bluuebunny/crossref_metadata_2025 huggingface dataset:
Identifying the surgical cavity following oncoplastic breast surgery.
Authors: Cross Michael , Lebovic Gail , Stubbs James , Ross Joe , Jones Scott , Beck Thad
Published: February 2017

81

Background: Oncoplastic surgery (OPS) has improved outcomes for partial mastectomy. However, tissue rearrangement poses challenges in the post-operative management of these patients. In most cases, these patients will require post-operative radiotherapy. Accurately visualizing the surgical cavity can be particularly troublesome in patients who have oncoplastic closure of the resection cavity. Recent advances have made it feasible to perform external beam radiation using advanced methods, but these are not commonly used for breast cancer. This is due to the difficulty in identifying the exact area of the surgical site. In this series of patients, a novel method for marking the surgical site when using oncoplastic techniques was evaluated. Methods: 65 patients had a 3-D tissue marker implanted at the time of lumpectomy. All patients were candidates for partial mastectomy and local breast reconstruction using OPS. Post-operative treatment plans for radiation and/or adjuvant chemotherapy were completed. Patients were evaluated with standard breast imaging methods for treatment planning. Results: The marker was easily identified and clearly delineated within the lumpectomy cavity. It provided 3-D characterization of the borders surrounding the cavity, and was easily distinguished from seroma and other tissue changes. Respiratory motion was easily tracked using the device making it possible to use IMRT and accelerated protocols. Use of the marker resulted in treatment volumes that were reduced by an average of 50% when compared to standard methods. In appropriate patients when the marker facilitated an accelerated protocol, total treatment time was decreased to 5-7 days. No complications were reported, and overall patient outcomes were excellent. Conclusions: This novel 3-D marker was consistently visualized without difficulty, was readily incorporated into standard practices and had appreciable benefits when designing optimal treatment plans. Its unique features were helpful in all cases, but particularly useful when using oncoplastic techniques to reconstruct the breast with local tissue flaps.
Contralateral mastectomy in young women with breast cancer: A population-based analysis of predictive factors and clinical impact.
Authors: Bouchard-Fortier Antoine , Baxter Nancy N. , Fernandes Kimberley , Camacho Ximena , Quan May Lynn
Published: February 2017

82

Background: Contralateral mastectomy (CM) has recently been shown to be associated with survival benefit in women with breast cancer. The objectives of the present study were to describe factors predictive of CM in young women (≤35 years old) with invasive breast cancer and evaluate its impact on survival, in a large population based cohort. Methods: All women diagnosed with invasive breast cancer aged ≤35 from 1994 – 2003 treated with mastectomy were identified from the Ontario Cancer Registry. Patient demographics, complete tumour and treatment characteristics were abstracted from primary chart review. Cox proportional hazard regression was performed to assess factors associated with performance of CM and its effect on recurrence and overall survival, performance of CM was modeled as a time varying co-variate. The models were controlled for known predictors including age, tumor size, nodal status, ER/PR, LVI, histologic grade, systemic therapy and adjuvant radiation. Results: There were 628 women identified. Of these, 101 underwent a CM (16.1%). On multivariable analysis, factors predictive of CM were negative lymph node status (HR: 1.74, 95% CI [1.052-2.872]; p-value = 0.031) and negative estrogen receptor status (HR: 2.7, 95% CI [1.314-5.736]; p-value = 0.007). After a median follow up of 11 years, no significant survival benefit was observed in women undergoing CM compared to those who did not (HR: 0.95, 95% CI [0.61-1.46], p-value = 0.80). Conclusions: Performance of CM in young women with invasive breast cancer did not result in a significant survival benefit, compared to those without CM. Factors found to be predictive of performance of CM negative lymph node status and negative estrogen receptor status. Further studies are needed to determine if a subset of young women might benefit from CM.
The effect of adjuvant radiation on survival for patients with resected localized or regional primary small cell carcinoma of the breast.
Authors: Hare Felicia , Patel Jashmin Kirankumar , Fenton Moon Jung , Martin Michael Gary
Published: February 2017

87

Background: Primary small cell carcinoma of the breast (SCCB) is rare and prognosis, the role of radiation therapy and outcomes are largely undefined. Methods: Using case listing session of SEER 18 (1973-2010) we examined outcomes for patients (pts) with SCCB. Analyses were conducted with SEER*Stat 8.1.2, Microsoft Excel 2007 and GraphPad Prism 6. Comparisons were made using the chi-squared test and log rank test (Mantel-Cox); all p-values were 2-sided. Results: 199 pts with primary SCCB with staging were identified; median age was 65 (range 28-97); 98% were female. 84 (42%) had localized disease (dz), 77 (39%) had regional dz and 38 (19%) had distant dz. 95% of pts with localized dz and 88% of pts with regional dz had breast surgery. Median overall survival (OS) varied by stage (150 months [m] v 56m v 7m, p<0.001) and radiation did not impact OS for pts with either localized (202m v 147m, p=0.477) or regional (52m v 75m, p=0.650) dz. For comparison 81,933 cases of small cell lung cancer (SCLC) were identified in SEER; 8% localized, 29%regional and 63% distant disease. Outcomes were superior for pts with SCCB with localized (150m v 16m, p<0.001) and regional dz (56m v 13m, p<0.001) but not distant dz (7m v 7m, p=0.043). Conclusions: SCCB presents at an earlier stage than and has a more favorable prognosis by stage for localized and regional dz than SCLC. Adjuvant radiation does not improve survival for patients with localized or regional SCCB.
A prospective evaluation of the relationship between bone mineral density and breast cancer.
Authors: Geffen David Barry , Novack Victor , Shafat Tali , Tokar Margarita , Lazarev Irena , Bogomolni Leonid , Troitsa Rita , Magidovich Hila , Liel Yair , Koretz Michael , Siris Ethel , Norton Larry , Shany Shraga , Fraenkel Merav
Published: February 2017

