bluuebunny/crossref_metadata_2025 huggingface dataset:
A questionnaire study to document surgical and oncologic management of axillary micrometastases and isolated tumor cells in early-stage breast cancer across the United Kingdom.
Authors: Tanna Nikhil , Cleator Susan Jane , Hadjaminas Dmitri , Palmieri Carlo
Published: February 2017

68

Background: A questionnaire study to document Surgical and Oncological management of Axillary Micrometastases and Isolated Tumour Cells in early-stage breast cancer across the U.K. Methods: A web-based 10-question survey examining management of axillary micrometastases (Mi) and Isolated Tumour Cells (ITCs) in early stage breast cancer was distributed to the membership of the UK Intergroup, a group of 130 breast cancer surgeons and 223 oncologists engaged in clinical breast research. Results: Responses were obtained from 58 breast cancer teams (‘multidisciplinary teams, MDTs’ or ‘tumour boards’), including academic and community-based. Of the 79 responses, 23 (29%) were from surgeons and 56 (71%) from oncologists. 15 centres provided responses from more than one member. For a given question, MDTs for which members gave inconsistent answers were excluded from the analysis. 17 centres (29.3%) reported performing intra-operative assessment of sentinel node biopsies (SNB); 23% Imprint Cytology; 31% PCR and 46% reported using frozen section. Regarding management of Mi, 8 centres (16%) reported performing axillary node clearance (ANC) to level 2 always; 8 centres (16%) clearance to level 3 always, 10 centres (20%) never ANC for Mi and 24 (48%) centres reported sometimes performing ANC. On asking whether centres would consider performing neither ANC nor delivering axillary Radiotherapy (RT) for macrometastases discovered at SNB, 1 centre (2%) reported always, 22 centres (42%) reported never and 29 centres (56%) reported sometimes. Regarding management of ITC’s, 2 centres (3.5%) reported performing ANC, 3 centres (5.3%) delivering RT only and 52 centres (91%) performed neither. The question associated with most inconsistency within an MDT was that which explored giving chemotherapy for patients with Mi or ITCs (80%). Conclusions: In a survey of U.K. breast cancer MDTs, significant variation in management of low volume disease in the axilla was seen. Given the challenge of performing phase 3 trials in this setting, clinicians should be supported to audit treatment and outcomes so the impact of differing protocols on outcomes may be established.
Evaluation of a cancer gene sequencing panel in a hereditary risk assessment clinic.
Authors: Kurian Allison W. , Hare Emily E. , Mills Meredith , McPherson Lisa , Kingham Kerry , Whittemore Alice S. , McGuire Valerie , Gong Gail , Ladabaum Uri , Cargill Michele , Ford James M.
Published: February 2017

7

Background: Multiple-gene sequencing panels are entering clinical practice. We report on research testing with a custom sequencing panel comprising 43 genes and 32 cancer-associated variants among patients referred for assessment of hereditary breast and ovarian cancer risk. Methods: Patients referred to the Stanford Cancer Genetics Program for clinical BRCA1 and BRCA2 (BRCA1/2) mutation testing from 2002-2012 were invited to donate a blood sample for research on an Institutional Review Board-approved protocol. Blood samples were frozen at -80 degrees, and DNA extracted after <1-10 years. The entire coding region, exon-intron boundaries (+/- 10bp) and all known pathogenic variants in other regions were sequenced for 43 genes that have published associations with risk of breast, ovarian and other cancers. An additional 32 cancer-associated variants were also sequenced. Clinically significant results were disclosed to patients. Results: Germline DNA samples were sequenced from 199 women: 141 had breast cancer, and 57 carried known BRCA1/2 mutations. Analytic results for BRCA1/2 sequencing and pathogenicity interpretations were concordant with prior clinical testing for all patients. Twenty variants designated as pathogenic, either based on published literature or due to a novel truncating or splice donor/acceptor effect, were observed in genes other than BRCA1/2, including ATM, BLM, CDH1, CDKN2A, MUTYH, MLH1, NBN, PRSS1, and SLX4. Thirteen patients had pathogenic variants warranting a change in cancer screening or risk reduction based on practice guidelines; they were invited for confirmatory clinical testing and counseling. One 53-year old patient with a personal history of breast and endometrial cancers was found to carry a pathogenic MLH1 mutation; she underwent risk-reducing salpingo-oophorectomy and colonoscopy, with removal of a tubular adenoma. Conclusions: Among patients referred for BRCA1/2 mutation testing, a comprehensive sequencing assay identified 20 [10.1%, 95% confidence interval (CI) 6.5%-15.1%] pathogenic mutations in other genes, of which 13 (6.5%, CI 3.8%-11%) prompted a change in care. Disclosure of research results to participants was feasible and well-tolerated.
Outcomes of triple-negative versus non-triple-negative breast cancers managed with breast-conservative therapy.
Authors: Bhatti Abu Bakar Hafeez , Khan Amina Iqbal , Siddiqui Neelam , Muzaffar Narjis , Shah Mazhar Ali
Published: February 2017

