bluuebunny/crossref_metadata_2025 huggingface dataset:
Social workers first-time treatment assessment.
Authors: Poole Christa , Nelson Tori , Barnes Jacqueline , Clay Angela , Coyle Erica , Dimitrov Juliette , Douglas Emily , Golias Brittany , Barrat-Gordon Rene , Spaulding IIana , Zeiter Rebecca , Carrino Cheryl M , Rothacker Andrew , Truchanowicz Rosemary , Cummings Chad W.
Published: September 2018

164

Background: Supporting emotional, psychological, financial and spiritual well-being of patients has been shown to have a positive impact on quality of life and patient experience. Social workers in our outpatient cancer center are responsible for completing new patient assessments at the start of chemotherapy treatment to provide early access to psychosocial support services. Assessments are to be completed within three weeks of the patient’s first chemotherapy treatment. Connecting with patients early in the care experience allows social workers to proactively assist with education, support and link patients to vital resources. Methods: Completed assessments were tracked and from October through December 2017. The social workers leveraged the use of data analytics and a team based approach to increase the number of new patient assessments completed within the first 3 weeks of chemotherapy. Weekly 30-minute huddles were held using problem solving methods, including brain storming, cause and effect diagrams, force ranking, and polling. Results: A team identified 39 potential causes to why 65.14% of patients were not receiving assessments within the first 3 weeks of chemotherapy treatment. Potential causes were grouped and themed. Work prioritization, inconsistent methods of identifying patients receiving chemotherapy for the first time, and lack of visual management to monitor progress of this metric were identified as key objectives for improvement. Countermeasures were developed and implemented; a dashboard was created to analyze the first time treatment assessment completion percentages by disease group and standardizing the process of notifying social workers of patients in need of an assessment. Social worker assessment completion rates improved from 34.78% (December 2017) to 75.35% (April 2018). Conclusions: This project demonstrates the value of utilizing problem solving, visual management, and data analytics for continuous quality improvement projects related to clinical care and processes. Cross-disciplinary collaboration should be explored with the use of visual tools and other resources to facilitate communication that is understood by all disciplines.
Defining the patient experience in medical oncology.
Authors: Odai-Afotey Ashley , Kliss Andrea , Hafler Janet , Sanft Tara B.
Published: September 2018

167

Background: The relationship between the physician and patient is directly associated with positive patient satisfaction. High patient satisfaction is associated with improved health outcomes, treatment adherence, and quality of life. The goal was to explore patients’ perceptions on their hospital experience, focusing on quality of care. Methods: A mixed-methods study design with a sample of 58 patients at Yale New Haven Hospital. Data were from patient interviews and observation of rounds. Results: Two themes emerged: patient experience and patient communication with physicians. Within patient experience positive factors identified were feeling attended to (45.9%), nurses (43.2%), staff (27.0%), doctors (27.0%), facility (10.8%) and coordination of care (8.1%). Negative factors were low quality of life (82.8%), lack of physician emotional support, attentiveness and availability (24.1%), and poor coordination of care (20.7%). Within physician communication positive factors included effectively engaging the patient (27.5%) and attending to patient needs (7.5%). Negative factors were nature of distilling information (17.5%), lack of coordination of care (15.0%), inadequate involvement of the patient and/or family (12.5%), use of medical jargon (10.0%), and inability to elicit patients’ perspective (7.5%). The quantitative data supported qualitative results of overall satisfaction with 72.4% of patients (n = 58) rating their experience as an ‘A’. Areas of dissatisfaction (an ‘A’ rating < 70% of time) included describing team member roles, explaining next steps in care or treatment to the patient and/or family, and meeting patients’ needs. Conclusions: Our findings, demonstrate that physician attentiveness or lack thereof defines the quality of patient experience, is an important theme in communication and that patients perceive their needs are not being fully addressed. Agreement in themes from mixed-method approach shows effectiveness of methods in exploring patients’ perceptions on quality of care. The study intends to inform clinical and operational practices physicians can incorporate into their patient relationships. These data are being used to design a faculty development program to address physician communication.
The effect of facility volume on treatment guideline compliance and overall survival in oral tongue squamous cell carcinoma.
Authors: Tam Samantha , Du Xianglin L. , Lewis Carol M. , Yamal Jose-Miguel , Weber Randal S.
Published: September 2018

17

Background: National treatment guidelines guide cancer care using the best available evidence and understanding the drivers of guideline compliance is essential to identifying modifiable factors to improve quality of care. This study aims to explore the impact of facility volume on the rate of guideline compliance in patients with oral tongue cancer and its effect on overall survival. Methods: Using National Cancer Database from 2004 to 2013, this retrospective cohort study investigated patients undergoing curative surgical treatment for oral tongue squamous cell carcinoma. Patients were divided into three tertiles according to mean annual case volume at their treatment facility. Guideline compliance was based on the National Comprehensive Cancer Network oral cavity cancer guidelines. Predictors of guideline compliance and overall survival were determined using multiple logistic regression and Cox Proportional Hazards models. Results: Guideline compliant care was delivered in 54.5% of the 35,810 eligible patients. Those treated at intermediate volume facilities had 1.75 times greater odds of receipt of guideline compliant care (95% CI = 1.57-1.96) and 2.14 times greater in high volume facilities (95% CI = 1.91-2.40) compared to low volume facilities. Guideline compliance (adjusted hazard ratio [HRadj] = 0.78, 95% CI = 0.72-0.84) and treatment at a high volume facility (HRadj= 0.88, 95% CI = 0.80-0.98) were independent predictors of overall survival. Conclusions: Facility volume independently predicted guideline compliance in oral tongue cancer. Guideline compliance and treatment at a high case volume facility were predictors of overall survival. Clinicians should apply guideline compliant care regardless of practice setting and treatment at higher volume centers should be considered.
Cancer patient (pt) attitudes and preferences towards smoking status assessment.
Authors: Eng Lawson , Liu Sophia , Zhang Qihuang , Farzanfar Delaram , Milne Robin , Yeung Sabrina , Brown M Catherine , Howell Doris , Xu Wei , Goldstein David Paul , Jones Jennifer M. , Selby Peter , Evans William K. , Giuliani Meredith Elana , Liu Geoffrey
Published: September 2018

