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Abstract: Aim: Superficial soft tissue sarcomas (S‐STS) are generally considered low‐risk tumors and have an excellent prognosis when treated with appropriate surgery and adjuvant therapy. However, they are often misdiagnosed then mistreated, leading to significant morbidity. This study aims to examine the patterns of care and outcomes of patients with S‐STS, comparing those initially managed through sarcoma units versus elsewhere. Methods: Patients with S‐STS from Prince of Wales Hospital in NSW (1995–2013) and Peter MacCallum Cancer Centre in Victoria (2009–2013) were identified from a national sarcoma database. Baseline variables, treatment and disease outcomes were recorded. Statistical tests performed included univariate and multivariate analyses, chi‐square tests, as well as the Kaplan–Meier method for 5‐year local recurrence and survival rates. Results: Eighty‐nine patients were identified, with 35% initially managed at a sarcoma unit and 65% elsewhere. Patients initially managed at sarcoma units had larger tumors (>5 cm 39% vs 17%; P  =  0.036) with a trend to higher grade (61% vs 48%; P = 0.39). Patients that were initially managed outside a sarcoma unit more often underwent open surgical biopsies (P < 0.0005), had multiple operations (P < 0.0005) and had higher rates of local recurrences (24% vs 6.5%, P  =  0.038). They also had lower 5‐year local recurrence‐free survival rates (P = 0.022), but had higher metastasis‐free survival (P = 0.014). On multivariate analysis, only larger STS size and male gender predicted for poorer metastasis‐free survival (P = 0.042 and 0.018, respectively). Conclusion: Patients with S‐STS initially managed outside specialized sarcoma units undergo more operations, with risk of greater morbidity, and have greater risk of local recurrence. [ABSTRACT FROM AUTHOR]

Purpose: The goal of the ESTRO Patterns of Care study for Brachytherapy in Europe (PCBE) 2002 was to develop an aid to analyse brachytherapy practices. A 2nd version of the PCB questionnaire was created for 2007. Data over 2007 were collected at the radiotherapy institutions in The Netherlands and compared with those from 2002. The aim of this study is to describe national brachytherapy practices, to demonstrate trends, and to provide data for rational health care planning.Material and methods: Data were collected using a web-based questionnaire. For each centre, a local coordinator, responsible for coordinating the questionnaires and support of the further analysis was assigned. Data from the national cancer incidence registry was used for comparison with the data from the 21 Dutch departments.Results: There was a decrease in low-dose rate equipment in parallel to an increase in both pulsed-dose rate and high-dose rate equipment. The use of 3D CT and MR based imaging techniques showed a slow rise. The most common clinical procedures were for prostate, gynaecological, and oesophageal tumours. A large increase (146%) in permanent implant prostate applications using 125I seeds was observed. The numbers of oesophageal and gynaecological treatmentsremained stable. There is concern on the low numbers of cases treated in some institutions for a few complex treatment sites. For head and neck, anal canal, paediatrics, bladder and eye interventions it ranged from 3-20 patients per year per institution.Conclusions: The increase in number of patient treated with brachytherapy is in accordance with the increases in cancer incidence. The percentage of all radiotherapy patients treated with brachytherapy (approximately 5%) remained stable. The survey identified certain trends in resources and techniques, as well as areas of expected improvement and possible gain in clinical outcome. Data reported from this survey can be used for further planning of resources, facilities and concentration of a low-volume specialised and complex treatments.

Background: There is a paucity of data on the current management of patients with advanced soft tissue sarcoma (STS) in the Australian health care setting. This study utilised the Australian sarcoma database to evaluate the patterns of care delivered to patients with advanced STS at Australian sarcoma services. Methods: Prospectively collected data from six sarcoma centres in Australia were sourced to identify patients diagnosed with advanced STS between 1 January 2010 and 31 December 2012. Descriptive statistics were analysed for patient demographics, clinicopathological characteristics and treatment patterns. Overall survival was estimated using the Kaplan--Meier product limit method. Results: Of 253 patients with advanced STS, four major STS subtypes were identiied: undiferentiated pleomorphic sarcoma (23 %), leiomyosarcoma (17 %), liposarcoma (14 %), and synovial sarcoma (8 %); with the rest grouped as "other STS" (38 %). Approximately one-third of patients received palliative systemic therapy with the most common irst-line therapy being doxorubicin alone (50 %). A small percentage of patients participated in clinical trials (20 %). Palliative radiotherapy was utilised mostly for treatment of symptomatic distant metastases and one-third of patients underwent metastasectomy, most commonly for pulmonary metastases. The median overall survival (OS) in this series was 18 months and no significant diference in OS was observed across diferent STS histological subtypes. Conclusions: This is the irst detailed study outlining patterns of care for Australian patients with advanced STS managed at sarcoma services. These data highlight a particular area of weakness in the lack of clinical trials for sarcoma patients and also serve as an important reference point for understanding how practice may change over time as treatment options evolve. [ABSTRACT FROM AUTHOR]

