bluuebunny/crossref_metadata_2025 huggingface dataset:
A survey on social media use and expectations in cancer patients.
Authors: Ali Shamsher , Knestrick Mark W. , Aciavatti Lori , Wen Sijin , Shah Nilay Arvind
Published: September 2018

e18183

Background: Social media encompasses a wide variety of web based and mobile technologies. It has become increasingly popular, allowing for rapid communication and dissemination of information. Many believe that social media can be used as a platform for patient education and knowledge sharing. This survey intended to assess patient use of social media and patient expectations for its role at our cancer center. Methods: The study took place at West Virginia University (WVU) Hospital/Mary Babb Randolph Cancer Center, a tertiary care center. This IRB-approved, anonymous, and voluntary survey included twenty-five questions that abstracted patient data which included: age, gender, cancer type, level of education, internet use, information sources for given cancer, use of social media, and the use of WVU cancer website and social media. The survey was distributed by nursing staff to patients who were at least 18 years of age Results: 370 surveys were collected in total. 87.6 % of patients reported using social media, with Facebook as the most commonly used platform at 85.6 %. 70% reported to view or update social media sites daily. All patients reported at least monthly internet use with 61.1 % of patients reported using the internet daily. 32.7% of patients interact with WVU Cancer Centeron social media daily. When asked how patients search for background information or reviews about their provider, 57.8% of patients reported they used our institution’s website. 55.7% of patients believe it would beneficial to contact their cancer provider through social media. Only 22% of patients reported they use social media for medical information. Conclusions: With the increasing use of social media for medical information over the past several years, it is crucial for academic centers and providers to keep up with the growing demand to provide accurate and practical information for patients. Our data suggests our patient population would like to see an increased use of social media from the cancer center and its providers. The information can be used to update our cancer website and social media sites to provide patient-centered cancer information in hopes that patients will have one reliable source for all of their disease related questions and concerns.
Libro Blu as a mobile app to improve cancer care.
Authors: Rapposelli Ilario Giovanni , Fusco Ornella , Deligiannis Panagiotis , Pastorini Alessandro , Fiumanò Mario Saverio , Menatti Elisabetta , Viaggi Valentina , Stiglich Francesco , Palazzolo Roberto , Soccodato Andrea Maria , Volpi Maurizio , Antoniazzi Francesca , Pedrotti Claudia , Malugani Fabio , De Filippi Francesco , Libera Eros , Songini Cristina , Tavasci Emanuela , Dell'Agostino Katia , Bertolini Alessandro Stefano
Published: September 2018

e18190

Background: When ASCO published Top Five List to improve cancer care in 2012, we applied the same principles to build local guidelines, resulting in first edition of our “Libro Blu” (Blue Book), named after a similar tool previously adopted by the Swiss institution IOSI. In 2015 a reform of Lombardy public health, with the establishment of ASST-VAL, covering a huge area with 5 hospitals, brought a further need for harmonization of our work; moreover, the increasing appearance of high cost drugs and the simultaneous restrictions in public health budget required a more rational expense. Methods: After first edition in 2012, Libro Blu underwent periodic updates. In 2015 a major revision took place; besides up-to-date guidelines in the management of specific cancers, edited by Oncology, Hematology and Radiation Therapy specialists, attention was paid to supportive care, with consultants from many other fields. All recommendations in Libro Blu derive from Italian and international guidelines, adapted to our local reality after multidisciplinary discussion, and have been approved after a final joint review. Results: The implementation of Libro Blu resulted in a more consistent application of treatment protocols in ASST-VAL, ensuring all patients the same standard of care, and allowed to raise the level of both specific cancer treatment and supportive care. Furthermore, guidelines for a rational use of drugs allowed to reduce costs in our institution. After one year, 2015 edition of Libro Blu was submitted for review by a number of Italian oncologists from other institutions. Following this review, we used the updated version of Libro Blu to build, with unconditional support from Eli Lilly, a mobile app that will soon be available for download. Conclusions: Libro Blu established a common standard of care in a broad area and allowed a cost reduction that is particularly relevant at this moment, with cancer care facing the appearance of many high cost drugs along with a spending review that involves the Italian health system. The review from other Italian oncologists ensured the adherence of Libro Blu to national guidelines and to state-of-the-art clinical practice. Finally, the mobile app will make consultation easier and will allow to share this tool across all Italian institutions.
Utilization of an electronic medical record trigger to promote palliative care consultation in ambulatory oncology.
Authors: Rauenzahn Sherri L. , Schmidt Susanne , Ali Nazneen , Tenner Laura LaNiel
Published: September 2018

