bluuebunny/crossref_metadata_2025 huggingface dataset:
Significance of HER2/neu overexpression in pure ductal carcinoma in situ: A clinicopathologic study with long-term follow-up.
Authors: Al-Mansour Zeina , Stockl Thomas , Khan Ashraf , Horner Richard , Cosar Ediz , Hsieh Chung-Cheng , Kandil Dina
Published: February 2017

85

Background: The prognostic value of HER2 (c-ERB2) overexpression in invasive breast cancer is well known, and correlates with aggressivene behavior. HER2 overexpression was reported in 13-56% of ductal carcinoma in-situ (DCIS). The significance of HER2 overexpression in DCIS has yet to be elucidated. The aim of this study was to correlate HER2 status with known prognostic indicators of DCIS and to evaluate whether the HER2 overexpression correlates with disease recurrence. Methods: All cases of DCIS diagnosed at our institution between 2000 and 2005 were retrieved. Cases without follow-up, those treated with mastectomy or those with concurrent invasive component were excluded. Clinicopathologic data were collected, including age at time of diagnosis, size of the lesion, nuclear grade, presence of comedo necrosis, margin status, estrogen (ER) and progesterone receptor (PR) status, type of adjuvant treatment received and length of follow-up. A representative block from each case was immunostained using the Hercept test. Slides were reviewed by 2 pathologists and interpreted in accordance with ASCO/CAP guidelines. Equivocal cases were reflexed for FISH testing. Results: A total of 152 cases were examined. Mean follow-up period was 77 months (range 12 to 138 months). HER2 was overexpressed in 49 cases (33%), and was significantly associated with high nuclear grade and presence of comedo necrosis. HER2-positive patients were more likely to be ER and PR negative. HER2 positive and negative patients did not differ significantly with respect to age at presentation or size of DCIS. On univariate analysis, HER2-type DCIS showed a higher risk of recurrence (P=0.037), however, this trend did not reach statistical signifance on multivariate analysis. Conclusions: HER2 overexpression was found to be associated with high nuclear grade, comedo necrosis as well as negativity for ER and PR but not with age or the size of DCIS. Patients with HER2-type DCIS (ER/PR-, HER2+) had a higher risk of disease recurrence than other types. However, after adjusting for all the other clinical variables, the molecular phenotype did not withhold its statistical significance as an independent predictor for recurrence.
Rethinking the Harvard scale of breast cosmesis: An analysis of patients treated with breast-conserving therapy on a phase II clinical trial.
Authors: Hunter Allison M. , Dragun Anthony E.
Published: February 2017

88

Background: The Harvard Scale of cosmetic outcome is frequently used to assess quality of life (QOL) outcomes and late toxicity in patients who have undergone breast conservation treatment. Our purpose is to evaluate its objectivity and reproducibility in the modern era of digital photography in a prospective phase II protocol. Methods: This assessment included at total of 68 digital photographs taken atfourpredetermined post-lumpectomy time points for seventeen (17) patients enrolled on a phase II protocol of once-weekly hypofractionated whole-breast radiotherapy for early stage breast cancer. Each time point assessment was completed by the principal investigator (PI) using the four-tier Harvard Scale (Excellent, Good, Fair, Poor) to compare the treated breast to the control breast. A computer-based survey including the same de-identified images was then distributed to forty-four (44) medical students and residents to determine congruence with the assessment of the PI. Results: Of the 44 respondents, there was equal distribution between male (23) and female (21), with the majority of whom were single (82%), Caucasian (70%), and less than twenty-nine (29) years of age (89%). The respondent assessment of cosmetic outcome differed somewhat from the PI averages: Excellent (43% vs. 27%), Good (34% vs. 34%), Fair (20% vs. 28%) and Poor (3% vs. 11%). PI-respondent congruence for the same four categories was 49%, 37%, 44%, and 86%, respectively. Combining the categories into a bimodal representation of Excellent/Good (70%) and Fair/Poor (72%), produced significantly better congruence (70% and 72%, respectively). Conclusions: Pysician-assessed cosmetic outcome using the traditional four-point Harvard Scale is highly variable and influenced by evaluator factors. A two point scale increases congruence among evaluators and may be a more reproducible and pragmatic approach for results reporting in cosmesis studies.
A breast cancer nomogram for prediction of non–sentinel-node metastasis in patients with sentinel node metastasis and validations of the 14 models.
Authors: Kuru Bekir , Koca Bulent , Ozen Necati , Yuruker Savas , Bek Yuksel
Published: February 2017