9

Background: Osteoporosis and breast cancer (BC) are each mediated by circulating estrogens. Insulin and insulin growth factors 1-2 have been linked to increased bone mineral density (BMD) and BC cell growth. The relationship between BMD and BC incidence has been analyzed in a number of retrospective studies with conflicting results. We have previously reported on a study of BC risk in 15,268 women who underwent BMD testing. Women in the highest Z-score tertile at the femoral neck had a higher risk of developing BC compared to those in the lowest tertile (OR 2.15, p = 0.004). The current study was undertaken in order to determine whether there is a direct correlation between BMD and BC when evaluated prospectively. Methods: This case-control study is planned to include 400 consecutive patients (pts) with newly diagnosed BC and 800 matched controls without BC. Pts and controls undergo BMD examination using dual photon technology. Serum is obtained for vitamin D, calcium, and a panel of bone turnover markers and cytokines. Pts and controls are interviewed and a questionnaire about BC and osteoporosis risk factors is completed. Results: We present clinical and BMD data from the first 200 BC patients recruited to the study. Median age 60, interquartile range 49.5-66. Body Mass Index: 28.4 ± 5.4 (mean ± SD). Postmenopausal: 148 patients, 74%. T-scores (mean ± SD): femoral neck: -0.68 ±-1.10, total hip: -0.28 ± 1.17, L1-L4: -0.52 ± 1.39. T-score of less than minus 2.5 (cut-off for osteoporosis) at any of the 3 sites, 24 (11.9 %) pts. Estrogen receptor pos: 162 (81%).BC stage: T0-T2, 175 (87.5 %). N0: 108 (54.5%), N1-2-3: 86 (43.4%). % pts node pos (N1-2-3) in each T score range: ≤ -2.5, 20%; -2.5 < T score ≤ -1,36%; -1 < T-score ≤+ 1,50%; +1 < T-score, 60%. % pts low grade in each T score range: ≤ -2.5, 25%;-2.5 < T-score ≤ -1,35%;-1 < T-score ≤ +1,37 % ;+1 < T-score, 20%. Conclusions: Only 11.9% of the first 200 BC patients studied had osteoporosis by BMD at diagnosis.Pts with higher BMD showed a trend for more nodal involvement. Pts with T-score > +1 had fewer cases of low grade histology compared to pts with lower T-scores. These preliminary results hint that higher BMD may be associated with more aggressive BC.
The significance of margin status in patients with DCIS undergoing breast-conserving surgery.
Authors: Gentile Rachel , Currey Adam D. , Forrester Jared , Tuyishimire Bonifride , Lin Jonathan , Kong Amanda L.
Published: February 2017

98

Background: Recently, SSO/ASTRO published a consensus statement on margins for stage I and II invasive breast cancer treated with breast conserving surgery (BCS). We examined patients with ductal carcinoma in situ (DCIS) who underwent BCS to determine the effect of clinicopathologic and treatment factors including margin status, on locoregional recurrence (LRR), breast cancer-specific (BCSS) and overall survival (OS). Methods: From 2003-2010, we conducted a retrospective chart review of 253 consecutively diagnosed patients who underwent BCS for DCIS. Clincopathologic and treatment data were extracted. Margin status was defined by pathology reports with a negative margin as ≥ 2mm, close margin < 2mm and positive margin as tumor on ink. Clinicopathologic variables were tested using the Fisher’s exact test, Chi-square test, ANOVA F-test, and Kruskal-Wallis test. A Cox proportional - Hazards model was used to calculate the impact of these factors on LRR, BCSS and OS. Results: The median age of the cohort was 57 (range 21-89) and the majority were white (79%), ER+ (78%) and underwent radiation therapy (67%). Forty six percent took anti-endocrine therapy. Of 252 patients, 29% had close margins, 63% had negative margins and 7% had unknown margins. One patient had a positive margin and was alive without disease at last follow-up. At a median follow-up of 5 years, OS was 96%. Thirteen patients experienced a LRR with a median time to recurrence of 4.9 years (5 with close margins, 7 with negative, 1 unknown). On multivariate analysis, age and PR status were significant predictors of LRR. Patients with age >70 were more likely to recur than those age 50-69 (HR 6.7 95% CI (1.7-25.4) p= 0.005) as were patients with PR negative tumors (HR 5.7 95% CI (1.7-19.5) p= 0.005). Those patients who did not receive radiation therapy had a worse OS than those who did (HR 4.3 95%CI (1.5-12.6) p = 0.007). No variables were significant for BCSS. Conclusions: In this cohort of patients with DCIS treated with BCS, age and PR status were the only predictors of LRR. OS was only impacted by receipt of radiotherapy. Margin status was not predictive of LRR, BCSS or OS. This data suggests that routine re-excision for close margins may not be warranted.
Novel data sharing between a comprehensive cancer center and a private payer to better understand care at the end of life.
Authors: Stuver Sherri Oliver , Fraile Belen , Donohue Caitlin C. , Odejide Oreofe Olukemi , Abel Gregory Alan , Dodek Anton , Fallon John A. , Jacobson Joseph O.
Published: February 2017

