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Access to PET/CT Scans Methodology

PET/CT Scan prior to radical treatment – Non Small Cell Lung Cancer
Short description of Indicator ​Percentage of non-small cell lung cancer patients (NSCLC) who had PET scan prior to radical treatment such as radiation, surgery or combined with radical intent systemic treatment in Ontario
Rationale for measurement NSCLC patient should receive a PET scan to confirm disease is localized before patient proceeds to any radical treatments (radiation, surgery or combined with radical intent systemic treatment were being considered)
Evidence/references for rationale This is the standard of care in Ontario.
Calculations for the indicator Rate of NSCLC patients who had PET scan prior to radical treatment = (Number of NSCLC cancer patients who had PET scan prior to radical treatment(s) ÷ Number of NSCLC cancer patients who received radical treatment(s)) x 100
Standardized Rate Calculation N/A
Unit 100
Data sources
  • Cancer Care Ontario, Ontario Cancer Registry
  • Discharge Abstract Data (DAD)
  • National Ambulatory Care Reporting System (NACRS)
  • Registered Person Database (RPDB)
  • Activity Level Reporting (ALR)
  • Ontario Health Insurance (OHIP) ÷
  • Postal Code Conversion File (PCCF)
  • PET Access
  • PET Registry
Time Frame Patient diagnosed from January 2013 to December 2017
Geographic Scale Provincial
Denominator description Number of non-small cell lung cancer patients diagnosed from January 2013 to December 2017; was also receiving radiation/systemic treatment or surgery for curative intent:
  1. Diagnosis Cohort:

    Inclusion Criteria
    • Use topography code = 'C34' to identify any patient who diagnosed with lung cancer
    • Patient diagnosed with lung cancer between January 01, 2013 and December 31, 2017
    • Use histology codes from Disease Pathway Management (DPM) to differentiate small cell carcinoma cancer, non-small cell lung cancer and unspecified malignant; only non-small cell lung cancer will be included
    • Patient was diagnosed at age 19 or older
    • Postal codes for LHIN of residence in geographical variation analysis are based on postal codes found in RPDB


    Exclusion Criteria

    • Patient with missing or invalid health card number
    • Method of confirmation code = 8 (Clinical Diagnosis only) and 9 (Unknown whether or not microscopically confirmed; death certificate only), similar to DPM lung concordance indicator
    • Patient with multiple primaries (regardless of whether the second primary was lung related or another disease site, about 35.2% of lung patients had multiple primaries)
    • Out of Ontario residence
  2. Intervention Cohort:

    Inclusion Criteria
    • Use Lung Resection procedure codes list that was used for DPM concordance indicator to define lung resection
    • Patient who died after surgery 
    • Patient who received surgery within 3 months prior to the diagnosis and within 6 months after diagnosis
    • If a patient received more than 1 surgery, only the first surgery was included
    • Patient also found in Diagnosis cohort
  3. Radiation Treatment Cohort:

    Inclusion Criteria
    • Patient received radiation treatment within 3 months after being diagnosed
    • Clinical practice group = LUNG
    • Radical treatment intent only (i.e., adjuvant, curative and neoadjuvant)
    • Active treatment record (i.e., ALR methodology key = 4)
    • Patient also found in Diagnosis cohort
  4. Systemic Treatment Cohort:

    Inclusion Criteria
    • Patient received systemic treatment within 3 months after being diagnosed
    • Clinical practice group = LUNG if record found in ALR
    • Radical treatment intent only (i.e., adjuvant, curative and neoadjuvant) if record found in ALR
    • Active treatment record (i.e., ALR methodology key = 4)
    • Patient had ICD10 code = Z51.1 if record found in National Ambulatory Care Report System (NACRS)
    • Patient had CCI code = 1.ZZ.35.^^ if record found in Discharge Abstract Database (DAD)
    • Patient also found in Diagnosis cohort


    Exclusion Criteria

    • Patient only receiving radical systemic treatment, but no other radical treatment (i.e., no radiation treatment and no surgery) will be excluded
Numerator description Number of lung cancer patients who received radical treatment:
  1. Patient diagnosed with non-small cell lung cancer between CY2013 and CY2017 also receiving radical treatment(s)
  2. Patient received PET scans that occurred before radical treatments when:
    - within 6 months before surgery
    - within 3 months before radiation treatment or
    - within 3 months before systemic treatment
  3. If the patients had more than 1 PET scan, then the PET scan that occurred closest to the date of first treatment will be used for analysis.
  4. All PET scans will be considered (the PET scan may have been OHIP encoded as esophageal, SPN etc., but – if it occurred prior to lung treatment it would still have contributed to appropriate staging; there wouldn't be any difference in technique)

Confidence intervals are based on the 95% upper and lower confidence limits for the rates.

Considerations The accuracy of these measures depends on accurate reporting of PET scans and any data source that used for defining treatment cohort.
Data availability & limitations Since NACRS does not collect treatment intent information, the record found in NACRS will be assumed as:
  1. NOT a Radical Intent if the NACRS record was on or after a palliative intent systemic treatment in ALR
  2. Radical Intent otherwise

Assumed patient received 2 PET scans when the PET scan date recorded in PET registry database is different from the service date in OHIP database.

CSQI Year 2019