Purpose: We performed the first comprehensive, population-based brachytherapy (BT) Patterns of Care Study in the Australian setting. Herein we report on prostate BT and assess the technical quality of BT practice, focusing on whether a caseload effect could be identified in New South Wales (NSW). Material and methods: Site visits were made to all radiation oncology departments in NSW that delivered prostate BT, collecting relevant data on NSW residents treated with prostate BT in 2003. Overall quality of NSW prostate BT treatment was assessed using benchmarks including treatment of appropriate prostate cancer disease risk category, absence of (relative) physical contraindications, optimal planned and treated dosimetry, and pre-/post-implant planning/CT. Quality was compared between higher and lower caseload departments. Results: One hundred and fifty-seven (67%) patients underwent temporary BT and 79 (33%) permanent seed BT. Prostate BT was concentrated in five departments, with three of four departments with active programmes treating greater than the recommended 25 cases. Rates of concordance with quality benchmarks were high (85-99%) with no consistent caseload effect identified. Conclusions: Prostate BT in NSW in 2003 was generally of high quality and a caseload effect on quality could not be identified. This may be because the number of departments was insufficient to determine a caseload effect, or because the prostate BT was largely concentrated in a small number of high caseload departments. [ABSTRACT FROM AUTHOR]

Background We sought to describe patterns of initial radiotherapy among non-metastatic prostate cancer (PC) patients by recurrence risk groups. Methods Medical records were abstracted for a sample of 9017 PC cases diagnosed in 2004 as a part of the Center for Disease Control and Prevention's Prostate and Breast Patterns of Care Study in seven states. Non-metastatic PC cases are categorized as low-risk (LR), intermediate-risk (IR) or high-risk (HR) groups based on pretreatment PSA, tumor stage, and Gleason score per 2002 NCCN guidelines. Univariate and multivariate analyses were employed to determine factors associated with the type and dose of radiotherapy by the risk groups. Results Of the 9,017 patients, 3153 who received definitive radiotherapy either alone or in combination with hormone therapy (HT) were selected for in-depth analysis. Multivariate models showed that LR patients were more likely to receive seed implant brachytherapy (BT) than those in higher risk groups. Those in the IR group were most likely to receive external beam radiotherapy (EBRT) combined with BT or high-dose radiotherapy. Use of HT in combination with radiotherapy was more common in the IR and HR groups than for LR patients. Intensity modulated radiation treatment (IMRT) was used to treat 32.6% of PC patients treated with EBRT, with the majority (60.6%) treated with high-dose radiotherapy. Conclusions Radiotherapy types and dosage utilization varied by PC risk groups. Patients in IR were more likely than those in LR or HR to receive high-dose radiotherapy. IMRT was used in about one third of patients to deliver high-dose radiotherapy. [ABSTRACT FROM AUTHOR]

Purpose: The patterns of care study (PCS) of radiotherapy for cervical cancer in Japan over the last 10 years was reviewed. Methods and Materials: The Japanese PCS working group analyzed data from 1,200 patients (1995–1997, 591 patients; 1999–2001, 324 patients; 2003–2005, 285 patients) with cervical cancer treated with definitive radiotherapy in Japan. Results: Patients in the 2001–2003 survey were significantly younger than those in the 1999–2001 study (p < 0.0001). Histology, performance status, and International Federation of Gynecology and Obstetrics stage were not significantly different among the three survey periods. Use of combinations of chemotherapy has increased significantly during those periods (1995–1997, 24%; 1999–2001, 33%; 2003–2005, 54%; p < 0.0001). The ratio of patients receiving concurrent chemotherapy has also dramatically increased (1995–1997, 20%; 1999–2001, 54%; 2003–2005, 83%; p < 0.0001). As for external beam radiotherapy (EBRT), the application rate of four-field portals has greatly increased over the three survey periods (1995–1997, 2%; 1999–2001, 7%; 2003–2005, 21%; p < 0.0001). In addition, the use of an appropriate beam energy for EBRT has shown an increase (1995–1997, 67%; 1999–2001, 74%; 2003–2005, 81%; p = 0.064). As for intracavitary brachytherapy (ICBT), an iridium source has become increasingly popular (1995–1997, 27%; 1999–2001, 42%; 2003–2005, 84%; p < 0.0001). Among the three surveys, the ratio of patients receiving ICBT (1995–1997, 77%; 1999–2001, 82%; 2003–2005, 78%) has not changed. Although follow-up was inadequate in each survey, no significant survival differences were observed (p = 0.36), and rates of late Grade 3 or higher toxicity were significantly different (p = 0.016). Conclusions: The Japanese PCS has monitored consistent improvements over the past 10 years in the application of chemotherapy, timing of chemotherapy, and EBRT methods. However, there is still room for improvement, especially in the clinical practice of ICBT. [Copyright &y& Elsevier]

Purpose: To delineate changing trends in radical external beam radiotherapy (EBRT) for prostate cancer in Japan. Methods and Materials: Data from 841 patients with clinically localized prostate cancer treated with EBRT in the Japanese Patterns of Care Study (PCS) from 1996 to 2005 were analyzed. Results: Significant increases in the proportions of patients with stage T1 to T2 disease and decrease in prostate-specific antigen values were observed. Also, there were significant increases in the percentages of patients treated with radiotherapy by their own choice. Median radiation doses were 65.0 Gy and 68.4 Gy from 1996 to 1998 and from 1999 to 2001, respectively, increasing to 70 Gy from 2003 to 2005. Moreover, conformal therapy was more frequently used from 2003 to 2005 (84.9%) than from 1996 to 1998 (49.1%) and from 1999 to 2001 (50.2%). On the other hand, the percentage of patients receiving hormone therapy from 2003 to 2005 (81.1%) was almost the same as that from 1996 to 1998 (86.3%) and from 1999 to 2001 (89.7%). Compared with the PCS in the United States, patient characteristics and patterns of treatments from 2003 to 2005 have become more similar to those in the United States than those from 1996 to 1998 and those from 1999 to 2001. Conclusions: This study indicates a trend toward increasing numbers of patients with early-stage disease and increasing proportions of patients treated with higher radiation doses with advanced equipment among Japanese prostate cancer patients treated with EBRT during 1996 to 2005 survey periods. Patterns of care for prostate cancer in Japan are becoming more similar to those in the United States. [Copyright &y& Elsevier]