93

Background: To avoid performing axillary lymph node dissection (ALND) for non-sentinel lymph node (SLN)-negative patients with SLN-positive axilla, nomograms for predicting the status of the axillary non-SLNs have been developed in many centers. We created a new nomogram predicting non-SLN metastasis in SLN positive patients with invasive breast cancer and evaluated 14 existing breast cancer models in our patient group. Methods: Two hundred and thirty seven invasive breast cancer patients with SLN metastases who underwent ALND were included in the present study. Based on the independent predictive factors for non-SLN metastasis identified by logistic regression analysis, we developed a new nomogram. Receiver operating characteristics (ROC) curves for the models were created, and the areas under the curves (AUC) were computed. Results: In a multivariate analysis, tumor size, presence of lymphovascular invasion, extranodal extension of SLN, large size of metastatic SLN in mm, the number of negative SLNs, and the multifocality were found to be independent predictive factors for non-SLN metastasis. The AUC was found to be 0.87 which is the highest value reported to date for previous models, and calibration was good for the present Ondokuz Mayis nomogram. Among the 14 validated models, the MSKCC, Stanford, Turkish, MD Anderson, MOU (Masaryk), Ljubljana, and 9 Eylul models yielded excellent AUC values of > 0.80. Conclusions: We present a new model (the Ondokuz Mayis nomogram) to predict the likelihood of non-SLN metastasis. Each clinic should determine and use the most suitable nomogram or should create their own nomograms for the prediction of non-SLN metastasis. [Table: see text]
Impact of care at NCI comprehensive cancer centers (NCICCC) on outcomes in children, adolescents, and young adults (AYA) with central nervous system tumors (CNSt).
Authors: Wolfson Julie Anna , Sun Can-Lan , Kang Tongjun , Bhatia Smita
Published: February 2017

123

Background: AYA (15-39yo) have not seen the same survival improvement as younger cancer patients with similar diagnoses (dx), leaving an AYA Gap. Treatment on pediatric trials is associated with superior survival in 15-21yo. However, impact of care at NCICCC for complex diseases with poor prognosis that require evidence-based care available at NCICCC (e.g. CNSt), remain unstudied. Methods: We constructed a cohort of 560 children (0-14yo) and 785 AYA with newly-dx CNSt, reported to the LA County (LAC) cancer registry between 1998 and 2008. While 82% of children (0-14y) and 65% of young AYA (15-18y) were treated at one of 3 NCICCC or 3 COG sites in LAC, only 17% of older AYA (19-39y) were treated at one of 3 NCICCC. We sought to determine the impact of NCICCC/COG on overall survival (OS) and barriers to access to care at NCICCC/COG in AYA with CNSt. Since distance to NCICCC/COG could serve as a barrier to accessing care, Geographic Information Systems were used to derive distance between patient’s residence to the nearest NCICCC/COG. Results: OS rates were uniformly good for children and AYA with grade 1 CNSt (96 vs. 89% at 5y, p=0.2) and uniformly poor for children and AYA with grade 3/4 CNSt (43 vs. 43% at 5y, p=0.6). Among patients with WHO grade 2 CNSt, AYA had worse outcome (HR=1.9, p<0.01) after adjustment for race/ ethnicity, SES, and gender. This difference in outcome between AYA and children was abrogated by care at NCICCC (HR 1.4, p=0.2). Furthermore, patients cared at non-NCICCC saw worse outcome (HR=1.6, p=0.04). Compared with children, young AYA (15-18yo) were less likely to receive care at NCICCC (OR=0.3, p=0.02); race/ ethnicity, SES and distance to NCICCC did not influence care at NCICCC. Among older AYA (19-39yo), low SES (OR 0.4, p=0.01), public/ no insurance (OR 0.3, p<0.01) and longer distance to NCICCC (5-12mi: OR=0.3 , p<0.01; >12mi OR 0.5 , p=0.05) reduced likelihood to receive care at NCICCC. Conclusions: Population-based data reveal that receipt of care at NCICCC abrogates the inferior outcome in AYA with WHO grade 2 CNSt. Young AYA are less likely to use NCICCC than children, as are older AYA with low SES, public/ no insurance, or living > 5 miles from an NCICCC.
Assessment of communication about palliative care between physicians and their patients with cancer prior to admission to the palliative care unit (PCU).
Authors: Storek Benjamin , Nickel Sebastian , Markwordt Janett , Behzadi Asita , Thuss-Patience Peter C. , Sturm Isrid
Published: February 2017

18

Background: Discussions on palliative care are particularly challenging for both cancer patients (pts) and their treating physicians. From the pts perspective, prior to their admission to the PCU, information about palliative care is often lacking and their opinions are not adequately respected. In our study, we evaluated 1) whether pts were satisfied with the received information about palliative care prior to admission to the PCU, 2) the pts level of understanding about palliative care options and 3) pts wishes for their stay at the PCU. Methods: n=180 from n=273 pts participated in the study (time period: 12 months). A standardized palliative care assessment was performed on the day of admission. Study interview was performed within 48h after admission; the questionnaire contained free response and multiple-choice questions. Analysis: Likert scaling method with descriptive statistics using SPSS. Results: Baseline characteristics: n=92 male, n=88 female, median age 64 (range 26-89), 53% with an ECOG 3, n=25 hematological and n=155 oncological malignancies. Symptoms: 56% had 8-14 physical symptoms, 36% had 3-4 emotional problems, 38% had high levels of distress. Prior knowledge about palliative care: 38% did not know what a PCU was and 31% believed it was a unit for dying patients. 44% received none, 26% some information about palliative care prior admission. 42% did not feel well informed, 34% felt they received some information on palliative care. Prior information about the disease: 27% felt minimally, 64% felt well informed about their current disease state. The following points were not addressed from the physicians: living will 57%, health care proxy 59%, home care supply 70%, hospice 70%, psychooncological care 52%, prognosis 43%. Wishes of pts on the PCU: improvement in their general condition 47%, pain relief 30%. Conclusions: Our study shows that the majority of pts do not feel sufficiently informed about palliative care prior to the admission at the PCU. A communication barrier between physicians and their pts may explain patient’s views. The data confirm the importance of early integration of palliative care in addition to oncological care.
An interdisciplinary process for improving pain management in oncology.
Authors: Goforth Harold W. , Karius Diana , Day Kathy , Fitz Anne , Akins Patti , Fetto Julie , Guthrie Amy E. , Stevenson James
Published: February 2017

