES and cancer incidence in Canada and the U.S. METHODS: The regions studied were the Canadian province of Ontario and the areas of the U.S. covered by the Surveillance, Epidemiology, and End Results (SEER) program. The populations at risk were defined using the 1991 Canadian Census and the 1990 U.S. Census. The populations of Ontario and of the SEER areas of the U.S. were each divided into deciles on the basis of median household income. Population-based cancer registries were used to identify incident cases. Age-standardized incidence rates for all major groups of malignant diseases were calculated for each SES decile in Ontario and in the U.S. Income-associated incidence gradients observed in Ontario and the U.S. were compared. RESULTS: The incidence of most types of cancer was similar in Ontario and the U.S. In both countries, there were moderately strong, inverse associations between income level and the incidence of carcinomas of the cervix, the head and neck region, the lung, and the gastrointestinal tract. In both Ontario and the U.S., several of these diseases were twice as common in the bottom income decile than they were in the top decile. In contrast, carcinoma of the female breast and carcinoma of the prostate were more common among higher income communities in both countries, but the observed associations were weaker in Ontario. CONCLUSIONS: Despite Canada's universal health insurance and more comprehensive social security system, the association between lower socioeconomic status and the incidence of many common cancers is just as strong in Ontario as it is in the U.S. The mechanisms responsible for these associations require further investigation.

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PURPOSE: The purpose of this study was to assess whether: (i) radiotherapy (RT) utilization varies with age in Ontario cancer patients; (ii) age-associated differences in the use of RT (if they exist) vary with cancer site and treatment intent; (iii) the age-associated variation in RT utilization is comparable to the decline in functional status in the general population; and (iv) the variation with age is due to differences in referral to a cancer center or to subsequent decisions. METHODS AND MATERIALS: Details for several cancer sites diagnosed between 1984-1994 were obtained from the Ontario Cancer Registry (OCR). RT records from all treatment centers were linked to the OCR database. Information about the functional status of the Canadian population was obtained from the 1994 National Population Health Survey conducted by Statistics Canada. RESULTS: The rate of RT use declined with age, particularly for adjuvant and palliative indications. The relative decline in RT with age exceeded the relative decline in functional status with age in the general population. Most of the decline in RT use was related to a decline in referral to cancer centers. CONCLUSIONS: The referral for, and use of, palliative and adjuvant RT decreases more with age than can be explained by age-associated decline in functional status observed in the general population.

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PURPOSE: The objectives of this study were as follows: (1) to compare the magnitude of the association between socioeconomic status (SES) and cancer survival in the Canadian province of Ontario with that in the United States (U.S.), and (2) to compare cancer survival in communities with similar SES in Ontario and in the U.S. METHODS: The Ontario Cancer Registry provided information about all cases of invasive cancer diagnosed in Ontario from 1987 to 1992, and the Surveillance, Epidemiology and End Results Registry (SEER) provided information about all cases diagnosed in the SEER regions of the U.S. during the same time period. Census data provided information about SES at the community level. The product-limit method was used to describe cause-specific survival. Cox proportional hazards models were used to describe the association between SES and the risk of death from cancer. RESULTS: There were significant associations between SES and survival for most cancer sites in both the U.S. and Ontario, but the magnitude of the association was usually larger in the U.S. In the poorest communities, there were significant survival advantages in favor of cancer patients in Ontario for many disease groups, including cancers of the lung, head and neck region, cervix, and uterus. However, in upper- and middle-income communities, there were significant survival advantages in favor of the U.S. for all cases combined and for several individual diseases, including cancers of the breast, colon and rectum, prostate, and bladder. CONCLUSION: The association between SES and cancer survival is weaker in Ontario than it is in the U.S. This is due to a combination of better survival among patients in the poorest communities and worse survival among patients in the wealthier communities of Ontario relative to those in the U.S.

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OBJECTIVE: To describe the variation in the use of radiotherapy (RT) in women in Ontario within 1 year of diagnosis of breast cancer, from 1982 to 1991, and to identify factors associated with these variations. DESIGN: Retrospective, population-based cohort study. SETTING: Ontario. POPULATION: All women registered by the Ontario Cancer Registry (OCR) with a diagnosis of invasive breast cancer between Jan. 1, 1982, and Dec. 31, 1991. INTERVENTIONS: RT to any anatomic site within 1 year of the diagnosis of breast cancer. OUTCOME MEASURES: Odds of receiving RT within 1 year of diagnosis (from RT files from all radiotherapy departments in Ontario) associated with year and with geographic, age-related and socioeconomic factors. RESULTS: Use of RT within 1 year of diagnosis increased from 21.1% (95% confidence interval [CI] 19.8-22.4) in 1982 to 44.7% (95% CI 43.4-46.0) in 1991 (p < 0.0001). Among the regions of Ontario, the use of RT varied from 24.5% (95% CI 23.5-25.6) to 44.4% (95% CI 43.0-45.9) (p < 0.0001). Increasing age was associated with decreasing likelihood of receiving RT (test for trend p < 0.0001), as was decreasing income (test for trend p < 0.0001). CONCLUSIONS: The use of RT within 1 year of the diagnosis of breast cancer in women in Ontario varies by region, age and income. Despite universal and comprehensive health insurance coverage, women with breast cancer in some populous regions of Ontario were less likely to receive RT within 1 year of their diagnosis than women in other populous regions.

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BACKGROUND AND PURPOSE: It is known that the socioeconomic status (SES) of the patient is associated with cancer survival in the United States. The purpose of this study was to determine whether the association between SES and survival is also present in Canada, a society with a comprehensive, universal, health insurance program. METHODS: A population-based cancer registry was used to identify the 357,530 cases of invasive cancer diagnosed in the Canadian province of Ontario between 1982 and 1991. Information from the 1986 Canadian census was linked to the registry and used to describe the SES of the area in which each patient resided. Cox regression was used to describe the association between median household income and survival while controlling for age, sex, and the region in which the patient resided. The Cox model was fitted in a competing risk framework to assess the association between income and the probability of specific causes of death. RESULTS: Lung cancer and cancers of the head and neck region were relatively more common in poor-income communities, and cancers of the breast, CNS, and testis were relatively more common in richer communities. A strong and statistically significant association between community income and survival was observed in cancers of the head and neck region, cervix, uterus, breast, prostate, bladder, and esophagus. Smaller, but significant associations were seen in cancers of the lung and rectum. No significant association between community income and survival was observed in cancers of the stomach, colon, pancreas, or ovary. Analysis of the cause of death showed that community income is associated both with the probability of death from cancer and with the probability of death from other causes. CONCLUSION: Although Canada's health care system was designed to provide equitable access to equivalent standards of care, it does not prevent a difference in cancer survival between rich and poor communities.

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