bluuebunny/crossref_metadata_2025 huggingface dataset:
Breast cancer subtypes in Chinese Americans: A study from the Mount Sinai Health System.
Authors: Masias Camila , Shao Theresa H.
Published: February 2017

39

Background: Breast cancer has been increasing in many Asian countries, as well as among Asian Americans. While many studies have examined breast cancer subtypes in African American and Caucasian populations, few have looked at tumor subtypes in the Asian population. We aimed to examine breast cancer subtypes in Chinese Americans. Methods: We identified all Chinese patients diagnosed with invasive breast cancers between 2005 and 2012 from the Cancer Registry of Mount Sinai Beth Israel, Mount Sinai St. Luke’s, and Roosevelt Hospitals. The following clinical data were collected for each patient: age at diagnosis, year of diagnosis, largest tumor size (cm), lymph node status, estrogen receptor (ER), progesterone receptor (PR) and HER2 status. Based on ER, PR, and HER2, patients were categorized into three molecular subtypes: 1) Hormone receptor (HR)+ (ER and/or PR positive, HER2 negative), HER2+ and triple negative (TN) (ER, PR, and HER2 negative). Descriptive variables were analyzed using one-way Anova test. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated from logistic regression models. Results: There were 175 Chinese patients diagnosed with invasive breast cancers from 2005 to 2012. Median age at diagnosis was 54 (range 27-90). One hundred fourteen (65%) were HR+, 41 (23%) were HER2+, and 20 (11%) were TN. There were 59 (34%) patients diagnosed at age ≤ 50 and twelve patients (7%) were diagnosed at age < 40. There were more HER2+ and TN breast cancers diagnosed in women age ≤ 50 compared to age > 50, but the difference was not statistically significant. Women in the HR+ group were diagnosed at an older age compared to the other two subgroups (57 ± 12, 52 ± 8, and 52 ± 10 for HR+, HER2+, and TN, respectively, p = 0.036). Patients with TN breast cancers were more likely to have lymph node involvement compared to HR+ or HER2+ patients (p = 0.02). There was a trend of increasing prevalence of HER2+ breast cancer observed in recent years: 18.5% in 2005-2006, 23.8% in 2007-2008, 18.4% in 2009-2010, and 29.8% in 2011-2012. Conclusions: We observed a high proportion of breast cancer among young Chinese Americans as well as an increasing prevalence of HER2+ breast cancer in this population in recent years. Further studies are warranted.
Predictors that influence contralateral prophylactic mastectomy election among women with ductal carcinoma in situ who tested negative for a BRCA mutation.
Authors: Elsayegh Nisreen , Lin Heather Y. , Gutierrez-Barrera Angelica M. , Profato Jessica , Litton Jennifer Keating , Kuerer Henry Mark , Hortobagyi Gabriel N. , Arun Banu
Published: February 2017

42

Background: Patients with ductal carcinoma in situ (DCIS) are at increased risk for developing contralateral breast cancer (CBC). Consequently, more women with DCIS are electing to undergo contralateral prophylactic mastectomy (CPM). We previously reported a 27% CPM rate among patients with DCIS who were evaluated for BRCA genetic testing (positive, negative, not tested). In this specific cohort, we further evaluated factors associated with CPM in patients with DCIS who tested negative for a BRCA mutation. Specifically, we aimed to identify differences within BRCA-negative patients who underwent CPM and those who did not. Methods: This retrospective study from a prospective registry included 100 women with DCIS referred for genetic counseling between 2003 and 2011. Patient characteristics included: age, marital and educational status, tumor markers, nuclear grade, family history of breast cancer (BC) and ovarian cancer (OC), race, Ashkenazi Jewish ancestry, and BRCA results. Univariate and multivariate logistic regression analyses were used to determine predictive factors associated with CPM election. Results: Of 100 BRCA-negative patients, 31 (31%) underwent CPM. Univariate analysis revealed patients who had a first-degree relative with OC were more likely to elect CPM that those who did not (p = 0.0278). Patients who had a family history of OC (53.3%) were more likely to choose CPM than those with no family history (p = 0.0425). Married patients were more likely to elect CPM than those who were not married (p = 0.0235). In multivariate analysis, married patients were more likely to elect CPM than those who were not married (OR = 4.367; 95% CI, 1.198-15.924; p = 0.0255). Conclusions: The CPM rate among patients with DCIS who tested negative for a BRCA mutation is high. Factors associated with increased rate of CPM among this group include a family history of OC and being married. Further studies are needed to evaluate patients' perceptions of CBC risk and their role in the likelihood of CPM choice.
The use of breast MRI in early-stage breast cancer: Findings after implementation of an institutional protocol at a county hospital.
Authors: Whitney Stewart , Arita Nestor , LaCross Jessica , Lassinger Brian , Bonefas Elizabeth , Liscum Kathy , Silberfein Eric Jay
Published: February 2017

