Clinical Investigation
Population-Based Study of Trends and Variations in Radiotherapy as Part of Primary Treatment of Cancer in the Southern Netherlands Between 1988 and 2006, With an Emphasis on Breast and Rectal Cancer

https://doi.org/10.1016/j.ijrobp.2008.08.074Get rights and content

Purpose

To explore current variations in the use of primary radiotherapy (RT) in a region with two RT departments with adjacent referral areas, one in the eastern and one in the western sector of the southern region of the Netherlands.

Methods and Materials

We calculated the proportion of 147,588 patients with newly diagnosed cancer between 1988 and 2006 in the southern Netherlands who received primary RT. Especially for breast and rectal cancer patients we studied primary RT use according to stage (breast cancer) and age and separately for the eastern and western sectors.

Results

The number of patients with new diagnoses receiving primary RT increased from 1,668 patients in 1988 to 2,971 patients in 2006, with the proportion of the overall patients receiving RT remaining more or less unchanged (±30%). However, only 20% of elderly patients (75+ years) received primary RT. Over time, more patients with prostate and rectal cancer, fewer patients with lung and bladder cancer or Hodgkin's lymphoma, and, recently, more patients with cervical or endometrial cancer received RT. The proportion of patients with most other tumor types treated with RT remained more or less unchanged. The total RT rate was slightly higher for patients in the eastern sector. Of particular note, patients with breast or rectal cancer in the eastern sector were significantly more likely to receive primary RT than were their counterparts in the western sector (odds ratio = 1.4, 95% confidence interval =1.4–1.5, and odds ratio = 1.4, 95% confidence interval = 1.3–1.6, respectively).

Conclusions

Although the number of RT-treated patients increased substantially during 1988 to 2006, the proportion remained essentially unchanged. In addition, large variations were found in referral rates for RT, especially in later years, between the eastern and the western sectors of the region.

Introduction

It is estimated that about 50% of all patients with cancer receive radiotherapy (RT) during the course of their treatment (1). This percentage is based on expert analysis and is often used to guide decisions about current and future needs for RT equipment and personnel. Factored into this planning is the reasoning that primary RT is usually part of initial treatment and that secondary RT is part of the treatment for recurrent disease or metastases 1, 2, irrespective of whether patients have already received primary RT. However, population-based studies done in the southern Netherlands showed that only about 30% of all cancer patients received primary RT during the years 1975 to 2002 3, 4, 5. Furthermore, other studies showed that 67% of all patients with breast cancer and 45% of all patients with rectal cancer received RT (primary or secondary) in the first 5 years after diagnosis 6, 7.

In addition, between 1988 and 1999, referral for primary RT from hospital to hospital varied substantially in our region (8). The same was true for other regions of the Netherlands and for the United States as well, especially for patients with breast cancer 9, 10. These variations in the use of RT, and the fact that these earlier percentages departed from the 50% predicted use, prompted us to conduct subsequent studies of the use of primary RT for different tumor types to determine whether there has been improved adherence to guidelines that have been disseminated at the national level in the Netherlands.

In the study reported here, we estimated the proportion of all cancer patients who received primary RT, and we determined the more in-depth trends and variations in the use of primary RT for patients with primary breast and rectal cancer newly diagnosed between 1988 and 2006 in the southern Netherlands.

Section snippets

Methods and Materials

Data were derived from the Eindhoven Cancer Registry (ECR), which contains data on all patients newly diagnosed with cancer since 1955. The registry covers a large part of the southern Netherlands, which had approximately 2.4 million inhabitants in 2004. The medical infrastructure consists of six pathology departments, 10 general hospitals (decreased from 20 hospitals 25 years ago), and two large RT departments, one in the west in Tilburg that operates as an independent facility (currently with

Total patient population

The annual number of patients with newly diagnosed cancer increased by 73%, from 5,479 patients in 1988 to 9,469 patients in 2006; the number of RT-treated patients increased from 1,668 to 2,971 over the same period, for an absolute increase of 78%. The annual percentage of patients receiving primary RT fluctuated between 30% and 32%, remaining at 30% in the western sector and becoming 35% in the eastern sector in the period 2003 to 2006 (Table 1). Patients older than 75 years in both regions

Total population

Although the total number of cancer patients and the number of RT-treated patients both increased substantially during the period 1988 to 2006 (19), the percentage of patients who received RT as part of their primary treatment remained stable at about 30%. However, it is important to bear in mind that this apparently stable percentage actually reflects a rising percentage of RT-treated patients with prostate and rectal cancer and a decreasing percentage of RT-treated patients with lung and

Conclusion

Although the absolute number of RT-treated patients with cancer increased substantially during 1988–2006, the proportion of patients referred for RT remained essentially unchanged in the southern Netherlands. However, substantial variations were found in referral rates for RT, especially in later years, between the eastern and the western sectors of the region, each with their own RT departments and referring hospitals. The unanswered question is whether this divergence might have been greater

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