70

Background: Triple-negative breast cancer represents a subgroup of breast cancer associated with aggressive behavior and high risk of local and regional failure. Aggressive surgical intervention is considered optimal for this cancer which has made role of Breast conservative therapy (BCT) debatable in these patients. The objective of this study was to compare outcome of BCT for triple negative versus non-triple–negative breast cancers. Methods: Data of patients who underwent breast conservative therapy between 1997-2009 at Shaukat Khanum Cancer Hospital and had complete receptor status information were extracted. Patients were divided into triple-negative breast cancer (TNBC) and non-TNBC. Patient characteristics, medical treatment modalities and adverse events between two groups were compared. Five year locoregional recurrence free, disease free and overall survival was calculated. Univariate and multivariate analysis was done to identify independent predictors of outcome. Results: A total of 194 patients with TNBC and 443 with non-TNBC were compared. Significant differences was present for age at presentation (p<0.0001), family history (p=0.005), grade (p<0.0001) and use of hormonal therapy (p<0.0001). The actual number of locoregional failures, distant failures, and mortalities were not significantly different. No significant difference was present in 5-year locoregional recurrence free (96% vs. 92%, p=0.3), disease free (75% vs. 74%, p=0.7) and overall survival (78% vs. 83%, p=0.2). Tumor size, nodal involvement and hormonal treatment were independent predictors of survival on multivariate analysis. Conclusions: Breast-conservative therapy has comparable outcomes for triple-negative and non-triple–negative breast cancers.
Endoscopic single port skin-sparing total mastectomy with periareolar incision: Early results.
Authors: Yamashita Koji
Published: February 2017

77

Background: Early-stage breast cancer, such as DCIS, may force to complete removal of the mammary gland because of its wide spread in the breast. For such cases, skin-sparing mastectomy (SSM) should be recommended. However, the conventional oncoplastic surgery leaves some ugly scars on the breast due to large skin incisions. By applying the endoscopic video-assisted breast surgery (VABS), we can provide more aesthetic surgery with single periareolar port approach, leaving only a small and inconspicuous scar on the breast. Methods: VABS of SSM consists of periareolar skin incision, dissection of whole mammary gland, sentinel node (SN) biopsy, and axillary node (AN) dissection. After SSM, the breast reconstruction was performed by the delayed or simultaneous method. We use the implant for simultaneous reconstruction. SN biopsy was performed endoscopically with only 1 cm incision in the axilla which was marked with 3D-CT lymphography prior to surgery. For SSM, we made a skin incision of 2.5 - 3.5 cm incision at the foot-side edge of the areola, to preserve blood flow around the areola. We cut across the gland near the nipple and quickly checked the transected stump by fast frozen section. Subcutaneous detachment was applied to the entire gland. Back of the gland was peeled just above the pectoralis major muscle fascia. The liberated gland was removed through the port with a plastic bag. Results: We performed VABS on 300 patients since 2001, and SSM on 30 patients. Tumor size is 1.6 cm on average. Age is 57.2 years. 23 nipples were preserved. 17 cases were DCIS. 4 were invasive lobular carcinoma. 9 were invasive ductal carcinoma. 2 cases had SN metastasis. One case had AN metastasis. Between VABS and the conventional surgery, there was no difference in the amount of blood loss and operation time. Postoperative aesthetics was particularly good after simultaneous reconstruction. They had less sensory disturbance and high satisfaction. After 38 months, there have been no distant metastases, no postoperative deaths, and one local recurrence). Conclusions: VABS SSM with periareolar skin incision approach makes better aesthetic results.
Utility of a three-dimensional bioabsorbable tissue marker in delineating the lumpectomy cavity.
Authors: Cross Michael , Ross Joe , Jones Scott , Beck Thad
Published: February 2017

78

Background: Advanced methods of external beam radiotherapy are not widely used to deliver post-operative treatment for breast cancer due to difficulty in defining the target region surrounding the surgical cavity. Common targeting methods utilize surgical clips and/or seroma based tissue changes. However, these methods can result in over-estimation of treatment volumes resulting in undesirable radiation exposure to adjacent normal tissues. In addition, these techniques fall short of the required precision necessary to utilize newer methods of radiation delivery. In order to assess its ability to assist with identification of the surgical excision site, we evaluated a 3-dimensional tissue marker surgically placed during partial mastectomy. Methods: A total of 30 patients were implanted with a 3-D bioabsorbable tissue marker at the time of partial mastectomy. Post-operative CT simulation and treatment plans were generated and compared. The tissue marker was rated for its utility in defining the target area for treatment planning as well as day to day patient positioning between fractions. Most patients received standard whole breast irradiation with a boost to the tumor bed as treatment, however advanced techniques were used in selected cases. Results: The marker was easy to use with standard surgical techniques. No complications were reported and it was consistently and easily visualized with clinical imaging allowing it to be readily incorporated into standard and advanced planning methods. The marker had appreciable benefits when designing optimal treatment plans, particularly when no seroma fluid remained. In these cases, the marker identified the surgical site that could not have been identified using traditional methods, and target volumes were decreased by >40% in most cases. In addition, the device assisted with image-based tracking of the lumpectomy cavity during respiratory motion (4-D CT) enabling use of IGRT. Conclusions: The Biozorb tissue marker provided a consistent method for identifying the lumpectomy site and was a useful tool for post-operative radiotherapy and clinical followup. In addition, it provided a novel method of marking the lumpectomy cavity when using oncoplastic techniques.
Radiation therapy practice patterns for elderly patients with early-stage breast cancer.
Authors: Healy Erin , Qi Lihong , Vuong Jason , Bold Richard J. , Rash Dominique , Mayadev Jyoti
Published: February 2017

