bluuebunny/crossref_metadata_2025 huggingface dataset:
Tumor and systemic immune responses to preoperative (pre-op) cryoablation (cryo) plus immune therapy with ipilimumab (ipi) in early-stage breast cancer (ESBC).
Authors: Page David B. , Yuan Jianda , Ginsberg Arielle , Dong Zhiwan , Wong Phillip , Emerson Ryan , Sung Janice S. , Comstock Christopher , Solomon Stephen Barnett , Sacchini Virgilio , Morrow Monica , Brogi Edi , Morris Elizabeth Ann , Patil Sujata , Robins Harlan , Wolchok Jedd D. , Hudis Clifford A. , Norton Larry , Allison James Patrick , McArthur Heather L.
Published: February 2017

64

Background: In mice, tumor cryo plus immunologic checkpoint blockade generates tumor antigen release, proliferation of tumor-specific T-cells, and enhanced survival. We previously demonstrated in a pilot study that pre-op cryo+ipi is well tolerated in women with ESBC and did not delay standard of care surgical resection. Here, we analyze pilot study tissue and blood to explore immune response. Methods: 18 ESBC patients (pts) were treated with preop cryo (n=6), single-dose ipi 10mg/kg (n=6), or cryo+ipi (n=6). As a potential surrogate for tumor immunogenicity, baseline T-cell tumor infiltrating lymphocyte (TIL) density was evaluated by T-cell receptor quantitative DNA sequencing. We explored the systemic immune response to cryo and/or ipi using previously described laboratory measures including inducible costimulator (ICOS, a marker of activated CD4+ T-cells) and plasma interferon gamma (IFNγ, a cytokine associated with T-cell activity). Results: Of the 18 study pts, 13 pts had hormone receptor-positive (HR+) disease, 2 pts had HER2+ disease (both treated with ipi alone) and 3 pts had triple-negative (TN) disease (1 ipi alone and 2 cryo/ipi). Baseline TIL density was highly variable overall (range 2-30%), but higher in HER2+ and TN pts (median 15%) compared with HR+ pts (median 5%). Sustained >2-fold elevations in ICOS and IFNγ were observed in the majority of cryo+ipi pts 30 days following treatment (ICOS: 5/6 pts; IFNγ: 4/6 pts), but in the minority of ipi pts (ICOS: 2/6 pts; IFNγ: 2/6 pts) or cryo pts (ICOS: 0/6 pts; IFNγ: 0/6 pts). Sustained ICOS and IFNγ elevations were observed regardless of baseline TIL density. Conclusions: Cryo+ipi was more likely to induce systemic immune activation compared to cryo or ipi alone. These potentially beneficial immune effects were observed in both HR+ and HR- subtypes, as well as in tumors with low or high baseline TIL density. These data support further studies of cryo+ipi in ESBC across HR+ and HR- subtypes, as well as in tumors that do not appear immunogenic at baseline.
Sources of information on decisions regarding contralateral prophylactic mastectomy: A prospective study.
Authors: Yao Katharine , Wroblewski Kristen , Van Haitsma Martha , Rabbitt Sarah , Williams Jordan , Kulkarni Swati
Published: February 2017

75

Background: The rate of contralateral prophylactic mastectomy (CPM) has increased but little is known about the sources of information women utilize to choose CPM. Methods: A 55-item survey validated with breast cancer survivors was administered to 136 patients before surgery from two institutions. Results: The median age was 58 years (range 30-85). Eighty-three (69.2%) were White. Seventy-five (58.6%) had a lumpectomy, 41 (32%) a unilateral mastectomy and 12 (9.4%) had a CPM. About 80% of women felt the information they were given about breast cancer treatment was consistent. Fifty-five patients (41.7%) sought out extra information beyond what the doctor gave them. Information with the strongest influence was websites, books recommended by their doctor (44%) and websites, books not recommended by their doctor (30.4%) was the second strongest influence. Women ranked their doctor’s spoken advice as the most important source of information (74.3%) compared to advice from individuals outside of medicine, online information, observing breast cancer survivors and advice from friends/family. Plastic surgeons and the spouse/partner had more influence on those <50 years old compared to >50 years old (p=0.03). When asked which individual outside of medicine influenced their decision, women chose breast cancer survivors as their top choice compared to their spouse/partner, church leaders and friends/relatives. However, 82 women (62.6%) stated that information provided by staff did not include any information about removing the healthy breast. Forty-one (36%) stated that no one discussed contralateral breast cancer risk and 67 (59%) stated that no one talked with them about the possibility that cancer could turn up somewhere else even if both breasts were removed. Conclusions: Women do not always receive information about CPM from their doctors but they still highly value their doctor’s advice. These findings highlight an opportunity for physicians to educate women about the utility of CPM as part of their surgical treatment.
The effect of margin status and molecular subtype on women with invasive breast cancer treated with breast-conservation therapy.
Authors: Forrester Jared , Currey Adam D. , Tuyishimire Bonifride , Lin Jonathan , Kong Amanda L.
Published: February 2017

