bluuebunny/crossref_metadata_2025 huggingface dataset:
Building a cancer registry performance dashboard by leveraging existing workflow documents at a comprehensive cancer center.
Authors: Yakowec Jing Jing Wang , Stendhal Ingrid , Lakhani Hakim , Jacobson Joseph O.
Published: September 2018

296

Background: Quantifying the performance of a cancer center’s cancer registry is important to plan for resources needed to address shortcomings and projected increases in workload. The objective of this project was to understand the workflow, reporting requirements, and existing documentation of the cancer registry at Dana-Farber Cancer Institute (DFCI) in order to build a dashboard that quantifies monthly performance. Methods: Current state workflow maps were created detailing the three phases of the cancer registry’s operations: case finding, case abstraction, and case follow-up. Individual meetings and a workshop with the cancer registry staff were held to validate workflows, gather operational challenges and improvement ideas, and set performance metrics. Leveraging information already being collected by staff as part of their workflow, a database was designed to collect and auto-visualize monthly performance using Excel and Tableau. Results: The performance dashboard shows monthly trends of ‘on target’ status of the cancer registry’s case finding, case abstraction, and case follow-up efforts. It also quantifies how delayed the cancer registry is in case finding or abstraction and provides new case count trends by care facility, staffing capacity based on case load, and trends in lost to follow-up patients. One hundred percent of the performance dashboard data is from documentation already generated by the cancer registry staff on a routine basis. Data on monthly case load from September 2017 through March 2018 are presented in the table below; given a maximum limit of 86 cases to abstract per abstractor per month, the cancer registry is currently at more than full capacity. Conclusions: A well-designed cancer registry performance dashboard that leverages existing data does not add burden to registry staff and informs how best to manage and utilize resources according to case load. [Table: see text]
Clinical pathway creation and adherence at a large hybrid cancer center.
Authors: Carnell Matthew , Fleming Martin D. , Portnoy David Craig , Ballo Matthew T. , Fisher Kristopher , Somer Bradley G. , Tauer Kurt W. , Prince Cheryl A. , Vanderwalde Ari M.
Published: September 2018

298

Background: Clinical pathways are valuable in reducing treatment variation, improving outcomes, and reducing costs in an oncology setting. With input of clinical stakeholders at West Cancer Center, we created and implemented a melanoma clinical pathway to improve care and facilitate standardization between melanoma sub-specialists and general oncologists. Retrospective pathway adherence was assessed to inform quality improvement goals. Methods: Using national guidelines and expert literature review, we developed a pathway defining a center-wide algorithmic approach to treat melanoma. Prior adherence to the pathway was retrospectively assessed by evaluating treatment during 1 year across 8 metrics. All patients who received systemic melanoma therapy during the study period at a large cancer center ( > 5000 new patients annually) were included in the assessment. Of the included patients, metric adherence was only measured when applicable. Adherence rates were described for predefined melanoma subspecialists versus predefined general oncologists without a declared subspecialty in melanoma. Significance was assessed with fisher exact test. Results: The following metrics were defined by the expert team as essential components of melanoma pathway; receipt of wide local excision; receipt of sentinel lymph node biopsy; presentation at multidisciplinary conference; molecular profiling before treatment of metastatic disease; treatment with preferred regimens in 1st line, 2nd line, and 3rd line; and clinical trial participation. Ninety patients were evaluated. Conclusions: Most differences in pathway adherence were found to be not significant. Clinical trial accrual was higher among melanoma subspecialists compared to general oncologists. Clinical pathways allow patients treated by general oncologists to benefit from the expertise of subspecialists and improve quality of care.[Table: see text]
Implications of short-term follow-up tomosynthesis mammography on downstream workup after breast conservation therapy.
Authors: Weinberger Kevin , Colosimo Brittany , Hasan Shaakir , Gresswell Steven , Anderson Sidney , Wegner Rodney E , Trombetta Mark G.
Published: September 2018

311

Background: We previously reported that premature (less than 6 months) follow-up screening mammography after radiotherapy in breast conservation therapy was associated with an increased rate of unnecessary downstream workup. We now present the results of a similar study conducted with follow-up tomosynthesis mammogram (TS). Methods: Between the years 2015-2017, 143 consecutive breast cancer patients between ages 33 – 82 were treated with lumpectomy and adjuvant radiotherapy with follow-up TS and reviewed in this IRB-approved study. Cases were stratified by time interval until the first post-radiation TS, and secondarily by radiation technique: conventional fractionation (n = 84), hypofractionation (n = 59), boost (n = 116), no boost (n = 27), and accelerated partial breast irradiation (n = 10). The primary endpoint was the rate of further imaging/workup following TS, correlated with clinical, treatment, and post-treatment timing related variables using multivariable binomial regression analysis. Results: The patient cohort included the following clinical characteristics: 6 patients with ductal carcinoma in-situ (the remaining demonstrated either invasive ductal or invasive lobular histology), Ninety-seven patients had stage T1 lesions, 34 had T2, and 4 had T3/T4 lesions. Eighteen patients were node+, 95 ER+/ Her2-, 13 were triple negative, and 13 triple positive. No patients had clinical suspicion of recurrence before their first follow-up TS. Conclusions: Unlike with post-treatment screening two-dimensional mammography, there was no association with post-treatment tomosynthesis timing and downstream workup. Further study should be considered to confirm these preliminary findings.
Reducing inappropriate rasburicase use to promote cost-effective care.
Authors: Gupta Arjun , Patel Komal , Roberts Taylor , Marley Eileen M. , Li Hsiao Ching , Sadeghi Navid
Published: September 2018