5

Background: Breast MRI has recently become standard-of-care in many practices, however, its proper utility in the preoperative management of early-stage breast cancer has not been fully elucidated. Our program recently instituted a protocol to obtain breast MRI at the time of diagnosis of breast cancer. We report the outcomes of this new approach in patients with surgically resected, early-stage breast cancer. Methods: An institutional database was queried for all patients that underwent surgery after a new histopathologic diagnosis of either noninvasive or invasive breast cancer from November 2012, the time of protocol implementation, through March 2014. Patients that received neoadjuvant treatment and patients with stage IV disease were excluded. Demographic, diagnosti,c and clinical data were extracted and analyzed using summary statistics and student’s t-test. Results: Fifty-eight patients met criteria. The median size of the index lesion on mammogram, ultrasound, MRI, and final surgical pathology was 1.2, 1.4, 2.1, and 1.3 cm, respectively. MRI size was significantly larger than mammogram, ultrasound, and final surgical pathology size (p < 0.05). The median time between initial pathologic diagnosis and breast MRI was 16 days. MRI identified 20 additional lesions in 19 (33%) patients leading to 14 additional biopsies and the diagnosis of two additional invasive and two noninvasive cancers. The median time between initial pathologic diagnosis and final report of these 14 biopsies was 36 days. Nine (64%) of the 14 patients that underwent a second biopsy went on to have a partial mastectomy, all with negative margins. Of the remaining five patients that went on to have total mastectomy, all but one were offered partial mastectomy but desired reconstruction. Conclusions: In this cohort of patients with early-stage breast cancer, MRI overestimated the size of the index lesion when compared to other imaging modalities and final surgical pathologic size. The use of MRI did not alter the surgical management in the majority of cases and increased the time from initial diagnosis to definitive surgical management. More studies are needed to determine the role of breast MRI in early-stage breast cancer.
Locoregional recurrence risk for women with various molecular subtypes of breast cancer treated with multicatheter interstitial accelerated partial-breast irradiation: Results from Pooled Registry of Multicatheter Interstitial Sites (PROMIS).
Authors: Anderson Bethany Marie , Kamrava Mitchell , Wang Jason , Jeffrey Demanes D. , Snyder Margaret B. , Kuske Robert R. , Chen Peter Y.
Published: February 2017

73

Background: This study was performed to determine in breast tumor recurrence (IBTR) and regional nodal recurrence (RNR) rates for women with different subtypes of invasive ductal breast cancer treated with multicatheter interstitial accelerated partial breast irradiation (mAPBI). Methods: Data from 5 institutions was collected for patients treated from 1992-2013. We report the outcomes of 821 women with 830 breast cancers, all with ≥ 1 year of follow-up after completion of mAPBI. Molecular subtype analysis was performed for 582 women in whom ER, PR, Her-2, and grade were known. The Kaplan-Meier method was used to calculate overall survival (OS), IBTR and RNR. A univariate proportional hazard model was performed to estimate the risk of IBTR based upon molecular subtype, age, grade, N-stage, T-stage, margin status, tumor size, dose rate, endocrine therapy, and chemotherapy. Results: The median age of our patient cohort was 60 years. 50.0% (n = 415) of women had luminal A, 6.9% (n = 57) luminal B, 5.7% (n = 47) luminal Her-2, 1.8% (n = 15) Her-2, and 5.8% (n = 48) triple negative breast cancer (TNBC); an additional 29.8% (n = 248) could not be subtyped. With a median follow-up time of 6.5 years, the 5-year OS of our patient cohort was 94.8%. The 5-year IBTR was 3.5% for luminal A, 4.1% for luminal B, 5.1% for luminal Her-2, 13.3% for Her-2, 11.3% for TNBC, and 1.7% for non-subtyped women. Positive surgical margins and high grade correlated with risk for IBTR; molecular subtype and other variables did not. The 5-year RNR rates were 0.3% for luminal A, 4.6% for luminal B, 2.6% for luminal Her-2, 34.5% for Her-2, and 2.3% for TNBC. RNR risk was significantly higher for women with Her-2 compared to the other 4 subtypes. In addition, risk of RNR was significantly higher for women with luminal B compared to those of luminal A. Conclusions: Women with Her-2 and luminal B breast cancer may have higher RNR but not IBTR risk after mAPBI, as compared with women with luminal A subtype. Further follow-up, correlation with use of trastuzumab, and comparison of outcomes with whole breast irradiation will be valuable.
Toxicity and cosmesis after oncoplastic surgery and interstitial brachytherapy.
Authors: Smith Linda A. , Kuske Robert R.
Published: February 2017