177

Background: Continued smoking after a cancer diagnosis is associated with poorer outcomes. Understanding pt attitudes towards smoking status assessment will help with integrating smoking cessation programs into survivorship care. Methods: Cancer pts were surveyed on their smoking history, assessment rates and attitudes/preferences towards smoking status assessment. Multivariate logistic regression models assessed for factors associated with screening preferences. Results: Among 501 pts, 115 smoked at diagnosis, 60% quit after; 53% had a tobacco related (lung/head and neck) cancer (TRC); 40% reported that their smoking status was assessed only on their first clinic visit, while 12% were assessed at all visits. Most felt smoking status should be assessed at the first visit (95%), while half (58%) felt it should be assessed each visit. Most felt comfortable with being assessed (96%), felt it was important for clinicians to be aware of tobacco use (98%) and that smoking cessation discussions should occur at the first visit (87%). Most preferred being assessed by their oncologist (88%); less preferred being asked by another healthcare provider (44%), on paper (29%) or e-surveys (32%). Compared to ex/never smokers, current smokers were assessed more often at most/every visit (36% vs 20%) and were less comfortable being assessed (88% vs 98%). Among current smokers, lung cancer pts were more agreeable being assessed each visit compared to head/neck (aOR 2.48 95% CI [0.9-6.5] P = 0.06) and non TRCs (aOR 2.63 [1.0-6.8] P = 0.05). Among all, pts who are older (aOR 1.03 [1.0-1.1]), curative (aOR 1.92 [1.1-3.2]) and smoked less (aOR 0.98 per pkyr [0.97-0.99]) were more agreeable to routine assessment. Most pts also felt oncologists should screen for second hand smoke exposure (92%), felt its assessment was important (93%) and should help others who smoke to quit (68%). Many felt that tobacco cessation programs for both pts (75%) and others who around them who smoke (65%) should be routine cancer care. Conclusions: Most cancer pts felt that assessment of smoking status was important, were comfortable being assessed and preferred direct assessment by their oncologist. Routine screening of those currently smoking is recommended to help with cessation.
Communication lapses and navigation needs for non-English-speaking patients: An MSK Patient and Family Advisory Council and Immigrant Health and Cancer Disparities initiative.
Authors: Niehaus Kate Southworth , Ramirez Julia , Gonzalez Javier , Licciardi Frank , Zimmer Alexander , Krug Elizabeth , Reidy Diane Lauren
Published: September 2018

178

Background: In 2017, 5,939 outpatients (5%) and 1,065 inpatients (9%) treated at MSK were non-English-speaking. Given the new and varying treatment paradigms combined with the need to consider clinical trial enrollment, there are increasingly complex communication needs. We sought to address the needs of this vulnerable patient population. Methods: Patient Family Advisory Council in collaboration with the Immigrant Health & Cancer Disparities Service conducted focus groups to determine needs of non-English speaking patients treated at MSKCC. Mass emails were sent out to the MSK attendings and nurses to recommend appropriate patients to participate. A coordinator called all those patients and invited them to the focus groups. A trained bilingual moderator led each 120-minute group discussion using an interview guide. Results: Three focus groups were conducted : 2 in Spanish and 1 in Russian. Questions related to communication, patient experience and support services were asked to the patient volunteers. In total, 10 patients and 4 caregivers participated. Across all 3 focus groups, three major themes emerged: (1) inadequate communication, participants brought up examples of communication breakdowns (2) access to resources and information, participants expressed that there was a substantial need for accessible, competent, and social support/navigation services and (3) MSK patient experience, participants discussed interactions with doctors, nurses, and staff. Conclusions: Non-English-speaking patients and family members not only deal have to deal with the fear of a cancer diagnosis but also lack the ability to comfortably communicate their concerns. Programs to empower patients and their families to ask for help and advocate for themselves are desperately needed. Additionally, navigation services are needed to provide assistance in making the appropriate linkages for the services required. This qualitative research at MSK is ongoing.
Simple interventions to decrease use of chemotherapy in patients at the end of life.
Authors: Chiang Anne C. , Adelson Kerin B. , Kapo Jennifer , Severino Kimberly M , Lilenbaum Rogerio
Published: September 2018