1

Background: Assessment of care at the end of life (EOL) is critical to improving the quality of care for oncology patients. EOL measures based on guidelines from the National Quality Forum (NQF) and ASCO have been examined in older cancer patients using Medicare claims. We performed a project to evaluate the use of private payer claims data to enumerate EOL measures in patients of all ages at a comprehensive cancer center. Methods: Claims data were obtained for Dana-Farber Cancer Institute (DFCI) adult patients who died between July 1, 2010, and December 31, 2012, and were insured by Blue Cross Blue Shield of Massachusetts (BCBSMA). We assessed NQF-based measures related to hospitalizations, emergency department visits, and intensive care unit admissions in the last 30 days of life, chemotherapy in the last 14 days, hospice stay, and death in a hospital. In addition, we examined red blood cell and platelet transfusions, radiation therapy, and surgery in the last 30 days of life, as well as death in the ICU. Results: Of a total of 674 patients, 580 had solid tumors and 82 had hematologic malignancies; their median age was 59 years (range, 18-92). The Table provides results for the EOL measures examined. Up to 50% of the measured events did not occur at a DFCI-affiliated hospital. Conclusions: Using private insurance claims data in conjunction with medical records, we were able to successfully capture a broad range of EOL quality measures. Access to the claims data provided information not readily available in hospital medical records and for care not occurring at DFCI. Data sharing between private payers and cancer centers may provide a unique method of comprehensively examining quality of EOL care for oncology patients. [Table: see text]
Converting a clinical indicator on patient missed treatments into a functional quality improvement metric.
Authors: Harrison Amy S. , Doyle Laura A. , Hurwitz Mark , Babinski Lilya , Williamson Jamie , Dicker Adam , Yu Yan , Anne' Rani , Den Robert Benjamin
Published: February 2017

101

Background: Extended time to complete a course of radiation can be detrimental to a patient’s overall local tumor control and survival. The American College of Radiology (ACR) Radiation Oncology Practice Guideline requires review of any unplanned interruptions during treatment. However, factors that impact missed treatments are neither required to be reviewed nor well characterized within the literature. We sought to understand the variables contributing to missed treatments by generating a functional metric for quality improvement. Methods: The departmental electronic medical record (EMR) was modified to create sub-sets of classifications for missed treatments. These categories were divided into intended and unintended breaks, with intended classification of physician prescribed break and eight subcategories of unintended breaks: patient preference, physician mandated, patient feels ill, transportation/social services, cancelled, no-show, weather, and machine downtime. Missed treatments were documented real-time by the treating radiation therapists using one of these eight categories. A custom report was generated to extract and separate missed treatments by category. Results: Over three years of ACR tracking, our department missed treatment rate ranged from 5-10%, out of 64,000 patient treatments. The new subcategory metric has been in place for the past six months. Overall compliance with documentation by therapists was 100%. The new metric yielded a six month total rate of missed treatments of 8% with detailed analysis showing the main reasons as: patient preferences (14%), inclement weather (14%), and machine down time (9%). Transportation was only a minor issue for the patient population. Conclusions: This stratification of a simple clinical indicator has identified the major factors influencing the total time to complete a course of treatment. Based on this analysis, our departmental quality committee is focusing on engaging and educating patients about the negative impact of missed treatments on their overall cancer care. Future research will attempt to identify patient characteristics that may predict individuals more likely to miss treatments.
Socioeconomic status and recurrent emergency visits amongst chemotherapy patients.
Authors: Kapil Priyanka , Enright Katherine
Published: February 2017