89

Background: Oncoplastic surgery fuses breast cancer surgical and reconstructive techniques, both simple and complex. Following sculpting and removing the appropriate malignancy, tissue rearrangement is utilized to minimize the dead space. PBI with brachytherapy provides excellent tumor control in this population. This study investigates cosmetic outcome and toxicity in select stage 0, 1, and 2 breast cancers treated by a single breast surgeon and radiation oncologist. Methods: 140 women were treated between May 2010 and December 2013 with breast conservation, sentinel node biopsy (SNB), and interstitial brachytherapy. Selection criteria included women of any age, any subtype, tumor size less than < 3 cm, N0 or N1mic, with excision margins > 1 mm. Strict modified Harvard cosmesis scale was used by direct examination by the surgeon, not photos. Toxicity was judged by the surgeon at the time of each follow-up, using the CTCAE scale, version 4. Median follow-up is 2 years. Results: Two patients were lost to follow-up. There were no in-breast and 1 axillary recurrence. Grade 2 or higher toxicities were seen in 10 patients (7.2%, one of whom had Lupus), and only 1 lasted beyond a year. Toxicity included 1 transient breast edema, 1 late mastitis at one year, 1 grade 4 (0.7%), 0 grade 3, 5 grade 2 (3.6%), and 7 grade 1 fat necrosis, 3 grade 2 fibrosis (2.2%), and only 1 transient arm lymphedema (all patients had SNB). Cosmesis was judged as poor in 1 (0.7%), fair in 2 (1.4%), good in 19 (14%), and excellent in 116 (84%). Pockmarks were visible on casual examination in 8% after one year. Conclusions: Oncoplastic surgery combined with sentinel node mapping and interstitial brachytherapy has resulted in low toxicity (7.2%) and high rates of acceptable cosmesis (98% good/excellent), as scored by a single surgeon with strict criteria at each follow-up visit. No conclusions about tumor control will be made until this cohort has mature follow-up.
Recurrence patterns among T1-2N0 triple-negative breast cancer patients following mastectomy.
Authors: Young Rebekah , Gergelis Kimberly , Kalnicki Shalom , Fox Jana Lauren
Published: February 2017

93

Background: Women with early-stage TN breast cancers are at increased risk for recurrence (RR) compared to other molecular subtypes, and are often treated with mastectomy without local adjuvant therapy. We wish to evaluate the RR for these women. Methods: In this single institution retrospective study, women with T1-2N0 TN breast cancer who underwent mastectomy between 2008-12 were identified from tumor registry. Adjuvant chemotherapy was allowed, but adjuvant radiotherapy (RT) was excluded. Of 3,000 cases reviewed, 52 women were identified. Median age was 58.5 (30–90). Lesions were high-grade (83%), and T1-2 (47%, 53%). 21 women (42%) had at least 1 risk factor. 5 women were BRCA+. Women underwent total mastectomy or modified radical mastectomy, and the majority (84%) had adjuvant chemotherapy. Results: At a median follow-up of 3.5 years (6-71 months), there were 8 recurrences (15.4%). 3 (5.8% of cohort) were locoregional (LR) only (2 chest wall (CW) and 1 ipsilateral axilla), 6 (11.5%) involved a concurrent LR and distant recurrence, and 2 (3.8%) were distant only. Median time to recurrence was 17.3 months. The isolated LR recurrences (LRR) were at 14, 15.6 and 15.1 months. Most women (41, 78.8%) were alive with NED. 3 were alive with disease, underdoing treatment, and 1 woman was disease free after treatment for CW recurrence. 8 patients (15.4%) are deceased, half from their cancer. On univariate analysis, there was no significant correlation (p>0.05) between age or high-risk features and RR (STATA v 11). Conclusions: T1-2N0 breast cancer patients are believed to have a low RR following mastectomy. TN disease, however, is more aggressive, and the question of irradiating early stage disease after mastectomy has arisen. A single institution, retrospective study found women with T1-2N0 TN disease fare better with BCT that includes RT, compared to mastectomy alone. Other studies have shown no statistical difference in RR between these 2 groups. We found an isolated LRR rate at 3.5 years of 5.8%. Follow-up and ultimately prospective data is needed to determine whether the isolated LRR warrants a change in treatment recommendations for this pt subset.
External beam radiation therapy evaluated in patients with breast cancer with cutaneous mastocytosis.
Authors: Chaiken Lisa , Yonemoto Les , Ziegner Ulrike , Kuhn Gilbert , DiNome Maggie Lee , Slates Randal , Juillard Guy
Published: February 2017

95

Background: Mastocytosis is a rare disease characterized by an excess of mast cells. The most common presentation is cutaneous mastocytosis (CM) presenting with skin lesions of urticaria pigmentosa (UP). There is concern of anaphylactic shock from the interaction of ionizing therapeutic radiation and mast cell activation in these patients. There is very little if anything published regarding radiation treatment of patients with cutaneous mastocytosis. Literature has ranged from radiation possibly causing mastocytosis in breast cancer patients to radiation treating canine mast cell tumors. Two patients are reported in order to explore and document the tolerance and safety of breast radiation in patients with cutaneous mastocytosis. Methods: Two patients with CM presented with early stage breast cancer for radiation treatment. Three dimensional conformal radiation to the breast was given. Epinephrine injection was kept at the patient’s side during treatment. With the initiation of radiation, a steroid and additional anti-inflammatory medicine or antihistamine were taken with the baseline medication, prior to each treatment. Monitoring was performed after treatment. To minimize potential toxicity, radiation started with the boost field to confirm acceptable tolerance. Results: Both patients tolerated the radiation without any unusual acute or late toxicities. There was no anaphylaxis. Both patients showed a decrease in the UP rash in the radiated field. Tryptase levels, a marker for CM, remained stable or decreased. Conclusions: Two patients with cutaneous mastocytosis showed excellent tolerance of breast radiation therapy. In the radiation field, UP improved and may be indicative of mast cells being sensitive to radiation in small volumes. Breast radiation avoids more extensive surgery and anesthesia, which are known to exacerbate CM. Radiation therapy to the breast appears to be safe for patients with cutaneous mastocytosis. Precautions of starting with the boost field, monitoring the patients, and maximizing medical treatment, should be taken given the limited data. This report is the first to document the safety of breast radiation in patients with cutaneous mastocytosis.
Ensuring head and neck oncology patients receive recommended pretreatment dental evaluations.
Authors: Margalit Danielle Nina , Losi Stephanie , Tishler Roy B. , Schoenfeld Jonathan Daniel , Fugazzotto JoAnn , Stephens Josie , Cebulski Amy , Hammerstrand Elizabeth , Ma Laura , Lopes Holly , Haddad Robert I. , Treister Nathaniel S. , Frustino Jennifer L.
Published: February 2017