181

Background: Early palliative care referral has proven useful in reducing chemotherapy given to cancer patients in the last 30 days of life. We designed a program to help train primary oncologists in having goals of care (GOC) conversations with patients. We conducted this initiative across the Yale Cancer Center/Smilow Cancer Hospital Care Centers (SCHCCs). The aim was to determine whether simple tools could be used by general oncologists to improve patient care, as measured by chemotherapy utilization at the end of life. Methods: A multidisciplinary team completed process mapping and cause-and-effect barrier analysis regarding GOC discussion with patients. Five interventions (PDSA cycles) were chosen to improve physician skills with GOC conversations. SCHCC physicians (n = 21) utilized each tool on 5 patients per month from July to December 2017. Interventions included asking patients simple questions regarding GOC, using the phrase “allow natural death”, giving patients a “serious conversation starter kit”, and identifying patients with poor prognosis. A GOC survey was administered to physicians at baseline and after completion of the initiative. Data on chemotherapy and immunotherapy given during the last 30 days of life for SCHCC patients were measured. Results: SCHCC physicians who completed the baseline survey (n = 17) were 27% likely to discuss GOC repeatedly during the course of illness, compared to 70% post intervention (n = 10), while 88% felt comfortable discussing GOC at baseline compared to 100% after intervention. Chemotherapy within 30 days of death was administered to 30.3% patients (n = 109) in Q1 2017 and 23.3% in Q3 (n = 103) in the Care Centers. Of note, immunotherapy administered within 30 days of death was 6.4% in Q1 and 6.7% in Q3. Conclusions: A quality initiative focused on providing oncologists with simple tools to improve GOC conversations led to decrease from 30.3% to 23.3% of patients receiving chemotherapy within the last 30 days of life. Survey respondents felt more comfortable in discussing GOC and were more likely to do this throughout the course of illness. This pilot suggests that palliative care training of primary oncologists is feasible and may help to decrease unnecessary treatment at the end of life.
The influence of patient-reported adverse events on Health Utility Score (HUS) and Health-Related Quality of Life (HRQoL) in small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) patients.
Authors: Shakik Sharara , Vedadi Ali , Brown M. Catherine , Xu Wei , O'Kane Grainne M. , Liu Geoffrey , Shepherd Frances A. , Leighl Natasha B. , Bradbury Penelope Ann , Lok Benjamin H. , Sacher Adrian G.
Published: September 2018

185

Background: The Patient Reported Outcome version of Common-Terminology-Criteria-for-Adverse-Events (PRO-CTCAE) and Edmonton Symptom Assessment System (ESAS) are validated tools that measure toxicities and symptoms in cancer patients. We compared the extent in which the presence and severity of toxicities and symptoms affected HUS in SCLC and NSCLC patients. Methods: Adult SCLC and NSCLC patients were recruited from the Princess Margaret Cancer Centre and surveyed cross-sectionally for clinico-demographic variables, EQ5D-5L, PRO-CTCAE and ESAS. HUS were estimated using EQ5D-5L. PRO-CTCAE toxicities include diarrhea, constipation, decreased appetite, nausea, vomiting, fatigue, neuropathy and rash. ESAS symptoms include pain, tiredness, drowsiness, appetite loss, nausea, shortness of breath, depression, anxiety and lack of well-being. These were combined to show frequency and average severity of toxicities/symptoms per patient. Univariable and multivariable linear regression analyses identified toxicity/symptom influencing HUS. Results: Of 75 SCLC and 150 NSCLC, 52% were male with median age of 65 years. The mean HUS was 0.76 (SCLC = 0.69; NSCLC = 0.79; p = 0.001). Compared to NSCLC, SCLC patients had a significantly higher number of toxicities (3.14 versus 1.33 using PRO-CTCAE, p < 0.0001); symptoms (6.75 vs 5.45 using ESAS, p = 0.0003) and severity of toxicities/symptoms (PRO-CTCAE 0-4: 0.95 versus 0.35, p < 0.0001; ESAS 0-10: 3.37 versus 2.04. p < 0.0001). There were significant correlations between the average severity of toxicities/symptoms and HUS (p < 0.0001) adjusted for age, histology, smoking pack years and performance status. For each increase in the average severity of toxicities, there was a corresponding mean drop of 0.03 in the HUS; for every increase in the average severity of symptoms, the drop was 0.04. These relationships were similar for both SCLC and NSCLC patients. Conclusions: Patient reported toxicities and symptoms have a significant impact on HUS in both SCLC and NSCLC patients. Early and aggressive management of such adverse events may be necessary to improve patients’ HRQoL.
Symptom Burden in Extensive Disease Small Cell Lung Cancer (ED-SCLC): A prospective, observational study in U.S. community practices.
Authors: Richards Donald A. , Hussein Maen A. , McCune Steven L. , Ulrich Brian Kent , Danese Mark D. , Gleeson Michelle L. , Lubeck Deborah P. , Abraham Pranav , Sanzari Jenine , Korytowsky Beata , Schwartzberg Lee Steven
Published: September 2018