Purpose: The German Cooperative Group on Radiotherapy in Benign Diseases (GCG-BD) conducted a pattern-of-care study (PCS) to analyze the radiation therapy (RT) practice for pigmented villonodular synovitis (PVNS). Methods and Materials: In 2007, a structured questionnaire to assess the number of patients, the pretreatments, the RT indication, technique, target volume concepts, outcome data, and possible early or late toxicity was circulated to 227 institutions. Results: Until August 2008, a response was available from 189 institutions (83.2 %), of whom 19 (10.0 %) experienced RT for PVNS. Complete clinical information was available for 41 patients from 14 RT departments. Thirty patients (73.2 %) received postsurgical RT because of primary incomplete resection, 11 patients (26.8 %) as an adjunct after complete resections of recurrences or unclear resection status. The total doses ranged from 30 to 50 Gy (median, 36 Gy), the median single dose was 2.0 Gy. Local control was achieved 95.1%, and 82.9% had no or only slight functional impairment. The early and late toxicity was mild (≤RTOG Grade II). Conclusions: Radiation therapy is a safe and effective treatment for PVNS in the postoperative setting after incomplete resection, and also as a salvage option for treatment of recurrences it provides a high rate of local control. [ABSTRACT FROM AUTHOR]

OBJECTIVE To evaluate the clinical results of radiotherapy (RT) for patients with regionally localized hormone-refractory prostate carcinoma (HRPC). PATIENTS AND METHODS As part of a Patterns of Care Study in Japan, a nationwide survey was conducted of RT for patients with prostate adenocarcinoma. We reviewed the detailed information of 140 patients with regionally localized HRPC who received RT between 1996 and 1998, and between 1999 and 2001, in 117 randomly selected institutes in Japan. The median (range) age of the patients was 74 (51–94) years, and their tumours were defined as well (14), moderately (51) or poorly (54) differentiated, or of unknown differentiation (21). The median (range) interval between hormonal therapy (HT) and RT was 32.5 (1.1–168.4) months. Ninety-five patients had T3-4 tumours and 28 had regional lymph node metastases before treatment. The median (range) prostate-specific antigen levels before the initial HT and before RT were 35.0 (1.5–276) and 10.0 (0.06–760.3) ng/mL, respectively. External beam RT was administered, with a median total dose of 66 Gy; 70 patients (50%) received pelvic irradiation. RESULTS At a median follow-up of 20.7 months, the 5-year overall and clinical progression-free survival rates (95% confidence interval) were 48.1 (36–60)% and 36.7 (26–47)%, respectively. Although there were distant metastases in 46 patients, only six had local progression. There was late morbidity of grade ≥3 in six patients. CONCLUSION To the best of our knowledge, this study comprises the largest series of regionally localized HRPC treated with RT reported to date. RT might have a limited role for HRPC, because in most patients RT failed, with distant metastasis. [ABSTRACT FROM AUTHOR]

Purpose: To describe patient characteristics and the process of radiotherapy (RT) for patients with esophageal cancer treated between 1999 and 2001 in Japan. Methods and Materials: The Japanese Patterns of Care Study (PCS) Working Group conducted a third nationwide survey of 76 institutions. Detailed information was accumulated on 621 patients with thoracic esophageal cancer who received RT. Results: The median age of patients was 68 years. Eighty-eight percent were male, and 12% were female. Ninety-nine percent had squamous cell carcinoma histology. Fifty-five percent had the main lesion in the middle thoracic esophagus. Fourteen percent had clinical Stage 0–I disease, 32% had Stage IIA–IIB, 43% had Stage III, and 10% had Stage IV disease. Chemotherapy was given to 63% of patients; 39% received definitive chemoradiotherapy (CRT) without surgery and 24% pre- or postoperative CRT. Sixty-two percent of the patients aged ≥75 years were treated with RT only. Median total dose of external RT was 60 Gy for definitive CRT patients, 60 Gy for RT alone, and 40 Gy for preoperative CRT. Conclusions: This PCS describes general aspects of RT for esophageal cancer in Japan. Squamous cell carcinoma accounted for the majority of patients. The standard total external RT dose for esophageal cancer was higher in Japan than in the United States. Chemoradiotherapy had become common for esophageal cancer treatment, but patients aged ≥75 years were more likely to be treated by RT only. [Copyright &y& Elsevier]

Background: This study was undertaken to analyze the practice process of thoracic radiotherapy (TRT) and evaluate changes in patterns of care for patients with limited-stage small-cell lung cancer (LS-SCLC) in Japan. Methods and Materials: The Patterns of Care Study (PCS) conducted the second nationwide survey of care process for patients with LS-SCLC treated by using TRT between 1999 and 2001. Results: The PCS collected data for 139 patients with LS-SCLC (man-woman ratio, 5:1; median age, 69 years; age > 70 years, 43%; Karnofsky Performance Status > 70, 73%; and Stage III, 88%). Median total dose was 50 Gy. Twice-daily TRT was used in 44% of patients. Median field size was 12 × 14 cm. The most commonly used photon energy was 10 MV (77%), whereas obsolete techniques using 60Co or X-ray energy less than 6 MV comprised 12%. Three-dimensional conformal therapy was used with 12% of patients. Computed tomography simulation was performed in 40% of cases. Only 12 patients (8.6%) received prophylactic cranial irradiation (PCI). Concurrent chemotherapy and TRT (CCRT) was used for 94 patients (68%). Only 6 patients (4.4%) entered clinical trials. Compared with the previous PCS 95-97, significant increases in the use of CCRT (34–68%; p < 0.0001), twice-daily TRT (15–44%; p < 0.0001), and PCI (1.7–8.6%; p =0.0045) were observed, although the absolute number of patients receiving PCI was still extremely low. Conclusions: Evidence-based CCRT and twice-daily TRT has penetrated into clinical practice. However, PCI is not yet widely accepted in Japan. [Copyright &y& Elsevier]