312

Background: Rasburicase is recommended for treating established Tumor lysis syndrome (TLS) and patients at high-risk for TLS. Unfortunately, it is an expensive medication and unnecessary use contributes to expenses. Methods: A multidisciplinary quality improvement team reviewed the process of ordering rasburicase and its prescription patterns at Parkland Heath and Hospital System, Dallas, TX between 10/2015-9/2017. Use was determined as appropriate/ inappropriate based on internally approved indications (laboratory TLS, at-risk for TLS, acute kidney injury and hyperuricemia, failure of or inability to administer allopurinol). Quality improvement interventions were implemented based on weaknesses identified. Results: 65 doses of rasburicase were administered during the 2-year baseline period; 21 (32.3%) of these were grossly inappropriate. The most common ordering providers were oncologists (23 orders, 35%), hospitalists (16 orders, 25%), intensivists (11 orders, 17%), and emergency physicians (8 orders, 12%). Ordering process review identified several pitfalls: one-click ready to sign order, auto-population of dosage, no hard-stop requiring providers to review rasburicase indications, and no pharmacy oversight. We aimed to reduce the percentage of inappropriate rasburicase orders from a baseline of 32.3% to 10% over 3 months. In 2/2018, we implemented PDSA cycle 1 including introducing a best practice advisory requiring providers to select an approved indication for medication use and changed auto-population of rasburicase dosage to 3 mg. A mandatory secondary review by pharmacy prior to dispensing the medication was implemented. Over a 3-month period post-change (2/2018- 5/2018), 11 of 11 rasburicase administered doses have been appropriate (0% inappropriate). Conclusions: A multidisciplinary team and classic quality improvement methodology was able to reduce inappropriate rasburicase use from 32.3% to 0%, with significant cost savings. Straightforward electronic medical record interventions and increased pharmacy oversight are effective interventions in curbing medication overuse. We will periodically re-assess utilization patterns and refine PDSA cycles as needed.
Development of a drug-drug interaction screening tool for oncology clinical trial enrollment.
Authors: Marcath Lauren A , Coe Taylor D , Redman Bruce G. , Hertz Daniel Louis
Published: September 2018

315

Background: Screening drug-drug interactions (DDI) for subjects enrolling in oncology clinical trials is critical to ensuring patient safety and the validity of clinical trial data. We previously reported that DDI screening is not uniformly conducted when screening patients for enrollment into SWOG clinical trials and found that at the University of Michigan Rogel Cancer Center up to 24.2% of subjects enrolled in National Clinical Trial Network (NCTN) trials had a DDI. Screening tools aid in DDI reduction in clinical practice, but none have been created for clinical trial enrollment. Our objective was to develop a clinical trial specific DDI screening tool based on features requested by the end-users of the tool at U-M. Methods: Semi-structured and informal interviews were conducted with all data managers who enroll patients into NCTN clinical trials at the U-M cancer center. Data managers were asked about their current workflow and desired features of a DDI screening tool. Responses were combined and reviewed for feasibility. Desired features were conveyed to PEPID, LLC (Phoenix, AZ) for tool development. Results: Four data managers were interviewed. Protocol-guided screening was a key workflow feature, which was completed by gathering DDI information primarily from the exclusion criteria and drug information sections of each respective protocol, Google, CredibleMeds, and the Indiana University P450 Drug Interaction Table. Consequently, a critical feature was the display of drug characteristics with wording that aligned with that in the protocol including transporter and CYP450 substrates, inhibitors, or inducers and QT prolongation potential. Additional desirable features included separate entry of study and concomitant drugs, filtering to display only DDI with study drugs, and PDF export of results. PEPID developed a prototype tool including these desired attributes for a prospective implementation pilot study. Conclusions: A first generation clinical trial specific DDI screening tool was developed based on end-user feedback. We are designing a prospective study to determine whether implementation of this tool can reduce DDI, enhance patient safety, and ensure validity of clinical trial data.
Automated quality control process for tracking appropriateness of antiemesis.
Authors: Cheema Naveed R. , Master Samip R. , Mansour Richard P.
Published: September 2018