196

Background: There is a paucity of data describing the effect of treatment on symptom burden and health status for patients with ED-SCLC receiving care in US community oncology centers. This study explores ED-SCLC patient-reported outcomes independently for either first-line (1L), second-line (2L) or third-line (3L) therapy. Methods: CA209-118 is a prospective observational study of adult patients with lung cancer, including patients with ED-SCLC, in 70 US community practices enrolled between 2014-2017. Participants completed the Lung Cancer Symptom Scale (LCSS) and Euro-QoL 5-D (EQ-5D) utility index and visual analog scale (VAS) at the start of 1L, 2L, or 3L treatment and at follow-up visits. The LCSS is summarized in 3 scales: LCSS total scale which ranges from 0 – 100, average symptom burden scale (ASBI) ranging from 0 – 100, and a three-item global scale (3-IGI) ranging from 0 – 300 (lower scores reflect reduced burden). The EQ-5D scale is a preference based measure of health status with higher scores reflecting better quality and ranges from 0 to 1.0 (index) or 0 – 100 (VAS). LCSS and EQ-5D values at 60 days were predicted in a repeated measures model for patients having a score at baseline and at least 1 follow-up. Results: The mean LCSS and EQ-5D scores at the start of each line of therapy and predicted 60 day change are presented in the table . 60-day improvement was observed only for appetite and cough in 1L. A slight declining trend was seen in 2L and 3L. Conclusions: Patients with ED-SCLC treated in the community reported a high symptom burden at the start of each line of therapy which did not diminish throughout 60 days of treatment. [Table: see text]
Incorporating geriatric patient-reported outcomes into novel screening tool of distress and supportive care concerns.
Authors: Weldon Christine B. , Martin Joanna , Scheu Amy , Khosla Paramjeet , Roggenkamp Betty , Berardi Rosa , Chow Selina Lai-ming , Trosman Julia Rachel , Pasquinelli Mary , Feldman Lawrence Eric , Dale William , O'Mahony Sean , Gerhart James , Mumby Patricia B. , Gordon Ana , Wiebe Lauren Allison , Deamant Catherine
Published: September 2018

198

Background: The Institute of Medicine (IOM) 2013 Report recommends that supportive oncology care start at cancer diagnosis; the Commission on Cancer (CoC) Standard 3.2 requires distress screening and indicated action. The Supportive Oncology Collaborative, collaborative of 100+ clinicians funded by The Coleman Foundation, developed a patient-centric screening tool (CSOC-ST) adapted from ASCO Distress, NCCN Distress Problem List, IOM report and CoC standards, and other validated sub-tools (Weldon, ASCO-Q 2017). The Collaborative revised the CSOC-ST tool to align with ASCO geriatric guidelines. Methods: Literature and guidelines review of geriatric screening, added items to CSOC-ST, and piloted at 4 sites. Descriptive statistics and Fisher’s exact test used. Results: 473 patients screened with added geriatric relevant items to CSOC-ST: self-care concerns (PROMIS Instrumental Support), living alone (ASCO Distress 2014), and memory / cognition (PROMIS item bank). Treatment/care concern items were revised to identify health care power of attorney and advance directive interest. Geriatric related items endorsed by patients, see Table. PHQ4, Anxiety and Depression, average score 2.4 (mild > 3). Higher scores on the PHQ-4 were significantly associated with each of the following: self-care concerns, memory/cognition concerns and specific treatment/care concerns (p < .0001). Conclusions: Pilot results and comparison to ASCO geriatric guidelines identified important items to support geriatric patient reported outcomes screening. After pilot, added 3 items for falls/frailty. Eight sites implementing this CSOC-ST.[Table: see text]
Routine collection of EQ-5D-5L derived utility scores in a brain metastases clinic: Correlation with health-related quality of life (FACT-Br).
Authors: Chen Judy , Gao Yizhuo , Baek Justine , Chaudhry Maha , Hueniken Katrina , Liang Mindy , Brown M. Catherine , O'Kane Grainne M. , Eng Lawson , Xu Wei , Howell Doris , Shultz David Benjamin , Liu Geoffrey
Published: September 2018

200

Background: Brain metastasis is a common occurrence in many cancers. However, with new therapies (stereotactic radiotherapy) and longer survival due to improved systemic therapies, more contemporary estimates of health utility scores (HUS) are required for this specialized cancer population. Further, recent efforts have tried to incorporate routine collection of such data, especially in an era when new radiation and new systemic therapies, especially targeted therapies require such data when undergoing health technology assessments. Methods: In a cross-sectional study design, patients in the specialized brain metastases clinic at Princess Margaret Cancer Centre were approached to complete the Health-related quality of life (HRQoL) tool, FACT-Br, and the EQ-5D-5L (to derived HUS using Canadian reference values) on iPad or paper. In addition, consent was obtained to collect clinico-demographic data from the patient and chart. In addition to descriptive analysis and participation rates, HUS were correlated to FACT-Br and its subscales. Results: Of 204 eligible patients, 134 were recruited (66% participation rate) from May 2017- Feb 2018. Of 105 patients in this preliminary analysis, the median age was 60 (range: 25-94) years; 73% were female; 64% were Caucasian; 20% were Asian; 49% had lung, 15% had breast, 37% had other primary cancer; 81% received some form of radiotherapy. Median time from first treatment of brain metastasis to survey was 12 (range 0.03-100) months. There were correlations with the following FACT-Br subscales: physical well-being (WB) (rho = 0.70), emotional WB (rho = 0.42), social WB (rho = 0.25), functional WB (rho = 0.59), and brain-specific subscale (rho = 0.67); overall FACT-Br (rho = 0.73); all correlations were p < 0.001. Conclusions: Patients with brain metastasis were generally willing to complete EQ-5D-5L, and patients had good HUS. HUS as measured indirectly by EQ-5D-5L were correlated to HRQoL as measured by FACT-Br or its subscales, with high correlation to the overall FACT-Br. EQ-5D-5L is a practical and useful tool to assess HUS routinely in brain metastases patients.
Electronic physician ratings and reviews process.
Authors: Denny, DBA Diane , Hizon Sarah , Caldarello Lauren , Hartman Scott , Markman Maurie
Published: September 2018