Summary: Surgery remains the mainstay of treatment for localized non-small cell lung cancer (NSCLC). However, wide variations have been reported regarding rates of operative therapy. We examined the influence of characteristics of the hospital of diagnosis on the likelihood of receiving surgical treatment and on survival. We evaluated patients with primary, first-time, localized NSCLC diagnosed from 1998 to 2003 in the region of the Amsterdam Cancer Registry. Treatment and survival data were extracted from the registry database. We investigated which provider characteristics (hospital category, mean annual lung cancer caseload, presence of a cardiothoracic surgery unit) were predictive of receiving surgical treatment and of survival. 1591 patients were diagnosed with clinically localized NSCLC, of which 1097 (69%) had surgery. Resection rates varied significantly between the various hospitals (48–90%, χ 2, P <0.001). Patients diagnosed at specialized centers or higher volume hospitals were more likely to receive surgical therapy, especially for patients over 80 years of age. In addition, there was a trend that octogenarians had higher odds of undergoing surgery when diagnosed in a center with a cardiothoracic surgery unit. Patients had a better survival after resection than without surgery (P <0.001). Survival after surgery did not differ between the various hospital categories. In conclusion, there is wide institutional variability in rates of surgical treatment in lung cancer patients. In addition to patient characteristics, attributes of the hospital of diagnosis also have significant influence on the likelihood of receiving surgical therapy. Future studies should examine the underlying mechanisms for this phenomenon. [Copyright &y& Elsevier]

Purpose: To describe the patterns of definitive radiotherapy practice for patients with uterine cervical cancer from 1999 to 2001 in Japan. Methods and Materials: The Japanese Patterns of Care Study (JPCS) working group conducted a third extramural audit survey of 68 institutions and collected specific information on 324 cervical cancer patients treated with definitive radiotherapy. Results: Almost all patients (96%) were treated with whole pelvic radiotherapy using opposing anteroposterior fields (87%). A midline block was used in 70% of the patients. Intracavitary brachytherapy (ICBT) was applied in 82% of cases. Most patients (89%) were treated with high-dose rate (HDR) ICBT. Calculation of doses to organs at risk (ICRU 38) was performed for rectum in 25% of cases and for bladder in 18% of cases. Only 3% of patients were given intravenous conscious sedation during ICBT applicator insertions. The median total biologically effective dose at point A (EBRT+ICBT) was 74 Gy10 in cases treated with HDR-ICBT. There was no significant difference in total biologically effective dose between stages. The median overall treatment time was 47 days. Concurrent chemoradiation was applied in 17% of patients. Conclusions: This study describes the general patterns of radiotherapy practice for uterine cervical cancer in Japan. Although methods of external radiotherapy seemed to be appropriate, there was room for improvement in ICBT practice, such as pretreatment. A substantial difference in total radiotherapy dose between Japan and the United States was observed. [Copyright &y& Elsevier]

Optimal management of radiotherapy for prostate cancer patients has become a major concern for physicians in Japan. We reviewed published reports identifying the differences in the patterns of care for prostate cancer patients treated with radical external beam radiotherapy in Japan, Germany, and the United States. The reports indicate that Japanese patients have more advanced primary disease than patients in Germany or the United States. These patient characteristics for Japan and the United States have been almost unchanged for several years. Regarding radiotherapy, conformal radiotherapy was less frequently administered to patients in Japan than patients in Germany or the United States, and the total radiation dose was higher in Germany and the United States than in Japan. Concerning changes in trends in the patterns of radiotherapy, the percentage of patients treated with higher dose levels in the United States has rapidly increased, whereas the percentage of patients receiving these dose levels in Japan has remained extremely low. On the other hand, hormonal therapy has been used more frequently in Japan than in Germany or the United States. These findings indicate that patient characteristics and patterns of care for prostate cancer in Japan are considerably different from those in Germany or the United States. [ABSTRACT FROM AUTHOR]

Summary: To investigate the practice process of postoperative radiation therapy for non-small-cell lung cancer (NSCLC) in Japan. Between April 2002 and March 2004, the Patterns of Care Study conducted an extramural audit survey for 76 of 556 institutions using a stratified two-stage cluster sampling. Data on treatment process of 627 patients with NSCLC who received radiation therapy were collected. Ninety-nine (16%) patients received postoperative radiation therapy between 1999 and 2001 (median age, 65 years). Pathological stage was stage I in 8%, II in 17%, IIIA in 44%, and IIIB in 20%. The median field size was 9cm×11cm, and median total dose was 50Gy. Photon energies of 6MV or higher were used for 64 patients, whereas a cobalt-60 unit was used for five patients. Three-dimensional conformal treatment was used infrequently. Institutional stratification influenced several radiotherapy parameters such as photon energy and planning target volume. Smaller non-academic institutions provided worse quality of care. The study confirmed continuing variation in the practice of radiotherapy according to stratified institutions. Outdated equipment such as Cobalt-60 units was used, especially in non-academic institutions treating only a small number of patients per year. [Copyright &y& Elsevier]

