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Objectives Industry-supported decision impact studies demonstrate that Oncotype Dx (ODX) changes treatment recommendations (TR) in 24-40% of hormone receptor+/HER2- patients. ODX is not reimbursed by third-party payers in Australia, potentially resulting in more selective use. We sought to evaluate the impact of self-funded ODX on TRs. Methods Data collected included demographics, tumor characteristics, indication for ODX and pre- and post-recurrence score (RS) TR. Primary endpoint was frequency of TR change and associations with TR change were sought. Results Eighteen physicians contributed 382 patients (median age 54). A total of 232 (61%) of tumors were T1 and were grade 1, 2 and 3 in 49 (13%), 252 (66%) and 79 (21%). A total of 257 (67%) were node negative. Assay indications were: confirm need for chemotherapy (CT) (36%), confirm omission of CT (40%) and genuine equipoise (24%). RS was low (≤17) in 55%, intermediate (18-31) in 36% and high (≥32) in 9%. Thirty-eight percent of patients had TR change post-ODX. Sixty-five percent of patients recommended CT pre-ODX changed to hormone therapy alone (HT)-more likely if lower grade and if ER and/or PR > 10%. Fourteen percent of patients with pre-ODX TR for HT added CT-more likely if ER and/or PR ≤10% and if Ki67 > 15% Overall, TR for CT decreased from 47% to 24%. Conclusion Patient-funded ODX changed TRs in 38% of patients, de-escalating 65% from CT to HT and adding CT to 14% of those recommended HT. These changes were greater than an industry-funded study suggesting that physicians can identify situations where the assay may influence decisions.

Background Octogenarians represent a growing population reviewed in medical oncology clinics, yet there is a paucity of data on how chemotherapy is tolerated in this age group. Aim To describe the use of palliative first-line chemotherapy in patients 80 years and over and factors associated with its use. Methods We identified all new patients aged 80 years or older diagnosed with incurable advanced solid organ cancer and seen in one of three Sydney medical oncology outpatient clinics between January 2009 and December 2013. Patient, disease and treatment details were summarised and factors associated with chemotherapy use explored. Results Of 420 eligible patients, 100 (24%) started first-line chemotherapy. Younger age at diagnosis was the only factor associated with receiving chemotherapy (median 82.9 vs 84.1 years, P = 0.002). A total of 78% of patients had single-agent chemotherapy, and 41% received a full dose for the first cycle. During treatment, 54% experienced toxicity, necessitating dose reduction, delay or omission, and 32% were hospitalised. These events were associated with receipt of combination chemotherapy (OR 5.1; P = 0.04) and full-dose chemotherapy for cycle 1 (OR 3.5; P = 0.02). Radiological disease control was achieved in 60%. Chemotherapy was stopped because of progressive disease (48%), toxicity (37%) or completion of planned course (17%). Conclusion A quarter of patients 80 years and older received first-line palliative chemotherapy. Despite most receiving a modified dose, one third were hospitalised during treatment. These findings highlight the need for careful clinical assessment and selection of older cancer patients for chemotherapy.

Background Shared understanding of prognosis is vital for optimal, multidisciplinary, clinical decision making. Aims This study aims to determine the frequency and nature of prognostic information in medical oncologists’ letters to referring doctors for patients with metastatic cancer. Methods We reviewed all consultation letters (to June 2014) for new patients with metastatic cancer presenting to medical oncologists at Concord and Macarthur Cancer Centres between June 2012 and June 2013. We recorded the presence and nature of prognostic information in the letters, patients’ characteristics and survival. Characteristics associated with inclusion of prognostic information were explored. Results We analysed 1344 letters pertaining to 272 patients with a median survival of 13 months. The median number of letters per patient was 4 (interquartile range 1–7), with 50% written by trainees. The terms ‘metastatic’ or ‘stage IV cancer’ were included in letters for 253 patients (93%), treatment was described as ‘palliative’ for 174 patients (64%) and the word ‘incurable’ was included for 93 (34%). Only 31 patients (11%) had a quantitative estimate of prognosis in any correspondence: median or average survival in 14, general time frame in 12 and, best case, typical and worst case scenarios in 5. Inclusion of quantitative prognostic information was not associated with patient age, cancer type, treatment plan, trainee authoring letter or shorter survival. Conclusion Inclusion of quantitative prognostic information in written correspondence from medical oncologists regarding patients with metastatic cancer was infrequent. Encouraging oncologists to include quantitative prognostic information in their letters could improve communication between oncologists, referring doctors and patients.