209

Background: According to JAMA, Public Awareness, Perception, and Use of Online Physician Rating Sites; 35% of patients selected a physician based on good ratings, and 37% avoided one with bad ratings. Yet, there exists a stark difference between unstructured (i.e. Yelp) online reviews as compared to validated survey-generated data. A national network of hospitals that specializes in treating patients with complex cancer had been collecting patient satisfaction data using a validated tool administered by a 3rd party for some time. An electronic physician rating and review process was implemented as an adjunct to that survey process, providing a new mechanism for consumers visiting the networks’ website with accurate information about patients’ satisfaction with its oncologists. Methods: Physician ratings are obtained directly from patients who had an encounter using two specific questions regarding confidence and likelihood to recommend. Ratings are posted by physician and maintained on a 12-month rolling basis once a minimum of 30 ratings is achieved. Likert scale survey data are converted to a one-to-five star rating. De-identified verbatim comments are also posted. Criteria are in place to review comments prior to posting with limited exclusions, such as comments containing PHI or slanderous content. Physicians receive an email to review comments 15 days prior to posting, allowing a process for advance notice or appeal. Both positive and negative reviews are published. Results: Physician performance scores were 4.7 stars pre-launch compared to 4.8 stars post-launch. Additional performance statistics are provided below. Conclusions: Sharing information on the talent of physicians is an important component of transparency and arming patients with information to make informed treatment decisions. As a result, physicians have become more engaged with their data and utilizing reviews to identify improvement opportunities. This translates to a culture of accountability and deepened understanding of patients’ perceptions about care.[Table: see text]
Trust but verify: Patterns of obtaining health information and the role of physician trust in decision-making amongst patients with metastatic breast cancer.
Authors: Niranjan Soumya J. , Wallace Audrey S. , Williams Beverly R , Turkman Yasemin E. , Williams Courtney , Forero-Torres Andres , Bhatia Smita , Knight Sara J. , Rocque Gabrielle Betty
Published: September 2018

218

Background: Increasing emphasis on patient-centered care has led to shared decision making, which better aligns medical decisions with patient preferences for care. In its 2004 report, Health Literacy: A Prescription to End Confusion, the US Institute of Medicine defines health literacy as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. However, little is known about the confluent role of patient health information seeking patterns and physician trust in the decision-making process. Therefore, we assessed perspectives of metastatic breast cancer (MBC) patients and health care professionals regarding how health information seeking and physician trust influence decision making. Methods: Qualitative interviews with 26 MBC patients and 6 community oncologists, as well as 3 separate focus groups involving lay navigators, nurses, and academic oncologists, were recorded and transcribed. Qualitative data analysis was conducted using a content analysis approach that included a constant comparative method to generate themes from the transcribed textual data. Results: Five prominent themes emerged from these responses. (1) Patients’ primary source of treatment information were physicians. (2) Patients differed in their approach to seeking further health information regarding the discussed treatment options (e.g. internet websites, family and friends, support groups). (3) Patients trusted their physician’s recommendations to achieve their goals of care. (4) Oncologists were cognizant of their fundamental role in facilitating informed decision making (5) Patient and physician discordant perspectives on shared decision making were apparent. Conclusions: Patient procurement of health information and their capacity to use it effectively to make informed decisions in conjunction with their trust in physicians, may play an important role in shared decision making.
Utilization of care at the end of life in Medicare decedents with advanced cancer.
Authors: Wallace Audrey S. , Williams Courtney , Pisu Maria , Oliver Debra Parker , Rocque Gabrielle Betty
Published: September 2018

22

Background: Despite increasing evidence supporting minimization of aggressive care at the end of life, little literature exists reporting timing of chemotherapy and radiation in relation to hospice referral. Methods: Deceased Medicare beneficiaries age ≥65 years with stage IV cancer at 12 sites in 5 southeast US states were identified from 2012-2015. All utilization of radiation, chemotherapy, hospice, hospitalizations, and emergency department [ED] visits were abstracted and tabulated from Medicare claims during the last 6 months of life. Results: Among 3516 deceased patients, median age at time of metastatic disease was 73 years (IQR 68-79). Most patients were white (81%), male (55%), with two or more comorbidities (54%). The most common primary cancer sites were lung (38%), gastrointestinal (27%), and genitourinary (10%). In the last 6 months of life, 65% and 66% of patients visited the ED or were hospitalized; 11% received radiation and 28% received chemotherapy. Median days from last course of treatment to death for patients with chemotherapy (n = 978) was 45 days (IQR 23-83) and with radiation (n = 380) was 52 days (IQR 19-100). After completion of radiation, 54% of patients continued to receive systemic therapy. In subset analysis of patients with a hospice referral after final delivery of radiation and/or chemotherapy (n = 768), there was persistent late referral to hospice. Patients referred to hospice within 0-7 days of completing radiation or chemotherapy had similar median length of time on hospice when compared to those referred to hospice between 91-180 days after treatment (median 14 [IQR 4-35] vs. median 18 [IQR 8-43] days). Conclusions: In decedents with poor performing cancer histologies, low utilization of hospice and high rates of ED visits and hospitalization remain. Late referral to hospice persisted irrespective of last course of radiation or chemotherapy timing. High utilization of hospitalization and emergency visits at EOL may be ameliorated by earlier hospice referral.
Evolving best practice for take-home cancer drugs in Ontario.
Authors: Pardhan Aliya , Vu Kathy , Gallo-Hershberg Daniela , Forbes Leta Marie , Gavura Scott , Kukreti Vishal
Published: September 2018

