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Watanabe, Mikami, Katabuchi, Kato, Kaneuchi, Takahashi, Nakai, Nagase, Niikura, Mandai, Hirashima, Yanai, Yamagami, Kamitani, and Higashi: Quality indicators for cervical cancer care in Japan
Original Article

J Gynecol Oncol 2018;29(6):e83.

Published online: 4 November 2018

DOI: https://doi.org/10.3802/jgo.2018.29.e83

Quality indicators for cervical cancer care in Japan

Tomone Watanabe1, , Mikio Mikami2, Hidetaka Katabuchi3, Shingo Kato4, Masanori Kaneuchi5, Masahiro Takahashi6, Hidekatsu Nakai7, Satoru Nagase8, Hitoshi Niikura9, Masaki Mandai10, Yasuyuki Hirashima11, Hiroyuki Yanai12, Wataru Yamagami13, Satoru Kamitani1, Takahiro Higashi1

1Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan

2Department of Obstetrics and Gynecology, Tokai University, Kanagawa, Japan

3Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan

4Department of Radiation Oncology, Saitama Medical University International Medical Center, Saitama, Japan

5Department of Obstetrics and Gynecology, Otaru General Hospital, Hokkaido, Japan

6Department of Medical Oncology, Tohoku University Hospital, Miyagi, Japan

7Department of Obstetrics and Gynecology, Kindai University Faculty of Medicine, Osaka, Japan

8Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Yamagata, Japan

9Department of Obstetrics and Gynecology, Tohoku University, Miyagi, Japan

10Department of Gynecology and Obsteterics, Kyoto University Graduate School of Medicine, Kyoto, Japan

11Division of Gynecology, Shizuoka Cancer Center Hospital, Shizuoka, Japan

12Department of Pathology, Okayama University Hospital, Okayama, Japan

13Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan

Correspondence to Tomone Watanabe Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan. E-mail: tomonwat@ncc.go.jp

Received 6 October 2017       Revised 9 July 2018       Accepted 9 July 2018

Copyright © 2018 Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

We aimed to propose a set of quality indicators (QIs) based on the clinical guidelines for cervical cancer treatment published by The Japan Society of Gynecologic Oncology, and to assess adherence to standard-of-care as an index of the quality of care for cervical cancer in Japan.

Methods

A panel of clinical experts devised the QIs using a modified Delphi method. Adherence to each QI was evaluated using data from a hospital-based cancer registry of patients diagnosed in 2013, and linked with insurance claims data, between October 1, 2012, and December 31, 2014. All patients who received first-line treatment at the participating facility were included. The QI scores were communicated to participating hospitals, and additional data about the reasons for non-adherence were collected.

Results

In total, 297 hospitals participated, and the care provided to 15,163 cervical cancer patients was examined using 10 measurable QIs. The adherence rate ranged from 50.0% for ‘cystoscope or proctoscope for stage IVA' to 98.8% for ‘chemotherapy using platinum for stage IVB'. Despite the variation in care, hospitals reported clinically valid reasons for more than half of the non-adherent cases. Clinically valid reasons accounted for 75%, 90.9%, 73.4%, 44.5%, and 88.1% of presented non-adherent cases respectively.

Conclusion

Our study revealed variations in pattern of care as well as an adherence to standards-of-care across Japan. Further assessment of the causes of variation and non-adherence can help identify areas where improvements are needed in patient care.

Keywords: Quality Indicators, Uterine Cervical Neoplasms, Standard of Care, Guideline Adherence, Practice Guideline

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Table 1.
Patient demography analysed using the HBCR and the DPC (n=15,163)
Variables Values
Age, mean (SD) 45.1 (15.0)
 <20 13 (0.1)
 20–29 1,528 (10.1)
 30–39 5,041 (33.2)
 40–49 4,113 (27.1)
 50–59 1,614 (10.6)
 ≥60 2,854 (18.8)
Histology type*  
 Squamous cell carcinoma 13,314 (87.8)
  Squamous cell carcinoma in situ 9,092
 Adenocarcinoma 1,371 (9.0)
  Adenocarcinoma in situ 296
 Other 478 (3.1)
FIGO stage  
 I 2,288 (15.1)
 II 1,314 (8.7)
 III 552 (3.6)
 IV 780 (5.1)
 Unknown† 806 (5.3)
 Tis‡ 9,423 (62.1)
First-line treatment  
 Surgery 10,129 (66.8)
 Radiotherapy 743 (4.9)
 Chemotherapy 167 (1.1)
 Surgery+chemotherapy 672 (4.4)
 Radiotherapy+chemotherapy§ 1,261 (8.3)
 Other 2,191 (14.4)

Values are presented as mean (SD) or number (%). CCRT, concurrent chemotherapy and radiation therapy; CIN3, cervical intraepithelial neoplasia 3; DPC, Diagnosis Procedure Combination; FIGO, International Federation of Gynecology and Obstetrics; HBCR, Hospital-Based Cancer Registry; ICD-O-3, International Classification of Diseases Oncology 3rd edition; SD, standard deviation.

