title: Trends in the quality of treatment for patients with intact cervical cancer in the United States, 1999 through 2011.
abstract: OBJECTIVE
  High-quality treatment for intact cervical cancer requires external radiation therapy, brachytherapy, and chemotherapy, carefully sequenced and completed without delays. We sought to determine how frequently current treatment meets quality benchmarks and whether new technologies have influenced patterns of care.
  
  
  METHODS
  By searching diagnosis and procedure claims in MarketScan, an employment-based health care claims database, we identified 1508 patients with nonmetastatic, intact cervical cancer treated from 1999 to 2011, who were <65 years of age and received >10 fractions of radiation. Treatments received were identified using procedure codes and compared with 3 quality benchmarks: receipt of brachytherapy, receipt of chemotherapy, and radiation treatment duration not exceeding 63 days. The Cochran-Armitage test was used to evaluate temporal trends.
  
  
  RESULTS
  Seventy-eight percent of patients (n=1182) received brachytherapy, with brachytherapy receipt stable over time (Cochran-Armitage Ptrend=.15). Among patients who received brachytherapy, 66% had high-dose rate and 34% had low-dose rate treatment, although use of high-dose rate brachytherapy steadily increased to 75% by 2011 (Ptrend<.001). Eighteen percent of patients (n=278) received intensity modulated radiation therapy (IMRT), and IMRT receipt increased to 37% by 2011 (Ptrend<.001). Only 2.5% of patients (n=38) received IMRT in the setting of brachytherapy omission. Overall, 79% of patients (n=1185) received chemotherapy, and chemotherapy receipt increased to 84% by 2011 (Ptrend<.001). Median radiation treatment duration was 56 days (interquartile range, 47-65 days); however, duration exceeded 63 days in 36% of patients (n=543). Although 98% of patients received at least 1 benchmark treatment, only 44% received treatment that met all 3 benchmarks. With more stringent indicators (brachytherapy, ≥4 chemotherapy cycles, and duration not exceeding 56 days), only 25% of patients received treatment that met all benchmarks.
  
  
  CONCLUSIONS
  In this cohort, most cervical cancer patients received treatment that did not comply with all 3 benchmarks for quality treatment. In contrast to increasing receipt of newer radiation technologies, there was little improvement in receipt of essential treatment benchmarks.
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Grace L
authors.initials: GL
authors.lastname: Smith
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Jing
authors.initials: J
authors.lastname: Jiang
authors.affiliation: Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Sharon H
authors.initials: SH
authors.lastname: Giordano
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Gynecologic Oncology and Reproductive Medicine (LAM), The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Larissa A
authors.initials: LA
authors.lastname: Meyer
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: peifel@mdanderson.org.
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Eifel
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D019985:Benchmarking; D001918:Brachytherapy / Q000592:standards* / Q000639:trends; D003131:Combined Modality Therapy / Q000592:standards / Q000639:trends; D005260:Female; D019983:Guideline Adherence / Q000592:standards; D006801:Humans; D008875:Middle Aged; D016634:Radiosurgery / Q000592:standards* / Q000639:trends; D011879:Radiotherapy Dosage; D050397:Radiotherapy, Intensity-Modulated / Q000592:standards* / Q000639:trends; D013997:Time Factors; D014481:United States; D002583:Uterine Cervical Neoplasms / Q000473:pathology / Q000628:therapy*
chemical_list: D000970:Antineoplastic Agents