106

Background: Multiple studies have found that cancer patients undergoing cytotoxic chemotherapy have a high rate of emergency department (ED) utilization throughout the course of their treatment and up to 20% of patients have recurrent ED visits. We assessed the effect of socioeconomic status (SES) on recurrent ED visits for infectious causes amongst chemotherapy patients. Methods: All patients who visited the Peel Regional Cancer Centre ED within 30 days of receiving cytotoxic chemotherapy between 04/12 - 3/13 were identified. Patients were included in the study if their primary reason for presentation was either fever or infection. Postal codes were cross-matched against 2011 census data from Statistics Canada to obtain estimates of income, education, and occupation. The impact of SES factors on the likelihood of multiple ED visits was analyzed. Results: 239 patients with at least 1 visit to the ED for infection were identified. Of these patients 103 (43.1%) had recurrent ED visits. Patients from areas with a higher proportion of arts, sports, culture, recreation, agriculture, and natural resources employment had a significantly (p<0.02) lower incidence of recurrent visits compared to single visits. Patients from areas with a lower proportion of healthcare, natural sciences, and applied sciences employment had a significantly (p<0.04) lower incidence of recurrent visits compared to single visits. Patients from areas with a greater proportion of people for whom the highest education completed was only high school had a significantly (p= 0.01) lower incidence of recurrent visits compared to single visits. Conclusions: Instead of observing a higher rate of ED visits for infection among patients with lower SES, patients residing in areas of lower education or in areas with a higher proportion of employment in fields associated with lower SES were less likely to have recurrent visits. It remains unclear if this represents decreased adherence to fever recommendations in patients with lower SES or over usage of ED services in patients with higher SES. Further studies are planned to better understand these observations to help inform educational interventions and community-based monitoring aimed at decreasing the risk of ED visits.
Provider perceptions of a cancer quality program.
Authors: Holcombe Randall F.
Published: February 2017

112

Background: In 3/2011, The Tisch Cancer Institute at Mount Sinai implemented a cancer quality program This involved the establishment of several new committees including a QI committee and a chemotherapy council focused on the provision of evidence-based treatment regimens, implementation of an EMR (7/2011) and an electronic chemotherapy ordering platform (3/2012), relocation to a new practice facility (10/2012) with a focus on operational efficiency and multidisciplinary care, creation of new nursing and pharmacy policies & procedures and successful achievement of quality certifications including Magnet, QOPI and ACOS. We wished to evaluate provider perceptions of the quality initiatives that had been implemented over the past 3 years. Methods: A 10-question survey was distributed to physicians, nurses (practice and infusion), mid-level providers and oncology pharmacists. There were 80 respondents (MD-32, RN/NP-39, Pharm-9) which represents ~50% of providers in the cancer program. Results: Overwhelmingly, the “best measure of quality” (68% of respondents) was felt to be patient outcomes, not achieving standardized benchmarks, high patient satisfaction scores or certifications. 29% felt that use of evidence-based protocols was the best measure of quality care delivery. Initiatives with the greatest impact on quality were implementation of an EMR and the QI committee. Operational efficiency was felt to be the most important influence on patient experience. Certifications felt to be a reflection of quality care delivery were (in order): QOPI, Magnet (#1 for RN/NPs), ACOS. Only 6% cited Leapfrog. Factors most important for the quality delivery of chemotherapy included certified infusion RNs, electronic chemotherapy ordering, defined nursing and pharmacy protocols and MD/mid-level oversight. 35% felt that patient satisfaction scores were a good measure of quality while 28% felt that patient satisfaction scores were either overemphasized or a poor measure of quality. Conclusions: This survey defines provider views on new quality-focused initiatives and their impact on the quality of patient care delivery for a large, academically-based oncology program. This information can be utilized to inform future initiatives at Mount Sinai and other centers.
A quality outcomes analysis following treatment with personalized genomic cancer medicine.
Authors: Nadauld Lincoln , Perkins Bryce , Stone Gary , Gilbert Heather , Tudor Brian P. , Lin Karen Yin , Ford James M. , Haslem Derrick S.
Published: February 2017

12

Background: Personalized genomic cancer medicine is an approach that has long shown efficacy in molecularly-defined subsets of breast and lung cancers, amongst others, but has not been employed more broadly, in part, due to limitations in testing technologies. Recent advances in genomic technologies have increasingly alleviated these constraints, thereby enabling precision cancer medicine. Data regarding the quality outcomes of patients treated with precision cancer medicine is an important next step along the path to widespread employment of this approach. Methods: We performed an IRB-approved retrospective analysis evaluating the use of targeted therapies matched to patients’ molecular aberrations as determined by genomic testing and recommended by a Molecular Tumor Board (MTB). This study assessed whether a detailed molecular profile of advanced solid malignancies including, but not limited to, the lung, gastrointestinal tract, bladder, prostate, ovary, uterus and skin, that were subsequently treated with matched targeted therapies resulted in improvements in three quality outcome measures: 1) Progression Free Survival (PFS), 2) treatment related morbidity, and 3) cost of treatment. Results: Preliminary results of the cohort analysis suggest that the costs associated with genomic targeted therapy are comparable to standard therapies; however, the costs of treatment related morbidities is significantly lower for patients receiving genomic cancer medicine compared to standard chemotherapy approaches. In line with these findings, overall treatment related morbidities are significantly reduced in the genomic cancer medicine cohort compared to a control cohort. Data regarding the Progression Free Survival are pending at the time of this report. Conclusions: These retrospective data suggest that personalized genomic cancer medicine approaches result in decreased morbidities and cost savings compared to standard chemotherapeutic approaches. In patients with advanced cancer, genomic-based treatments appear to be cost-effective, safe and viable option for treating advanced cancer patients. Additional data regarding survival outcomes are required to determine efficacy of treatment.
Developing a standardized protocol for the prescription of oral chemotherapy.
Authors: Shah Nirav Niranjan , Capozzi Donna L. , Casella Erica , McGettigan Suzanne , Gangadhar Tara C. , Schuchter Lynn Mara , Myers Jennifer
Published: February 2017