100

Background: Pre-treatment dental evaluations are recommended for head and neck (H&N) cancer patients (pts) prior to radiation therapy (RT) to minimize the risk of acute and long-term side effects of treatment. We previously created a dental instructional guide (DIG) outlining the necessary components of the pre-radiation dental evaluation for pts undergoing community-based dental evaluation. Yet our program did not have a system for documenting which pts received the DIG. We aimed to create a system to ensure that pts are given the DIG early in their care-plan and that such pts are readily identifiable so we can follow-up and confirm that the recommended dental care is complete prior to starting RT. Methods: Chart review was performed to determine the percentage of eligible pts with documented provision of the DIG. A diagnostic survey of H&N oncology clinicians was analyzed with a Pareto chart to determine common barriers to DIG provision and documentation. Clinicians were surveyed on potential ways to document DIG provision to eligible pts. The Model for Improvement and DMAIC (Six Sigma) methodologies were used and multiple Plan-Do-Study-Act (PDSA) cycles were performed to implement the intervention and monitor change. Change data was analyzed using a P-chart, 3-sigma. Results: We used a process map to identify 3 potential care-plans within the H&N oncology program and assist in defining which providers had primary responsibility for providing the DIG. We then designed and implemented a template within the electronic medical record that documents the clinician who gave the DIG and the date it was given. There was an improvement in the rate of DIG documentation from a baseline of 0% (range 0-0%) to a mean of 40% (range 0-100%) over 3-months (p<0.01). This improvement was sustained through last follow-up at 5 months. Conclusions: Through a multidisciplinary approach, we implemented an intervention to identify pts undergoing community-based dental evaluation prior to RT for H&N cancer. Further efforts are focused on increasing the DIG documentation rate and increasing our interaction with community dentists to promote expeditious pre-radiation dental care.
Quality of febrile neutropenia management in a regional cancer center emergency department.
Authors: Kapil Priyanka , Enright Katherine
Published: February 2017

104

Background: ASCO's current guidelines for febrile neutropenia (FN) management support antibiotic administration within one hour of presentation to the emergency department (ED). Prompt initiation of antibiotic therapy is vital to decrease the likelihood of adverse outcomes. Many studies, however, have reported significant delays in antibiotic initiation with mean wait times far exceeding ASCO's guidelines. We aimed to assess the quality of FN management at a regional cancer centre ED. Methods: Patients undergoing chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada between 04/12 - 03/13 were identified using electronic medical records. Patients were excluded if there was no record of chemotherapy delivery within 30 days prior to ED visit. ICD-10 codes and chart data were used to identify patients who had presented for either fever or infection. The primary outcome measures were three major quality of health indicators; time to assessment by a physician, Canadian Triage and Acuity Scale (CTAS) score, and time to initiation of intravenous antibiotics. Results: In total 239 records were included in the analysis. CTAS score was concordant with recommendation for FN (level 1-2) in 85% of patients and did not vary based on primary cancer site (p = 0.17). The mean time to physician assessment was 97.2 min and the mean time to initiation of IV antibiotics was 194.7 min. Overall, 14.6% of patients received their first dose of antibiotic therapy within the recommended 1 hour window. Conclusions: Our audit identified a large margin for improvement in the time to initiation of antibiotic therapy for chemotherapy patients with suspected FN. Prompt recognition and initiation of standardized treatment pathways for FN in the ED may improve the time to initiation of antibiotic therapy. In an attempt to address this gap in quality we have developed and distributed a standardized wallet-sized fever card to all patients receiving cytotoxic chemotherapy within our regional cancer program. This card contains information pertaining to the current chemotherapy treatment and recommended ED treatment protocols for FN. An evaluation of the impact of these cards is ongoing.
Improving safety culture at a large AMC.
Authors: Lennes Inga Tolin , Bohlen Nie , Ryan David P.
Published: February 2017