82

Background: Controversy exists regarding the benefit of whole breast radiation (RT) after breast conservation surgery (BCS) in elderly early stage breast cancer patients. We investigated the clinical and pathological characteristics that influence referral patterns and consent for RT. Methods: Between 2006 and 2011, 93 women, aged ≥ 70 were treated with BCS at the University of California Davis Medical Center (UCDMC). Electronic medical records were reviewed to identify pathological and clinical tumor characteristics, including stage, nodal involvement, lymphovascular invasion, margin status and molecular subtype. Patient factors including Karnofsky performance status, Charlson comorbidity index, and distance from UCDMC were recorded. Adjuvant therapy recommendations regarding RT, radiation dose and fractionation, hormonal and chemotherapy, and the ultimate treatment plan were noted. Descriptive statistics were used to characterize the referral pattern data. Patient and tumor characteristics were compared between those referred and not referred for RT using chi-square tests for categorical variables and Student’s t tests for continuous variables. Similar comparisons were also conducted for those who consented and declined RT. Results: Of the 93 women eligible for adjuvant whole breast radiation, 79 (85%) were referred to radiation oncology. Sixty five patients had stage I, 16 had stage II, and 4 had stage III breast cancer. Seventy four patients had a luminal A molecular subtype, 11 of whom declined RT. Hormonal therapy was recommended for 78 patients, of which 11 were not referred to RT. The mean age of those referred to RT was significantly less than those not referred, 76 vs. 81 years, P = 0.006. Mean distance to UCDMC was 17.2 miles for those not referred and 34.4 miles for those referred, P = 0.02. There were no significant correlation between stage, molecular subtype, margin status or lymph node involvement and referral to RT. Conclusions: The majority of elderly patients are referred to RT but increased age and comorbidity were associated with non-referral. Patients’ perception of their own comorbidity, previous experience with RT and the decision to pursue hormonal therapy contributed to patients’ decisions to decline RT.
Acute and late side effects for intraoperative electron radiotherapy during breast-conserving surgery of breast cancer.
Authors: Boelke Edwin , Alessandro Marina , Budach Wilfried , Zwiefel Karin , Janni Wolfgang , Matuschek Christiane
Published: February 2017

94

Background: Intraoperative boost irradiation as part of breast-conserving therapy is a perfect method to adequately capture the high risk tumor relapse area. The most homogeneous dose distribution is achieved with electrons. Intraoperative radiotherapy (IOERT) as a boost for breast cancer releases a high single dose of radiation to the breast tissue; therefore acute toxicity is of particular attention. To date there is only inadequate information available on breast cancer patients treated with IORT using electrons applied as a boost. We therefore analyzed the acute toxicity and late side effects after radiotherapy with 10 Gy as a boost with a minimum follow-up of 3 months. Methods: A total of 385 patients treated with IOERT (10 Gy with 5, 7 and 9 MeV electrons) with a dedicated robotic linac (NOVAC 7, New Radiant Technology, Aprilia, Italy) to the tumor bed during breast-conserving surgery as a boost followed by whole-breast radiotherapy (WBRT,50- 50.4 Gy; 1.8-2 Gy per fraction) were included in this study. All patients underwent a retrospective follow-up regarding acute and late side effects. Toxicities were documented using the common toxicity criteria (CTC 4.0 of the European Organization for Research and Treatment of Cancer). Results: The IOERT was well tolerated and the cosmetic results were good. As a side effect there were five patients with seroma. Two patients developed a secondary wound healing. Two patients developed chronic pain in the irradiated breast. Ten patients developed a grade 2 fibrosis. The remaining patients did not develop any grade 3 or 4 side effects. The observed toxicity rates were not influenced by age, tubus size, electron energy or systemic therapy. 80 patients had a follow up longer than 5 years. Three of them developed distant metastasis and one patient died. Conclusions: After IOERT of the breast using electrons we did not find any unexpected acute and late toxicity rates.
Access to personalized medicine: Factors influencing the use and value of gene expression profiling in treatment decision making.
Authors: Bombard Yvonne , Rozmovits Linda , Trudeau Maureen E. , Leighl Natasha B. , Deal Ken , Marshall Deborah
Published: February 2017