120

Background: Over the last 10 years there has been a dramatic increase in the use of oral chemotherapy in the treatment of cancer. However, despite the route of administration, oral chemotherapies carry many of the same risks as intravenous agents and may have greater risks of drug-drug interactions due to variability in absorption and metabolism. Due to these risks, ASCO included oral chemotherapy as part of their updated chemotherapy safety standards in 2013. With this in mind, we sought to examine and improve the reliability and safety of the oral chemotherapy prescription process at the Abramson Cancer Center (ACC) of the University of Pennsylvania. Methods: A multi-disciplinary quality improvement team consisting of oncologists, nurse practitioners, and pharmacists was formed to analyze the current state of our oral chemotherapy practice. We identified an absence of signed informed consent and lack of pharmacist prescription review as areas for improvement. To address these deficiencies, we electronically routed our oral chemotherapy orders to an oncology specific pharmacist for review and implemented a policy change requiring that oral chemotherapy have signed informed consent. These changes were applied to the melanoma group of the ACC. Results: Over a 3 month time period, 33 orders for oral chemotherapy were placed for 18 individual patients. Signed informed consent was obtained in 9 of 18 patients (50%). Of the 33 orders, all were reviewed by ACC pharmacists, and as a result, 11 interventions were made by these providers (33%). Types of interventions included dose adjustment (9%), modification of an interacting drug (27%), and additional monitoring specific to the oral agent (64%). Conclusions: Despite its route of administration, oral chemotherapy should be prescribed and reviewed with the same oversight as intravenous chemotherapy. At our institution, involvement of an oncology specific pharmacist in the review of oral chemotherapy led to meaningful interventions in about 1/3 of orders, and with a policy change, signed informed consent was performed in 1/2 of patients. Given these findings, and the clinical implications of this pilot, we plan to continue to study and disseminate this intervention throughout our cancer center.
Quantifying physician performance using peer review during prospective contouring rounds.
Authors: Cox Brett Wayne , Chou Henry , Kapur Ajay , Goode Gina M. , Antone Jeffrey , Sharma Anurag , Potters Louis
Published: February 2017

125

Background: This study presents the results of a physician evaluation system (PES) associated with a novel prospective contouring rounds (CR). Traditional chart rounds in radiation therapy (RT) occur after treatment planning and initiation of therapy. In CR, peer review occurs at a more logical process-point, once the contours and written directive (WD) are completed, but before initiation of treatment planning. We previously reported that CR improved quality of care, with the percentage of timely, errorless cases increasing over time. Methods: Starting 9/12, all patients undergoing RT at a high-volume academic center were reviewed in a daily prospective CR attended by physicians, medical physicists, and therapists. The clinical suitability for RT, contours, prescription, and remainder of the WD were prospectively peer reviewed. PES was implemented in 9/13, with each case receiving a grade (A = no deficiencies, B = minor modifications of PTV,OARs, WD, or a prescription/WD mismatch, and C = incomplete contours, significant contour modifications, prescription changes, or laterality modifications). A's were cleared for planning. B's were cleared for planning once remediated. C's were re-presented at CR upon remediation. Information was pooled to determine physician performance by assigning a grade point average. Results: 1,260 cases from 10 physicians have been reviewed using the PES. 25% of cases (318 patients) required modifications before treatment planning commenced. The breakdown of grades was 70% A’s, 18% B’s and 12% C’s. The average number of cases reviewed per day was 7. The median number of weekdays between contour completion and CR review was 0.8 days. The median contour grade point average was 3.6 (3.3 – 3.9). Conclusions: Peer review during a prospective CR can be used to develop physician performance metrics. 25% of all cases required modifications before starting treatment planning, and 12% of cases required significant remediation. Using the PES, several metrics can be combined to transparently quantify general physician performance. We intend to develop this PES to improve physician performance, optimize continuing medical education efforts, and integrate its use in PQIs for MOC.
Using an online portal and nurse navigators to improve access to cancer care between network hospitals.
Authors: Miller Eleanor , Rummel Margaret
Published: February 2017