182

Background: Upcoming changes in Medicare reimbursement models take into account HCAHP scores, and over the next 1-3 years, penalties will be enacted towards those institutions falling below a standard on their publicly available HCAHP scores. The HCAHP pain domain can be one of the most challenging to impact directly due to lack of pain management knowledge, proper assessment skills, expertise in managing complex pain syndromes, and the heterogeneity of pain symptomatology reported by advanced cancer patients. Methods: This project identified inpatient oncology units with suboptimal HCAHP scores. The objective was to improve HCAHP pain scores to > 90th percentile. Nursing intervention focused on five primary areas: a) A requirement to attend a mandatory class on malignant pain management; b) making available nursing pain mentors; c) a requirement to address pain during rounds with physicians; d) priority access to medications to address pain; and, e) encouraging event reporting for uncontrolled pain issues. Resident physicians were provided expectations for pain management and attended a mandatory class on malignant pain taught by a palliative medicine attending physician. A palliative medicine physician was also assigned to the unit to evaluate patients with pain scores > 6/10 or complex pain needs. An algorithm for pain control was designed to include a timeline for intervention as well as an escalation process for slow or inadequate physician response. A hand-off report was provided to the charge nurse by the senior resident physician at the end of each day that included a tentative plan for treating any escalating pain. Results: All initiatives were implemented in September 2012. By February 2013, Pain HCAHP scores increased 10% over the entire Taussig Cancer Institute, and increased 20% for the solid tumor oncology unit. This placed all units who received this targeted intervention above the 90th percentile as compared to other hospitals on the HCAHPS pain score. Conclusions: A well-defined collaborative model between physicians and nursing produced measurable improvement in pain outcomes for oncology inpatients. An interdisciplinary approach is essential for the management of complex pain issues in an oncology patient population.
High-needs hematology/oncology patients: A quality improvement project.
Authors: Tobin Swanee , Fenuta Joyce , Kruchowski Julie , Hicks Lisa K.
Published: February 2017

197

Background: St. Michael’s Hospital (SMH) is an academic, inner-city hospital in Toronto, Canada. In the hematology/oncology (hem/onc) program, a small number of patients appeared to contribute disproportionately to hospital admissions and emergency department (ED) visits. We hypothesized that high needs hem/onc patients could be recognized early in their care and that ED visit and admission rates among these patients could be decreased through targeted interventions. Methods: Members of the hem/onc team were interviewed regarding characteristics, which they felt predicted higher needs and greater liklihood for hospital admission/ED visit. A list of high risk features was generated. ED visit and admission rates for a prospectively identified high needs cohort were compared to rates for the entire hem/onc clinic. An intervention targeting high needs hem/onc patients is on-going. Pre and post-intervention ED visit and admission rates will be compared. Results: Interviews with 3 nurses, 1 social worker, 1 discharge planner, and 4 physicians identified 10 factors that the hem/onc team believed were predictive of higher needs and subsequent higher ED visit and admission rates. Between December 1, 2012, and February 28, 2013, 42 high needs hem/onc out-patients were prospectively identified. The ED visit and admission rates for this cohort were retrospectively compared to those of the entire hem/onc clinic and found to be dramatically higher (Table). Begininng in June 2013, hem/onc patients identified as “high needs” were offered enrollment in a NP-based program offering telephone assessments following ED visits, hospital admissions or discharges. Assessment of the impact of this intervention is ongoing. Conclusions: It is possible to prospectively identify hem/onc patients who are at risk of higher than usual ED visit and admission rates. Identifying this population may provide an opportunity to decrease their ED visit and admission rates. An evaluation of an intervention targeting high needs hem/onc patients is ongoing. Preliminary data will be presented. [Table: see text]
Optimizing patient scheduling for ambulatory chemotherapy.
Authors: de Mendonca Ben , Wield Kirsty , Boudreau Angela , Singh Simron , Cheung Matthew C. , Palmer Sherrol
Published: February 2017