e18201

Background: Research insupportive care demonstrates improvements in overall survival, quality of life, symptom management, and reductions in the cost of care. Despite the American Society of Clinical Oncology recommendation for early concurrent supportive care in patients with advanced cancer and high symptom burden, integrating supportive services is challenging. Our aims were to 1) implement an electronic medical record (EMR) provider alert of high symptom burden based on Edmonton Symptom Assessment Scale (ESAS) criteria and 2) determine the impact an alert has on supportive service referrals. Methods: ESAS scores were implemented in medical ambulatory oncology clinics to quantitatively assess symptom burden. An EMR alert was programmed for a total ESAS score > 30 and any single response of ≥9 to capture approximately 15% of our high symptom burden patient population. The provider could elect to accept the alert placing an order for palliative consultation or decline the prompt. Referral rates and symptom assessment scores were followed as metrics for EMR alert efficiency. Results: Over 10 months, 9,710 patient visits used the ESAS system resulting in 7,707 fully completed ESAS scores (79.4% completion rate). There were 78 total consults to palliative care, a referral rate of less than 1% of the population, which was unchanged from prior to trigger implementation. Of the total completed ESAS forms, the trigger alerted 686 times (8.9% of patient visits) with only 55 of those triggers leading to a supportive care referral (8.0%). Conclusions: This project highlights the challenges of an EMR based alert system and the need for continued efforts to improve supportive care referrals through provider education and tool implementation. [Table: see text]
Use of a cognitive computing system for treatment of colon and gastric cancer in South Korea.
Authors: Baek Jeong-Heum , Ahn Sung-Min , Urman Alexandra , Kim Young Saing , Ahn Hee Kyung , Won Park Sung , Lee Won-Suk , Sym Sun Jin , Park Heun Kyu , Chun Yong-Soon , Cho Eun Kyung , Lee Woon-Kee , Shin Dongbok , Kim Young-Bo , Dankwa-Mullan Irene , Norden Andrew D , Rhee Kyu , Lee Uhn
Published: September 2018

e18204

Background: IBM Watson for Oncology (WFO) is a Memorial Sloan Kettering-trained cognitive computing system that provides oncologists with evidence-based treatment options for cancer. Treatments are presented in three categories: “Recommended”, “For Consideration” and “Not Recommended”. We examined the concordance of treatment options between WFO and the tumor board from Gachon University Gil Medical Centre (GMC), Incheon, South Korea. GMC is an urban center that cares for 50,000 cancer patients annually. Methods: We enrolled 340 patients with stage II, III and IV colon cancer and 185 with chemotherapy-naïve advanced gastric cancer, all treated between 2012 and 2016. Cases were processed using WFO, and the output was compared to blinded tumor board recommendations. Treatment options were considered concordant when the GMC recommendation was included in the “Recommended” or “For Consideration” categories. Results: Treatment recommendations were concordant in 248 (73%) of the 340 evaluated colon cancer cases. Of 250 patients treated in the adjuvant setting, 212 (85%) were concordant. Of 90 patients with metastatic disease, 36 (40%) were concordant. Treatment recommendations were concordant in 90 (49%) of 185 chemotherapy-naïve gastric cancer patients. Low concordance rates in gastric cancer were explained by two observations: (1) The trastzumab/FOLFOX regimen is not covered by the Korean National Health Insurance System, and (2) A regimen known as S-1 (tegafur, gimeracil, and oteracil) plus cisplatin is routinely used in Korea and is not used in the U.S. Conclusions: Treatment options suggested by WFO were concordant with the therapeutic decisions of GMC in the large majority of colon cancer patients treated in the adjuvant setting. Lower degrees of concordance were seen in patients with metastatic colon and gastric cancer, reflecting differences in practice patterns between the United States, where WFO was trained, and GMC, in Korea. Geography-specific customization is available in WFO and should enable physicians and patients to benefit from WFO worldwide. WFO's ability to learn from gastric cancer cases in a part of the world with increased incidence may reveal insights that are applicable elsewhere.
Preliminary evaluation of a novel blood test to predict delayed nausea for breast cancer patients.
Authors: Parikh Kinjal , Wang Yue , Brady Amy L , Ali Zonera A. , Shevade Aarti Lothe , Zeger Erik L. , Gilman Paul , Wallon Margaretha
Published: September 2018

e18210

Background: We have previously reported on glutathione recycling capacity (GRC) in red blood cells as a predictor of delayed nausea in cancer patients treated with platinum-based chemotherapies [1]. The test identifies individual variations in the efficiency to scavenge reactive oxygen species, produced by chemotherapy-induced cell-damage, which triggers release of serotonin – a know inducer of chemotherapy-induced nausea and vomiting. In this current study, we have examined if the GRC assay and/or changes in substance P (SP), another inducer of nausea, can predict delayed nausea among breast cancer patients receiving doxorubicin- or taxane-based therapies and thereby provide better guidance to individualized antiemetic therapies. Methods: Chemotherapy naïve breast cancer patients were asked to participate in this IRB-approved study. Consented patients donated a tube of blood prior to each treatment cycle. Commercial kits were used to measure GRC (OxPhos, Rockland Inc.) and Substance P (Parameter, R&D Systems). On-set, duration and severity of nausea, and anti-emetics prescribed were documented by the medical staff. Results: Obtained GRC and SP values were compared to documented incidences of nausea. We found that 26.8% of taxane treated patients [N = 42] had moderate/severe nausea and demonstrated a similar GRC pattern to platinum-based induced nausea, i.e. low GRC results in more severe nausea. Among doxorubicin treated [N = 31] patients, 41.9% had moderate/severe nausea but showed no correlation with GRC. However, preliminary evaluation of these patients showed a continuous increase in SP levels (average 1.74 fold increase after one cycle). Conclusions: In this initial evaluation of our on-going study, we found that fewer patients had nausea in the taxane treated group with a similar GRC predictive pattern as previously reported. However, patients in the doxorubicin treated group were more likely to experience nausea with no correlation to GRC but with a steadily rising level of SP during the early part of their regimen. Using SP testing could help identify patients that might have a medical benefit from additional NK1 antagonist therapy. 1. Kutner, T., et al. Supprot Care Cancer (2017) 25:581-587.
Identifying potential barriers to sperm cryopreservation among Pakistani male cancer patients.
Authors: Latif Nida , Ali Natasha
Published: September 2018