246

Background: Take-home cancer drugs (THCD) have become a standard treatment for many cancers and present opportunities and challenges for patients, providers and administrators. Ontario’s system has been described as two-tiered, with intravenous cancer drugs (IVCD) viewed as more comprehensive, organized, safer, and more patient-centred. Cancer Care Ontario (CCO) is the Ontario government’s principal cancer advisor. In April 2017, CCO established an Oncology Pharmacy Task Force to develop consensus-based recommendations on best practices for THCD to ensure that all patients are receiving consistent high-quality care regardless of the method of delivery of treatment. Methods: The Task Force included 34 members with representation from patient advocacy groups, pharmacy and pharmacist associations, regulatory and standard setting organizations, and subject matter experts. Standards, guidelines and recommendations from leading authorities were extracted by CCO’s Evidence Search and Review Service and synthesized by a core working group to develop 29 statements. The consensus process included a three-step modified Delphi method with two electronic surveys and a face-to-face meeting. Seventy percent agreement was required to include a recommendation. Thereafter, an extensive review process was conducted with relevant CCO programs and committees as well as subject matter experts, stakeholders and standard setting bodies at the local-regional and national levels. Results: Sixteen consensus-based recommendations were developed: training and education for providers (2); drug access (1); prescribing (4); patient, family/caregiver education (3); communication (1); dispensing (3); monitoring for adherence, identification and management of symptoms/adverse effect (1); and incident reporting (1) . This guidance will have most relevance for patients receiving THCD that require routine monitoring and for clinicians involved in delivering systemic treatment, and associated medications. Conclusions: Through the rigorous use of the Delphi technique, the Task Force developed a robust set of recommendations for THCD delivery in Ontario. Further work will be required to understand implementation enablers and barriers
Developing a standard approach to immune checkpoint inhibitor toxicity management in Ontario.
Authors: Crespo Andrea , Abella Lourdes , Baetz Tara D. , Gallo-Hershberg Daniela , Lakhani Nita , Leighl Natasha B. , Pasetka Mark , Seymour Lesley , Vu Kathy , Forbes Leta Marie
Published: September 2018

255

Background: The use of immune checkpoint inhibitor medications (ICIs) in the province of Ontario, Canada has increased in volume by almost 4 fold between 2015/16 to 2017/18 and has expanded from use primarily in melanoma to lung, genitourinary, and other cancers. Lack of widespread clinical experience with ICIs and provincial variation in the management of the potentially life-threatening immune-related adverse effects (irAEs) was identified as a safety and quality gap. Cancer Care Ontario (CCO) set out to develop user-friendly health care provider and patient resources to facilitate a standard approach to ICI toxicity management in Ontario. Methods: A multidisciplinary working group of oncology clinicians with ICI experience reviewed available literature and current approaches to ICI toxicity management. An iterative consensus-building process was used to develop a practical guideline. This was circulated to an external expert review panel for content validity. Complementary patient/caregiver information was created based on best practices in health literacy and input from patient and family advisors. All resources were made publicly available via the CCO website and disseminated broadly to relevant stakeholders. Results: A user-friendly clinical practice guideline was created. It contains a description of irAEs associated with ICIs, guidance on the general management of irAEs, detailed algorithms describing the assessment and management of ten specific irAEs, and general considerations for patients on ICIs. A toolkit was developed with direct links to the algorithms, a customizable wallet card, a “Dear Healthcare Professional” letter template, and a patient information sheet. The guideline and toolkit webpages were accessed over 1500 times in the first month, suggesting that broad dissemination has been successful. Informal reports of guideline implementation were received from several Ontario hospitals. Conclusions: Careful analysis of the available literature and application of oncology professionals’ expertise resulted in evidence-informed, consensus-based practical resources to help facilitate safe, standardized ICI toxicity management across the Ontario health care system.
Safety and clinical efficacy of programmed cell death 1 antibodies (PD-1 Ab) in patients with advanced non-small cell lung cancer (NSCLC).
Authors: Ksienski Doran , Wai Elaine , Croteau Nicole , Lesperance Mary
Published: September 2018