105

Background: Building a culture of safety in a large, growing academic oncology practice presents several challenges including: 1) lack of basic knowledge of QI and safety processes, 2) lack of systems thinking and 3) poor cross-disciplinary relationships. In 2011, the MGH Cancer Center piloted a program where groups of cancer center employees convened to address these issues. Safety reporting by physicians was tracked as a metric for improved safety culture. Methods: Quality Rounds are held bimonthly at the main campus of the MGH Cancer Center. A comprehensive group of all members of the Cancer Center including MDs, NPs, PAs, RNs, pharmacists, medical assistants, administrators, financial coordinators, students and members of our patient and family advisory committee are invited to attend. Groups are kept small to facilitate interaction and discussion. The program consists of a didactic section which includes: 1) definitions of quality and types of variation, 2) methods of performance improvement, and 3) safety reporting systems at MGH. Case studies developed for Quality Rounds are discussed. The MGH Cancer Center data regarding safety events on our campus was reviewed. Questions, discussion and personal reflection are encouraged. Results: 188 MGH employees have participated in the Quality Rounds program. Of the participants, 94/188 (50%) were physicians. During the course of the program, physicians have been allowed to repeat attendance once. Of the participating physicians 20/94 (21%) voluntarily repeated the program. Since the implementation of Quality Rounds, physician generated safety reporting has increased 42% over 3 years. Overall reporting by physicians has increased every year since 2011. Pre and post program surveys showed that Quality Rounds shifted the perception that errors are caused by only individuals to a more comprehensive appreciation of the multi-factorial nature of errors in healthcare. Conclusions: Implementing a program designed to teach the basic tenets of healthcare quality and safety to a wide variety of cancer center employees was feasible. Physicians were a majority of participants and their involvement in the quality and safety program at MGH has increased as evidenced by increased numbers of filed safety reports after participation.
Does three-dimensional intraoperative specimen imaging reduce the need for re-excision in breast cancer patients?
Authors: Chagpar Anees B. , Butler Meghan , Killelea Brigid K. , Horowitz Nina Ruth , Stavris Karen , Lannin Donald R.
Published: February 2017

107

Background: Intraoperative specimen radiography is used by surgeons to evaluate partial mastectomy specimens to ensure that the lesion in question has been adequately removed. We sought to determine whether three-dimensional (3D) specimen imaging would better predict margin status and reduce the need for re-excision than conventional two-dimensional (2D) imaging. Methods: A prospective study using standard 2D as well as 3D specimen imaging was undertaken. Surgeons were asked whether the additional orthogonal view would change their management (i.e., result in further margins being taken intraoperatively), and the impact of this on final margin status. Results: Of the 100 women participating in the study, pathology results were available in 99. Of these, 10 had no residual tumor in the definitive specimen (either due to neoadjuvant chemotherapy, or due to the entire tumor being removed in the core biopsy). The remaining 89 patients formed the cohort of interest. 21 (23.6%) had DCIS, 18 (20.2%) had invasive cancer, and 50 (56.2%) had both. The median tumor size of the largest component was 1.7 cm (range; 0.2 – 8.1 cm). Based on the conventional two-dimensional imaging, surgeons stated they would take more tissue in 26 patients (29.2%). Of the 63 patients in whom no further excision would have been indicated on 2D imaging, the 3D imaging changed management in 4 patients (6.3%). Two of these patients would have had positive margins if the intraoperative resection done on the basis of the 3D imaging would have been omitted. Patients who surgeons felt, either by 2D or 3D intraoperative imaging, warranted intraoperative re-excision tended to have a closer initial margin than those in whom re-excision was thought not to be needed on the basis of intraoperative imaging (median 1.0 vs. 2.0 mm, p=0.038). Furthermore, patients in whom an immediate intraoperative margin was taken (either due to imaging or as a matter of routine) were less likely to require subsequent re-excision (13.4% vs. 40.9%, p=0.012). Conclusions: While 3D specimen imaging changes management in only 6.3% of cases, these data highlight the role of intraoperative immediate re-excision in potentially reducing re-excision rates.
The toxicity gap: Do real-life patients get hospitalized more during chemotherapy compared to trial patients?
Authors: Prince Rebecca Michelle , Krzyzanowska Monika K. , Atenafu Eshetu G.
Published: February 2017

109

Background: Toxicity related hospitalizations during chemotherapy are poorly reported in the literature. We sought to compare “real world” versus clinical trial rates of hospitalizations among patients with metastatic non-small cell lung cancer (mNSCLC) receiving chemotherapy. We hypothesised that hospitalization rates in real life patients would be significantly higher. Methods: We conducted a systematic review of Medline and EMBASE (1946-June 2013) to identify articles reporting hospitalization rates during chemotherapy in patients with cancer. Both observational studies and clinical trials were eligible. This report focuses on patients with mNSCLC receiving palliative chemotherapy as data was available for this clinical scenario in both the observational and clinical trial setting, allowing comparison. Study results were abstracted using a standardised form. Summary statistics were used to describe results and the chi-square test used to compare hospitalization rates. Results: The search identified 61 articles (all published after 1987), of which 16 were clinical trials and 45 were observational (“real world”) studies. Nine studies examined chemotherapy in mNSCLC - four observational studies and five randomised trials. The four observational studies included 7,456 patients; three included patients on any chemotherapy while the other focused on doublet regimens. Of the five randomised trials which included 3,962 patients, three treated patients with platinum doublets and two used single-agent chemotherapy. The real life cohort was older (70 years vs. 62 years). The aggregate hospitalization rate among real life patients was significantly higher than among trial patients (49% vs. 16%, OR=7.7, 95% CI 7-8.5, p-value < 0.0001). Performance status and type of chemotherapy were associated with hospitalization during chemotherapy in clinical trials while type of chemotherapy was a risk factor in observational studies. Conclusions: Clinical trials in mNSCLC consistently report lower rates of hospitalization than real life cohorts of patients undergoing similar therapies but very few clinical trials report this information.
Standardizing coordination between surgical oncology and reconstructive surgery for breast cancer patients undergoing mastectomy with immediate reconstruction.
Authors: Golshan Mehra , Hergrueter Charles A. , Camuso Kristen , Lin Nancy U. , Cutone Linda , Hirshfield-Bartek Judith , Roberts Phil , Runkle William , Kadish Sarah , Losk Katya , Bunnell Craig A.
Published: February 2017