317

Background: Quality tracking and improvement are areas of importance for delivery of high value patient care. Quality Oncology Practice Initiatives (QOPI) are tools designed by ASCO to help oncology practices deliver high quality care. Specifically, QOPI measure 29 tracks whether antiemetics are administered appropriately with moderate/high emetic risk chemotherapy. In this study, we attempted to automate this quality measure using an adapted Microsoft Structured Query Language (SQL) procedure. Our primary aim was to develop an efficient and cost effective system to track appropriate anti emesis that is adaptable to other cancer centers. A secondary aim was to quantify any degree of over treatment in anti emesis in our center. Methods: We created an SQL procedure which accessed the EPIC CLARITY database and used 9 steps to identify how many chemotherapy administrations in our center for the year 2017 were given sufficient, over, or under anti emesis. We adapted our center’s antiemesis guidelines from 2017 ASCO Clinical Practice Guideline Update for antiemetics. The program identified “pass”/”fail”/”pass(-)” for appropriate/insufficient/over treatment of anti emesis, respectively. Results: 1490 patient/chemotherapy encounters were found for 2017. 862/118/510 were high/intermediate/low emetic risk, respectively. 1314/14/162 chemotherapy administrations received “pass”/”fail”/”pass (-)”, respectively. The reason for 13 of 14 “fails” was lack of steroid in high emetic risk regimens. The primary reason for “pass (-)” was use of fosaprepitant in low/intermediate risk regimens. The time required to execute the program for all 1490 encounters was 40 seconds; the average time for manual review was 3 minutes per encounter. There was no discordance between “pass/fail” status in comparing automated and manual reviews. Conclusions: We have created an automated process which rapidly and accurately verifies adherence to QOPI measure 29. It eliminates time and costs associated with manual review. Further, this program saves costs by identifying areas of over treatment in anti emesis. We have demonstrated on a large scale an adaptable and shareable process for other centers using similar EMR databases.
Patient-centered cancer care (PCCC) as a roadmap to success in Alternate Payment Model (APM): A case study-based learning.
Authors: Patel Kashyap B. , Clinton Natasha
Published: September 2018

318

Background: Cancer care is among the fastest-growing segments of the US healthcare system. In the US, total spending on cancer care has increased to $124 billion in 2010. Total costs of cancer care for the US population are predicted to increase across all phases of care. One possible way to reduce overall cost, improve patient experience, and improve outcomes is to shift care away from volume and towards value. Patient-centered cancer care (PCCC) holds the promise of addressing these issues. The Oncology Care Model (OCM), developed by CMS’s Center for Medicare & Medicaid Innovation (CMMI), is a pilot designed to assess the efficacy of PCCC for Medicare beneficiaries over the next 5 years. Our practice participates in the OCM model. We share our practice transformation into PCCC reducing cost, reduce ER visit and improve patient experience. Methods: At CBCCA, we transitioned to PCCC center for accreditation as a Patient Centered Specialty Practice (PCSP) through the National Center for Quality Assurance (NCQA). Our path for PCSP primed us for the OCM with expanded access (including same-day appointments and weekend access), reduced ER visits and hospitalizations. We predicted that transition to PCCC would lower expenses, improve the patient experience, and likely improve outcomes. Based on our projected savings with the delivery of PCCC, we expected CMMI to save about a million dollars. Upon receiving reconciliation reports from CMMI, we were pleased to see that our projections were well within the actual outcomes of savings. Results: Pursuant to our transition to PCCC we were able to reduce ED visits by 40%, hospital stay by 20%, Observation unit stay by 45%, stay in long term care unit by 40% and home health visits by 24%, resulting in overall savings to over $500,000 savings to CMS. Our patient satisfaction survey was in 75% across major parameters. Conclusions: PCCC transition is a viable option for physicians to reduce overall cost, maintain or improve outcomes and patient experience. OCM is the first major initiative that will likely validate journey towards value-based care. Close to 25% of all practices have achieved target savings.
Using Best Practice Advisory alert to increase early advanced care planning discussion and palliative care referral in advanced cancer patients.
Authors: Pandya Chintan , An Amy , Duberstein Paul , Dougherty David W. , Noel Marcus Smith
Published: September 2018

320

Background: Patients with advanced cancer can benefit from early initiation of palliative care (PC) and advanced care planning (ACP). In theory, the Medical Order for Life-Sustaining Treatments (MOLST), which provides a vehicle for end-of-life discussion, could lead to improved uptake of ACP and PC. In order for MOLST forms to influence these care process outcomes, methods are needed to help clinicians introduce the forms to patients in a compassionate manner. The objective of this study is to develop a best practice advisory (BPA) alert in the electronic medical record (EMR) to help oncologists identify appropriate patients for ACP and PC referral and evaluate its impact on improving MOLST form and palliative referral order documentation in EMR for these patients. Methods: BPA alert criteria included Lung and GI cancer patients with stage IV disease or undergoing treatment with palliative intent. The oncologists could act on the alert by either acknowledging it with action statement (I have already discussed ACP, I intend to discuss ACP in this or next visit, Patient unlikely to die in next 12 months, other) or dismiss it. We examined the rates of MOLST form and PC referral orders in the EMR 12-months before and after the BPA was implemented in 03/2018. Results: The BPA fired in 424 patients who met the criteria over a period of 9 weeks. It was acknowledged in 409 and cancelled in 15 patients. Following the alert, 40 (9%) patients had a MOLST form added to the chart compared to only 9 (2%) patients before the alert and 17 (4%) patients had palliative care referral order placed vs. 10 (2%) patients before the alert. Physicians acknowledged discussing ACP in 145 patients, most of whom (25/30) initiated these conversations after the BPA was implemented. Data collection is ongoing to capture BPA effect for longer follow-up. Conclusions: The BPA alert intervention resulted in significant increase in documentation of ACP and palliative referral order suggesting the potential of this tool in improving adherence to national guidelines calling for early initiation of palliative care and advance care planning in patients with advanced cancers.
Best practice alert and cost transparency information for high cost oncology medications.
Authors: Cinar Pelin , Lin Tracy , Rodondi Kevin
Published: September 2018