126

Background: Nurse navigation-facilitated access to cancer care is an emerging trend in healthcare. One way to improve access to specialized cancer care is through nurse navigators in collaboration with affiliated network hospitals. The Abramson Cancer Center (ACC) has a network of 15 community hospitals in the tri-state area that provides patients access to an academic medical center for subspecialty care that is not always available the community cancer center. Methods: In 2010, a navigation referral process was developed using nurse navigators from the ACC and the network hospitals. Then in 2012, an online portal was developed to further streamline physician referrals to and from the ACC. Updates were made to the online portal in 2013 and 2014 for continued improvement. Results: Prior to the online portal, no central repository for network referrals existed to ensure that patients were scheduled with the correct provider(s). Now with the portal patients are referred, assessed, and scheduled with appropriate providers by the nurse navigator. This has increased accountability and streamlined the scheduling process. Now, patients can be seen by multiple providers during one visit to the ACC. It has also provided a network for the ACC nurse navigators to connect patients back to the community setting for ongoing care once consults or treatments at the ACC are completed. Since the navigation process was implemented, over 1200 patients have been referred (over 500 in the past year alone) for second opinions, clinical trials, proton radiation, bone marrow transplants, surgical options, and cutting- edge technology that may not have otherwise been available. Conclusions: Using nurse navigators at the core of the process ensures that patients are triaged and scheduled in a timely and medically-appropriate manner, thus enhancing their access to specialized cancer care.
Development of an evidence-based clinical pathway for patients undergoing pancreaticoduodenectomy.
Authors: Wei Alice Chia-chi , Devitt Katharine Sarah , Ahmed Mahrosh , Barretto Beverly , Kacikanis Anna , Gallinger Steven
Published: February 2017

130

Background: Pancreas cancer is the 4th cause of cancer death. Surgical resection is the optimal treatment. But pancreaticoduodenectomy (PD) is complex with high perioperative morbidity. Complications following PD have a negative effect on quality of life and survival. Clinical pathways (CPW) are quality improvement (QI) tools that standardize the processes of care. Our aim was to develop and implement an evidence-based CPW for PD in the province of Ontario, Canada. Methods: A CPW following PD was developed using the Knowledge-to-Action framework. All 9 high volume Hepato-Pancreato-Biliary (HPB) centers in Ontario were invited to participate in a needs assessments workshop to promote awareness and early agreement for a CPW. Enthusiasm for a CPW was confirmed. End user input was incorporated into a multidisciplinary CPW. Barriers and enablers to implementation were assessed. Evidentiary support for CPW elements was integrated into the final product. An active implementation strategy that addressed key barriers was developed to promote CPW adoption and adherence. Pilot testing was undertaken. CPW uptake, compliance, and impact on clinical outcomes were evaluated. Pilot results were used to design the final CPW product and implementation strategy. Results: The needs assessment confirmed variability of perioperative processes at all sites. Participants expressed interest for a CPW and consensus was obtained on essential CPW components. During a 15 month pilot phase, 83/122 (68%) of eligible patients were initiated on CPW. Subjects able to achieve the goals of the CPW had a shorter length of stay (7 vs 11 days), lower in-hospital complications (9, 22% vs 19, 45%) and readmission (6, 15% vs 11, 26%) compared to those who were unable to achieve CPW targets. The majority of CPW users reported that the CPW was easy to use (26, 93%) and did not adversely affect workload (20, 71%). Pilot data were used to finalize the strategy used to implement the CPW at all Ontario HPB centers. Conclusions: We report that introduction of a standardized CPW for complex cancer surgery is possible with early engagement of stakeholders. Initial results suggest that this standardized approach is safe and positively impact quality of surgical care.
A new model of care: An advanced practice radiation therapy role.
Authors: Lockhart Elizabeth , Gutierrez Eric , Warde Padraig Richard , Bak Kate , Zychla Laura , Bolderston Amanda , Lewis Donna , Smoke Marcia , Wenz Julie , Nagata Lynne , Ang Michelle , Harnett Nicole
Published: February 2017

131

Background: Due to the rising incidence of cancer, increasing complexity of cancer treatment and growing resource constraints, there is demand for innovative interprofessional models of care. Cancer Care Ontario (CCO), in collaboration with Ontario’s Ministry of Health and Long-Term Care, launched the Clinical Specialist Radiation Therapist (CSRT) project to investigate a new advanced practice (AP) radiation therapy (RT) role. Methods: A series of pilot phases commenced in 2004. A system wide implementation phase began in 2010. The overall goal of the project was to enable CSRTs to assume responsibility for certain key radiation medicine activities, optimize RT team functioning, and improve quality of care. This was to be achieved by applying advanced clinical, technical and professional RT competencies. A project team coordinated assessment of new position proposals, implementation activities, and data collection. Work towards formalizing the role is being conducted through partnerships with cancer centre administrations and the national professional association for RTs. Results: Currently there are 17 CSRTs in 6 of 14 Ontario cancer centres, practicing in palliative and disease-site specific positions. The provincial total will be 24 CSRTs in 10 centres by Fall 2014. Data show a major impact on patient throughput and wait times, with significant increased capacity in some clinics. CSRTs’ impact within their departments is being evaluated with regards to: 1) capacity building, 2) quality of care, and 3) knowledge translation (KT). In terms of role formalization, 6 positions are now considered permanent within their centres and the first iteration of a national certification process is anticipated for fall 2014. Conclusions: The CSRT project is aligned with CCO's priorities of improving Ontario’s cancer system performance by implementing innovative models of care and providing high quality care. This jurisdictional implementation project has demonstrated that an AP RT role can be successful in addressing system pressures and improving quality of care and innovation in Radiation Medicine. Further work is necessary to develop and formalize this AP role and leverage learnings for national implementation and future models of care work.
Incorporation of externally generated next-generation tumor genotyping into clinical and research workflows: Successes and lessons learned.
Authors: Rioth Matthew J. , Staggs David , Warner Jeremy
Published: February 2017