10

Background: Genomic information is increasingly used to personalize health care. One example is gene-expression profiling (GEP) tests that estimate recurrence risk to inform chemotherapy decisions in breast cancer treatment. Recently, GEP tests were publicly funded in Ontario. We assessed the clinical utility of GEP tests, exploring the factors facilitating their use and value in treatment decision-making. Methods: As part of a mixed-methods clinical utility study, we conducted interviews with oncologists (n=14), and focus groups and interviews with breast cancer patients (n=28) who underwent GEP, recruited through oncology clinics in Ontario. Data were analyzed using content analysis and constant comparison. Results: Various factors governing access to GEP have given rise to challenges for patients and oncologists. Oncologists are positioned as gatekeepers of GEP, providing access in medically appropriate cases. However, varying perceptions of appropriateness led to perceived inequities in access and negative impacts on the doctor-patient relationship. Media attention facilitated patient awareness of GEP but complicated gatekeeping. Additional administration burden and long waits for results led to increased patient anxiety and delayed treatment. Collectively, these factors inadvertently heightened GEP’s perceived value for patients relative to other prognostic indicators because of barriers to access. Conclusions: This study delineates the factors facilitating and restricting access to GEP, and highlights the roles of the media and organization of services in GEP’s perceived value and utilization. Results identify a need for administrative changes and practice guidelines to support streamlined and standardized utilization of the test.
Coordinating cancer care: Measurement and intervention approaches across the cancer continuum.
Authors: Sheinfeld Gorin Sherri , Haggstrom David , McDonald Kathryn , Han Paul , Fairfield Kathleen , Ganz Patricia A. , Cheung Winson Y. , Clauser Steven ,   QCCC_CCI Work Group
Published: February 2017

103

Background: According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs. The aims of this presentation are to: (1) describe the state-of-the science on cancer care coordination measures and intervention outcomes from a systematic review and meta-analysis of empirical papers published between 1980-2013; (2) explore the implications of these findings from the patient, provider, healthcare system, and national policy perspectives. No similar review has yet been published. Methods: Of 1,241 abstracts collected from a systematic search of PubMed, MeEMBASE, Medline, CINAHL, and Cochrane Library, 50 studies met the inclusion criteria. Each study had US or Canadian participants; comparison or control groups, measures, times, samples, and/or interventions. Two raters independently applied a standardized search strategy and coding scheme. Eight studies (14 outcomes) met the additional criteria for the meta-analysis. We used the Care Coordination Atlas (McDonald, 2010) definition of care coordination. Results: Overall, coordination improved cancer care across 83% (44) of the measured outcomes. Interventions led to more appropriate healthcare use (g = 0.37 [95% CI = 0.29 – 0.46]; I2= 0.00) across screening (patient navigation), treatment (home telehealth, nurse case management and education), and end-of-life care (early palliation). Measures varied considerably in psychometric quality and were limited in focus. They included; rates of guideline compliance (screening), timeliness of care (diagnosis), health-related quality of life (treatment), cancer-related distress (survivorship), and home death (end-of-life). Conclusions: The findings revealed effective interventions across the cancer continuum from screening to end-of-life. More, and better measures are needed across the cancer continuum. We discuss the implications of these findings for more and better measures, approaches to implement effective interventions in clinical settings, and to develop supportive policy (and reimbursement) contexts.
Guideline discordance in the use of radiographic imaging during initial workup of patients with prostate cancer (CaP).
Authors: Falchook Aaron David , Hendrix Laura H. , Chen Ronald C.
Published: February 2017

109

Background: Overuse of imaging in patients unlikely to have metastatic disease is costly and can lead to patient harm from unnecessary procedures. However, underuse of imaging leads to undiagnosed metastatic disease, resulting in aggressive treatments in incurable patients. The National Comprehensive Cancer Network (NCCN) recommends bone scans and computed tomography (CT) or magnetic resonance imaging (MRI) during initial work-up of select patients with intermediate or high risk CaP. We quantify the proportion of patients who received work-up discordant with NCCN guidelines. Methods: Patients in the Surveillance Epidemiology and End Results (SEER)-Medicare database diagnosed from 2004-2007 were included. We report bone scan and CT/MRI from date of diagnosis to the earlier of treatment or 6 months. Results: 65% of patients for whom bone scan is recommended received it, and 49% received recommended CT/MRI. Further, 43% of patients for whom bone scan is not recommended received it, and 38% received unnecessary CT/MRI. Age and race were significantly associated with discordance on multivariate models (Table). Underuse of recommended bone and CT/MRI scans decreased in more recent years, but overuse of unnecessary CT/MRI increased. There was significant regional variation. Conclusions: There is a high prevalence of both overuse and underuse of guideline-recommended imaging in CaP. [Table: see text]
Impact of an oncology management program using level I pathways, a nurse call system, and advance care planning.
Authors: Hoverman J. Russell , Klein Ira , Harrison Deb , Hayes Jad , Nelson Greg C. , Garey Jody S. , Harrell Robyn K. , Sipala Maria , Houldin Scott , Ciaglo John , Taniguchi Cynthia , Jameson Melissa , Abdullahpour Mitra , McQueen Jessica , Verrilli Diana K. , Neubauer Marcus A.
Published: February 2017