323

Background: Oncology medication cost is often absent from therapy decision process until issues arise with payer denial resulting in potential patient financial toxicity. To incorporate cost, Best Practice Alert (BPA) and Cost Transparency Information (CTI) for high cost oncology medication (HCOM) were implemented into prescribing platform as care coordination tools. Methods: Ten HCOM were identified in gastrointestinal (GI) and breast oncology groups for which BPA and CTI were developed. Over a 6 month period, HCOM prescriptions triggered BPAs to alert providers and to place automated referrals to social work (SW). CTI – with drug costs and comparable treatment plan(s) – were posted in prescribing platform. Descriptive analyses examined differences in total payment to hospital and patients out-of-pocket payments (OPP) between treatment plans. Pre- and post-intervention surveys evaluated oncologists’ perception and behavior toward treatment cost. Results: The analysis included 162 patients and 1406 medication claims. In the GI group, BPAs effectively identified treatments incurring higher mean total payment (diff = 46733, p < 0.001) and higher mean OPP (diff = 115, p < 0.001). For the breast group, the impact was mixed. BPAs identified treatments with higher total payment at the 90% quantile (p < 0.001) and higher mean total payment (diff = 72612, p < 0.001), but there was no statistically significant difference in OPP between treatments. Pre-intervention survey (n = 26, 50% response rate) indicated 46% of oncologists rarely discuss medication cost with patients and 35% rarely refer patients to SW. Only 4% of oncologists strongly agreed that they could easily acquire cost information. Post-intervention survey highlighted that CTI improved oncologists’ awareness of medication costs, but BPA exerted no substantial influence on provider behaviors. Conclusions: BPA intervention effectively highlighted treatment cost and accurately identified patients at risk for financial toxicity. The lack of statistically significant difference in oncologists’ behavior and perception may be due to a small sample size. Comments from providers suggest that BPA combined with OPP would be more useful in reducing financial toxicity.
Impact of travel time on hospitalizations and patient cost responsibility by phase of care for older patients with cancer.
Authors: Williams Courtney , Kenzik Kelly , Pisu Maria , Ingram Stacey A. , Gilbert Aidan , Rocconi Rodney Paul , Rocque Gabrielle Betty
Published: September 2018

37

Background: Healthcare reimbursement changes are contributing to increased closures of community hospitals and oncology practices, which may lead cancer patients to travel greater distances for care. Limited data exists on the impact of travel time on hospitalization rates and patient cost responsibility by phase of care for older cancer patients. Methods: This was a secondary analysis of Medicare claims from 2012-2015 for cancer patients age ≥65 receiving care in the University of Alabama at Birmingham Cancer Community Network. Patient addresses were obtained from network data, hospitalizations from inpatient claims, and patient cost responsibility from inpatient, outpatient, skilled nursing facility, carrier, and durable medical equipment claims. Drive time was calculated from patient home to cancer care site (CCS). Phase of care-specific (initial, survivorship, end-of-life [EOL]) rates of hospitalizations overall and by CCS vs. other care site (OCS) were calculated per 100 person-years. Hierarchical linear models compared average monthly phase-specific costs by drive time to CCS. Results: Of 23,605 older cancer patients, median drive time to CCS was 32 minutes (IQR 18-59), with 24% driving ≥1 hour to CCS. Rates of hospitalizations by initial (n = 14,225), survivorship (n = 18,805), and EOL (n = 8,211) phases of care were 54, 26, and 301 per 100 person-years, respectively. Higher rates of hospitalizations at OCS vs. CCS were shown for patients traveling ≥1 hour to CCS (initial, survivorship, and EOL rate of 41 vs. 20, 21 vs. 6, and 220 vs. 95 per 100 person-years, respectively). Median monthly costs by phase were $401 (IQR $182-$814) for initial, $369 (IQR $123-$1046) for survivorship, and $2075 (IQR $1123-$3723) for EOL. Patients traveling ≥1 hour to their CCS had higher cost responsibility, with patients in initial, survivorship, and EOL phases having $303 (95% CI $130-$476), $75 (95% CI $46-$105), and $736 (95% CI $308-$1164) higher average costs per month than those traveling < 1 hour, respectively. Conclusions: Cancer patients traveling further to receive care are potentially vulnerable to higher cost responsibility and limited access to care if community hospitals close, especially at EOL.
Using standardized electronic pathology data to identify practice variation, potential impact to patient outcomes, and quality improvement initiatives.
Authors: Kitchen Jessica , Sone Shaalee , Mukhi Shaheena , Argent-Katwala Mary , Srigley John
Published: September 2018

