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Purpose: To compare the risk for fatal myocardial infarction (MI) after adjuvant radiotherapy (RT) for left-sided breast cancer with the risk for MI after adjuvant RT for right-sided breast cancer., Methods: We studied women with local- and regional-stage breast cancer diagnosed from 1973 to 1992 from the Surveillance, Epidemiology, and End-Results (SEER) cancer registries. We performed life-table analysis, the log-rank test, and Cox proportional hazards regression to compare the time to fatal MI from diagnosis between left-sided and right-sided cases, censoring deaths from other causes., Results: Among irradiated patients, the relative risk (RR) for fatal MI in women with left-sided breast cancer was 1.17 (95% confidence interval [CI], 1.01 to 1.36), controlling for age, compared with those with right-sided breast cancer. The RR for fatal MI among left-sided cases was increased for those under the age of 60 years (RR = 1.98; 95% CI, 1.31 to 2.97) compared with right-sided cases, but not at age 60 years or older. Among women with irradiated regional-stage cancer who were younger than 60 years of age, the risk was significantly increased (RR = 2.24; 95% CI, 1.38 to 3.64) for those with left-sided compared with right-sided breast cancer, but not among patients aged 60 years or older. Among irradiated local-stage cases, the risk for those with left-sided breast cancer was not significantly elevated in either age category. Analysis of 5-year conditional survival cohorts showed an increased risk for irradiated left-sided cases among women younger than 60 years of age in the 10- to 15-year conditional survival cohort (RR = 5.28; 95% CI, 1.82 to 15.3)., Conclusion: Adjuvant RT for left-sided breast cancer diagnosed in women younger than 60 years of age is associated with a higher risk for fatal MI 10 to 15 years later compared with adjuvant RT for right-sided cases.

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.

Guideline Question: Should preoperative (neoadjuvant) cisplatin-based chemotherapy with or without postoperative radiotherapy be offered to patients with technically resectable stage IIIA non-small-cell lung cancer (NSCLC) to improve survival? (Resectability should be determined preoperatively by a thoracic surgeon.), Objective: To make recommendations about the use of preoperative cisplatin-based chemotherapy with or without postoperative radiotherapy in technically resectable stage IIIA NSCLC., Outcomes: Survival is the primary outcome of interest. PERSPECTIVES (VALUES): Evidence was collected and reviewed by 4 members of the Lung Cancer Disease Site Group (LCDSG) of the Cancer Care Ontario Practice Guidelines Initiative. The evidence was then presented to the full LCDSG and discussed extensively at 5 of its meetings. The LCDSG comprises medical and radiation oncologists, pathologists, surgeons, epidemiologists, a psychologist and a medical sociologist. A community representative was present at one meeting during which the recommendation was discussed., Quality of Evidence: Four small randomized controlled trials (RCTs) were available for review; 2 were completed and were reported in full in the literature, 1 was published in abstract form, and 1 was closed and was reported as an interim analysis. Although the RCTs used appropriate clinical trials methodology, including planned interim analyses and early stopping rules, retrospective review revealed inconsistencies between the treatment arms for subsets of stage IIIA disease and for prognostic factors. These factors and the small samples in each study limit the interpretation of the results., Benefits: The data from 2 of the 4 trials were not combined because the data were not mature in one case and not extractable in the other. The 2 fully published, completed trials reported a survival benefit for patients treated with preoperative chemotherapy with or without postoperative radiotherapy compared with those not given preoperative chemotherapy. One trial reported a median survival of 26 months in the treatment group versus 8 months in the control group (p < 0.001). A second trial reported an estimated median survival of 64 months versus 11 months (p < 0.008) and a 3-year survival rate of 56% versus 15% respectively. A pooled analysis of the 2-year survival data from the 2 completed RCTs yielded an odds ratio for death of 0.18 (95% confidence interval 0.06 to 0.51) in favour of preoperative chemotherapy., Harms: There was no difference in the postoperative mortality between the trials reviewed. Toxic effects associated with the chemotherapy were limited primarily to neutropenic fever, nausea and vomiting.

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.