e18223

Background: Cancer survivor rates have increased over the past few decades leading to a growing interest in research related to quality of life. The American society of clinical oncology’s updated guidelines of 2013 recommend that health care providers discuss the possibility of infertility with patients and present fertility preservation options to those who express interest. We attempted to explore the unique barriers that might prevent adult male cancer patients from accessing sperm cryopreservation in Pakistan Methods: We conducted semi-structured interviews of male cancer patients aged 18-45 years, diagnosed with cancer of any stage or type. The interviews were audio-recorded in Urdu and translated to English, following which they were transcribed ad verbatim. The topics included quality of information received regarding the risk of infertility following chemotherapy, future reproductive choices and barriers to sperm cryopreservation Results: Out of the 25 patients interviewed, there were n = 10 cases of Leukemia, n = 3 of Lymphoma, n = 2 cases each of colorectal carcinoma and Multiple Myeloma, n = 1 case each of Neuroblastoma and Osteosarcoma, and solitary cases involving the lung, breast, thymus, brain, jaw and testis. Only n = 4 patients knew about the potential for infertility due to cancer chemotherapy, all of whom were also aware of the option of sperm cryopreservation. Two patients had their sperm preserved prior to the initiation of chemotherapy. Perceived treatment related expenses appeared to be the biggest barrier to sperm cryopreservation for n = 9 patients (36%). This was followed by lack of information which was cited by n = 8 patients (32%) and religious reasons (n = 2 patients, 8.3%). Other barriers were identified as family wishes, female gender of the doctor and patient’s preferences. Four patients stated there are no barriers. Conclusions: There is a significant lack of awareness among male cancer patients regarding threat to fertility following cancer treatment. It is imperative that physicians inform them of this and discuss treatment options, along with addressing potential barriers.
Institutional scientific review of cancer clinical research protocols: Impact of requirement on activation timelines.
Authors: Dietrich Martin Frederik , Ning Ning , Yan Jingsheng , Xie Xian-Jin , Gerber David E.
Published: September 2018

e18224

Background: The National Cancer Institute (NCI) requirement that clinical trials at NCI-designated cancer centers undergo institutional scientific review in addition to Institutional Review Board review is unique among medical specialties. We evaluated the impact of this process on protocol activation timelines. Methods: We analyzed oncology clinical trials that underwent full board review by the Harold C. Simmons Comprehensive Cancer Center Protocol Review and Monitoring Committee (PRMC) from January 1, 2009, through June 30, 2013. We analyzed associations between trial characteristics, PRMC decisions, protocol modifications, and process timelines using Chi-square test, Fisher’s exact test, Wilcoxon rank-sum test, Kruskal-Wallis test, and logistic regression. Results: A total of 226 trials were analyzed. Of these, 77% were industry-sponsored and 23% were investigator-initiated. While only 40% of trials were approved initially, 97% of trials were eventually approved after a mean of 0.6 protocol changes were requested and a mean of 0.5 protocol changes were implemented. Protocol changes were more likely to be requested ( P< 0.001) and implemented ( P= 0.008) for investigator-initiated trials. Median time from submission to PRMC approval was 55 days. The longest component interval was from submission initiation to completion of required documents by the study team (median 29 days). Total process duration depended on approval timing: median 35 days for first review, 68 days (2nd review), and 116 days (3rd review) ( P< 0.001). Similarly, process duration was also associated with the number of changes/clarifications requested: median 39 days for none, 64 days for 1-3, and 73 days for ≥4) ( P< 0.001). Requested changes/clarifications had greater impact on timelines for industry-sponsored trials than for investigator-initiated trials. Conclusions: NCI-mandated institutional scientific review of cancer clinical trials contributes substantially to protocol activation timelines. Further evaluation of this process and the value added to research quality is warranted.
Cancer patients with undiagnosed and poorly managed diabetes mellitus.
Authors: Kim Sooha , Garg Anukul , Raja Fharat
Published: September 2018