45

Background: Practice variation in diagnosis and treatment exists between clinicians and regions across Canada. This variation can impact the quality of care that patients receive and affect patient outcomes. We aimed to gain a better understanding of the scale and type of variation between clinicians and provinces within the cancer system. Methods: Fifty pathologists, surgeons, and medical oncologists from 10 regions were convened to leverage literature and the College of American Pathologists data standards to create 48 indicators related to five cancers: breast, lung, colorectal, endometrial and prostate. Six months of synoptic pathology data were used to generate the indicators, which were reviewed by 65 clinicians to identify practice variation and potential quality improvement areas. Results: Five provinces generated 48 indicator data analyses. Practice and performance variation across five cancer sites and jurisdictions was found. For example, guidelines recommend examining at least 12 lymph nodes in colorectal cancer resections as this directly impacts staging, treatment and patient prognosis. Only one province met this guideline in 90% of cases. Another example is Lynch syndrome testing, a hereditary condition that increases the risk of developing multiple primary cancers – particularly colorectal and endometrial. The data showed unequitable access to screening with 0-70% of colorectal cancer patients aged ≤70 years and only 10-40% of endometrial cancer cases being screened for Lynch syndrome. The value of these indicators is enormous to inform potential training opportunities and set standards of care at the local or broader clinical governance level so that consistent, high-quality care is delivered in accordance with evidence-based guidelines. Conclusions: Practice variation exists between clinicians and jurisdictions. In two jurisdictions (200 pathologists), comparative pathology indicator data are being used to self-reflect and converse with peers with the goal of reducing practice variation and improving patient care.
Institutional adherence to National Comprehensive Cancer Network (NCCN) guidelines in neoadjuvant treatment of breast cancer and its correlation to outcomes.
Authors: Vaddepally Raju Kumar , Hejab Amal , Ali Haythem Y.
Published: September 2018

47

Background: The aim of the study is to assess the adherence to National Comprehensive Cancer Network (NCCN) guidelines in the neoadjuvant treatment of breast cancer and evaluate its correlation to outcomes. Higher adherence rates correlate with improved survival and are a potential measure of the quality of care. Methods: We screened patients who were treated with neoadjuvant chemotherapy at our institution for the years 2015 & 2016, a total 46 patients met the criteria. To evaluate adherence we tabulated 8 adherence categories per NCCN. We then screened patients who were only eligible to receive the treatment specific to a certain adherence category. A total adherence rate was calculated by dividing the number of categories for which they underwent intervention by the total number of eligible adherence categories. Rates of pathologic complete response (PCR) and Breast Conservation surgery (BCS) were calculated to measure the outcomes. Results: We had 9 triple negative breast cancer (TNBC), 28 Her2 overexpression (Her2+) and 17 triple positive patients. We had 100% adherence in categories such as, appropriate pre-chemotherapy evaluation {total eligible patients, n = 46}, completeness of histopathology report (n = 46), use of anti-Her2 antibody drug in patients with Her2 overexpression positive by IHC or FISH (n = 28) and adjuvant radiation therapy (n = 39). In the following categories, adherence rates were as follows, 70% (n = 33) genetic consult, 69% (n = 32) reconstructive surgery, 65% (n = 46) cancer distress screen performed. We could not assess the adherence to reproductive gynecology consult. Our median total adherence rates were 85% for all of the adherence categories in eligible patients. We had PCR and BCS rates of 39% & 41% respectively. Further analysis showed PCR & BCS rates of 46% & 39% in Her2+ patients, 33% & 44% in TNBC patients, 35% & 38% in Doxorubicin treatment and 46% & 39% in anti-Her2 antibody treatment group respectively. Conclusions: Our study shows adherence to NCCN guidelines leads to improved outcomes. To improve quality of care, institutions should closely monitor the adherence to NCCN or other alternative national guidelines.
Pathology quality improvement in British Columbia using performance measurement and knowledge mobilization.
Authors: van der Westhuizen Nick , Lee Cheng-Han , Rabel Brigette , Young Katherine , Mukhi Shaheena
Published: September 2018

54

Background: Pathology reporting content and formatting varies considerably in British Columbia (BC). The impact of this variability on the quality of care is unknown but it hinders effective data collection and measurement to guide quality improvement. A knowledge mobilization project that digitalized standardized reporting would ensure report completeness and generation of comparative performance data could be used within communities of practice to facilitate peer-to-peer conversations and create action plans to improve patient care. Methods: In 2014 BC adopted the College of American Pathologists cancer checklists as the standard for synoptic reporting using a single standalone electronic synoptic reporting program which interfaced with all five provincial laboratory information systems. Using the tool ensures all mandatory clinical prognostic indicators are reported. Discrete data elements were transmitted to a central data repository (CDR) which was mined to compile key performance indices reports for individual pathologists and generate comparative data reports at the institutional, regional and provincial level. Results: In the first six months of its implementation there was variation from 11-94% across different laboratories in their adoption of the reporting tool. The goal is to increase the average adoption rate from 76% to 90%. Analysis of data showed a highly comparable pattern of pathology practice across the major cancer sites/types and comparable to other Canadian provinces and the literature. Advisory committee reviews with interdisciplinary discussion of comparative data reports revealed potential areas for clinical improvement. For example, significant variation in the number of lymph nodes in colorectal resections was identified with some sites falling short of published recommendations. Conclusions: Population-based standardized digitalized pathology data reporting with centralized data collection can be achieved. Analysis of this data enables monitoring of performance metrics and meaningful discussions via communities of practice identify areas for quality improvement and create action plans.
Evaluation of the impact of a multidisciplinary intervention to increase pneumococcal vaccination rates in patients with advanced lung cancer.
Authors: Rostamnjad Leila , Goodwin Kelly , Temel Jennifer , Connolly Pamela , Zydel Julie , Blouin Gayle C.
Published: September 2018