Aim In early stage breast cancer chemotherapy relative dose intensity (RDI) of

Background Survival times of women starting first-line chemotherapy for metastatic breast cancer (MBC) in routine clinical practice were determined and compared with those from a systematic review of randomised clinical trials. Methods We identified women with MBC starting first-line chemotherapy from June 2003 to February 2011 and recorded their demographics, tumour and treatment characteristics, and survival times from the start of chemotherapy. Their survival distribution was summarised by the following percentiles (represented scenarios for survival): 90th (worst-case), 75th (lower-typical), 25th (upper-typical) and 10th (best-case), which were compared with the same percentiles from our systematic review of first-line chemotherapy trials. Results The 273 women had a median age of 56 years, and a median time from diagnosis of MBC of 3 months. Eastern Cooperative Oncology Group performance status was 0–1 in 80%. Tumours were hormone receptor positive in 69%, human epidermal growth factor receptor 2 (HER2)-positive in 27% and triple negative in 13%. Survival times in months in routine clinical practice (vs the systematic review) were: 90th percentile 4 (6); 75th percentile 9 (12); median 20 (22); 25th percentile 36 (36) and 10th percentile 61 (56). Independent predictors of overall survival included HER2-positive disease (hazard ratio (HR) 0.49, P = 0.0002), hormone receptor positive disease (HR 0.51, P = 0.0004), Eastern Cooperative Oncology Group performance status 0–1 (HR 0.36, P < 0.0001) and adjuvant chemotherapy (HR 1.86, P = 0.0002). Conclusion Median and better survival times in routine practice were similar to those from randomised clinical trials; however, survival times worse than the median were shorter, likely reflecting patient selection in trials. Oncologists should adjust trial-based survival estimates for patients not meeting typical trial eligibility criteria.

Background: Delays in commencing adjuvant chemotherapy for early breast cancer beyond 12 weeks are associated with increased mortality. The aim of this study was to identify factors delaying chemotherapy in an inner metropolitan, outer metropolitan, small rural and large rural cancer centre in New South Wales, Australia.Methods: We retrospectively reviewed 400 consecutive patients that received adjuvant chemotherapy for stages I-III breast cancer. We evaluated factors affecting time from primary and definitive surgery until commencing chemotherapy.Results: The primary factor associated with chemotherapy delays was the geographic location of the cancer centre. The median time from primary surgery to chemotherapy was longer for the large rural centre (median 58 days), compared with the outer metropolitan (45 days), small rural (39 days) and inner metropolitan centre (33 days). Treatment delays in the large rural centre were associated with higher rates of multiple operations (43% versus 31% elsewhere), mainly because of more staged axillary dissections (34% versus 19%), and longer time from definitive surgery to oncology assessment.Conclusion: Patients in the large rural centre, who are served by fly-in medical oncology services, are more likely to experience delays in receiving adjuvant chemotherapy for early breast cancer. Strategies to reduce delays include use of intraoperative frozen section analysis, multidisciplinary meetings, improving efficiency in pathology reporting and employment of a breast cancer care coordinator and an on-site medical oncologist.

Summary The purpose of the present paper was to review the outcomes of care of small cell lung cancer (SCLC) at one Sydney teaching hospital. A retrospective cohort study was carried out of patients with SCLC seen between January 1996 and July 2000. The main outcomes were relapse-free and overall survival. Secondary outcomes of interest were the uniformity of staging investigations, initial treatment, use of prophylactic cranial irradiation (PCI), patterns of relapse and treatment received following relapse. One hundred and three patients with SCLC were treated at the Liverpool Hospital Cancer Therapy Centre during this period. There were 58 men (56%) and 45 women (44%). Forty-two patients (41%) had limited stage disease (LD) and 61 (59%) had extensive stage disease (ED). There was considerable variation in staging investigations. There was little variation in systemic treatment of SCLC. Only 32 of 42 patients with limited stage SCLC were candidates for thoracic radiotherapy and only seven patients received PCI. Median relapse-free survival was 11.2 months (95% confidence interval (CI): 7.7−14.8) for patients with LD and 6 months (95%CI: 4.4−7.5) for ED. Median overall survival was 15.1 months (95%CI: 11−19.1) for patients with LD and 8.9 months (95%CI: 7.5−10.2) for ED. Some health outcomes similar to that reported in clinical trials can be achieved in clinical practice. Measuring health outcomes is an important process of maintaining quality of care.

The syndrome of adenocarcinoma of unknown primary (ACUP) is a frequent problem in both medical and surgical practice. The prognosis is poor, the median lifespan being 4 months. In general, multiple invasive procedures aimed at determining the primary tumour are not warranted due to the low frequency of detecting a tumour for which adequate treatment exists. In this paper we wish to highlight a subset of female patients presenting with malignant ascites and no evidence of a pelvic mass, who on laparotomy were found to have primary peritoneal papillary serous adenocarcinoma. These tumours must be regarded as a potentially treatable subset of patients with ACUP in view of their frequent response to chemotherapy and relatively good prognosis.