110

Background: Timely diagnosis and treatment of breast cancer, endorsed by organizations such as ASCO and NCCN, are essential to ensure optimal clinical outcomes and patient satisfaction. Inefficient care coordination may adversely affect care quality. At our cancer center, 75% of patients who undergo mastectomy seek a reconstructive surgery consult and over 60% elect mastectomy with immediate reconstruction. We sought to evaluate and reduce the time to reconstructive surgery consult and first definitive surgery (FDS) by streamlining coordination between services. Methods: We studied 330 patients who underwent mastectomy with immediate reconstruction between January 2011 and April 2013. Time intervals between initial surgical consult, reconstruction consult, and FDS were calculated. After examining existing best practices in patient referral and scheduling, we established targets of 7 days from initial consult to reconstruction consult and 28 days from initial consult to FDS. To achieve these targets, facilitated sessions were held with administrative and clinical experts to create a standard referral and scheduling process, including a referral template and establishing surgical teams based on clinic and operating room alignment. The interventions were implemented over a 6-month period. Results: Mean days from initial consult to reconstructive surgery consult decreased, with significant improvement in reaching the 7 day target. No significant changes from time of initial consult to FDS were observed. Conclusions: Standardizing coordination has led to timelier reconstructive surgery consults for patients undergoing mastectomy with immediate reconstruction. Other factors, such as operating room availability, pre-operative testing and patient preference should be explored to reduce the time to FDS. [Table: see text]
Evaluation of a risk-adapted visit for post-treatment cancer survivors.
Authors: Rosenberg Carol A. , Flanagan Carol , Brockstein Bruce , Obel Jennifer Carrie , Wade Elaine Lee , Law Teresa Murray , Dragon Leon Harold , Merkel Douglas E. , Khandekar Janardan D. , Hensing Thomas A.
Published: February 2017

113

Background: The Living in the Future (LIFE) Cancer Survivorship Program at NorthShore University HealthSystem provides a risk adapted visit (RAV) directed by a physician and facilitated by an oncology nurse during which an electronic medical record documented LIFE survivorship care plan (SCP) is provided and discussed. We evaluated the degree to which a RAV promotes individualized healthcare and self-management as survivors transition from active treatment to follow-up care. Methods: Patients anonymously complete a post-RAV evaluation on the day of their RAV and then another at least one year after their RAV. Results: 1,713 RAVS, the majority for breast cancer, occurred from 1/2007 to 3/2014.There are 1,615 complete “day of” post- RAV evaluative data with a median time from completion of last therapy of < 6 months. Respondents scaled statements as strongly agree/ agree/disagree/ strongly disagree. Combined strongly agree/agree ratings are: 94% felt more confident in their ability to communicate information about their cancer treatments to other members of their healthcare team; 90% felt more comfortable recognizing signs and symptoms to report to their healthcare provider; 98% had a better appreciation for potentially helpful community programs and services. Of the 488 respondents (RAV between 1/2007 and 12/2012 n=1,366) to a questionnaire at least one year after the RAV, nearly 100%/97%/93%/91%/85% found the SCP useful in at least 1/2/3/4/5 ways: to summarize medical information, to reinforce follow up care, to recognize symptoms to report, to identify lifestyle practices that promote health, and for assistance in identifying local resources for support. 72% discussed their SCP with their PCP or another healthcare provider, 97% stated they made at least one positive lifestyle change, 89% attended at least one LIFE health promotion seminar, and 80% continue to work on wellness goals. Conclusions: Participation in a LIFE RAV following oncology treatment helps survivors construct a useful understanding of their cancer experience to guide self-care behavior. Data demonstrate that benefits persist one year after the visit and support the feasibility of a nurse-led RAV to establish a SCP in post-treatment cancer survivors.
Implementation of clinical practice guidelines in a multicenter radiation oncology department.
Authors: Teckie Sewit , Lee Lucille , Chou Henry , Zuvic Petrina , Potters Louis
Published: February 2017