61

Background: National Comprehensive Cancer Network recommends pneumococcal vaccination for adults 19 years and older with cancer. Currently at Massachusetts General Hospital (MGH) pneumococcal vaccination is not part of routine cancer care. A vaccination quality improvement project was developed to increase pneumococcal vaccination in lung cancer patients. The primary objective of this evaluation is to assess the impact of a multidisciplinary intervention to increase pneumococcal vaccination in patients with advanced lung cancer receiving intravenous anticancer therapy. Methods: Thoracic oncology clinic schedule and patient electronic medical records were reviewed prospectively from 01/01/2018 to 05/31/2018 by the clinical pharmacist to identify patients with advanced lung cancer eligible for vaccination. Patients list along with recommended vaccine type and schedule was emailed by the clinical pharmacist to clinical team (oncologist, nurse practitioner and practice nurses). Practice nurses obtained immunization records for patients with non-MGH primary care providers. A designated thoracic oncology nurse practitioner ordered appropriate vaccines. Vaccinations were administered by infusion nurse. Results: 50 patients were identified as eligible for vaccination: 7 patients had history of receiving prevnar 13, and 9 patients had history of pnemovax 23. 34 patients had no prior vaccination history. Through this intervention, 10 patients completed vaccination with both prevnar 13 and pnemovax 23. 15 patients received one of the two recommended vaccines. 22 patients refused vaccination, and 3 patients died before their next scheduled infusion visit. Conclusions: Pneumococcal vaccination is recommended for patients with cancer prior to initiation or three months after completion of immunosuppressive therapies. However, it is not always feasible to vaccinate patients prior to start of therapy as delays in cancer care can lead to disease related complications. Incorporating multidisciplinary intervention to identify patients with advanced lung cancer who are candidate for pneumococcal vaccination can improve the adherence to the guidelines.
Timing of adjuvant chemotherapy administration for early breast cancer.
Authors: Salner Andrew L. , Smith Shelby , Yu Peter Paul
Published: September 2018

62

Background: Adjuvant chemotherapy treatment has contributed to the reduction in cause-specific mortality from early stage breast cancer by reducing the risk of recurrence and metastasis. The initiation of adjuvant chemotherapy is typically started within 4-8 weeks following surgery. Although earlier treatment does not necessarily render a better prognosis, treatment delayed beyond 12 weeks may result in an unfavorable decrease in disease-free survival. In order to explore quality data for each of our 5 cancer centers and their breast surgeons, we conducted a quality outcomes project to examine our data and factors which could result in delay. Methods: We conducted a retrospective review evaluating all cases of patients diagnosed with stage 1 and 2 breast cancer at all of our cancer centers during the 2015 and 2016 calendar years, utilizing patient lists obtained from our cancer registries. Patients who received neoadjuvant chemotherapy or who had inadequate data were excluded. Variables included stage at diagnosis, percent of nodal positivity, age at diagnosis, race and ethnicity, attending surgeon, type of surgery (breast conservation vs. mastectomy +/- reconstruction), and number of days from final breast surgery to initiation of adjuvant chemotherapy treatment. Results: 757 and 319 patients with Stage I and II breast cancer respectively were identified in our 5 cancer centers. 16% had nodal positivity, and 25.6% received adjuvant chemotherapy. Average age at diagnosis was 62.5, and average age for node positive and adjuvant chemotherapy were 58.5 and 56.8. Days to chemotherapy ranged from 3-208, with 94% of patients treated in less than 12 weeks and ranges of mean days to begin chemotherapy 35.6 to 55.4 in our cancer centers. No significant differences were noted by age, race, ethnicity, stage, surgery type, surgeon, or hospital. Conclusions: This study reveals outcomes suggesting that our breast cancer teams at our cancer centers are meeting the current standard of care for initiation of adjuvant chemotherapy, and points to the value of quality studies in assuring standards of care.
Treatment patterns, toxicity, and outcomes of elderly patients with advanced pancreatic cancer receiving first-line chemotherapy.
Authors: Kudlovich Robert , Zhang Hanbo , Kim Christina , Dawe David
Published: September 2018