119

Background: The Innovent Oncology Program (IOP) addresses rising costs of cancer treatment but maintains the use of evidence-based medicine. McKesson Specialty Health and Texas Oncology (TXO) collaborated with Aetna, Inc to launch a pilot program to evaluate IOP’s impact on Level I Pathways (PW) compliance, implement Patient Support Services (PSS), measure the rate and costs of chemotherapy-related ER visits and hospital admissions (IP), and evaluate the feasibility of introducing Advance Care Planning (ACP). Methods: Prospective, nonrandomized evaluation of pts enrolled in IOP June 1, 2010-May 31, 2012. Data from the iKnowMed electronic health record, McKesson Specialty Health’s financial data warehouse, and Aetna’s claims data warehouse were analyzed. Results: 221 pts were included and stratified by disease and age. 76% of ordered regimens were ON-PW, improved from TXO’s baseline adherence of 63%. Of 221 pts, 81% enrolled in PSS. ACP was introduced to 85% and 14% of these participated in ACP discussions. In the breast, colorectal, and lung groups, 14% and 24% had an ER visit and IP (baseline) vs. 10% and 18% in the IOP. Average IP days decreased from 2.1 to 1.2, respectively (table). Total savings for all 3 groups was $506,481. Conclusions: Implementation of IOP positively impacted pt care with fewer ER visits, IP, and IP days, cancer-related utilization costs, and increased Pathway adherence. [Table: see text]
Mental health outcomes in a national sample of adult cancer survivors in the United States: Has psychosocial care improved?
Authors: Whitney Robin L. , Bell Janice F. , Joseph Jill G. , Bold Richard J.
Published: February 2017

120

Background: Recent cancer care recommendations include routine mental health (MH) screening and support. We provide national estimates of psychological distress, MH visits, and unmet need (defined as having distress but no MH visit) for MH services among adult cancer survivors. Additionally, we test for temporal differences between years 2005 and 2010 to assess whether the estimates differ before and after important policy recommendations for psychosocial cancer care. Methods: This study analyzed cross-sectional data from the National Health Interview Survey (NHIS), years 2005 and 2010, for adults (≥18yrs) in the United States (n=58,585) categorized as having: 1) no chronic disease; 2) chronic disease other than cancer; 3) cancer without co-morbid chronic disease; 4) cancer with co-morbid chronic disease. In these four groups we compared psychological distress, MH visits, and unmet need for MH services. Survey-weighted logistic regression was used to model the dependent variables as functions of disease status, socio-demographic variables and self-reported health status. Estimates are generalizable to the US civilian non-institutionalized population. Results: Compared to the group with no chronic disease, the cancer with co-morbid chronic disease group had the highest odds of psychological distress (OR 2.78; 95% CI: 2.18, 3.54) and MH visits (OR 1.7; 95% CI: 1.42, 2.05), with no change from 2005 to 2010. The other two groups (cancer without co-morbid chronic disease and chronic disease other than cancer) also had statistically significantly higher odds of both outcomes compared to those with no chronic disease. Among individuals with cancer, estimates of unmet need for MH services were significantly lower in 2010 (OR 1.53; 95% CI: 1.03, 1.88) compared to 2005 (OR 2.89; 95% CI: 2.09, 3.99). Conclusions: Individuals with cancer have disproportionate MH needs. We find evidence of MH care quality improvement among individuals with cancer between 2005 and 2010, a time period that coincides with continued policy and clinical attention to psychosocial needs in this population. These efforts appear to have reduced, but not eliminated, unmet need for MH services for individuals with cancer.
Long-term central venous catheters and infections in older adults with cancer.
Authors: Lipitz Snyderman Allison Nicole , Sepkowitz Kent , Elkin Elena B. , Pinheiro Laura C. , Bach Peter
Published: February 2017

125

Background: Long-term central venous catheters (CVCs) facilitate venous access to administer intravenous fluids and treatments such as chemotherapy. However, CVCs can also be a source of harmful bloodstream infections, a risk that may be underappreciated. Our objective was to assess the impact of long-term CVC use on the risk of infections in a population-based cohort of cancer patients. Methods: Retrospective analysis using the population-based SEER-Medicare dataset for patients over age 65, diagnosed from 2005 to 2007 with invasive colorectal cancer (n = 36,272), head and neck cancers (n = 8,459), lung cancer (n = 56,770), pancreatic cancer (n = 10,536), or non-Hodgkin lymphoma (n = 14,432), or invasive or non-invasive breast cancer (n = 42,271). Cox proportional hazards regression was used to examine the impact of CVC use on infection risk, with CVC exposure treated as a time-varying predictor. We used multivariable analysis and propensity score methods to control for patient characteristics. Results: Adjusting for demographic and disease characteristics, long-term CVCs significantly increased the risk of infection by at least 40%, across all cancer types (Table). The greatest effect of CVCs on infection risk was in patients with breast cancer. Conclusions: Long-term CVC use is associated with an increased risk of infections for older adults with cancer. Careful assessment of the need for long-term CVCs, and targeted strategies to reduce infections for patients requiring their use, are critical to improving cancer care quality. [Table: see text]
Evaluation of the physician-patient communication assessment tool (CAT) in a hematology-oncology practice.
Authors: Desai Amrita , Olszewski Adam J.
Published: February 2017