117

Background: Recent reports suggest that less than 20% of cancer care is based upon level I evidence. As a result, the majority of cancer care tends to be ad-hoc. Furthermore, deviations from established standards-of-care are associated with worse clinical outcomes. Systematic and evidence-based approaches to cancer care are widely regarded as an effective way of improving quality and value in oncology, yet their implementation remains broadly circumspect. In our multicenter radiation medicine department, we developed clinical practice guidelines (CPGs) that encourage consistent care in order to minimize variations in patient treatment, outcome, and experience. We hypothesized that CPGs would also improve efficiency, performance, and cost. Methods: We developed a system for prioritizing value in radiation oncology (Smarter Radiation Oncology) comprising three pillars – quality, evidence-based care, and patient experience. We created 87 unique, evidence-based and consensus-driven electronic CPGs that apply to the majority of patients undergoing radiation therapy in our department. Each CPG delineates an evidence-based treatment approach for a specific cancer site and stage, as well as many technical components such as simulation, treatment planning, quality assurance, clinical care requirements and survivorship. Results: Overall compliance to CPGs was >88%. Six-sigma Z-scores indicated improvement in efficiency and compliance. Treatment delays decreased and patients reported more favorable ratings on a variety of measures, including likelihood to recommend, wait times, understanding of treatment, and physician sensitivity. For breast and prostate cancer, adherence to CPG treatment resulted in 20% and 15% average lower costs than standard, non-CPG treatment. Conclusions: We demonstrate that consensus- and evidence-based CPGs can be successfully implemented in a multicenter department, with high adherence rates. CPGs improve safety and reduce costs by minimizing variation and deviations from standards-of-care. In an era of rising cancer spending, CPGs can be expanded beyond radiation oncology to the entire oncologic care process, thereby improving value for all cancer patients.
Who dies in the ICU? A qualitative analysis of cancer deaths.
Authors: Donohue Caitlin C. , Fraile Belen , Zhang Yichen , Stuver Sherri Oliver , Dalby Carole Kathleen , Jacobson Joseph O.
Published: February 2017

118

Background: Providing safe and nurturing end-of-life (EOL) care to cancer patients is a challenge in any setting, but particularly so in the intensive care unit (ICU). In a unique collaboration between a comprehensive cancer center and a payer, we sought to identify cancer patients who died in the ICU and conducted a chart review-based qualitative analysis to better understand their location of death. Methods: We completed an exploratory, qualitative analysis based on a cohort of 264 active Dana-Farber Cancer Institute (DFCI) patients who died during 2012 and had claims data from Blue Cross Blue Shield of Massachusetts. Of the 160 patients admitted to the hospital in the last 30 days of life, 28 (17.5%) expired in an ICU. For the 22 patients who died in the ICU of a DFCI-associated hospital, vignettes were created from a chart abstraction. Using an inductive qualitative analysis approach, we explored each vignette using rounds of open, axial, and selective coding and identified common themes that described the patients’ ICU death incidents. Results: For the 22 cases, the most salient themes are reflected in the Table below. Conclusions: Using a qualitative research approach, we identified relevant factors to help understand why cancer patients die in the ICU. Most families requested aggressive therapy and, even though goals of care may have been modified, patients remained in the ICU. In addition, a substantial proportion of patients were transferred from a community hospital to an academic, tertiary hospital presumably to receive more aggressive treatment. In the future, the relationships among the themes identified from this research should be tested by a quantitative approach. [Table: see text]
Cincinnati’s adoption of a web-based portal to promote reportable evidence-based care.
Authors: Loy Bryan A. , Gallagher Jude , Peterson Barry A. , Forston Stanley , Sturgill Michael
Published: February 2017

121

Background: Health plans have limited ability to assess compendia and preferred pathways, as claims data lack tumor subtyping, staging, line of therapy, and performance status. Attempts by health plans to gain visibility into compendia compliance have resulted in pre-authorizations and medical record analysis, which incur administrative burdens for physicians and plans. Alternative, more efficient approaches for payers and oncologists to share clinical data on treatment decisions may promote evidence-based care. Methods: In 2011, Humana and New Century Health implemented a registry-like platform to improve administrative efficiencies and facilitate compendia and preferred pathways in participating oncology centers in the Cincinnati metropolitan area. This web-based platform replaced faxed pre-authorization forms and created the opportunity to obtain real-time authorization. In the 3 years after implementation of the platform, process metrics for breast, colon, lung cancers, and lymphoma were reported. Coverage determinations were grouped as 1) withdrawn or not approved, or 2) approved, defined as compendia-based, inclusive of pathways, off-compendia approvals, and clinical trial notifications. Results: Widespread physician adoption of the platform exceeded 99% in 2011 and remained above 95% in the following 2 years. The trends in non-approved and approved reviews remained stable. As a subset of approved-reviews, compendia-based care remained consistently above 95%, while off-compendia plus clinical trial notifications occurred at frequencies below 5%. Conclusions: Compendia compliance was high and remained stable over time. Widespread adoption of a web-based platform can ease the administrative burden and support timely enrollment of patients into clinical programs. Evolution of the platform intends to shift the information closer to the point of decision making by the treating oncologist. [Table: see text]
CANES family health team EMR optimization pilot.
Authors: Dhanji Zabin , Cunningham Nicki , Carr Dafna
Published: February 2017