Purpose: To present the results of a process survey on breast-conserving therapy (BCT) in Japan from 1995 to 1997. Methods and Materials: From September 1998 to December 1999, data on the treatment process of 865 randomly selected BCT patients were collected by extramural audits. Results: For primary surgery, wide excision or tumorectomy was performed in 372 patients (43.0%), and quadrantectomy or segmental mastectomy was performed in 493 patients (57%). The extent of axillary dissection was equal or beyond Level II in 590 patients (68.2%). Systemic chemotherapy was administered to 103 of 160 node-positive patients (64.4%) and 180 of 569 node-negative patients (31.6%). Tamoxifen was administered to 234 of 323 hormone receptor-positive patients (72.5%) and 68 of 130 hormone receptor-negative patients (52.3%). Photon energy of 10 MV was administered for whole breast irradiation in 38 patients (4.4%) without bolus. Conclusions: The extent of surgical resection for BCT was large in Japan. Pathologic assessment and the technique of radiation therapy were apparently suboptimal in some cases. Information on prognostic/predictive factors was not fully utilized to individualize systemic adjuvant therapy. Establishment and widespread use of guidelines for BCT for in Japan are desirable. Repeated surveys will demonstrate how such guidelines affect clinical practices. [Copyright &y& Elsevier]

To report the characteristics and treatment process of esophageal cancer patients treated with radiation therapy (RT) in Japan. The Patterns of Care Study (PCS) in Japan was conducted in 78 facilities nationwide including 40 academic (A) and 38 nonacademic (B) institutions using the original two-stage cluster sampling. Detailed information was accumulated on patients with cancer in the thoracic esophagus in stage I, II, or III who had received RT between 1995 and 1997. Of a total of 776 patients, 479 were treated in A institutions and 297 in B institutions. Median age was 67 years; 85.0% were men and 14.3% were women. Patients in stage I disease were more frequently identified in A institutions than in B (18.8% vs. 13.4%; P = 0.001). More than 99% had squamous cell carcinoma by histology, and the main tumors were often located in the midthoracic esophagus (62.2% of all patients). Pretreatment diagnostic modalities such as esophagram, endoscopy, endoscopic ultrasound, and computed tomography were done equally in A and B institutions. Chemotherapy was used for 39.7% of the patients. RT was combined with esophagectomy in the pre- or postoperative setting for 26.8% of the patients. Median fractionation and total external RT dose were 2 Gy and 60 Gy, respectively. Brachytherapy was more frequently used in A institutions than in B ( P = 0.001). This PCS study revealed the background and process of RT for esophageal cancer in Japan and also revealed the differences of the characteristics of patients and treatment procedures among two types of institutions. [ABSTRACT FROM AUTHOR]

Purpose: The Patterns of Care Study survey process evaluation has been an effective means of assessing the evaluation and treatment practices used by radiation oncologists in the United States for Stage I-II breast cancer. The current 1998¿1999 report updates the previous 1989 and 1993¿1994 analyses and reflects the recent changes in surgery and systemic therapy observed nationally in the management of early-stage disease. Methods and Materials: A weighted sample size of 71,877 patient records of women treated with breast-conserving surgery and radiotherapy (RT) was obtained from a stratified two-stage sampling of 353 patient records. These cases were centrally reviewed from academic and private radiation oncology practices across the United States. The data collected included patient characteristics, clinical and pathologic factors, and surgical and RT details. The results were compared with those of previous Patterns of Care Study survey reports. Results: Of the patients in the current survey, 97% had undergone mammography before biopsy. A review of the primary tumor pathologic findings indicated improved quantification of an intraductal component from 7.0% in 1993¿1994 to 20.4% in 1998¿1999 (p = 0.01). The tumor characteristics were better defined, with estrogen and progesterone receptor measurement performed in 91.4% and 91.3% in the 1998¿1999 survey vs. 83.7% and 80.3% in the 1989 survey, respectively (p = 0.03 and p = 0.002, respectively). Axillary dissection was performed in 82.2% in the present survey compared with 93.6% in the 1993¿1994 survey (p = 0.0004); sentinel node biopsy was performed in 20.1% of the present cases. The use of CT for planning was increased in the current survey, with 22.9% cases CT planned vs. 9% in 1993¿1994 (p = 0.10). In the present survey, 100% had received whole breast RT. When a supraclavicular field was added, the dose was prescribed to a specified depth in 67.5% of cases, most commonly 3 cm. When an axillary field was added, the dose was generally prescribed to the mid-plane. Chemotherapy and tamoxifen was used in 36% and 55.8% of patients, respectively, in the 1998¿1999 survey, representing a statistically significant increase compared with the 1993¿1994 survey, despite comparable pathologic tumor size and nodal involvement. Conclusion: The present results demonstrate a high level of compliance of the sampled radiation oncology practices with current breast conservation standards and continued improvement in many categories compared with prior patterns of care study surveys. The estimates in the current survey after whole breast RT will serve as a benchmark against newer trends in breast cancer RT, such as partial breast RT. [Copyright &y& Elsevier]