* The number of patients in each category was extracted using ICD-O-3 codes;

† In HBCR, the category includes patients who were resected before definitive diagnoses;

‡ Although “Tis” is not included in the FIGO system, patients with CIN3 and adenocarcinoma in situ were extracted from this stage using ICD-O-3 codes. Further description of stage was refrained due to the complicated nature of code extraction;

§ Those who have received both radiation therapy and chemotherapy regardless of time gaps between treatments (includes CCRT).

Table 2.
Adherence rates for various QIs
QIs Target patients (denominator) Specified care (numerator) No. Adherence rate (95% CI)
QI1* Conization for CIN3      
  CIN3 patients who are under age 43 years Patients who had total hysterectomy without conization 242/6,256 3.9% (3.4–4.4)
QI2 Total hysterectomy for adenocarcinoma in situ      
  Patients who had adenocarcinoma in situ over age 44 years Patients who had total hysterectomy as the last treatment 81/93 87.1% (78.5–93.2)
QI3 Radical hysterectomy for stage II adenocarcinoma      
  Stage II adenocarcinoma patients Patients who had radical hysterectomy 115/170 67.6% (60.1–74.6)
QI4 CCRT as the first-line treatment for stage III or IVA      
  Stage III or IVA patients Patients who had CCRT as the first-line treatment 397/720 55.1% (51.4–58.8)
QI5 CCRT using cisplatin for stage III or IVA      
  Stage III or IVA patients who had CCRT Patients who had cisplatin-based regimen for CCRT 333/417 79.9% (75.7–83.6)
QI6* Chemotherapy for stage III or IVA      
  Stage III or IVA patients who had curative radiation therapy Patients who had chemotherapy before the main 8/663 1.2% (0.5–2.4)
  or CCRT as main treatment treatment    
QI7 Chemotherapy using platinum for stage IVB      
  Stage IVB patients who had chemotherapy Patients who had platinum-based chemotherapy 422/426 99.1% (97.6–99.7)
QI8 Cystoscope or proctoscope for stage IVA      
  Stage IVA patients Patients who had cystoscope or proctoscope before the treatment 87/174 50.0% (42.3–57.7)
QI9 Curative radiation therapy using brachytherapy      
  Patients who had curative radiation therapy without surgery Patients who had brachytherapy 1,211/1,536 78.8% (76.7–80.9)
QI10* * Post-treatment maintenance therapy using oral      
  chemotherapy      
  Stage I or II patients who had surgery, radiation or CCRT for the first time. Patients who used oral chemotherapy 28/2,313 1.2% (0.8–1.7)

CI, confidence interval; CIN3, cervical intraepithelial neoplasia 3; CCRT, concurrent chemotherapy and radiation therapy; QI, quality indicator.

* Treatment modality defined as not recommended.

Table 3.
Adherence rates for PCIs
PCIs Target patients (denominator) Specified care (numerator) No. Adherence rate (95% CI)
PCI1 Total hysterectomy for CIN3      
  CIN3 patients who are over age 50 years Patients who had total hysterectomy 562/1,188 47.3% (44.4–50.2)
PCI2 Post-operative CCRT for pN1      
  pN1 patients who had surgery without preoperative Patients who had post-operative CCRT 163/368 44.3% (39.1–49.5)
  chemotherapy      
  JSGO guideline recommendation for the denominator population: CCRT    
PCI3 Post-operative therapy for pN1      
  pN1 patients who had surgery without preoperative Patients who had adjuvant chemotherapy without CCRT as 162/349 46.4% (41.1–51.8)
  chemotherapy post-operative therapy    
  JSGO guideline recommendation for the denominator population: CCRT    
PCI4 Post-operative therapy for pN0 or pT1      
  pN0 or pT1 patients who had surgery without preoperative Patients who had adjuvant chemotherapy without CCRT as 248/469 52.9% (48.2–57.5)
  chemotherapy post-operative therapy    
  JSGO guideline recommendation for the denominator population: radiation therapy (CCRT)    
CI, co Onco onfidence interval; CIN3, cervical intraepithelial neoplasia 3 ology; PCI, pattern-of-care item. 3; CCRT, concurrent chemotherapy and radiation therapy; J SGO, Japan S Society of Gynaecologic
Table 4.
Reasons for non-adherence to specified care* (47 hospitals)
QI QI descriptor No. of patients QI score (%) Sufficient reasons (%) Insufficient reasons (%)
Comorbidities Referral Patient preference Errors in data Other Unknown
QI3 Radical hysterectomy for stage II adenocarcinoma 12 67.7 41.2 – 8.3 8.3 16.7 25.0
QI4 CCRT as the first-line treatment for stage III or IVA 66 55.1 63.6 6.1 12.1 3 6.1 9.1
QI5 CCRT using cisplatin for stage III or IVA 15 79.9 66.7 – 6.7 – – 26.6
QI8 Cystoscope or proctoscope for stage IVA 14 50.0 7.1 14.3 7.1 7.1 7.1 57.1
QI9 Curative radiation therapy using brachytherapy 59 78.8 30.5 18.6 6.8 1.7 30.5 11.9

CCRT, concurrent chemotherapy and radiation therapy; QI, quality indicator.

* Reasons cited for less than 10 patients were excluded from the list.

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