e18232

Background: Cancer patients are at increased risk of developing diabetes mellitus (DM) or having worsening control of their pre-existent DM. The causes of this are multifactorial but the use of steroids, either in the palliative setting or short-term whilst on chemotherapy, is a significant contributor. An audit carried out at a district general hospital demonstrated that 5% of all oncology admissions were secondary to DM complications. A study was conducted to evaluate the prevalence of impaired blood glucose (BG) control and to assess the value of routine HbA1c testing in this population. Methods: Patients having routine chemotherapy blood tests were also tested for HbA1c over a 10 day period in December 2016. HbA1c diagnostic criteria was used as per NICE guidelines. Information on previous diabetic status, primary tumour type, chemotherapy status (number of cycles and treatment intent) was recorded. Results: 134 patients were tested for HbA1c; 28 (21%) had a HbA1c diagnostic of DM and 32 (24%) were at high risk of DM. The mean HbA1c of those in the DM group was 67.3 mmol/mol (range 48-120). Of the 28 with a HbA1C diagnostic of DM, 13 (46%) were already known to have DM with 15 (54%) being newly diagnosed from this study. 11 (73%) of those with a new diagnosis of DM were receiving a short course of steroids with chemotherapy. 12 patients in the DM group were having chemotherapy with curative intent; 6 of whom were newly diagnosed. Conclusions: 11% of the study cohort met criteria for a new diagnosis of DM with 73% of this group receiving steroids. NICE advises on monitoring of BG for all diabetics receiving steroids. Monitoring of BG and using anti-diabetic medications could prevent DM related complications. This highlights the need to involve local diabetic services and primary care providers for diabetic management. 43% of patients in DM group were receiving chemotherapy with curative intent. This has large implications on cancer survivorship and it is vital that these patients receive appropriate DM treatment. This will not only improve quality of care and patient satisfaction but also lead to significant cost savings from reduced admissions and length of stay in hospital. We therefore recommend a routine HbA1c test for all cancer patients having chemotherapy.
Delays in treatment for colorectal cancer patients in an NCI-designated cancer center serving a Hispanic majority community.
Authors: Wangjam Tamna , Rauenzahn Sherri L. , Iruku Praveena , Lindauer Stephanie Purkat , Butler Matthew James , Hung Annie , Yarta Kinan , Jones Jessica Trevino , Konkel Brandon , McCracken Andrew , Arora Sukeshi Patel
Published: September 2018

e18233

Background: Timeliness of cancer treatment is an important aspect of health care quality. Colorectal cancer (CRC) care requires the coordinated multidisciplinary effort of various aspects of the health care system, which can lead to delays between initial diagnoses to definitive therapy. Little is known about the time from diagnosis to cancer-directed treatment, neither about the factors that cause delays or its effect on patient outcomes. Delays to curative surgery beyond 12 weeks are associated with increased mortality in CRC. Longer time to adjuvant chemotherapy is associated with worse survival among patients with resected CRC. The objective of our study is to identify delays in initiation of CRC treatment and its causative factors. Methods: We retrospectively reviewed the medical records of CRC patients who were either initially diagnosed or had initial surgical resection at University Hospital and had further treatment at Cancer Therapy and Research Center, between 7/1/2010 and 12/22/2014. Data were collected on patient and disease characteristics, treatment timelines and outcomes, till pre-specified data cut-off date of 8/1/16. Results: Of 256 patients treated for CRC, majority were males (59 %), Hispanic (59 % ) and uninsured (34 %). Most had non-metastatic disease (70%). 72 % were still alive at the time of data cut-off. The median time from diagnosis to treatment (TDT) was 21 days, with most of te patients getting first treatment between 0-30 days of diagnosis (60 %). Median time from first treatment to first progression or recurrence was 12 months (range 0.9- 42 mos.). Median overall survival (OS) was 17 months (0.1- 51 months). There were no statistically significant difference between the progression or recurrence free survival and OS in patients with TDT < 30 days, 30-89 days and > 90 days. Compared to non-Hispanics, Hispanic patients were more likely to have a TDT of 31-89 days (31% vs 37%, p = 0.0003) and > / = 90 days (3% vs 7%, p = 0.0001). Conclusions: Hispanic patients were more likely to have a longer time from diagnosis to treatment compared to non-Hispanic patients. The factors for such disparities in health care quality and their effect on survival needs to be explored further.
Early integration of palliative care in Ontario cancer settings.
Authors: Wright Frances Catriona
Published: September 2018

e18234

Background: Introducing palliative care early in the cancer journey results in a better life quality, less aggressive care and possibly longer survival compared to patients receiving standard care. The INTEGRATE project aimed to identify and manage patients who may benefit from palliative care earlier in their cancer treatment. This pilot project assessed whether multidisciplinary forums (Multidisciplinary Cancer Conferences, Clinics and Diagnostic Assessment Programs ) could be used to identify patients using the UK Gold Standards Framework Surprise Question (SQ) “Would you be surprised if this person died within the next year?” Methods: Cancer centres volunteered to pilot test the efficacy of the SQ at multidisciplinary forums and implement a palliative model of care. A survey was completed at 3 different points during the project to measure provider comfort in providing palliative care. All sites received primary level palliative care education. Patient and caregiver experience were assessed using interviews and a validated survey. Identified patients received Advance Care Planning (ACP), symptom management, referrals and standardized reporting to primary care. Patient level data was collected. Results: 3 academic and 1 non-academic cancer centres used the SQ in multidisciplinary forums to identify patients in the Lung, Gastrointestinal and Central Nervous System disease sites between February '15-August '16. A baseline survey showed over 50% of providers had no palliative care training. 157 providers received education and at the end of the project providers had increased comfort & confidence in delivering palliative care. Analyses show that 933 patients were identified using the SQ, from which 78% had ACP initiated and 83% are receiving community palliative care services Conclusions: Multidisciplinary forums appear to be excellent for identifying patients who may benefit from a palliative approach to care. Inter-professional provider education and organized approaches to linking patients to community resources, had a positive impact on provider willingness to address end-of-life and palliative issues. Patients & caregivers report positive experiences of care, but different levels of ‘readiness’ to have the ACP discussions.
Kidney cancer mobile application: Comparison of treatment choice of online and offline medical oncologists.
Authors: Tsimafeyeu Ilya , Vetluzhskiy Andrey
Published: September 2018