129

Background: While Electronic Medical Records (EMRs) have been widely adopted within primary care, practices are at various stages of maturity in their use. Cancer Care Ontario (CCO) has embarked on an EMR Optimization initiative, in collaboration with primary care providers (PCPs) and OntarioMD. The project is intended to support PCPs in leveraging the functionality in their EMR systems in order to support cancer screening through the development of training guides and tools. Working with the CANES Family Health Team (FHT), CCO is piloting the usefulness and effectiveness of these tools in meeting these objectives and using the results to inform how to support provincial pilots. Methods: The EMR Optimization guides and tools provide practices with training on five key areas: practice workflows, data discipline, searches, reminders and preventative care summary reports. Working with a multi-disciplinary team at the CANES FHT, CCO provided the team with the EMR Optimization tools and training on these five key areas. The training was supplemented with exercises on topics such as data discipline and practice workflow. The practice team then had opportunities to work with the guides and tools and integrate them into their daily workflow. Results: Preliminary results of an EMR maturity survey show that even after a short period of time, the team has developed an awareness of and a focus on improving data quality through standardization. In addition, they have learned how to leverage the functionality of their EMR system for preventative care purposes. Participant feedback indicates that they found the EMR guide and tip-sheets easy to understand and follow. Conclusions: The CANES pilot has resulted in practice staff moving up the EMR maturity curve and has taught the team how to leverage their EMR to support cancer screening. In addition, the pilot has helped inform CCO’s training strategy and refine the guides and tools. The next steps are to develop self-directed training tools and resources that will support a broader scale pilot to be implemented throughout 14 regions in Ontario.
Proteinuria monitoring in patients receiving bevacizumab at a community cancer center.
Authors: Benyounes Amin , Pomerantz Sherry , Christian Ann , King Gentry Teng , Leahy Nancy , Tester William J. , Leighton John Charles
Published: February 2017

13

Background: The use of bevacizumab has been associated with the development of proteinuria. The manufacturer suggests monitoring for proteinuria with serial urine dipsticks. We set to evaluate the relevance and cost of this practice in a Community Cancer Center in Philadelphia. Methods: We performed a retrospective chart review at Albert Einstein Cancer Center. Consecutive patients treated with bevacizumab from January 2011 to March 2014 were included in the study. Primary endpoints were the incidence and grade of proteinuria under bevacizumab therapy and the implication of proteinuria in treatment (holding or cessation of bevacizumab). Secondary objectives included the association between the number of bevacizumab infusions or patient’s comorbidities (diabetes, hypertension, chronic kidney disease) and the development or worsening of proteinuria. We also calculated the cost of monitoring for proteinuria in our cohort. Results: 71 patients were screened. A total of 66 patients (corresponding to 738 infusions) were included in the analysis. Typical monitoring interval was every 2 cycles. None developed nephrotic range proteinuria. One patient (1.5%) developed grade 2 proteinuria. Bevaciuzumab was discontinued due to proteinuria in 2 patients (3%): neither of them developed permanent kidney damage or required an intervention as a consequence of the proteinuria. The most common reason of bevacizumab discontinuation was progression of disease (75%). Neither the number of infusions nor concomitant comorbidities were significantly associated with the development or worsening of proteinuria (p=0.8, p>0.05 respectively). The cost of monitoring for proteinuria in our cohort was estimated at $3980. Conclusions: These results show that the development of grade 2 proteinuria, let alone grade 3, with bevacizumab is uncommon and rarely affects treatment decisions in our Community Cancer Center. We therefore question the necessity of routine monitoring for proteinuria during bevacizumab treatment.
SMART chemotherapy: A comprehensive cancer center’s journey to shared medical appointments.
Authors: Prescott Lauren S. , Dickens Andrea S. , Guerra Sandra L. , Tanha Jila , Phillips Desiree G. , Lowe Kathryn B. , Lozano Garcia Miguel A. , Soliman Pamela T. , Garcia Elizabeth A. , Lang Kai E. , Lewis-Patterson Paula A. , Levenback Charles F. , Bodurka Diane C.
Published: February 2017

135

Background: Shared medical appointments (SMA) offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. To our knowledge, there are no established SMA models for oncology patients undergoing treatment. Our objective was to develop and implement a SMA for chemotherapy education and clearance for women with gynecologic cancer. Methods: We first assessed the level of interest in SMAs among our patients and providers through qualitative interviews. We subsequently created a multidisciplinary team comprised of physicians, mid-level providers, nurses, pharmacists, administrators, health education specialists and members of the QI Department. Our project consisted of several phases: 1) provider buy-in, 2) program development, 3) staff education, 4) implementation; and 5) patient recruitment. A plan-do-study-act cycle was performed following each SMA, using patient and provider feedback. Appropriate modifications were made before the subsequent SMA. Results: Both patients and providers identified pre-chemotherapy as an optimal area to pilot SMAs. We established a multidisciplinary Shared Medical Appointment and Readiness Teaching (SMART) clinic for all gynecologic oncology patients initiating chemotherapy with platinum- and taxane-based regimens. This model of care provides patient education within a framework of social support that empowers patients. We developed a standardized chemotherapy education presentation, and also provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advanced directives and center contact information. Surveyed patients reported being highly satisfied with the group visit and would recommend SMA to other patients. Our preliminary data analysis revealed that SMART visits decreased wait time and increased value-added time for patients. Conclusions: SMAs for oncology patients initiating chemotherapy is both novel and feasible. A patient centric model, collaboration of multidisciplinary team members, and timely responsiveness to constructive feedback are essential to the successful integration of SMAs in an academic center.