14

Background: Interpersonal communication skills are critical for building physician-patient relationships. The usefulness of feedback instruments to assess communication in oncology is uncertain. The simple, 15-item, patient-oriented CAT (Makoul G, et al. Patient Educ Couns 2007;67:333) was previously validated in non-oncologic specialties, using 20-30 samples per physician. The mean proportion of “Excellent” scores (MPES) was recommended as a summary estimate (76% in the above study). We evaluated the usefulness of this survey in a hematology-oncology practice. Methods: We administered CAT anonymously to all consenting outpatients during visits in our center, from January to March 2013. The association of “Excellent” scoring with patient age, gender and type of visit (cancer-related or unrelated) was studied using random-effects logistic regression. Results: We obtained 144 surveys (23-52 per physician). Median patient age was 65 years (range, 19-93) with 67% women and 54% cancer-related visits. The MPES for each survey question varied between 86% and 96%. The average MPES per physician was 92.1% (range 88.5-95.8%). MPES was higher for patients >65 years old (94.9% vs. 90.4%), men (96.7% vs. 90.3%), and for cancer-related visits (94.8% vs. 89.7%). In a multivariable model, the association was significant for age>65 (odds ratio, OR 5.38, 95%CI 1.06-27.5, p=.043) and female sex (OR 0.12, 95%CI 0.02-0.76, p=.024). The physician score strongly correlated with satisfaction with office staff recorded as part of the CAT (odds ratio, OR, 28.5, p<.0001). Conclusions: In a hematology-oncology practice, CAT results were considerably more skewed towards “Excellent” scores than in other previously studied specialties. Patients’ age and gender significantly influence the scores, which may confound comparisons between physicians or practices in quality assessment projects. As the needs, concerns and problems of cancer patients may differ from other medical settings, further research is needed to establish if CAT can be used for performance improvement, and whether oncology-specific questions can provide more discriminating measures of patient satisfaction and physician communication skills.
Avoidable and unavoidable visits to the emergency department among advanced cancer patients (AdCa) followed by the supportive care (SCPC) outpatient clinic.
Authors: Delgado-Guay Marvin Omar , Shin SeongHoon , Chisholm Gary B. , Williams Janet L. , Allo Julio , Bruera Eduardo
Published: February 2017

140

Background: Admissions to ED are considered undesirable for AdCa receiving palliative care. There is limited research about clinical characteristics of AdCa followed by SCPC who visited ED, and if these ED visits can be categorized as avoidable or unavoidable. Methods: Retrospective study of 200 consecutive AdCa evaluated by the SCPC physician who visited ED between January 2010 and December 2011. All patients were instructed to call to our main number if any change in symptoms. Based on pre-defined criteria AdCa were classified as having an avoidable (if the problem could have been managed at the outpatient center or by telephone) or unavoidable visit. Demographics and clinical characteristics were collected and analyzed. Results: 47/200 (23.5%) AdCa had avoidable ED-visits (AvED) and 153/200 (76.5%) had unavoidable ED-visits (NAvED). Main reasons for NAvED: changes in mental statu s(24/153, 16%), infectious processes (32/153, 21%), new onset/worsening of pain and dyspnea (75/153,49%), and severe worsening others symptoms (22/153,14%). Age, gender, marital status, and cancer types, reasons for referral to SCPC, and time to ED-visit after SCPC visit were not significantly different between AvED and NAvED patients. Baseline Edmonton Symptom Assessment Scale showed no significant difference in pain, dyspnea, fatigue, drowsiness, nausea, well-being, anxiety, and depression for AvED vs. NAvED; except for sleep ≥1: 141/153 (92%) vs. 37/47 (79%), p=0.01001, respectively. None of the patients phoned the SCPC before to ED visit. 17/153 (11%) of AdCa called their primary oncology before NAvED visit vs. 1/46(2%) call before AvED, p=0.078. Multivariate analysis showed that NAvED was associated with worsening of pain (OR:2.485, p<0.0179), changes in mental status (OR:23.143, p<0.0098), and sleep disturbance(OR:3.611, p<0.0116). 0/47(0%) AvED vs. 93/153 (51%) of NAvED were admitted to the hospital, p<0.0001. Conclusions: More than one in five of ED visits by AdCa are avoidable. Efforts through to improve communication after the scheduled appointments, through clinician initiated phone calls, electronic communication and more frequent visits are needed.
Effect of intervention on a quality measure of pain management at Medstar Washington Cancer Institute.
Authors: Ranpura Vishal Navnitray , Wood Lynne , Heller Stephanie , Self Linda , Jang Sekwon
Published: February 2017

144

Background: Medstar Washington Cancer Institute (MWCI) has participated in Quality Oncology Practice Initiative (QOPI) since 2008. Adherence to pain assessment and intensity documentation was high, but lower in plan of care for moderate/severe pain documentation (69%, compared to QOPI aggregate of 79%) during the fall 2011 round. One potential explanation for the discrepancy was lack of communication between the nursing staff assessing the pain and the physician treating pain. We hypothesized that the use of pain card can improve the communication between nurses and doctors, as well as prompt physicians to document the plan of care for moderate/severe pain. Methods: MWCI created a team of physicians, nurses, quality resources, and administrative staff in December 2011. We abstracted up to 10 patients charts per oncologist for those patientswho reported moderate to severe pain (pain score of more than 3 of 10 on numeric rating scale) each quarter during 2012.We used data for quarter 1 and 2 as a baseline. We implemented the use of pain card by nurses to report pain for these patients to the physician in quarter 3 and 4. Chi square test was used to compare documentation rate in the first two quarters and last two quarters. Results: The total number of charts evaluated, pain documentation as well as confidence intervals for each quarter are shown in the table. Our results show significant improvement in pain documentation by physician in last two quarters compared to first two quarters ( p = 0.0007). Conclusions: Our study demonstrates pain card improved communication between nurse and physician resulting improved documentation of pain by physician. [Table: see text]
Enhancing the quality of the patient experience in an academic medical center.
Authors: Colman Gerard , Hardeman Emily , Moorad Julianna Grisham
Published: February 2017