e18240

Background: There are online tools aimed at helping professionals assess the risks of getting therapy after surgery . Our kidney cancer mobile application (KCMA) has been designed for oncologists to help them decide on the ideal course of treatment of metastatic renal cell carcinoma (mRCC). Here, we present results of comparison of treatment choice of oncologists used KCMA and oncologists made choice based on their knowledge. Methods: KCMA has been developed in 2016. It is strictly built on NCCN guidelines (ver. 3.2016). In our study 122 medical oncologists participated at the RCC meetings were involved. Three clinical cases were proposed. First clinical case described non-treated mRCC patient with favorable MSKCC prognosis (0 unfavorable factors) and clear-cell RCC. Second case described non-treated mRCC patient with poor prognosis (3 factors) and non-clear-cell RCC. Third case characterized patient treated with sunitinib in first-line with progression. 60 and 62 oncologists made treatment choice with (online) or without (offline) mobile application, respectively. Results: Comparison of choice is listed in Table. 100% oncologists used KCMA recommended sunitinib, pazopanib, bevacizumab+IFN or temsirolimus in first-line treatment. 6%, 6% and 12% of offline doctors chose sorafenib, everolimus and axitinib in first-line treatment of clear-cell mRCC. 98.3% of oncologists correctly used application for administration of second-line. 21 of 62 (34%) offline doctors recommended axitinib or everolimus as second-line and 66% prescribed bevacizumab+IFN (31%), sorafenib (15%), pazopanib (4%), temsirolimus (8%) or even continued sunitinib (8%) in patient with disease progression on sunitinib. Conclusions: Online tools based on guidelines could educate and support oncologists to score prognosis and to select best systemic therapy in daily practice. [Table: see text]
Predicting the failure of randomized clinical trials in radiation oncology: What can we learn?
Authors: Nguyen Timothy K. , Nguyen Eric K , Warner Andrew , Louie Alexander V. , Palma David A.
Published: September 2018

e18241

Background: Although randomizedcontrolled trials (RCTs) are essential to evidence-based medicine, a significant proportion of cancer RCTs fail to complete. As RCT failure is not well understood in the field of radiation oncology, we sought to review radiotherapy RCTs to identify predictors of RCT failure. Methods: We undertook a review of the trial registry ClinicalTrials.gov to assess factors influencing the completion of RCTs involving radiotherapy. Eligible trials were registered in ClinicalTrials.gov between 09/27/2007 to 12/31/2010, included radiation (brachytherapy or external beam radiotherapy) in at least one study arm, and were closed due to either successful completion or failure to complete. Data was abstracted by two independent investigators, with discrepancies settled through consensus. Univariable and multivariable logistic regression analyses were performed to determine factors predictive of RCT failure. Results: The initial search yielded 460studies. After reviewing protocol details, 138 studies met inclusion criteria, of which 41 (30%) failed to complete. Most common reasons for RCT incompletion were: lack of accrual (59%), inadequate funding (15%), drug unavailability (7%) and interim data monitoring report recommendations (7%). The highest proportion of RCT failure was observed in the most recent era (p = 0.009), with rates increasing from 11% (1987-2006) to 39% (2009-2012). On univariable analysis, independent predictors of failure included RCTs with a surgical comparator (odds ratio [OR] of failure 6.45; p = 0.010), government sponsorship (OR 3.68; p = 0.024), inclusion of a safety endpoint (OR 3.03; p = 0.014) and study start year (OR 1.18; p = 0.030). On multivariate analysis, surgical RCTs were strongly predictive of failure (OR 7.90; p = 0.015), while behavioral RCTs were less likely to fail (OR 0.14; p = 0.047). Conclusions: Rates of RCT failure in radiation oncology are high. Trials with a surgical comparator are highly prone to failure, whereas behavioral trials are more likely to succeed. These factors can help to inform the design of future RCTs, and develop strategies to mitigate the risk of failure in future radiation RCTs that include a surgical comparator.
Patterns of futile care for comorbidities in colorectal cancer patients near the end of life.
Authors: Sam Davis , Lee-Ying Richard M. , Lau Sally C , Cheung Winson Y.
Published: September 2018

e18242

Background: Futile care includes interventions that no longer provide benefit, may cause significant harm, and/or lack sufficient utility to justify the required resources. Cancer care such as chemotherapy use has been shown to be overly aggressive near the end of life. We hypothesized that futile care for non-cancer comorbidities in terminal colorectal cancer (CRC) patients may also be prevalent and associated with specific clinical factors. Methods: We constructed a large retrospective cohort of decedents aged ≥18 years who were diagnosed with CRC during 2008-2012 and who died by the end of 2013. We analyzed population-based data through linked provincial files with information on cancer management, pharmacy records, hospital discharges, and vital statistics. We defined endpoints for futile care as ≥1 hospitalization and/or ≥1 prescription for statins, dihydropyridine calcium channel blockers (CCBs), or acid suppressants within 2 months preceding death. Different time points were used in sensitivity analyses. Results: We included 2,530 patients. Median age at CRC diagnosis and death was 70 (IQR 61-79) and 72 (IQR 62-80) years, respectively. Among them, 59% were men, 66% had colon cancer, and 87% were diagnosed with advance disease. Median time from diagnosis to death was 452 (IQR 201-800) days. In terms of futile care, 4.7% had hospitalizations, 8.7% received statins, 6.8% received CCBs, and 38.2% received acid suppressants within 2 months prior to death. In multivariate analyses, there were no clear associations between demographics and hospitalizations. With respect to medication use, advanced age was correlated with increased use of statins (OR 2.235, 95%CI 1.469-3.401, p < 0.001) and CCBs (OR 2.039, 95%CI 1.304-3.190, p = 0.002), but inversely associated with use of acid suppressants (OR 0.750, 95%CI 0.598-0.941, p = 0.013). Men were also more likely to receive statins (OR 1.653, 1.099-2.488, p = 0.016), but less likely to receive acid suppressants (OR 0.764, 0.608-0.960, p = 0.021). Conclusions: Even near death, a fair number of decedents with CRC continued to receive medications for comorbidities that were unlikely to provide clinically meaningful benefits. Futile care was more prevalent in men and in the elderly.
Impact of multidisciplinary discussion on therapeutic decision in cancer patients: a prospective observational study.
Authors: Amaro Carla Pires , Gomes Larissa , Almeida Daniel , Reiner Kelly , Almeida Gustavo Fernandes Godoy , Cruz Marcelo Rocha S
Published: September 2018