Purpose: After a general Patterns of Care Study (PCS) the German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) initiated a multicenter cohort study to analyze the radiation therapy practice for aggressive fibromatosis. Methods and materials: In 2002 a PCS was conducted in all German radiotherapy (RT) institutions by mailing a standardized structured questionnaire, to assess patients accrual, number, pretreatment, treatment indications, RT, and target volume concepts for irradiation in aggressive fibromatosis. In addition, the treatment outcome of individual patients was evaluated. The PCS was structured and analyzed according to the model for quality assessment by Donabedian in three major components: structure, process, and outcome evaluation. Results: A total of 101 institutions returned the questionnaire: 52.7% reported satisfactory clinical data and experience for inclusion in this analysis. A total accrual rate of 278 patients per year was reported with median number of 2 cases (1–7 cases) per institution. Satisfactory data for a long-term clinical evaluation was reported for 345 patients from 19 different institutions. The applied total doses ranged between 36 and 65 Gy (median, 60 Gy). The local control rate was 81.4% in primary RT for unresectable tumors and 79.6% in postoperative RT. No acute or late radiation toxicities > Grade 2 (RTOG) were observed. No clear dose–response relationship could be established, but there was a tendency toward a lower local control rate in patients with a higher number of operative procedures before RT and patients treated for recurrent aggressive fibromatosis. Conclusions: This study comprises the largest database of cases reported for RT in aggressive fibromatosis. Radiotherapy provides a high local control rate in the postoperative setting and in unresectable tumors. This PCS may serve as a starting point for a national or international prospective multicenter study or registry, or both. [Copyright &y& Elsevier]

purpose: To determine the influence of research findings and evolving technology on the practice of radiotherapy in patients with carcinoma of the cervix.Methods and materials: Radiation oncology facilities were randomly selected from two strata: those that treated <500 and those that treated ≥500 new cancer patients annually. Patient records were randomly selected from lists of eligible patients treated between 1996 and 1999 at each institution. A total of 442 patient records were reviewed at 59 facilities (55 with eligible patients). National estimates were made using weights that reflected the relative contribution of each institution and of each patient within the sampled institutions. Most estimates were based on the 383 patients who had received their initial therapy at a surveyed facility (excluding the 59 patients who were referred for brachytherapy only after initial treatment at another facility). The estimates of brachytherapy practice were based on the 408 patients who had received their brachytherapy at a surveyed facility. The data were compared with those obtained from a similar 1992–1994 survey.Results: Overall, 40.5%, 25.4%, and 33.9% of patients had Stage IA-IIA, IIB, or IIIA-IVA disease, respectively. CT was the most common method of nodal evaluation, with surgical evaluation performed in only 12% of patients. Of the 55 facilities with eligible patients, 32 had treated ≤8 eligible patients during the 4-year study period. We estimated that 27.5% of patients were treated at facilities that treated ≤2 patients with intact cervical cancer annually; 43% were treated at facilities that treated <500 new patients annually. Patients treated at small facilities were significantly more likely to have received a total dose to Point A of <80 Gy, to have had their treatment protracted to >70 days, and to have undergone adjuvant hysterectomy or chemotherapy. In large facilities, radiotherapy was less likely to be protracted to >70 days in the 1996–1999 survey than in the 1992–1994 survey (p < 0.0001); however, in small facilities, treatment was more likely to be protracted than in the earlier survey (p = 0.06), contributing to increasing disparities between the treatments given in large and small facilities. Overall, 92.4% of patients treated with nonpalliative intent were treated with brachytherapy. Of the patients who received brachytherapy, 16.4% had at least part of their brachytherapy delivered at a high dose rate; this was not significantly greater than the proportion treated with high-dose-rate brachytherapy in the 1992–1994 survey (9.1%; p = 0.3). The proportion of patients receiving chemotherapy as part of their initial treatment in 1996–1999 (34.6%) was not significantly different statistically from that in 1992–1994 (25.6%; p = 0.3). However, in 1999, 63% of patients had received chemotherapy compared with 19%, 28%, and 26% in 1996, 1997, and 1998, respectively. The details and confirmation of chemotherapy administration were rarely documented in the radiation oncology clinic notes and hospital records.Conclusion: The sharp increase in the use of chemotherapy in 1999 suggested rapid application of the results from randomized trials. However, considerable heterogeneity in practice patterns remains, particularly in the use of brachytherapy. The practice at small facilities appears to differ significantly from that at larger facilities in several respects, with a statistically significantly larger proportion of treatments at small facilities failing to meet current guidelines for optimal treatment. [Copyright &y& Elsevier]

Purpose: In Austria, a Patterns of Care Study (PCS) has been conducted to evaluate the standards of practice for breast cancer patients. The year 1985 was selected in order to establish a base data set.Materials and methods: At all nine radiation therapy facilities active in patient treatment in 1985, ten patients charts were randomly selected and reviewed. Evaluation of the radiotherapeutic standards was the principal purpose, however, surgical and histopathological parameters were also considered.Results: Results of the Austrian PCS (including 90 patients) were compared with the “1983 Patterns of Care Process Survey for Definitive Breast Irradiation” performed in 1983 in the U.S. (including 191 patients). Documentation of pathologic tumour size (83% vs. 73%), histologic tumour subtype (99% vs. 97%) and microscopic margin analysis (60% vs. 51%) showed comparable results. Technical equipment was obviously quite different in the two countries, cobalt therapy was used in 25% in the US-PCS compared to 71% in the Austrian PCS. A clear difference also was obtained concerning the use of wedges for tangential breast/thoracic wall fields (64% vs. 21%) and the frequency of portal films (93% vs. 26%).Conclusions: Comparing both PCS studies, we found overall many similarities. Differences could be obtained in the quality level of radiation treatment, as for example use of wedges for tangential fields and the number of portal films. In a next step, a further Austrian PCS is planned to compare the Austrian base data from 1985 with quality standards from 1993 and 2001. [Copyright &y& Elsevier]

