Quality of End-of-Life Care for People with Advanced Non-Small Cell Lung Cancer in Ontario: A Population-Based Study

Round 1

Reviewer 1 Report

Quality of end-of-life care for people with advanced non-small 2cell lung cancer in Ontario: A population-based study

Interesting analysis but I have several concerns

1. Method section: Why the authors add mental health symptoms within 30 days of death. This indicator is not usually used in EOL studies. Authors should give some reference.
2. Results: it’s not clear why the authors start the inclusion period in 1964 and why they don’t start in January 2009 to have a more homogenic period; between 1964 and 2018 there was a lot of changes….Can you confirm the date of 1964 and reported the reason to choose this period.
3. Deaths in hospital is the major Individual indicators of aggressive care. I suggest performing an sensitivity analysis excluding this indicator from the list defining aggressive care to check if results change or no.
4. Discussion section: some studies publish since 2010 should be discuss when the authors benchmark the rate of aggressive cares ie: Bylicki O, Clin Lung Cancer. 2021; .Colombet I,.BMC Palliat Care2019; Cheung MC, Cancer2015; Garrido MM,.J PainSymptom Manage2016
5. Discussion section: why the Prevalence estimates (7.49%) for this cohort were lower than have been 321previously described in longitudinal studies of patients with lung cancer [31, 32] ?

 

 

Minors comments

Introduction: the authors give the incidence of lung cancers in Canada. The incidence in Ontarion will be also relevant to report.

Results:

The authors reported the mean number of months between cancer diagnosis and death, but the median will be more relevant.

Table 1: place of residence is not useful, as we don’t know we do not know the meaning of the numbers

In the table 1, is difficult to find the 17,535 patients who did not receive palliative intent anticancer treatment,

Results section “patients who received aggressive care were 265slightly younger (70.9 versus 72.7 years),” can you give comment in the text the HR reported in table 3

Table 3: again, place of residence is not informative for the readers as we don’t know the meaning of the numbers

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the opportunity to review this paper which is very well written and comprehensively documents an important population wide issue of quality of end of life care.

I have just a few comments for consideration which I believe would improve the manuscript:

The paragraph ‘classification of variables’ has a sentence which is slightly ambiguous:  “NSCLC patients who died of cancer into individuals who did and did not receive palliative intent anticancer treatment (including systemic therapy, radiotherapy or surgical metastasectomy).”  Does this mean that surgical metastasectomy is a palliative intent treatment?  This may be the case but also it may be the resection of a single metastasis with a (hoped for) curative intent.  Later there is more discussion of this but perhaps it could be clarified here.

Line 147 – it is not clear why not just include those with metastatic disease as the cohort? This would enable clarity of the intention of treatment and might allow different understanding of the associations.

Line 173 in the classification of dependent variables:  I am interested if you might explain the decision to code palliative care according to:  “These codes identify palliative care consultation from a physician who spends a minimum of 50 mins with them and/or their representative/family”.  I am unclear why the consultation needs to be at least 50 mins to be included?  In my clinic appointments are booked ½ hourly and while new patients may take up to an hour, they may take less.  Could this please be clarified.  Further, could you specify ‘first palliative care consultation’  - which is not highlighted here or elsewhere in the manuscript yet I understand this is what you seek to examine when considering contact with palliative care in relation to time from death.

Methods:   A new quality of end of life variable is introduced:  mental health symptoms within 30 days of death.  Some additional explanation about what this means, how it is defined ie presence of what and how recorded / coded is needed so that the reader can understand how/why this should be considered to be part of the Quality of end of life index.  

In Table 1,

• it is not clear what “Place of residence (LHIN) at death date “ refers to. Could more detail be provided on this for an international audience or perhaps it may be omitted altogether.
• I am unclear what was trying to be explained in the section headed: Number of months from first cancer diagnosis to palliative intent treatment .  Were you interested in a quality index of how quickly treatment was given?  Also some will have 'curative treatment before and then will have palliative treatment? So I aam not clear what you are seeking to demonstrate/explore.
• Prior adjuvant systemic therapy or concurrent chemoradiation and Palliative systemic therapy, radiotherapy and metastasis surgery – again could you please explain what you are hoping to demonstrate here? Is it number of people who had any adjuvant xxxxx  or any palliative systemic therapy etc xxxx.  ‘Prior to death’ in both instances is redundant.
• What was the median survival overall of the group?

 

Table 2

• It would be useful to explore the associations of access to palliative care and timing of access to palliative care according to the palliative intent vs no palliative intent treatment (Table 2).

Table 3 is a very large table.  It would be helpful if those key variables of interest and significance are highlighted – to assist the focus of the less committed reader.

Typo line 302:  This shift is likely the result of better symptom(s) control, changing practice patterns and the emergence of seminal research…

The discussion is largely a focus on local implications and benchmarks, yet there is an opportunity to heighten the interest and also to benchmark against similar international data from broadly similar health systems.   For example in Australia Philip et al Med J Aus 2015, 202(3):139-43;  And in Belgium:  Verleye et al. Eur J Cancer Care 2018; 27(1): e12747

 

 

 

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

no more commentss

 

thanks for yours responses