ONCOLOGY Vol 9 No 11

Quality-adjusted survival as a measure of the effectiveness of medical interventions captures the tradeoffs between length and quality of life that are often involved in choosing between alternative treatment strategies.

Ovarian cancer is the leading cause of death from a gynecologic malignancy in the United States. Most patients present with advanced disease and are treated with a combination of surgery and chemotherapy. Recently,

Often, new treatments for cancer are evaluated solely on the basis of increased survival, depriving us of valuable information about other benefits and drawbacks of these treatments. It is important to raise the question of the

Economic analysis of cancer pain management is hampered by the lack of systematic outcomes research. There is some consensus on the broad structures that should be in place to provide optimal care, but the relative costs and

The administration of hematopoietic colony-stimulating factors (CSFs) to reduce the severity and duration of neutropenia associated with systemic chemotherapy has become widespread, although the appropriate use of

Each year more than 100,000 cancer patients in the United States develop brain metastases [1]. Of these, the majority will have either multiple lesions or uncontrolled primary or metastatic disease [2-4]. The treatment and care of patients with brain metastases remains a serious health-care problem. The article by Berk is a comprehensive review of completed or ongoing clinical trials worldwide evaluating the role of radiotherapy in the treatment of patients with brain metastases.

A review of the English literature was undertaken to (1) determine the efficacy of radiation therapy for the treatment of brain metastases, (2) identify prognostic factors, and (3) ascertain whether there is an effect of treatment technique on outcome. Critical analysis of relevant randomized trials indicated that radiation therapy can effectively palliate the symptoms of brain metastases.

Changes in the health care system have caused a shift in research to outcomes of care, effectiveness, efficiencies, clinical practice guidelines, and costs. The greater use of computer systems, including decision support systems, quality assurance systems, effectiveness systems, cost containment systems, and networks, will be required to integrate administrative and patient care data for use in determining outcomes and resource management. This article describes developments to look forward to in the decade ahead, including the integration of outcomes data and clinical practice guidelines as content into computer-based patient records; the development of review criteria from clinical practice guidelines to be used in translating guidelines into critical paths; and feedback systems to monitor performance measures and benchmarks of care, and ultimately cost out cancer care. [ONCOLOGY 9(Suppl):161-167, 1995]

The reimbursement policies of Medicare, Medicaid, and private insurers can have a major impact on the ability of oncologists to deliver care to their patients. This article explores current issues of particular interest to

The myeloid growth factors G-CSF and GM-CSF have had an impact on the supportive care of cancer patients as well as on the strategies utilized in chemotherapy dose intensification. Therapy with these factors has not been

Outcomes research is the study of the net effects of the health care process on the health and well-being of individuals and populations. It encompasses a wide breadth of issues, including measurement of patient preferences and health status, broadly referred to as quality of life. Evaluation of health-related quality of life in research studies has been facilitated by the development of a number of measurement tools. In addition to general health tools, cancer-related tools are available, some of which include cancer site-specific or symptom-specific measures. Preference assessment, from the perspective of the patient or general population, is necessary to incorporate quality of life into economic analyses. Various techniques are available to assign preference values to outcomes; metrics such as quality-adjusted life-years (QALYs) are then used to combine quality and quantity of life into a usable value for economic analyses. In the future, quality of life and economic measurements should be incorporated into phase III trials, effectiveness trials, and observational studies. [ONCOLOGY 9(Suppl):23-32, 1995]

This publication is the fourth in a series of quality of life symposia proceedings. The title of our first symposium, which took place in 1989, was "Quality of Life in Current Oncology Practice and Research." In the foreword to the first proceedings, we

The development of clinical practice guidelines in oncology presents unique problems and challenges due to the heterogeneity of disease presentations and the complexity of therapeutic decisions. Guidelines should incorporate

The author gives a comprehensive review of the literature on the treatment of brain metastasis by radiation therapy. His emphasis is on randomized trials, the most extensive and comprehensive of which are those conducted by the Radiation Therapy Oncology Group (RTOG). This commentary will provide some amplification of the data presented in the review.

The 1992 metaanalysis of adjuvant therapies after surgery in early breast cancer summarizes the most extensively studied of all cancer treatments via randomized controlled trials. This study found overall benefits with use of adjuvant therapies, and their expanded use outside the clinical trial setting was assumed to be effective and implied to be cost effective. Thus, the primary remaining questions are which form of adjuvant therapy to use and how to identify which patients are unlikely to benefit. In British Columbia, the effectiveness of adjuvant therapy outside the clinical trial setting was reassuringly similar to the metaanalysis efficacy. Our decision analysis model of hypothetical cohorts of women with early breast cancer confirmed that the efficacy of adjuvant treatment is the primary determinate of its incremental cost effectiveness. Future cost-effectiveness and quality of life assessments should move from hypothetical cohorts assessed via models to prospective data collected within clinical trials or integrated health delivery system. [ONCOLOGY 9(Suppl):129-134, 1995]

With the recent surge in interest in health care reform and the growth of managed care organizations, the cost of care has become a major determinant of the types and intensity of therapy that patients receive. If data on the

The value of prostate cancer screening remains controversial because of the high prevalence of the disease and the fact that many tumors detected through screening are not destined to lead to morbidity or mortality, rendering

Anderson and colleagues present a comprehensive and factually accurate overview of systemic treatment for advanced melanoma. They correctly identify dacarbazine as the only single agent officially sanctioned for the treatment of metastatic melanoma. They further opine that "dacarbazine alone remains the standard of care for initial chemotherapy treatment of metastatic melanoma." With overall response rates of 10% to 20%, a complete response rate of less than 4%, and no evidence that treatment with dacarbazine improves survival over best palliative care, one questions whether or not dacarbazine would merit approval if reevaluated today.

Stephenson and Wiley demonstrate that three-dimensional (3D) CT-based simulation is an improvement in the simulation process. The growing importance of CT in radiation oncology treatment planning has been discussed previously [1] and is further emphasized in this article. The advantages of geometric optimization in three dimensions for radiation therapy treatment planning also are described. These results are applicable to both 3D and two-dimensional (2D) dose planning, because the treatment team can visualize and delineate structures on axial or reconstructed CT planes in greater detail than is possible with conventional simulation projected radiographs.

Increasingly, economic data are being considered in formulary decisions. In oncology, pharmacoeconomic evaluations are essential to help decision makers weigh the associated costs and outcomes of competing