199

Background: The Odette Cancer Centre (OCC) manages more than 24,000 chemotherapy visits annually. The delivery process is complex and patients have significant wait times for treatment. The OCC was faced with improving this process with no data infrastructure to support continuous quality improvement. Methods: An electronic scheduling manager, Chemotherapy Appointment Reservation Manager (CHARM) was built in house to improve scheduling logic and optimize bed and chair utilization. The chemotherapy unit has recently undergone renovations to change the staff-to-patient ratio and chair distribution. At baseline, a nurse is assigned to 4 chairs in a “pod” without adjustment for patient and chemotherapy intensity variation. An interprofessional team participated in a Kaizen event to create a Value Stream Map of the scheduling process. Scheduling logic considerations were identified to better match nursing and chair resources to patient appointment times. An analysis was performed to evaluate the distribution of patients throughout the chemotherapy unit by time of day, and day of week to identify opportunities to align the schedule with nursing and pharmacy resources. Results: The mean number of patients seen per day was 85 with a range of 65 to 105. 80% of patients are scheduled before 11:30 (the unit operations 08:30 to 18:00). The mean number of patients assigned to a pod was 8 with a range of 3 to 15. Unit performance on days of >95 patients was observed to be poorest. Load levelling techniques were established to reduce the range of patients booked per day throughout the week. New considerations for scheduling are: maximum 12 patients per nurse per pod per day, maximum 3 new patients per nurse per pod per day, maximum 10 clinical trials per day, and maximum 50% of patients scheduled before 11:30 per day. Conclusions: Matching the patient schedule to the nursing and pharmacy resources of the unit is critical to efficient and safe chemotherapy delivery. A Plan-Do-Study-Act is scheduled for September 2013 to implement the scheduling changes and evaluate the impact of the new logic on unit operations. Further work to improve the delivery process and pharmacy medication processing is ongoing.
Implementation of chemotherapy treatment plans (CTP) in a large comprehensive cancer center (CCC): The key roles of infrastructure and data sharing.
Authors: Bryar Julie M. , Dalby Carole Kathleen , Anastas Susan , Brady Lauren , Hassett Michael J. , Shulman Lawrence N. , Jacobson Joseph O.
Published: February 2017

20

Background: ASCO recommends that prior to initiating chemotherapy, a synoptic CTP should be created. At a large CCC, there was no tool to consistently or clearly communicate chemotherapy plans within the electronic health record (EHR). Methods: In 2011, a structured tool was created in the EHR to document patient diagnosis, tumor characteristics, planned regimen, side effects, performance status, and other elements when starting a new chemotherapy. Completion of a CTP generates a synoptic note in the EHR, pre-populates a chemotherapy consent form and computerized chemotherapy ordering template, helping to integrate CTPs into normal workflow and removing steps for possible errors. Completed CTPs can be accessed by care team members and sent to external referring providers. Implementation strategy included education on the importance of and how to complete CTPs and sending monthly compliance reports to disease centers (DC) and regional sites (RS). Compliance was defined as number completed CTPs / number new chemotherapy starts. Results: The CTP tool was introduced in a staggered rollout in mid-2011 (compliance reporting began in 2012). Six DC and 3 RS presently complete and use CTPs. 3,569 CTPs were completed since 2012. The table shows compliance by quarter, demonstrating significant variation among DC and RS. We attribute increased compliance to introduction of formal feedback reports that allow for identification of high-volume providers not completing CTPs, triggering individual interventions, especially targeted re-education. We also suspect shared reporting led to competition among providers, further improving performance. No incentives were provided for CTP completion. Conclusions: By creating a tool within the existing workflow and providing formal feedback, CTPs have been implemented as a communication tool at a CCC. [Table: see text]
Dissemination, implementation, and quality improvement research within the HMO Cancer Research Network.
Authors: Mittman Brian S. , Dearing James W. , Mazor Kathleen , Nutter James ,   CRN Communication and Dissemination Scientific Working Group
Published: February 2017

215

Background: The HMO Cancer Research Network, funded by the National Cancer Institute, provides infrastructure support to facilitate cancer research in non-profit integrated healthcare delivery systems. A key CRN goal to improve quality and outcomes through research and research-based methods for accelerating implementation of innovations in cancer care. Methods: The CRN is led by a Steering Committee and an Executive Committee. CRN Scientific Working Groups support activity within distinct areas; the CRN Communication and Dissemination Scientific Working Group (C&D SWG) supports the design, conduct and reporting of research on (1) communication and decision makin in cancer care and (2) dissemination and implementation of cancer research findings and best practices. C&D SWG activities include monthly calls presenting C&D research resources, project ideas and funding opportunities; individual consultation and technical assistance to support CRN researchers developing funding applications and conducting research in relevant areas; and mentorship for CRN Scholars. General CRN resources to facilitate research to improve cancer care quality include a multi-institution Virtual Data Warehouse with accompanying query tools to facilitate preparatory-to-research and collaborative research studies and specific cancer-related data items; funding for Developmental and Pilot Studies; and an Outreach and External Collaborations Core to facilitate research collaborations among (a) CRN institution-based scientists, (b) scientists at other institutions, and (c) clinical and operations partners. Results: The CRN C&D SWG continues to stimulate increased awareness and interest in conducting dissemination and implementation studies and quality improvement research in cancer care, and to support the development of new project ideas and funding applications and the successful completion and publication of such studies. Conclusions: CRN activities facilitate innovative multi-site, multi-disciplinary cancer studies in the integrated delivery system setting, and motivate continued evolution of CRN institutions as the nation's premier learning health care systems. Supported by U24 CA171524.
Adult survivors of childhood cancer: Development of a regional transistions program.
Authors: Klemp Jennifer R. , Stegenga Kristin A. , McClellan Wendy , Krebill Hope , Ryan Robin , Sharma Mukta , Panicker Jyoti , Fulbright Joy M. , Lowry Becky , Nelson Eve-Lynn
Published: February 2017