260

Background: In advanced NSCLC, clinical trials have shown significant benefits to pembrolizumab (P) and nivolumab (N). At BC Cancer, clinicians utilize protocol based algorithms to manage immune related adverse events (irAE). The incidence of irAE and efficacy of PD-1 Ab in everyday practice might differ from clinical trials. Methods: Advanced NSCLC patients (pts) treated with N or P between 11/2015 to 10/2017 at BC Cancer were identified. Demographic, tumor, treatment details, and frequency and grade (Gr, CTCAE v4.0) of irAE, were abstracted. Kaplan-Meier curves of median overall survival (OS) from initiation of PD-1 Ab were generated. Multivariable analysis (MVA) with 6-week landmark analysis was performed with Cox proportional hazard regression models. Results: Characteristics of cohort (230 N- and 41 P- treated): median age 64y (range 39-82), non-squamous histology 75%, ECOG PS > 1 at start of PD-1 Ab 31%, brain metastases (mets) 13%, liver mets 12%, and median Charlson Comorbidity Index (CCI) score 6. One hundred sixteen pts experienced 169 separate irAE: Gr1(74), Gr2 (68), Gr3(13), Gr4(10), Gr 5(4). Pneumonitis (14.6% vs. 4.8%, p = 0.041) and arthralgias (12.2% vs. 3.5%, p = 0.044) were more common in P than N. Steroids were administered to 25.2% of N pts and 19.5% of P pts (p = 0.557). Median follow-up from initiation of PD-1 Ab was 8.1months (range 0.1-33.9); median OS (95% CI) for N was 9.2 months (7.75-12.4) and for P was 13.5 months (10.6-not reached). 6-week landmark MVA for whole cohort revealed that male sex (p = 0.051), CCI≥3 (p < 0.001), ECOG PS > 1 (p < 0.001), liver mets (p = 0.017) and development of irAE > Gr2 versus no irAE (p = 0.036) were associated with decreased OS. Age, smoking status, histology, brain mets, EGFR status, irAE Gr 1/2 versus no irAE, and type of PD-1 Ab were not significant. Conclusions: Severe irAE were rare; pneumonitis and arthralgias were more common in P- than N- treated patients. The association with CCI, ECOG PS, and liver mets with decreased OS are consistent with literature. Association of severe irAE with shorter OS might reflect the need for improved physician education in irAE treatment algorithms.
Optimization of immune-related adverse event management in a thoracic oncology clinic.
Authors: Berwick Lexie , Rangachari Deepa , Costa Daniel Botelho , Sehgal Kartik , Shea Meghan
Published: September 2018

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Background: Improved awareness and management of immune checkpoint inhibitor (ICI) related adverse events (IRAEs) is a mandate for best practice given widespread use of ICIs in clinic. IRAE grading is standardized by the Common Terminology Criteria for Adverse Events (CTCAE); management has been standardized in recently published consensus guidelines. In the thoracic oncology clinic at the Beth Israel Deaconess Medical Center grading and management of IRAEs has been inconsistent. Methods: A retrospective review of 98 patients receiving ICIs in the thoracic oncology clinic from March 2015-April 2018 was conducted with a focus on IRAE grading and management. Oncologists were surveyed regarding barriers to grading, management, and subspecialty referral for IRAEs. We aimed to improve documentation of IRAE grading to 75% as well as the rate of specialist referral for grade 3-4 IRAEs. As an intervention we implemented a macro to document IRAE CTCAE grade and management. Additionally, our team created a pathway for specialist referral for patients with grade 3-4 IRAEs. Results: Upon review of 98 patient charts, 38 patients developed 58 IRAEs of which 36% were grade 1-2, 17% were grade 3, 0% were grade 4 and 47% were ungraded. The most commonly affected organs were skin (25%), thyroid (25%) and lung (11%). 53% of active IRAEs were formally graded in the oncologist’s assessment, only 6% of resolved IRAEs were documented in the subsequent oncologic history. A total of 11 patients were hospitalized for IRAEs, 7 of which had undocumented severity; 40% of grade 3 IRAEs were hospitalized. 14 specialist referrals were made, most with undocumented severity; 30% of patients with grade 3 IRAEs were referred. Overall, 18 patients required steroids, of these 40% were ungraded, and 19 had immunotherapy stopped or held, of these 45% were ungraded. Conclusions: While the presence of IRAEs is consistently documented, documentation of severity and subsequent management are inconsistent- including amongst those patients requiring hospitalization, specialty referral and/or treatment modification. Further data will be reported regarding utilization of the macro, documentation of IRAE grading and management as well as specialist referral rate.
Improving the assessment and documentation of constipation at UF Health Cancer Center through mandatory prompts.
Authors: Ramnaraign Brian Hemendra , Farooqi Bilal , Gopalan Priya Kadambi , Markham Merry Jennifer
Published: September 2018