149

Background: As value-based purchasing evolves, there is a constant focus on efficiency and quality of care delivered during patient interactions before, during, and after each encounter. While perception of quality varies amongst patients, effective communication, patient involvement, and employee engagement have proven to impact patient satisfaction and perceived quality. MD Anderson Cancer Center is re-thinking its practices to provide exceptional quality in clinical care and operations. Methods: MDA has developed a Patient Experience Steering Committee to lay the foundation for the experience strategy and standardization of quality care. The creation of a dedicated patient experience position and the formation of inpatient and ambulatory experience groups have helped to focus initiatives around patient feedback and satisfaction scores. Steps have been taken to enhance patient-focused care: Incentive goals for staff/faculty; Focused communications; Enhanced standards and accountability; Formal rounding; Patient Ambassador pilot; Physician partnerships; New Employee Orientation re-design; Patient involvement; Language of Caring. Results: Ambulatory satisfaction awareness began in July 2011 with an overall score (including custom questions) of 85.6. Focused initiatives began fall 2011, and by March 2013 the score jumped 2.1 points to 87.7. The standard score moved from 88 to 89.6 taking MDA’s C4QI percentile ranking from 6 to 35 over 20 months. Incentive goals focused on information around delays (75.2 to 79.3) and courtesy of staff (93.6 to 94.3). Satisfaction around wait times to see physicians increased from 74.8 to 79.3. Focused efforts revealed increased scores for reaching office staff on the phone and wait time between 1st call and appointment. Conclusions: While a portion of value realized by these initiatives will be evident through reimbursement, VBP rules have led to a much needed structure of standardized operational practices and quality across an academic system. We understand that quality of administrative practices substantially impacts the patient experience, but with over 19,000 employees that treat over 100,000 patients per year, identifying ways to change those practices is not always simple.
Development of a side-effect self-monitoring HOME notebook (HNB): Results from a single institution experience.
Authors: de Marino Elvira , Rossetti Sabrina , Posca Teresa , Lattuada Sara , Chiavola Laura , Cecutti Mara , Pettinati Veronica
Published: February 2017

150

Background: Cancer treatments can be associated with distress and side effects. As therapies are often provided in ambulatory care settings, patients (Pts) have to manage related effects at home, without specialised real-time support. In some cases, Pts are also responsible of prescribed oral adiuvant therapy. In this study we present evaluation results of a self-monitoring and self-education tool to be included in clinical record. Methods: From Jan 2011 to Jan 2013, we enrolled 227 (114M, 113F) Pts new diagnosed with cancer, 204 entered the study, 23 refused. Pts received a note book (HNB) including 2 guidelines about alimentation and skin/mucous/sexuality, 1 daily diary. Pts were asked to complete diary recording side-effects and managing toxicities following the simple guidelines provided. Pts also had a self-administered questionnaire (SQ) to give opinion about tool. Two hundred and four diaries were given; 112 SQ collected. Start-up educational meetings were conducted to illustrate how to register symptoms on diary and monthly we monitored compliance by auditing. Results: SQ analysis shows the following. Average age was 65.14 (median 66); 55% were ≥65 yrs old; 50% received adiuvant treatment, 43% palliative. HNB was used by 33% Pts, 64% Pts and relatives, 3% relatives. 100% Pts say it’s very useful and 98% easy to understand/fill. Most usefull and consulted sections are: alimentation 42%, diary symptoms checklist 31%, skin/mucous/sexuality 25%. Alimentation 42% and diary 24% were the parts they would deepen. Most usefull suggestions about self-care were those on fatigue/decrease in appetite 54%, altered taste 27%, oral cavity inflammation 13%. Sixtynine Pts had nausea and find suggestions given on it useful; 111 rated informations on treatments helpful. Evaluations on study were excellent for 46% Pts, good for 50%, sufficient for 4%. Conclusions: Results confirm HNB efficacy and usefulness. It is easy to understand and fill and provides Pts with heplfull self-managed informations. It’s a precise and higly reliable assessment and monitoring tool at home both for Pts and oncologists. We are evaluating use of HNB as a tool for continuity of care and for phase IV trials.
Health literacy screening prior to education for patients with cancer.
Authors: Berry Donna Lynn , Halpenny Barbara , Chang Peter , Hayes Julia H. , Noel Jon , Vedachalam Srik , Fox Erica , Sorrentino Erica
Published: February 2017