217

Background: With increased survival rates, adult survivors of childhood cancers (ASCC) face lifelong screening and healthcare needs. Given increasing costs and demands across healthcare institutions, there is a significant need for survivorship models that emphasize regional collaboration, transition of pediatric patients to adult care, and focus on survivor-centered outcomes. Specific aims: Over the last two years, the presenters developed and implemented a survivor-centered regional approach to meet ASCC needs, addressing system, provider, and survivor barriers to successful transition and ongoing ASCC care. Methods: The presenters will describe community engagement strategies utilized to build a successful, sustainable survivor-centered approach across the region. The Midwest Cancer Alliance (MCA), the outreach arm of University of Kansas Cancer Center (KUCC), provides a supportive, neutral environment to bridge institution-specific concerns. Interdisciplinary teams from Children’s Mercy Hospital and University of Kansas’ Pediatrics department developed a formal working group with KUCC adult-focused partners. The group has taken an inclusive approach, bringing together pediatric and adult healthcare teams as well as expertise in outreach, patient navigation, telemedicine, education, and evaluation/research. Emphasis will be placed on how the team has prioritized needs-driven deliverables across metropolitan and rural communities. Results: The transitions program has maintained monthly working group meetings; completed a survivor needs assessment and disseminated findings; and initiated a cross-institutional transitions clinic. The team is collaborating on a comprehensive survivorship training approach to educate regional healthcare providers. The presenters will describe the team’s performance improvement processes to monitor outcomes and continuously refine the ASCC/AYA model. Conclusions: Community engagement is an ideal platform for regional program development to meet ASCC survivor needs. Future steps include measuring program outcomes, working toward EHR integration, increasing survivor input, and incorporating education into residency/fellowship training.
Use of the electronic medical record (EMR) to identify women at increased risk for hereditary breast and ovarian cancer (HBOC).
Authors: Kershberg Hilary B. , Alvarado Monica , Natoli Jaime L. , Parkhurst Emily , Zhou Hui , Tiller George E.
Published: February 2017

236

Background: Diagnosis of breast cancer at a young age is an indication for genetic counseling and possible BRCA testing. However, not all women with this early diagnosis are referred for genetic counseling, especially if they do not have a family history of breast or ovarian cancer. Methods: The genetics department in Kaiser Permanente Southern California (KPSC) provides clinical genetic services in an integrated health care system serving over 3.6 million members. Using data from the KPSC tumor registry, the KPSC EMR system, and a departmental cancer test results database, we identified 454 women diagnosed with early breast cancer (<46 years) between September 2005 and September 2010 who had not received genetic counseling. We contacted these women with a letter and/or phone call offering a genetics consultation, and we offered BRCA testing to all those who came for counseling. Results: 142 women (31%) came in for genetic counseling, and 312 women (69%) declined, did not keep their appointment, or never responded. Hispanics were more likely to schedule and keep an appointment than Caucasians (OR=1.35, 95% CI, 0.79-2.31), although this was not statistically significant. Of those who came in for counseling, African Americans were significantly less likely to accept genetic testing than Caucasians (OR=0.31, 95% CI, 0.10-0.98).Of the 142 patients who were counseled, 122 (86%) accepted testing. We identified 6 patients (5%) who were positive for a deleterious BRCA mutation and 6 patients (5%) who had a variant of uncertain significance. Of the 6 women with deleterious mutations, only 1 had a first-degree relative with breast or ovarian cancer, and 4 had mutation probabilities <10%. Conclusions: This project demonstrates how an integrated care approach and EMR system provide an opportunity to identify and contact women who are at increased risk for inherited cancer susceptibility.
Lessons learned from the development of the CancerLinQ prototype: Clinical decision support.
Authors: Schilsky Richard L. , Swain Sandra M. , Hauser Robert , Mann Joshua , Sledge George W. , Yu Peter Paul , Lichter Allen S. , Hudis Clifford
Published: February 2017