e18243

Background: Continued and rapid evolution of diagnosis and staging methods along with the development of new treatments has changed decision-making process of cancer patient into a more complex task. We evaluated the impact of multidisciplinary tumor board meetings (MTM) in the final decision of cancer patients approach in comparison to the initial decision based on clinical oncologist’s individual choice. Methods: Between April 2016 and January 2017, data were collected prospectively during the MTM held daily at the Antônio Ermírio de Moraes Cancer Center, Sao Paulo, Brazil. Data were gathered by filling out a questionnaire. The therapeutic plan initialy proposed by the physician was compared to the proposal offered by the multidisciplinary team. We evaluated data from breast, gastrointestinal (GI) and lung cancer MTM. Results: We evaluated 100 questionnaires: 39% GI tumors, 34% lung cancer, 27% breast cancer. The main theme for discussion was selection of systemic therapy (65%). The rate of change in therapy choice was 24.6%. The recommendation suggested by the MTM surgeons and radio-oncologists showed disagreement with the one initially proposed in 21 cases. The majority of discordant cases was related to the choice of therapeutic method (57%) with 42% changes in the chemotherapy protocol. Eight patients were submitted to genetic test and mutations search. Only two cases were recommended for clinical trial enrollment. Conclusions: The rate of therapy plan change after MTM is in accordance with international studies. The largest volume of discussions on systemic therapies reflects the large number of new therapies as well as new treatment strategies. This research highlights the potential of multidisciplinary discussions in changing decision-making in cancer cases, allowing a more comprehensive care with the patient. In addition, a MTM allows the access of more patients to new medications made available through clinical trials and protocols. The small number of patients referred to a clinical study reflects the lack of clinical protocols available in Brazil, a problem that needs to be acknowledged and become a priority for Brazilian medical societies and regulatory agencies.
Tumor flare reaction (TFR) in cancer treatments: A systematic review.
Authors: Taleb Amina B.
Published: September 2018

e18258

Background: In the last decade, TFR was described as a side-effect associated with immunomodulatory agents IMiDs (thalidomide and lenalidomide), and as a specific condition to chronic lymphocytic leukemia (CLL). However, this phenomenon is seen with the use of new immunotherapy (checkpoints inhibitors) in solid tumors, in addition, cases of TFR were reported in advanced gynecologic, prostate cancer and lymphoid malignancies. TFR is defined as an increase of lesion size related to treatment which simulates disease progression. This phenomenon that occurs after initiating cancer therapy is poorly understood and incidence is under-estimated, since not captured by Recist. It has been suggested that TFR may be the results of immune system activation and may precede tumor shrinkage. TFR is associated with morbidity, severe cases were reported, some of them life-threatening or leading to death. So, early recognition and initial management of patients presenting with TFR, is critical. Methods: From 1985 to 2016, a search was performed in the Pubmed, ASCO and ASH abstracts to identify publications reporting TFR or pseudoprogression. Results: The incidence of all grades of TFR in CLL, ranged from 28% in a study to 58% in another trial. In CLL, painful lymph nodes and/or spleen enlargement were reported with a sudden onset after the first dose. Following initial progression (TFR), tumor response in patients treated beyond progression, was reported inmelanoma trials: 9.7% with ipilimumab, 10% with nivolumab, 6.7% and 12% with pembrolizumab, and in renal cell carcinoma 69% with nivolumab. Even if rare cases of life-threatening or fatal TFR were reported, symptoms are usually mild. While correct diagnosis and adequate management are critical, it is important to better recognize TFR, and avoid an effective treatment discontinuation. Some studies showed that treating patients beyond progression yielded tumor responses, considering TFR as predictive of response. Conclusions: Treatment with immunomodulatory agents is associated with TFR. This is likely to be misinterpreted as progression, hence the need to identify appropriate clinical benefit criteria and the use of immune-related RECIST (irRC) in prospective trials for a better understanding.
Risk of infectious, hematological, and gastrointestinal side effects in patients treatedwith ibrutinib: A systematic review and meta-analysis of randomized controlled trials.
Authors: Zaw Myo , Thein Kyaw Zin , Tun Aung , Tijani Lukman , Guevara Elizabeth
Published: September 2018

