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William K. Evans, Melissa C. Brouwers and Chaim M. Bell

The global increase in cancer has fueled a large investment into research for more effective treatment strategies. The payoff from this investment has been a knowledge explosion that is overwhelming to the average oncologist. In response, a knowledge-synthesis industry has developed that uses the tools of systematic searches and standardized analytic processes to make sense of the large volume of frequently contradictory literature. Experts review the evidence and provide interpretation in the context of their professional values to guide their colleagues in clinical practice. Typically, guideline developers focus on questions of clinical effectiveness and efficacy, but rarely, if ever, consider the budgetary impacts of implementing the guideline or the cost-effectiveness of a new treatment. This issue of JNCCN focuses on guidelines for small cell and non-small cell lung cancer produced by the NCCN; neither of these guidelines mentions cost. In this commentary, we look at guideline development processes in general and specifically in Ontario, Canada, to consider the question: Is this an important omission or an irrelevancy? For more than a decade, a multidisciplinary Lung Disease Site Group (LDSG) in the province of Ontario, Canada, has developed practice guidelines through Cancer Care Ontario's Program in Evidence-Based Care (PEBC), based at McMaster University. The LDSG has produced 25 clinical practice guidelines (CPGs), including 12 for non-small cell lung cancer and 4 for small cell lung cancer. Guidelines were also developed for each of the 8 new chemotherapeutic agents introduced since 1995 for the treatment of lung cancer, the radiotherapeutic management of...
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Lauren Lapointe-Shaw, Hani Abushomar, Xi-Kuan Chen, Katerina Gapanenko, Chelsea Taylor, Monika K. Krzyzanowska and Chaim M. Bell

Background: Patients admitted to the hospital on weekends experience worse outcomes than those admitted on weekdays. Patients with cancer may be especially vulnerable to the effects of weekend care. Our objective was to compare the care and outcomes of patients with cancer admitted urgently to the hospital on weekends and holidays versus those of patients with cancer admitted at other times. Materials and Methods: This was a retrospective study of all adult patients with cancer having an urgent hospitalization in Canada from 2010 to 2013. Patients admitted to hospital on weekends/holidays were compared with those admitted on weekdays. The primary outcome was 7-day in-hospital mortality. We also compared performance of procedures in the first 2 days of hospital admission and admission to critical care after the first 24 hours. Results: 290,471 hospital admissions were included. Patients admitted to hospital on weekends/holidays had an increased risk of 7-day in-hospital mortality (4.8% vs 4.3%; adjusted odds ratio [OR], 1.13; 95% CI, 1.08–1.17), corresponding to 137 excess deaths per year compared with the weekday group. This risk persisted after restricting the analysis to patients arriving by ambulance (7.1% vs 6.4%; adjusted OR, 1.11; 95% CI, 1.04–1.18). Among those who had procedures in the first 4 days of admission, fewer weekend/holiday-admitted patients had them performed in the first 2 days, for 8 of 9 common procedure groups. There was no difference in critical care admission risk after the first 24 hours. Conclusions: Patients with cancer admitted to the hospital on weekends/holidays experience higher mortality relative to patients admitted on weekdays. This may result from different care processes for weekend/holiday patients, including delayed procedures. Future research is needed to identify key outcome-driving procedures, and ensure timely access to these on all days of the week.