237

Background: CancerLinQ (CLQ) is a rapid learning system (RLS) for oncology in development by ASCO. CLQ is based on the transfer of electronic health records (EHR) from participating oncology practices to a data warehouse where data aggregation and de-identification occurs. A prototype was built using open source software and has collected de-identified data on 170,000+ pts with breast cancer (BC) from 31 community oncology practices using 4 different EHRs. The primary goals for the prototype were 1. Aggregate patient data from any EHR platform, process it and create a longitudinal record; 2. Develop quality reports from EHRs; 3. Point of care Clinical Decision Support (CDS) from ASCO guidelines; 4. Data visualization for hypothesis generation; 5. Demonstrate desire to share data for quality improvement; 6. Describe lessons learned (LL). This report focuses on LL about CDS. Methods: Physician experts identified specific elements from each ASCO BC guideline to make machine readable (MR). Abstractors then GEM-cut the elements using the GEM Abstraction Manual and Style Guide. The output reports were reviewed for comprehensiveness, accuracy, and style. Following verification of the GEM-cut content, reports were sent for meta-tagging, done by selecting widely used EHR vocabulary from the Unified Medical Language System (UMLS). The GEM-cut output and meta-tags were converted to DROOLS syntax and the resulting coded files were inserted into the DROOLS rules engine. When the rules engine encounters a combination of facts that match a rule, that rule is presented to the user. The enduring responses are collected using ‘queries’ and the CDS results are delivered to the EHR. Results: Guidelines are often not written as “if”/“then” statements which is key for computer-based CDS. Any unintentional ambiguity must be removed for machine MR CDS. Using new methodologies, we have been able to convert narrative guidelines into MR CDS. Conclusions: Conversion of ASCO’s clinical guidelines into a MR format is possible. New and emerging methods such as GLIDES, BRIDGE-Wiz, and GEM-cutting provide excellent tools to migrate existing narrative recommendations into MR format that can populate CDS tools, such as those provided by CancerLinQ.
eOutcomes-H&N: Development of an electronic point-of-care outcomes collection system for head and neck cancer.
Authors: Lockhart Elizabeth , Gutierrez Eric , Warde Padraig Richard , Dubeau Davin , Huang Sophie , Johnson Harry , Melamed Saul , Sarsfield Lisa , Sioson Roehl , Sutcliffe Ken , O'Sullivan Brian
Published: February 2017

247

Background: Outcomes data increases the ability to understand the impact of cancer treatment and helps ensure that we direct appropriate investments to achieve improvements in quality of care. Cancer Care Ontario (CCO) has developed an outcomes data collection system for patients with head and neck cancer treated with radiotherapy. Methods: Clinicians involved in the care of these patients agreed on 5 key clinical outcomes to collect as a part of this initiative: local failure, regional failure, distant metastasis, second primaries, and treatment toxicity. Based on the Princess Margaret Hospital Head and Neck Cancer Anthology of Outcomes process, CCO has developed a similar system to collect outcomes data at the point-of-care on a provincial scale. The population-based provincial system aims to provide practice efficiencies and allow for evolution of the system in response to user feedback and expansion to other clinical areas. Results: The system includes a secure web application and iPad mobile application to facilitate the collection and management of outcomes data for head and neck cancer patients treated with radiotherapy in Ontario. Cancer centres upload patient clinic schedule details (including patient identifiers and appointment dates) prior to clinics. A list of patient summaries, including corresponding diagnosis, radiotherapy information and previously recorded outcomes is then generated. In clinic, physicians use these lists to capture outcomes noted at the point-of-care. Data captured are then transferred in real time to a secure central database. Following initial testing, the application was piloted to assess usability, system reliability, and overall satisfaction. Initial results show high physician satisfaction and no documented issues with system availability. Feedback has identified potential improvements and will inform future modifications. Conclusions: The identification of potential variation in recurrence, toxicity and survival data will inform the areas in which quality improvement initiatives or additional investments may be needed. The intent is to leverage project learnings for future outcomes initiatives in other diseases and treatment modalities.
Trends in chemotherapy-related treatment of advanced-stage colorectal (CRC) cancer.
Authors: Bradley Cathy , Yabroff K. Robin , Warren Joan L. , Chawla Neetu , Zeruto Christopher , Lamont Elizabeth B.
Published: February 2017

258

Background: New drugs and technology are primary drivers of health care costs, but their marginal benefit is questionable, particularly in patients with incurable cancer. We examined trends in population-based treatment following diagnosis for metastatic colon and rectal cancer in elderly adults. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) – Medicare linked database to identify persons aged 65 and older diagnosed with distant stage colon (N=16,086) and rectal cancer (N=4,003) between 2000 and 2009. For each year, we report the percent of patients who received cancer directed surgery, chemotherapy, antiemetics/premedications related to the chemotherapy, and hematopoietic growth factors, and the mean cost of care. All estimates are adjusted for patient characteristics, SEER region, survival, and year of diagnosis. Results: The percent of patients who had cancer directed surgery declined 12 and 11 percentage points for colon and rectal cancer patients, respectively. The percent of patients who received chemotherapy increased from 41% to 46% for colon patients and from 52% to 57% for rectal patients. Chemotherapy treatment intensified from 2000 to 2009, with longer duration in chemotherapy and more agents given. Over a third of colon and rectal cancer patients received three or more agents in 2009, often including oxaliplatin and/or bevacizumab. The percent of patients who received hematopoietic growth factors rose appreciably from 4% to 19% for colon patients and from 6% to 21% for rectal patients. Antiemetics/premedication use increased approximately 20 percentage points for all patients. Total costs of care rose from a mean of $61,171 to $74,567 per colon patient and from $68,213 to $82,031 per rectal patient. The percentage of costs due to hospitalizations declined for colon (56% to 47%) and rectal (47% to 40%) cancer patients. Conclusions: The use and intensity of chemotherapy, along with cost of care, for patients with advanced cancer increased markedly from 2000 to 2009. The inclusion of newer more expensive agents shifted the bulk of treatment costs from hospitalizations to the outpatient setting. The value of these treatments for advanced stage elderly patients is unknown.
Trends in patient copays for hospital and office-based chemotherapy 2005-2012 for Medicare and commercially insured patients.
Authors: Foley Kathleen A. , Bechhold Rebecca
Published: February 2017