Purpose: In the Canadian province of Ontario, all radiotherapy is provided by a centrally managed provincial network of nine cancer centers. The primary goal of this study was to determine whether this highly centralized radiotherapy system provides adequate and equitable access to care for the province's dispersed population., Methods: The Ontario Cancer Registry (OCR) was used to identify 295,386 cases of invasive cancer, excluding nonmelanoma skin cancer, which were diagnosed in Ontario between 1984 and 1991. Electronic radiotherapy records from each of the province's radiotherapy centers were linked to the registry at the level of the individual case., Results: The proportion of incident cases treated with radiotherapy was 18.8% at 4 months after diagnosis, 23.7% at 1 year, 25.8% at 2 years, 28.2% at 5 years, and 29.1% at 8 years. These rates of radiotherapy use are much lower than the accepted national and international targets, and lower than rates reported from other jurisdictions. The rate of radiotherapy use at 1 year varied significantly from county to county across Ontario (range, 18.6% to 32.4%; P < 10(-6)), and the highest rates were recorded in communities close to radiotherapy centers. There was a common geographic pattern of rate variations among several disease groups, including breast cancer, lung cancer, the genitourinary malignancies, and the gastrointestinal malignancies., Conclusion: The low and uneven rates of radiotherapy use across the province indicate that Ontario's centralized radiotherapy system does not, at present, provide adequate or equitable access to care.

Brain metastases (BRM) are common complications of malignancy, frequently associated with disability and death. Clinical trials have addressed a few of the issues arising from treatment options for BRM. Phase III trials have shown superior survival for patients with solitary resectable BRM (SRBRM) when palliative radiation treatment (RT) to the brain is preceded by resection compared to brain RT alone, but no trial has explored resection plus brain RT compared to resection alone. One Phase III trial in patients with solitary unresected BRM comparing lower to higher doses of RT has shown a small survival advantage with higher-dose radiotherapy. All other trials, however, comparing different radiation doses and fractionation schedules have failed to indicate improved outcomes from treatment more intense than 2000 cGy in 5 fractions over 1 week (in any subset of patients with unresected BRM). A panel of radiation oncologists and medical oncologists discussed a literature review and results of Phase III trials of therapy for BRM. The panel was instructed to identify from these trials any evidence for the efficacy, indications, toxicity and fractionation of palliative RT for BRM. The panel concluded that unresected BRM is a possible indication for brain RT. The panel concluded that the benefits and toxicities of brain RT for unresected BRM are not characterized adequately to allow a stronger recommendation. The panel concluded that there is no evidence for superiority for any dose or schedule of brain RT for BRM more protracted or intense than 2000 cGy in 5 fractions over one week. The panel recommended further study in order to characterize the benefits and toxicities of brain RT for unresectable BRM. The panel considered the potential value of conducting a Phase III trial comparing palliative care and strategies that included brain RT to the same strategies excluding brain RT; the panel did not, however, reach consensus on the feasibility of such a trial.

Prospectively gathered information in the Ontario Cancer Foundation's computerized clinical database was analysed to provide a description of the management of 12,399 patients with unresected non-small cell lung cancer (NSCLC) registered at seven regional cancer centres in Ontario between 1982 and 1991. Overall, 44% received initial thoracic radiotherapy, 19% received initial radiotherapy to metastatic sites, and 36% received no immediate radiotherapy. Of those who received thoracic radiation 41% received doses > or = 40 Gy and 59% received doses < 40 Gy. Among the seven centres, the proportion of patients receiving initial thoracic radiotherapy ranged from 41% to 56% (p < 0.001), and the proportion of those receiving doses > or = 40 Gy ranged from 30% to 68% (p < 0.001). Between 1982 and 1991, the overall proportion of patients who received initial thoracic radiotherapy decreased from 48% to 38%, the proportion of those receiving high dose treatment decreased from 55% to 28%, and the mean number of fractions given to the chest decreased from 17 to 10. Only 10% received chemotherapy at any time, and that proportion ranged from 3% to 21% (p < 0.001) among the seven centres. Between 1982 and 1991 the proportion of patients receiving chemotherapy decreased significantly from 15% to 8% (p < 0.001) across the Cancer Foundation as a whole. These wide variations in management policies were not associated with any significant differences in survival, which was similar at all seven centres, and remained constant between 1982 and 1991.