156

Background: The future of oncology will increasingly utilize information about tumor genomics. A growing number of tumor subtypes require genomic information as standard of care to inform treatment decisions. Clinical decision support (CDS) systems are able to improve healthcare and ensure best practices, but rely on machine-readable data. Typically, 3rd party genotyping results are returned in PDF reports that are not computable for standard presentation, CDS, or research purposes. Proposed oncology CDS platforms (such as CancerLinQ) will require computable tumor genomic information. Methods: A 3rd party CLIA-certified laboratory performed targeted exome tumor sequencing for a subset of cancer patients seen at Vanderbilt University (VUMC). The variants considered “actionable” were packaged into a standardized extensible markup language (XML) message and transmitted securely to a clinical server on a daily basis; the full PDF report was also transferred electronically. These messages were automatically received and parsed to match patients and display mutation data in their electronic medical record (EMR) for clinicians. This information was also placed into the VUMC Research Derivative (see Danciu et al. J Biomed Inform 2014 for more details). Results: The XML message, including specimen metadata, was successfully created by the 3rd party lab and received by VUMC after an iterative testing process was conducted. Clinicians were notified automatically when results were ready, within their EMR workflow. Because the primary purpose of the test is clinical, variants of unknown significance were not included in the XML transfer (these were however available in the PDF report). Conclusions: To our knowledge, this is the first demonstration of the automated incorporation of tumor genotype information from a 3rd party lab into a clinical EMR. Electronic transfer of genotype data enables rapid consumption of results by clinicians within their standard workflow, passive CDS (e.g. pointers to external knowledge bases), active CDS (e.g. standard and clinical trial treatment recommendations), and secondary use: all activities that improve the quality of cancer care.
Improving the efficiency of a block schedule for treatment planning simulation in a radiation oncology department.
Authors: Martin Neil E. , Potiris Spyros , Mersereau Robert , Mackin Mark J. , Jaehn Barbara A. , Nissen Kristopher , Nguyen Paul Linh
Published: February 2017

158

Background: The use of a weekly assigned block time schedule to allocate appointment slots to providers for treatment planning simulations caused appointment delays, provider frustration, and a perceived lack of capacity at the Dana-Farber/Brigham and Women's Cancer Center Department of Radiation Oncology. While providing predictability for physician schedules, the slots assigned to individual providers often could not accommodate their patient volume or patient availability. Consequently, providers in need of additional slots had to ‘borrow’ them from other providers. To increase schedule flexibility and reduce the need to ‘borrow’ slots, we proposed opening part of the weekly appointment slots for use by any provider. Methods: Historical data from the scheduling system were obtained to identify the weekly volume of appointment slots used by each provider within and outside their assigned time. Using these data we developed a mathematical model that allowed clinicians to convert a desired number of weekly assigned slots to slots open for use by any provider and examine the resulting effect on the number of ‘borrowed’ slots. The model illustrated the availability and usage of weekly assigned and open slots, as well as the number of ‘borrowed’ slots. Results: In the original schedule, 40% of the weekly appointment slots are ‘borrowed’. The mathematical model revealed that converting 38% of the weekly assigned slots to open slots would completely eliminate the need to ‘borrow’ slots. Conclusions: Data-driven, simple models can address complex problems in clinic operations. A mathematical model that illustrates the effect of opening slots in a block time schedule can help end-users increase efficiency in clinic, as well as eliminate provider and staff frustration, patient dissatisfaction, and delays. [Table: see text]
Moving to secondary use of IT solutions: A provincial “near miss indicator” for chemotherapy.
Authors: Kukreti Vishal , Teimoortagh Megan , Cheung Annie , Gradin Sharon , Gilks John , Rae Erin , Kaizer Leonard
Published: February 2017