71

Background: Advanced pancreatic cancer (APC) has a poor prognosis despite treatment with palliative chemotherapy. Randomized trials have demonstrated improved overall survival (OS) with combination chemotherapy including 5-fluorouracil, irinotecan, leucovorin, and oxaliplatin (FOLFIRINOX) or nab-plaxictaxel and Gemcitabine (NG) compared to Gemcitabine (GEM) alone, however, combination therapy is associated with higher rates of toxicity. There is limited data regarding the efficacy and toxicity of FOLFIRINOX, NG, and GEM in elderly patients with APC. Objective: Describe the treatment patterns, toxicity, and outcomes of patients ≥ 65 years of age treated with first-line palliative FOLFIRINOX, NG, or GEM. Methods: Patients ≥ 65 diagnosed with APC from 2012-2016 and treated with palliative chemotherapy in Manitoba were identified from the Manitoba Cancer Registry. Retrospective review identified patients who received first line FOLFIRINOX, NG, or GEM. Patient and treatment characteristics including hematologic and non-hematologic toxicities, dose reductions or delays, tumour response and survival were recorded. Results: 87 patients aged ≥ 65 received palliative chemotherapy: 52 (60%) FOLFIRINOX, 21 (24%) NG, and 14 (16%) GEM, with median ages of 69 (65-84), 75 (65-88), and 73 (67-82), respectively. More patients treated with FOLFIRINOX had an ECOG 0-1 compared to other treatments (p = < 0.001). There was no difference in hematologic toxicity according to treatment group (p = 0.807). There was more non-hematologic toxicity with FOLFIRINOX (p = < 0.001), particularly neuropathy (p = 0.008), fatigue (p = < 0.001), and nausea/vomiting (p = 0.008). Tumour response was highest with FOLFIRINOX (p = 0.005), with a trend towards improved survival compared to NG and GEM (median OS 267 vs 232 and 126 days, respectively, p = 0.057). Conclusions: Many older patients with APC received FOLFIRINOX, with more toxicity, but also greater tumour response and a trend toward improved survival. This suggests that selected elderly patients can tolerate first-line FOLFIRINOX. This may be also due to effective patient evaluation and appropriate assignment to different treatments.
Underutilization of GnRH analogues (G) and exemestane (E) in young patients with early-stage breast cancer (BC) in Ontario.
Authors: Keech James , Trudeau Maureen E. , Blanchette Phillip S. , Ngan Annie , Eisen Andrea
Published: September 2018

73

Background: In 2014-15, the randomized control trials SOFT and TEXT showed that premenopausal women with hormone receptor-positive, early stage BC treated with ovarian suppression (G or oophorectomy) in combination with E had improved outcomes compared to those treated with tamoxifen (T) alone. The largest benefit was observed in women younger than 35 ( < 35y). In Ontario, these regimens are not fully publicly funded for premenopausal women. We examined the utilization of adjuvant G + E for premenopausal BC patients in Ontario, as underutilization might reflect difficulty accessing these drugs. Methods: We determined the current utilization of adjuvant endocrine therapy for patients with BC through Ontario’s systemic therapy database. In particular, we examined the utilization of T, E and E + G in BC patients < 35y as these patients are expected to have the highest rates of uptake based on the outcomes of SOFT and TEXT. Results: In the first year following the publication of SOFT and TEXT, 20% of BC patients receiving adjuvant endocrine therapy received E + ovarian suppression (G or oophorectomy). This value was 14% in the following year, reflecting low uptake of the optimal treatment strategy. Conclusions: In Ontario, uptake of G + E is low in BC patients < 35y. One possible barrier to access is the lack of public funding for these drugs in this population. The low uptake may also reflect the toxicity associated with this treatment and the need for further knowledge translation. A 2017 provincial prioritization process ranked this unmet funding need as a high priority. Thus, a funding submission will be prepared to promote access to this evidence informed therapy. The submission will include a full evidence review and pharmacoeconomic analysis.[Table: see text]
Prognostic value of patient-reported outcomes (PROs) in advanced cancer.
Authors: Patel Shiven B. , Akerley Wallace L. , Ose Dominik , Haydell Tyler , Martineau Jim , Dunson William A. , Chalmers Anna Weinberg , Cannon Laura , Meropol Neal J. , Haaland Ben
Published: September 2018

8

Background: Performance status, which is prognostic of survival, is a physician’s interpretation of PROs. This retrospective study evaluated prognosis of PROs, independent of physician assessment, with overall survival (OS) and hospitalization-free survival (HFS). Methods: Patients (pts) at HCI were assessed using the NCI PROMIS-Ca bank from May 2016. Physical function (PF), fatigue, depression, anxiety, and pain scores were collected via iPad in pts with metastatic cancers. A single PRO score collected within 6 months of metastatic diagnosis for each pt was merged with outcome data using the Flatiron Health database. Associations between PROs, gender, cancer type, OS and HFS were assessed. Results: 287 complete sets of pt data were available. The PRO domains were interrelated with moderate-strong correlations (0.40-0.79). Cancer types differed by OS and HFS (p’s < 0.001). PF scores were worse for NSCLC than other cancers (p < 0.001). Individual PRO scores were worse for women than men, HFS was better for women and survival was not different. All individual PRO domains were strongly associated with HFS and OS. After correction for gender, cancer type, and individual PROs, only PF remained significant among individual PROs. Conclusions: PROs, especially PF, are prognostic of OS and HFS without physician interpretation. Gender difference may influence PROs. [Table: see text]
Assessment of health care resource utilization (HRU) in patients with castration-resistant prostate cancer (CRPC).
Authors: Li Sophia , Ding Zhijie , Lin Jennifer H , Pericone Chris , Behl Ajay S. , Shore Neal D.
Published: September 2018