: PurposeAfter a general patterns of care study, the German Cooperative Group on Radiotherapy for Benign Diseases conducted a multicenter cohort study to analyze radiotherapy (RT) in painful heel spur syndrome (HSS).: Methods and materialsIn 2001, a patterns of care study was conducted in all German RT institutions using a standardized structured questionnaire. Patient accrual, patient number, pretreatment, pain record, treatment indications, RT technique, and target volume concepts for painful HSS were assessed. In addition, the functional and subjective outcomes were evaluated.: ResultsOf the institutions, 146 (79.3%) returned the questionnaire: 10 (6.8%) reported no clinical experience with RT for HSS, and 136 (93.2%) treated 3621 patients annually, a median of 23 cases/institution. The indications for treatment were chronic or therapy refractory pain. The total dose ranged between 2.5 and 18.75 Gy (median 6), and single fractions ranged between 0.3 and 1. 5 Gy (median 1). Of the responding institutions, 44.9% applied two fractions and 37.5% three fractions weekly. RT was delivered with orthovoltage units (38.2%), linear accelerators (53.7%), 60Co units (5.1%), or other treatment units (3%). Seventy-six institutions presented their retrospective clinical evaluation in a total of 7947 patients. Pain reduction for at least 3 months was reported in 70%, and persistent pain reduction was reported in 65% of the treated patients. In 19 institutions, a second RT series was applied for inadequate pain response or early pain recurrence. No radiogenic acute or chronic side effects were observed.: ConclusionThe study comprised the largest number of cases reported of RT for painful HSS. Despite variations in the daily RT practice, this national patterns of care study represents a very large number of painful and refractory HSS cases that were treated effectively with RT. [Copyright &y& Elsevier]

: PurposeWe examined whether the data registered in the Japanese Patterns of Care Study (PCS) for patients with non–small-cell lung cancer (NSCLC) represent the actual situation of radiotherapy in Japan. The Osaka Cancer Registry (OCR) data, forming the largest database of a regional cancer registry in Japan, were adopted for use as a benchmark against the national condition.: Patients and methodsWe examined 906 patients of the PCS treated between 1995 and 1997 and 845 patients of the OCR registered between 1988 and 1992. The investigation was made by descriptive statistical methods to measure age, stage, combined treatments, type of treated hospitals, and prognosis. Furthermore, the national averages (NAs) of the PCS process (PCS NA) were also calculated to compensate for the imbalance in the PCS data sampling.: ResultsThe mean age was 67.3 ± 10.1 in PCS and 64.4 ± 11.0 in OCR (p < 0.001), 67.2 in PCS NA. The male ratio was 84.2% in PCS and 84.0% in OCR (p = 0.411), 84.1% in PCS NA. The ratio of the patients at the localized stage was 24.2% in PCS and 15.6% in OCR (p = 0.001), 21.1% in PCS NA. The ratio of surgery combined was 24.2% in PCS and 28.9% in OCR (p = 0.026), 25.3% in PCS NA. The ratio of chemotherapy combined was 50.1% in PCS and 67.5% in OCR (p = 0.001), 47.4% in PCS NA. Because the definitions of institution classification and period of prognostic inquiry were different between the two databases, the 3-year survival rates were calculated for reference. In the nonsurgery group, it was 20.3% in PCS and 11.3% in OCR (p = 0.001), and in the surgery group it was 52.5% in PCS and 42.2% in OCR (p = 0.057).: ConclusionsAges in the two databases were inconsistent. Sex distributions were consistent. Surgery and chemotherapy were more frequently performed for the OCR patients, and more patients at more advanced stages were also observed in OCR. The PCS NAs of sex, stage, and ratio of surgery combined were at the midpoints between those of PCS and OCR. The survival rate of NSCLC patients in the OCR was significantly inferior to that in the PCS. The follow-up rate of the PCS was lower than that of the OCR. The general features of PCS data showed similarity to OCR data, and the results of the PCS NAs suggested the effectiveness of this method to adjust the sampling imbalance in PCS. [Copyright &y& Elsevier]

: PurposeTo evaluate the quality of radiotherapy (RT) in Japan, we have been carrying out a national survey through patterns-of-care studies (PCSs) since 1996. We present the preliminary results of surgery combined with RT with or without chemotherapy for thoracic esophageal cancer.: Methods and materialsA Japanese PCS data format for esophageal cancer was established based on one used in the United States and including information used in the surgical registration system in Japan, so that the results in both countries could be compared. An independent panel of radiation oncologists surveyed randomly selected institutions and patients between September 1998 and March 2001. There were 767 esophageal cancer patients, of whom 220 had undergone preoperative or postoperative RT.: ResultsThe median age of the 220 patients was 62.3 years (range 31–89); of them, 88.1% were men. Pathologically, 218 patients (99.5%) had squamous cell carcinoma, predominantly located in the middle and lower thoracic esophagus, 41.7% of the patients had Stage III disease; they accounted for 52.6% of patients in nonacademic institutions and for 37.7% of those in academic institutions (p = 0.016). Sixty-nine patients received preoperative RT; of them, 60.9% received chemotherapy; 145 patients received postoperative RT with or without chemotherapy. The spinal cord of 23 (11.7%) of 196 patients was irradiated with ≥50 Gy. In academic institutions, extended radical “three-field” lymphatic dissection was performed for 72 (48.7%) of 148 patients; however, this sophisticated surgical procedure was done in only 13 (25.5%) of 51 patients in nonacademic settings (p = 0.004). In all large academic institutions (those treating ≥300 patients annually), ≥6 MV of photon energy was used; 30.5% of nonacademic institutes had linear accelerators of <6 MV photon (p = 0.001). No deviations occurred in the radiation dose (median 46 Gy), fractionations, or fields between the two types of institutions. Univariate analyses showed that the statistically significant prognostic factors affecting overall survival were stage (p = 0.001), extended radical “three-field” lymphatic dissection (p = 0.001), no residual tumor (p = 0.001), supraclavicular RT (p = 0.001), mediastinal RT (p = 0.025), Karnofsky performance status (p = 0.006) photon energy (p = 0.011), and stratification of the institutions (p = 0.001). Multivariate analysis showed that the type of institution (p = 0.045, risk ratio = 0.604), stage (p 0.029, risk ratio = 0.572), no residual tumor (p = 0.006, risk ratio = 0.487), photon energy (p = 0.043, risk ratio = 0.579), and use of chemotherapy (p = 0.012, risk ratio = 1.907) significantly affected overall survival.: ConclusionThis PCS showed that in Japan important issues are present regarding RT for esophageal cancer that should be solved immediately, namely, treatment strategy, photon energy, and dose applied to the spinal cord. The PCS provided important information on how much improvement in structure and process would be required nationwide for RT of esophageal cancer. [Copyright &y& Elsevier]