161

Background: In Ontario, 93% of outpatient IV chemotherapy is prescribed through Systemic Treatment Computerized Order Entry Systems (ST CPOE). To support this, Cancer Care Ontario (CCO) has developed guidelines, evaluation tools, a Community of Practice (COP) and quality indicators. Using data collected in ST CPOE systems a “Near Miss Indicator” is being developed. Methods: Clinical consensus indicated that intercepted order rate, a proxy for a near miss indicator, would further the provincial safety agenda. This is defined as the percent of course 1, day 1 intravenous (IV) chemotherapy drug orders that were changed post-first time prescribing a new regimen (excludes clinical trials). An extraction standard for dose adjustments was developed encompassing clinical and laboratory values and body surface area (BSA). Three months of data was collected from 3 centres using the same ST CPOE system. Results: A total of 6822 orders were reviewed for possible near misses; 1,446 (21.2%) were course 1 orders. For course 1, day 1 IV chemotherapy drug orders, 209 (3.2%) were changed. Most orders were changed several hours to days post prescribing and hence were not felt to represent normal clinical workflows. Physicians modified 65 and pharmacy modified 169 orders. “Other” was chosen as the reason for change in 95 (45.5%) of orders and despite multidisciplinary team review, these records were not interpretable. A near miss rate of 2.2% resulted (32/1,446). Clinical and laboratory values and BSA were equally responsible. A fourth category of “dose rounding for ease” by pharmacy was identified and felt to possibly represent poor regimen builds and pharmacy workload. Conclusions: A near miss indicator is under development via a process of identifying a need, exploration of data and socialization of the results through a COP. Initial results show a low near miss indicator rate of 2.2% which is felt to be clinically actionable. Future system modifications may facilitate capture of this indicator. The feasibility of extending the indicator to multiple vendor ST CPOEs is under study.
Use of self-reporting outcomes to inform patient care.
Authors: Bosch Brandon , Denny Diane , Markman Maurie
Published: February 2017

176

Background: Cancer Treatment Centers of America, Inc (CTCA) is a national network of hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer. The Symptom Inventory Tool (SIT) is an assessment tool that captures the patients’ perceived symptom burden for real-time clinical intervention, from the point of no intervention (baseline) and every 21 days or greater. The SIT is comprised of 27 questions utilizing the MD Anderson Symptom Inventory tool, a validated assessment instrument with eight questions added and a free text box by CTCA. The SIT became an integral part of patient care at CTCA beginning in 2012. Methods: Non-clinical stakeholders administer the SIT via an electronic tablet. Upon completion of the assessment, a trending graph known as Symptoms-at-a-Glance (SAG) report is auto populated and available to clinicians in the EHR or may be printed at the point of care. The SAG provides run graphs for each symptom including arrows identifying clinically relevant changes in score. An accompanying e-mail notification system was created for physicians to review specific symptoms of interest at a threshold of their choosing, and refer patients to other specialties deemed integral for the patient’s treatment plan. Results: The SIT assessment is utilized by the nurse as a starting point from which they can initiate a more pointed conversation with the patient including the need for appropriate intervention including follow-up with the oncologist and/or referral to a member of the extended integrative care team. The percentage of new and returning patients completing an assessment is at 94.94% and 84.81%, respectively, for patients (1/1/14-6/9/14) across CTCA suggesting this process is useful for both patient and clinicians. Patients comment that the time for self-reflection is a healthy exercise enabled by the user-friendly tablet. Clinicians value both the ease of administration/use as well as the ability to create a large data set for quality improvement. Conclusions: With a majority of new and returning patients participating in the SIT, the SAG report fully implemented into the EHR along with the use of an e-mail functionality, clinicians and physicians can now better manage symptom burden real time
Quantifying the psychosocial needs of cancer patients and associated provider workload to build PSO services into the funding model for systemic treatment in Ontario.
Authors: Zwicker Victoria , Andrien Tory , Blais Irene , Green Esther , Ismail Zahra , Kaizer Leonard , Lalonde Carlin , Simanovski Vicky , Tabing Reena
Published: February 2017

18

Background: As part of a broader set of provincial health funding reforms, Cancer Care Ontario (CCO) developed a new funding model for systemic treatment. A decision was made to build dedicated funding for psychosocial oncology (PSO) services into the model. The objective of this work was to estimate the psychosocial needs of cancer patients and the associated PSO provider workload to inform the incorporation of these services into the model. Methods: PSO clinicians formed advisory groups for six disciplines: social work, psychology, nutrition, physiotherapy, occupational therapy, and speech language pathology. For each cancer type, treatment intent, and phase of the cancer journey, advisors were asked to estimate: 1) proportion of patients who need services, 2) length of an average visit, and 3) average number of visits needed to address patient needs. Groups utilized online surveys to generate estimates to serve as a starting point for discussion. Evidence was used to inform the advisory groups’ consensus when available. Results: Each group produced recommendations based on estimated patient needs and associated workload. For example, the dietitian group recommended that prior to beginning systemic treatment, 50% of lung cancer patients receive a first consult visit (~75 minutes), followed by 1-2 follow up visits (~30 minutes each). Direct activities for these visits included nutrition assessment, weight loss management, and managing symptoms such as dysphagia. Indirect activities included documentation, chart review, and making referrals. Conclusions: This was an initial attempt to measure PSO workload based on patient needs, and the consensus process used could be leveraged by other jurisdictions. This work allowed the identification of specific funding for PSO services for patients who undergo systemic treatment in Ontario. Limitations included a lack of rigorous evidence and the complex nature of the funding model. Further efforts are underway to refine the recommendations and to leverage this work for quality improvement purposes.