e18265

Background: Bruton’s tyrosine kinase (BTK) is essential for signaling of B-cell and chemokine receptors. Ibrutinib targets BTK and has become frontier in many hematologic malignancies. We undertook systematic review and pooled analysis of randomized controlled trials (RCTs) to determine infectious, hematological and gastrointestinal risks associated with ibrutinib. Methods: We performed a comprehensive literature search using MEDLINE, EMBASE databases and meeting abstracts through December 31, 2016. The RCTs that mention infectious, hematological and gastrointestinal side effects as adverse effects were incorporated in the analysis. Mantel-Haenszel method was used to calculate the estimated pooled risk ratio with 95% confidence interval (CI). Results: Four RCTs with a total of 1505 patients were eligible for the analysis. Studies compared Ibrutinib (I) vs ofatumumab, I vs chlorambucil, I+ bendamustine (B)+ rituximab (R) vs placebo + B+ R and I vs temsirolimus were included in the analysis. The relative risks (RR) of all-grade side effects were as follows: infection, 1.34 (95% CI: 1.04 – 1.74; p = 0.02); pneumonia, 1.16 (95% CI: 0.82–1.66; p = 0.38); anemia, 0.77 (95% CI: 0.64 – 0.93; p = 0.007); neutropenia, 0.99 (95% CI: 0.87 – 1.14; p = 0.98); thrombocytopenia, 0.86 (95% CI: 0.71 – 1.04; p = 0.12); diarrhea, 1.74 (95% CI: 1.48 – 2.05; p < 0.0001); nausea, 0.94 (95% CI: 0.80 – 1.10; p = 0.45); and vomiting, 0.98 (95% CI 0.74 – 1.30; p = 0.93). The RR of high-grade adverse effects were as follows: febrile neutropenia, 1.32 (95% CI: 0.84 – 2.08; p = 0.21); infection, 1.20 (95% CI: 0.73 – 1.98; p = 0.45); pneumonia, 1.22 (95% CI: 0.76–1.95; p = 0.39); anemia, 0.48 (95% CI: 0.33 – 0.71; p < 0.0001); neutropenia, 0.99 (95% CI: 0.86 – 1.15; p = 0.94); thrombocytopenia, 0.61 (95% CI: 0.47 – 0.81; p = 0.001); diarrhea, 1.72 (95% CI: 0.88 – 3.34;p = 0.10); nausea, 2.56 (95% CI: 0.59 – 10.99; p = 0.20); and vomiting, 0.42 (95% CI 0.11 – 1.63; p = 0.21). Conclusions: Ibrutinib increased the risk of all-grade diarrhea and infection whereas the risks of all-grade anemia, high-grade anemia and thrombocytopenia were significantly lower in the study arm, favoring ibrutinib.
Enhancing clinician confidence on the therapeutic management of non-small cell lung cancer (NSCLC) through continuing medical education (CME).
Authors: Jaganathan Hamsa , Roc Anne , Socinski Mark A. , Turell Wendy
Published: September 2018

e18271

Background: The evolving strategies to personalize NSCLC treatment have challenged clinicians to remain abreast of and integrate targeted therapy into practice. To address this challenge, 2 CME programs on NSCLC were developed in 2 formats (1-hour cumulative program and a series of 3-1 hour specified programs). Participant responses were compared between the 2 formats to examine differences in learner confidence and competence regarding the management of NSCLC with targeted therapy. Methods: PlatformQ Health developed and executed 2 virtual CME programs in NSCLC. The first program, broadcast in August 2015 and offered for 6 months, attracted 225 learners. This 1 hour program reviewed the latest data of EGFR inhibitors (EGFRi), ALK inhibitors (ALKi), and immunotherapy. In 2016, these 3 topics were divided into a series of 3-1 hour CME programs and offered across the year, which has attracted 371 learners. Survey-based evaluations targeted self-reported clinician data on competence (via patient case studies) and confidence. Results: As of January 2017, learner surveys from EGFR- and ALK-focused education were analyzed. It was observed that learners gained more confidence in managing EGFRi-related toxicities after the 2016 serial education vs the 2015 cumulative education (62% vs 43%, respectively). Learners also felt more confident when evaluating data of available and emerging ALKi (49% vs 35%). Greater competence in management was observed with serial vs cumulative education regarding EGFRi (42% and 15%, respectively) and ALKi (30% and 4%) therapies. Both programs demonstrated a high learner commitment to change in: medical and practice knowledge (93% and 91%, respectively), care attitudes (87% and 87%), practice behavior (85% and 79%), and patient clinical outcomes (86% and 77%). Data analysis on immunotherapy education is ongoing. Conclusions: Overall, education on targeted therapy for NSCLC have demonstrated positive learner outcomes. However, designing education in a serial format that dives deeper into each therapeutic target class affords greater improvements in clinician confidence and learner competence in the therapeutic management of NSCLC.
Electronic calculation of quality measures in the EMR and dependence on data capture in structured fields: The OCM quality reporting experience.
Authors: Hamrick James , Revol Cindy , Parulkar Rohit , Lemmers Olaf , Gippetti James , Bauer-Levey Nick , Lee DJ , Fugaro Alison , Green Robert J , Abernethy Amy Pickar , Kolodziej Michael A.
Published: September 2018