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Background: Opioids are commonly prescribed to patients for management of pain and the most common and persistent side effect from opioid use is constipation. Opioid-induced constipation (OIC) affects 52% of patients with advanced cancer and 87% of terminally ill patients. In the Spring 2017 Quality Oncology Practice Initiative (QOPI) chart abstraction round, UF Health Cancer Center’s Medical Oncology clinic notes documented the assessment of constipation in only 45.45% of charts. This is below the academic hospital aggregate documentation rate of 55.61%. Methods: Our objective was to improve the rate of documentation of assessment of constipation in the Thoracic Oncology Clinic at UF Health Cancer Center by 33% to a goal rate of at least 60% by 3 months. We used a Plan-Do-Study-Act model in order to design our project. We worked with the EPIC developers to include a mandatory prompt at the end of the assessment/plan section of the clinic template notes for the Thoracic Oncology practice. Our prompt was “Constipation was addressed and @HE@ {DOES/DOES NOT} have symptoms” where the author chooses from a drop down list to select whether the patient “does” or "does not” have symptoms. We planned to assess a total of 60 random charts in the 3 month post intervention period. Results: At the end of our study, a total of 48 out of 60 charts (80%) documented constipation thus surpassing our goal of 60%. Of the 12 charts assessed that did not address constipation, 11 did not use our revised templates and were notes that were “copied forwarded” from previous encounters. Conclusions: Given that our intervention was a success, we plan to expand these revised templates to the other medical oncology subspecialties in order to better document assessment of constipation for all cancer patients. While our mandatory prompt was shown to lead to increased documentation of constipation, further studies to show whether or not this leads to decreased complaints of abdominal pain, decreased incidences of bowel obstructions, and/or decreased hospital admissions, would be interesting to pursue.
Central venous access in oncology patients: A pragmatic approach to minimizing complications following port insertion.
Authors: Skelton William Paul , Franke Aaron J , Woody Lindsey , Welniak Samantha , Bosse Raphael , Murphy Martina Cathryn , Starr Jason Scott
Published: September 2018

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Background: Subcutaneous venous access devices, specifically implantable ports, are vital in the care of oncology patients. Despite routine use, complications remain prevalent. This retrospective single-institutional review was performed to identify rates of complications following port placement and target areas to improve patient outcomes. Methods: Retrospective analysis of 539 cancer patients who underwent port insertion in a one-year span at University of Florida was conducted. Data examining 18 potentially predictive factors was collected, and multivariate analysis was conducted using logistic regression and odds ratios with standard errors to determine predictive factors. Results: Of 539 patients, 100 (19%) experienced a complication, and 12 (2%) experienced 2 or more complications. An overall lower rate of complications was seen in patients on therapeutic anticoagulation (OR 0.17, p < 0.001) or on antiplatelet agents (OR 0.47, p = 0.02). No patients on therapeutic anticoagulation developed VTE (0%). Right-sided port insertion was associated with decreased rates of infection (OR 0.44, p = 0.04). Insertion as inpatient was associated with increased risk for mechanical failure (OR 4.60, p < 0.01) and catheter migration (OR 4.33, p < 0.01). Conclusions: This analysis identified multiple predictive factors that can potentially put patients at higher risk of complication following port insertion. A thorough risk assessment for VTE should be done prior to port insertion, and high-risk patients (i.e. prior VTE, Khorana score > 3) should be considered for prophylactic anticoagulation. Further analysis on optimal port insertion site (right/left) and location (inpatient/outpatient) are also targets that can potentially decrease complication rates. As ports inserted while inpatient had increased risk of both mechanical failure and catheter migration, and as ports inserted on the left side had increased risk of infectious complications, a prospective quality improvement initiative coordinated between Oncology and Interventional Radiology departments as to whether insertion of right-sided ports on an outpatient basis may improve outcomes is the next step in our investigation.
Tele-oncology at MSK: Delivering innovative, patient-centered care.
Authors: Otto Christian , Wang Jennifer , Walters Chasity , Robson Mark E. , Breitbart William , Cotter Kylie , Harris Jashonna , Harlan Fleischut Megan , Kim Youngho Paul , Saldivar Reggie , Nelson Judith Eve , Sidlow Robert
Published: September 2018

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Background: MSK is deploying teleoncology solutions that improve the patient experience, quality of care, and enhance patient access. MSK’s teleoncology mission is to utilize digital technology as a mainstream channel for connected care across the cancer continuum. Methods: Teleoncology programs were established between Manhattan and four regional sites in support of Psychiatry, Genetic Counseling, and Supportive Care. MSK’s “Virtual Programs” delivered tele-education and tele-support to patients and caregivers in their home or place of work to prepare them for each stage of their care. Patient acceptability ratings were evaluated for quality of care, ease of use, interaction quality, and satisfaction and future use. Results: The four programs generated 7563 teleoncology visits. Virtual Programs served 3865 patients over 766 sessions. Fifty-eight percent (N = 2269) of patients participated in group education sessions (8.3±1.2 patients per session), while 41.3% (N = 1596) participated in support groups (3.2±0.3 patients per session). Overall, 60% of Virtual Program sessions were delivered to patients at home, and 20% to patients at work. Tele-genetics counseling was provided to 3516 patients. The majority of tele-genetics sessions occurred at regional sites (61.4%). Thirty-eight patients completed 159 telepsychiatry visits (4.2±5.8 visits/patient). In Supportive Care, 23 patients completed 38 visits (1.6±1.4 visits/patient). Patients saved 95 minutes of travel time per teleoncology visit. Acceptability ratings for teleoncology were collected from 1185 patients (15.7%). Ninety-one percent of patients were satisfied or extremely satisfied with their teleoncology experience, 95.6% with the information they received, 94.4% with the skill of the provider, and 86.3% with the ease of use of the teleoncology platform. Conclusions: Teleoncology offers an innovative means of providing cancer care to patients by decreasing the stress of travel, missed work, and caregiver requirements. Patients reported that teleoncology made care more accessible and allowed them to remain in their community with family support. For clinicians, teleoncology expanded patient outreach, and improved patient adherence.