260

Background: With the growing shift towards chemotherapy administration in outpatient hospital settings (OHS) versus office-based settings (OBS), we sought to characterize the percent of patients with a copay and the mean copayment by setting and insurance type over time. Methods: Using the MarketScan Research Databases, first administrations of bevacizumab and trastuzumab were identified from 1/1/2005 through 12/31/2012 for patients with commercial or employer-sponsored supplemental Medicare insurance. Bevacizumab claims were excluded if the claim had a diagnosis related to macular degeneration or other eye disease. All claims were identified in OHS, OBS, or other setting. Results: The percent of patients with a copayment varied by insurer and setting but within each group remained fairly consistent over time. The average percent with a copay was 14% OHS and 19% OBS for commercial and 17% OHS and 28% OBS for Medicare patients. Per administration copayment amounts varied over time, with peaks of $978 OHS and $631 OBS for commercial in 2012 and $721 OHS and $464 OBS in 2011 for Medicare with 2012 Medicare copayments declining somewhat for bevacizumab. For herceptin peak mean copayments were $886 and $439 in 2012 for OHS and OBS commercial patients, respectively, and $458 and $474 in 2010 with declines in 2011 and 2012 for Medicare, respectively. Commercial patients receiving care in OHS settings consistently faced copayments that were 50 to 100% higher those paid by patients receiving chemotherapy in OBS. Copayment differentials were smaller for Medicare patients. Conclusions: As more patients are receiving care in OHS, these data imply significant financial burdens on patients, especially for those with commercial health insurance. Additional research is necessary to understand the overall cost burden on patients and whether the shift to OHS-based care has negatively impacted patient adherence or quality of life due to financial burden. [Table: see text]
The cost of adverse events in metastatic breast cancer in taxane- and capecitabine-based regimens.
Authors: Masaquel Anthony , Hansen Ryan N. , Ramsey Scott David , Lalla Deepa , Brammer Melissa , Hurvitz Sara A. , Sullivan Sean D.
Published: February 2017

261

Background: Over 155,000 women are living with metastatic breast cancer (mBC) in the US. Chemotherapies can prolong survival for women with mBC, but adverse events (AEs) stemming from their use are common and costly to manage. We compared the healthcare costs for taxane- (TAX) and capecitabine-based (CAP) treatments for mBCpatients as either first- or second-line (FL or SL) therapy in the US. Methods: Using the Marketscan Commercial Database, a nationally representative database of over 52 million people, we selected mBC patients diagnosed from 2008-2011. Patients were categorized into FL and SL chemotherapy including either a TAX (paclitaxel or docetaxel) or CAP using an algorithm based on pharmacy and medical claims data. Chemotherapy-related AEs were identified by ICD-9 codes. Costs were tabulated from a payer perspective. Average monthly costs were stratified by treatment and the presence/absence of AEs. Results: Among 15,535 mBCpatients we identified 15,472 FL and 6,809 SL cases treated with TAX or CAP. The mean age of patients was 51 years (SD 8). At least one AE was experienced during FL treatment by 74% (SD 44%) and 68% (SD 46%) of TAX and CAP users and during SL treatment 60% (SD 49%) and 59% (SD 49%), respectively. Average monthly total costs during the FL period were $2,385 higher (p <0.0001) and $1,679 higher (p=0.28) for TAX- and CAP-treated patients who experienced at least one AE. In SL, costs for patients with at least one AE had were $2,995 (p<0.0001) higher for TAX-treated patients and $4,870 (p=0.0026) higher for CAP-treated patients. Conclusions: Among community-treated patients, AEs are common in women with mBC receiving TAX- and CAP-based chemotherapy regimens. These AEs are associated with higher costs in FL and SL. When possible, prevention or earlier management of AEs may represent an opportunity to reduce costs and improve outcomes for women with mBC. [Table: see text]
Time-driven activity-based costing and the impact on cost measurement in the face of health reform.
Authors: Albright Heidi Wied , Incalcaterra James , Feeley Thomas W.
Published: February 2017