89

Background: Although patients with CRPC frequently develop metastasis within 3 years following castration resistance, the impact of metastasis on HRU in these patients is not well understood. Methods: The Optum de-identified electronic health record database (1/1/2007 – 4/30/2016) was used in this single cohort observational study comparing HRU after metastasis with HRU before metastasis. The cohort included only non-metastatic CRPC (nmCRPC) patients who later developed metastasis. The pre-metastasis period spanned from nmCRPC identification to development of metastasis; the post-metastasis period spanned from metastasis until death or end of data availability. Per-patient per-month (PPPM) HRU was estimated during both pre- and post-metastasis periods by a generalized linear mixed model adjusted for log-transformed baseline PSA, age, testosterone levels, and Charlson Comorbidity Index. Results: With a mean time of 11 and 17 months of pre- and post-metastasis periods, respectively, 540 CRPC men were included, with a mean age at nmCRPC identification of 75 years. Higher HRU was seen across all service types during the post-metastasis period. There was a 2.5-fold increase in inpatient admissions and a 6.4-fold increase in inpatient length-of-stay in the post-metastasis period compared to the pre-metastasis period (p < 0.01). For emergency department (ED) visits, there was a 2.0-fold increase from the pre- to post-metastasis periods (p < 0.01). For observation unit visits, a 2.7-fold increase was seen in the post-metastasis period (p < 0.01). Finally, patients were 40% more likely to have an office visit after developing metastasis (p < 0.01). The PPPM use of intensive care unit, hospice or skilled nursing facility were too low for meaningful comparison between the pre- and post-metastasis periods. Conclusions: Shorter time to metastasis was observed in this cohort vs. other nmCRPC studies, likely due to delayed disease identification. CRPC patients incurred substantially higher HRU after developing metastasis, attributable to inpatient, ED, observation unit as well as office visits, suggesting that delaying metastasis may reduce or delay the increased HRU in patients with nmCRPC.
Uncovering oncologists’ gaps and attitudes toward biosimilars: Impact of a two-phase educational program.
Authors: Schwartz Zachary , Schulz Jenny , Vinther Angelique , Agarwala Sanjiv S. , Kuklinski Alyce
Published: September 2018

91

Background: Biosimilar agents are changing the clinical landscape in oncology. We sought to measure oncologists’ competence and knowledge of biosimilars and to address identified educational gaps related to biosimilars’ clinical application. Methods: We designed a 2-phase online educational program focused on biosimilars that included questions to measure oncologists’ knowledge and competence. These questions were administered before and then repeated after the education was delivered. Oncologists were also invited to submit their own questions about biosimilars and their use in clinical practice. To uncover key educational gaps, we identified questions with high incorrect responses at baseline, persistence of incorrect responses, and questions submitted by learners during Phase 1 of the education. These gaps were used to refine the teaching in Phase 2 of the education. Results: Between March and December 2017, a total of 1616 oncologists participated in the education. Among the subset of oncologists who answered at least 1 question, we identified persistent misunderstandings about biosimilars at baseline: 59% incorrectly believed a biosimilar could have efficacy that differs from its reference agent; a further 15% were unsure (n = 238)  Absolute improvement in optimal response was 19% over baseline ( P = .0002) after Phase 1 of the education and 42% ( P < .0001) after Phase 2 66% did not understand that, in the US, biosimilars cannot be substituted at the pharmacy without the prescriber’s approval (n = 220)  Absolute improvement in optimal response was 13% over baseline ( P = .0571) after Phase 1 of the education and 33% ( P < .0001) after Phase 2 82% did not understand extrapolation of indications among biosimilars (n = 114)  Absolute improvement in optimal response was 41% over baseline ( P < .0001) after the education Oncologists’ willingness to prescribe biosimilars also increased. Conclusions: We uncovered gaps in oncologists’ understanding of the efficacy, substitution, and indications of biosimilars, which may explain some oncologists’ reluctance to consider biosimilars as a treatment option for their patients. This educational program increased oncologists’ competence with biosimilars.
What factors are associated with oncologist discussions of the costs of genomic testing and related treatment?
Authors: Yabroff K Robin , Zhao Jingxuan , de Moor Janet , Sineshaw Helmneh M. , Freedman Andrew N , Zheng Zhiyuan , Han Xuesong , Rai Ashish , Klabunde Carrie N.
Published: September 2018

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Background: Use of genomic testing to inform cancer treatment is an increasingly common practice in the US. Genomic testing and related treatment can be expensive and not all tests and treatments are covered by health insurance plans. Little is known about how often physicians discuss costs of genomic testing and related treatment with their patients, nor about the physician and/or practice factors associated with those discussions. Methods: We identified 1220 oncologists who participated in the National Survey of Precision Medicine in Cancer Treatment in 2017 and reported discussing genomic testing with their patients within 12 months. Weighted percentages were used to describe the frequency of cost discussions and multivariable polytomous logistic regression analyses were used to assess associations between physician and practice characteristics and the frequency of cost discussions. Results: Among oncologists who discussed genomic testing, 50.0% reported often discussing the likely costs of testing and related treatment; 26.3% reported sometimes discussing costs; and the remaining 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists who used next-generation sequencing gene panel tests were more likely to have cost discussions with their patients often (OR = 2.3; 95% CI: 1.6,3.2) or sometimes (OR = 1.8; 95% CI: 1.2, 2.7) compared to rarely or never. Other physician and practice factors associated with more frequent cost discussions were treating solid tumors only (rather than hematologic only or both hematologic and solid tumors), training in genomic testing, and working in practices with electronic medical record (EMR) alerts for genomic tests (all p < 0.05). Conclusions: Physician and practice factors are associated with discussions of the costs of genomic testing and related treatments. As professional organizations increasingly recommend discussions of costs with cancer patients, consideration of modifiable physician and practice factors, such as training in genomic testing and use of EMR alerts, may help achieve these aims.