e18278

Background: Reporting of quality measures is ideally achieved electronically. This is dependent on presence of data elements in structured fields. We report on the variability of quality measure reporting in the OCM for quality measures OCM 8 (adjuvant chemotherapy in stage 3 colon cancer), 9 (adjuvant chemotherapy in HR- breast cancer), 10 (adjuvant trastuzumab for Her2+ breast cancer), and 11 (adjuvant hormonal therapy for HR+ breast cancer). Methods: Quality measures were calculated for 30,524 patients across 35 practices participating in the OCM. We examined the calculation of quality metrics OCM-8, 9, 10, and 11 based on presence or absence of data elements in the medical record. Results: For quality measures OCM-8 and 9 that require documentation of date of surgery, only 1.3% and 1.6%, respectively, of patients could be included in the calculation due to absence of surgical date in a structured field. For quality measures OCM 9 and 11 that require attestation of surgical staging of breast cancer, this data element was documented in 0% of patients. For OCM 9 and 10 that require stage documentation of breast cancer, this data element was documented in 63% and 75%, respectively, of patients (range 12-100%). In cases where staging criteria were not met, 58% and 44%, respectively, of patients were removed due to total absence of staging data in structured fields. Conclusions: Quality measure calculation and reporting is highly dependent on documentation of data elements in structured fields. Lack of documentation of key elements distorts calculation of the measure. Modification of physician workflow or restructuring of measure calculation to optimize use of well documented structured elements will improve generalizability of quality measure reporting. Manual abstraction of data does not represent a feasible alternative.
The impact of continuing medical education (CME) programs in metastatic castration-resistant prostate cancer (CRPC).
Authors: Jaganathan Hamsa , Roc Anne , Armstrong Andrew J. , George Daniel J. , Turell Wendy
Published: September 2018

e18280

Background: The concurrent development of many CRPC treatments within a short period of time has made prospective data on their sequential use and efficacy complicated, which have challenged clinician confidence, knowledge, and competency. Four hours of CME focused on the therapeutic management of CRPC were developed and participant responses analyzed to determine if these challenges were addressed. Methods: PlatformQ Health developed and executed 4 hours of virtual CME programs in CRPC. The 1st 2-hours, broadcast in May 2015 and offered online for 6 months, attracted a total of 545 learners. The 2nd 2-hours, broadcast in July 2016 and offered for 12 months, attracted a total of 345* learners. Survey-based evaluations targeted self-reported clinician data on satisfaction, clinical practice change and observed patient outcome. Clinician participation data and self-reported patients with CRPC seen per week were used in extrapolations of patients impacted by the CME education per week. Results: Between the 2015 and 2016 CME programs, learners gained confidence in their ability to employ a personalized, sequential approach to treat CRPC (12% vs 35%). Overall, 68% of all learners reported a positive clinical practice impact and 59% reported a positive impact on patient experience and/or outcomes as a result of CME participation. Learner commitment to change was consistently observed in both 2015 and 2016 programs in: medical and practice knowledge (90% and 94%, respectively), care attitudes (83% and 85%), practice behavior (79% and 77%), and their patients’ clinical outcomes (76% and 78%). An estimated 4,066 patients in 2015 and 3,374 patients in 2016 were impacted as a result of the education. Conclusions: Outcomes results of 2 years of education on evolving treatment paradigms of metastatic CRPC demonstrate learner improvements in both clinical practice and patient outcomes. Continuing education in the management of CRPC is recommended, particularly on strategies to appropriately sequence treatments, treatment of bone metastases, keeping abreast of new data, and understanding the rationale for investigational agents. *As of Jan 2017, data collection is ongoing
The oncology prognosis and informed consent: Presentation of a new model to best inform patients.
Authors: Garmezy Benjamin , Worden Francis P. , Blumenthal-Barby Jennifer
Published: September 2018

e18286

Background: Receiving a malignant diagnosis is challenging and patients must be properly informed of their prognosis to make the best decisions for themselves and their families. The general population has a low degree of statistical literacy and therefore approximations should be considered favorable. However, given that half of patients desire quantitative data, physicians must provide this information within a context that is relevant and comprehensible. Single-point median survival data is less meaningful for patient decision-making. What is preferable is that physicians give experience-based estimations on how a patient might compare to the ‘average’. Including this information leads to more informed consent and best follows the ethical principle of autonomy. Methods: This is a novel framework for providing a prognosis that builds upon the multiples-of-the-mean model established in 2010 by Kiely, Tattersall, and Stockler. This framework was derived from original ethics research involving patient preferences, statistical comprehension, healthcare communication, and medical decision-making. Results: Graphical representation of Kiely’s model provides an intelligible view of quantitative data and allows for the physician to include an experience-based estimation. Steps: (1) Draw a Horizontal line, (2) Calculate from median survival data by using five multiples: 0.25 (Worst-Case, 10% of patients), 0.5 (Lower-Typical, 25%), 1 (Median, 50%), 2 (Upper-Typical, 75%), and 3 (Best-Case, 90%), (3) Label the chart using simple time points in months or years (4) Draw a circle over the region that best represents the patient’s expectation, (5) Provide the diagram alongside easy-to-understand language that clarifies the meaning of the numerical data with written likelihood of the occurrence, such as “almost no chance”, “not likely”, “even chances”, “likely”, and “fairly confident”. Conclusions: Kiely’s model has proven an accurate estimation in colorectal, castration-resistant prostate, non-small-cell lung, and metastatic breast cancer. A graphical representation should provide physicians an easy tool to strengthen informed consent and better aid their patients in decision-making.