262

Background: In 2010, the Institute for Cancer Care Innovation (ICCI) began measuring the true cost of cancer care delivery by following the patient treatment cycle from initial referral to survivorship or supportive care. The project was prompted by both internal and external concerns about the rising costs of health care, the ability to demonstrate value for services provided, and potential changes in reimbursement. Hospital cost accounting systems are historically charge-based and are inherently skewed to shift costs towards procedures or encounters that are higher volume and well-reimbursed. However, these systems do not accurately reflect the actual acquisition costs of the resources providing care. Methods: In order to more accurately and transparently capture costs, the ICCI piloted the use of the time-driven activity-based costing (TDABC) methodology. This methodology allowed the team to map the entire patient experience of care while also capturing costs and capacity associated with each activity in the care delivery cycle. Results: To date, the team has created over 150 maps made up of over 6,500 unique activities with associated cost and capacity rates, which make up various costing equations. Actual clinical volumes are then run through the model to produce cost and capacity results. Initial results provided an unexpected view of the costs of various processes occurring within the care delivery cycle with the ability to rank the processes from most to least costly. This provided a unique opportunity to target specific areas for improvement. Additionally, transparency of the costing equations allows for precise modeling of episode-based bundles of care for different diseases and treatments. Conclusions: TDABC provides a more accurate and transparent approach to developing cost and capacity rates for cancer care delivery to aid in identifying the greatest opportunities for improvement, as well as providing a mechanism for creating episode-based bundles of care that are reflective of actual treatment being provided.
Trends in hospital and office-based chemotherapy administration 2005-2012 for Medicare and commercially insured patients.
Authors: Foley Kathleen A. , Bechhold Rebecca
Published: February 2017

274

Background: The 2013 Community Oncology Practice Impact Report notes an increase of 20% in the number of community clinics closing since 2011. The objective of this study was to examine trends in location and reimbursement of chemotherapy in office-based (OBS) and outpatient hospital settings (OHS). Methods: Using the MarketScan Research Databases, first administrations of bevacizumab and trastuzumab were identified from 1/1/2005 through 12/31/2012 for patients with commercial or employer-sponsored supplemental Medicare insurance. Bevacizumab claims were excluded if the claim had a diagnosis related to macular degeneration or other eye disease. Claims for both drugs were excluded if the reimbursed amount was less than $100. Chemotherapy administration reimbursements were identified through CPT codes on the same day as the day as the drug charge. All claims were identified as occurring in OB or OHS. Results: The percent of bevacizumab claims occurring in OHS increased from 6 to 34% among Medicare claims, and from 15 to 42% among commercial claims from 2005 to 2012. For trastuzumab, the increases were 4 to 35%, and 10 to 35% in Medicare and commercial claims, respectively. OHS reimbursements were consistently higher than OBS reimbursements for chemotherapy administration and drug for both drugs across both payers. Conclusions: Although the differential in reimbursements between OHS and OBS declined in the most recent two years, OHS reimbursements remained substantially higher while the shift in chemotherapy administration from OBS to OHS has continued through 2012. Continued attention to reimbursement differences between OHS and OBS is warranted and additional research is needed to more fully document the impact on patients, providers, and payers. [Table: see text]
The influence of employer-based health insurance and job support on receipt of adjuvant chemotherapy in stage III colorectal cancer.
Authors: Veenstra Christine Marie , Regenbogen Scott E. , Hawley Sarah T. , Banerjee Mousumi , Kato Ikuko , Ward Kevin C. , Morris Arden M.
Published: February 2017

278

Background: Approximately 15% of the U.S. population lacks health insurance. Adjuvant chemotherapy confers significant survival benefit in stage III colorectal cancer (CRC), yet many patients fail to receive recommended care. We hypothesized that access to employer-based health insurance (EBHI) and other job-related support programs influences receipt of chemotherapy. Methods: We performed a population-based survey of patients diagnosed with stage III CRC in the state of Georgia and Metropolitan Detroit SEER catchment areas. The primary outcome was receipt of adjuvant chemotherapy. Patients were queried regarding clinical, sociodemographic, and employment characteristics (EBHI and job support - e.g., sick leave, disability, flexible schedule, unpaid time off). We used χ2 analyses to examine associations between health insurance coverage, job support availability and receipt of chemotherapy, adjusting for other characteristics. Results: To date, 630 patients have responded (preliminary response rate=56%). 257 (41%) were working for pay at diagnosis, of whom 46% had EBHI and 9% had no insurance at all. Rates of chemotherapy receipt were higher among those with EBHI than those without (97% vs. 90%, P=0.001). 26% with EBHI reported that they kept their job mainly to keep insurance. 79% of those working for pay reported some form of available job support. Rates of chemotherapy receipt were higher among employed respondents with job support compared to those without (97% vs. 85%, P<0.001). Availability of job support was significantly associated with ability to retain employment; 48% of those without support stopped working altogether because of CRC vs. only 11% of those with support (P<0.001). Conclusions: Patients with EBHI and job support were significantly more likely to receive recommended adjuvant chemotherapy after surgery for stage III CRC. Further, lack of job-related support for medical illness was significantly associated with loss of employment for patients undergoing treatment for CRC. These findings suggest that employer-based health insurance and job support are important contributors to receipt of recommended cancer care.