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Background: We have developed and tested the Personal Patient Profile-Prostate (P3P), an efficacious decision intervention for men with localized prostate cancer (LPC). Usability evaluations in minority men of varying education levels suggested additional development needs for this web-based intervention. Establishing the link between health literacy and comprehension and use of education materials is important as we develop interventions for all patients with cancer and is critical to assuring informed consent to treatment and adherence to therapeutic regimens. Appropriate methods of literacy assessment are infrequently used in clinical settings. Methods: The purpose of this analysis was to explore feasibility of health literacy testing prior to P3P use in minority men with a new diagnosis of LPC. Black and Hispanic men were recruited at 3 Boston hospitals. Prior to using the P3P, patients completed the Short Assessment of Health Literacy-English (SAHL-E), an 18-item measure of an adult’s ability to read and understand medical terms. Scores >14 indicate adequate health literacy. Assessment duration was recorded and demographic information collected. Results: Nine men participated in the first 3 months of the study. All identified as Black/African-American, and three also identified as Hispanic/Latino (Dominican, Central American, Cape Verdean). Participants’ median age was 68 (range 52-77), and education level ranged from less than high school diploma to post-graduate degree. Administration of the SAHL-E took from 4 to 12 minutes (median=5). Data completeness was high. Scores ranged from 5 to 18 (median=16), with two patients scoring below 14; these two with low health literacy were the only two without any college education and also required at least 10 minutes to complete the screening. Conclusions: The SAHL-E was a feasible approach to screening for health literacy in a sample of minority men prior to providing a patient decision support intervention. Preliminary results suggest some ability to identify those patients who will require greater support during use of educational interventions or understanding written documents.
Evolving techniques for negative pressure wound therapy and the value of grass roots comparative effectiveness research.
Authors: Lohman Robert , Jayaprakash Vijayvel , Dorafshar Amir , Gottlieb Lawrence , Franczyk Mieczyslawa
Published: February 2017

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Background: There is debate over the value of comparative effectiveness research to address national health problems, but less attention has focused on its value to solve smaller questions. We present an example of local, clinician initiated, and unfunded comparative effectiveness research to address problems related to negative pressure wound therapy (NPWT) at our hospital. NPWT was popularized as the VAC (Vacuum Assisted Closure, Kinetic Concepts, Inc., San Antonio, TX) system and became standard treatment for many inpatient wounds. Between 2000 and 2006, VAC was the only form of NPWT at our hospital. When it became apparent that VAC therapy was costly, and painful, clinicians tried an alternative method using wall suction and gauze (GSUC). In 2007 and 2008 a randomized prospective trial showed the techniques were equally effective while GSUC was less painful and less costly. After the trial, we tracked the frequency of VAC and GSUC use, as well as the cost of NPWT. Methods: From 2000 to 2011, 3,184 inpatients required NPWT; demographics, the method of treatment, and associated costs were recorded prospectively. Data from 2000 – 2006, when only VAC was available, was compared to data from 2009 – 2011, when both VAC and GSUC were available. Results: Between 2000 and 2006, all patients (N=1,746) were treated using the standard VAC. After 2008, fewer patients were treated using the VAC compared to GSUC: 21 (2%) vs 907 (98%), p=0.001. Between 2000 and 2006, the daily cost of therapy with VAC was $97.09/patient (SD=2.54). After 2008, the daily cost of therapy with VAC was $101.34/patient (SD=0.80) compared to $4.22/patient (SD=0.80) for GSUC, p=0.001. The average yearly direct cost of NPWT was $217,500 from 2000 – 2006 and then fell to fell to $14,690 per year for the period of 2009 – 2011, p=0.001. Conclusions: The tools of comparative effectiveness research can be scaled down to assess problems facing single institution. When encouraged to take ownership of the research process, clinicians will also take ownership of the results. In this case, a standard method of wound care was abandoned less than a year after an in-house trial showed it was more painful, more expensive, but not more effective than a homegrown method.
Improving quality and safety of oncology patient care: Standardization of the post-clinic message triage process.
Authors: Donohue Caitlin C. , Kaymakcalan Marina , Elfiky Aymen , Dalby Carole Kathleen , Bryar Julie M. , Jacobson Joseph O.
Published: February 2017

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Background: Due to the rapidly increasing complexity of the treatment and management landscape of genitourinary oncology patients,the high volume of patient calls within our practice has raised safety concerns among providers about follow-through on issues and coordination of care. Survey data revealed that more than 20% of providers and staff (n=19) were unsatisfied with the existing message triage process and indicated that it was not the most efficient and timely way to respond to clinical messages. Patient survey data (n=94) and analysis of messages showed 80% of messages were related to direct patient care issues. The aim of this project was to analyze and streamline the message triage process with the goal of creating a standardized approach to respond to clinical messages in a timely and efficient manner. Methods: A multidisciplinary team constructed a process map, administered surveys, conducted cause-and-effect analyses, orchestrated brainstorming sessions, and used a priority/pay-off matrix to devise and implement an intervention using a standardized message template. Results: Baseline data showed that 18% of emails contained the necessary components to provide direction on who held responsibility for answering a message. Three Plan-Do-Study-Act (PDSA) cycles were conducted: (1) Education provided to administrative staff; (2) Implementation of email template; and (3) Subsequent modification in response to PDSA 2. After 3 weeks, 85% of emails contained the necessary components. Compared to a baseline of 79%, 96% of providers and staff prefer the new process. Conclusions: The interventions implemented using three sequential PDSA cycles resulted in an improved process for triaging clinical calls in conjunction with enhancing provider satisfaction. Additional steps are planned to further standardize the email notification template. [Table: see text]