Purpose: To evaluate the practice process using the national average (NA); to compare differences in the process of care by age group; and to provide a preliminary outcome data for limited-stage small-cell lung cancer in Japan.Methods and Materials: The Patterns of Care Study conducted a nationwide survey of the care process for Stage I–III small-cell lung cancer in Japan. Patients were divided into three age groups: <65 years (younger group, n = 73); between 65 and 74 years (intermediate group, n = 81); and ≥75 years (elderly group, n = 20).Results: The NA for the total dose was 49.0 Gy, and for use of photon energy ≥6 MV, chemotherapy, and prophylactic cranial irradiation was 77.3%, 93.2%, and 1.69%, respectively. Age stratification had no impact on the variables of radiotherapy (RT) such as total dose and field size. Only 37% of patients received chemotherapy and thoracic RT concurrently. The proportion of patients who received chemotherapy and RT concurrently was 44%, 27%, and 25% of the younger, intermediate, and elderly groups, respectively (p = 0.029). Etoposide and cisplatin were less frequently used in the elderly group (≥75 years old). Overall survival at 3 years for the entire group was 26%. The 3-year survival rate was 30% in the younger group, 28% in the intermediate group, and 9% in the elderly group. Variables found to have a significant impact on survival by multivariate analysis were the use of chemotherapy (p = 0.030), age (p = 0.032), and T stage (p = 0.042).Conclusion: Calculated NAs showed that the results of clinical study had favorably penetrated into the practice process in Japan. The results demonstrated that patient age significantly influenced the process of chemotherapy such as the use of etoposide and cisplatin for limited-stage small-cell lung cancer in Japan. More concurrent chemotherapy and thoracic RT and the application of prophylactic cranial irradiation for complete responders need to be investigated in the future. [Copyright &y& Elsevier]

The Patterns of Care Study (PCS) conducted a nationwide audit survey in order to establish the national practice process of radiation therapy for small-cell lung cancer (SCLC) and examined the influence of institutional stratification on the process of care in Japan. The PCS randomly sampled institutions and patients using a two-stage cluster method and surveyed the process of radiation therapy for 174 stage I–III SCLC patients according to the category of institution, stratified as follows: A1, academic institutions treating ≥300 patients a year; A2, <300 patients; B1, non-academic institutions treating ≥120 patients a year; and B2, <120 patients. Karnofsky performance status distributions showed significant variance by stratification of institutions (P=0.013). Patients treated on an outpatient basis accounted for 32% in A1, 23% in A2, 8% in B1, but only 5% in B2 (P=0.007). A photon energy ≥10 MV was used for 87% of patients in A1, 69% in A2, 54% in B1 and 23% in B2 (P=0.001). Contralateral hilus was irradiated for 11% of patients in A1, 17% in A2, 29% in B1 and 3% in B2 (P=0.001). Field size reduction during the treatment course was done for 77% of patients in A1, 54% in A2, 60% in B1 and 42% in B2 (P=0.007). Ninety-two percent of patients received combined chemotherapy and radiation therapy, and the most frequently used drugs were etoposide (91%) and cisplatin (69%). The results of clinical studies on SCLC had favorably penetrated into the clinical practice. However, the stratification of institutions significantly affected the process of radiation therapy in Japan. [Copyright &y& Elsevier]

Purpose: To overcome the lack of written guidelines for radiation therapy (RT) of benign diseases, the German Working Group on Radiotherapy of Benign Diseases initiated a consensus process in 1999 to warrant continuous quality assurance and outcome research in this field.Methods: An expert panel was convened to define key issues and develop written guidelines for RT of benign diseases. Pertinent information and data from published literature were reviewed, and data of most importance were identified. In addition, a patterns of care study was conducted to obtain a nationwide survey on the current status and treatment standards.Results: From the data gathered, the expert panel prepared a first consensus statement that was open to propositions and comments from all participating institutions. After completion of the multicenter discussion, a final written consensus statement was compiled, discussed, and finally agreed on during a national conference of radiation therapists. For each individual nonmalignant disease, the accepted RT concepts were documented. Finally, specific evaluation tools and recommendations for follow-up examinations were defined.Conclusions: For the first time, written consensus guidelines for RT of nonmalignant diseases have been developed by the interaction of all institutions involved. These guidelines may serve as a starting point for quality assessment, prospective clinical trials, and outcome research. [Copyright &y& Elsevier]

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