83

Background: A consensus statement was recently published by SSO/ASTRO on margins for stage I and II invasive breast cancer treated with breast conserving surgery (BCS). We examined patients with invasive breast cancer who underwent BCS to determine if margin status and molecular subtype influence outcomes. Methods: We the reviewed charts of 754 Stage I-III breast cancer patients treated with BCS from 2003-2010. Margin status was defined as negative ≥ 2mm, close < 2mm and positive as tumor on ink. Conventional receptor analyses were used as markers for molecular subtype classification (luminal A, luminal B, Her2 positive, and basal). Clinicopathologic variables were tested using the Fisher’s exact, Chi-square, ANOVA F-test, and Kruskal-Wallis tests. A Cox proportional - Hazards model was used to measure the impact of these variables on locoregional recurrence (LRR), breast cancer-specific (BCSS) and overall survival (OS). Results: The median age of the cohort was 58 (range 27-89 years). Most were white (88%), had T1 tumors (76%), luminal A tumors (66%), invasive ductal histology (80%), and were node negative (76%). Of the 754 patients, 26% had close margins, 2% positive margins, and 9% unknown margins. With a median follow-up of 5.2 years, OS was 92%. Twenty eight patients had a LRR with a median time to recurrence of 5.1 years. On multivariate analysis, molecular subtype, pathologic grade (p=0.01), and use of radiation (p<0.0001) were the only significant predictors of LRR. Unknown subtype, compared to Luminal A, was less likely to have a LRR (p=0.04). Basal (p=0.0002), Her2+ (p=0.03), Luminal B (p=0.002) and unknown subtype (p=0.04) had worse BCSS compared to Luminal A tumors. Margins had no impact on LRR or BCSS but those with close margins and unknown margins had worse OS compared to negative margins (p=0.01, p=0.007). Variables predictive of OS were margins, age, race, node status, chemotherapy, anti-endocrine therapy, and radiation. Conclusions: In this cohort treated with BCS, molecular subtype was a predictor of LRR and BCSS but not OS. Margin status did not impact LRR and BCSS. Although margin status was a predictor of OS, tumor biology remains the significant determinant of outcome.
HBV screening before adjuvant chemotherapy in patients with early breast cancer: A cost-effectiveness analysis.
Authors: Wong William W. L. , Hicks Lisa K. , Tu Hong-Anh , Krahn Murray , Pritchard Kathleen I. , Feld Jordan J. , Chan Kelvin K.
Published: February 2017

11

Background: The seroprevalence of hepatitis B virus (HBV) infection among Canadian was 0.4%, and 1.6% among immigrants. Most infected individuals have clinically silent disease. Cytotoxic chemotherapy causes reactivation in 30% of the HBV infected patients. This can be severe and fatal, may also lead to interruption of chemotherapy. HBV screening before adjuvant chemotherapy (ADJ) for breast cancer (BC) seems to be a plausible strategy. Our objective is to estimate the health and economic effects of HBV screening strategies. Methods: We developed a state transition microsimulation model to examine the cost effectiveness of 3 strategies for 55 year old BC patients undergoing ADJ: (1) No screen; (2) Screen Imm: Screen immigrant only and treat; (3) Screen all: Screen all and treat; with antiviral therapies. In the model, health states were constructed to reflect the natural history of BC and HBV. Model data were obtained from published literature. We used a payer perspective, a lifetime time horizon, and used a 5% discount rate. Results: Screen all would prevent 43 severe reactivations (SR), 9 deaths from reactivation (DR), 22 chemotherapy interruptions (CI), 36 decompensated cirrhosis (DC), 48 HCCs, and 67 HBV deaths per 100,000 persons screened over the lifetime of the cohort. Screen Imm would prevent 34 SR, 4 DR, 20 CI, 30 DC, 41 HCCs, and 52 HBV deaths. Screen all was associated with an increase of at least 0.00368 quality adjusted life years (QALY) and cost C$116 more per person, translating to an incremental cost effectiveness ratio (ICER) of C$31,518-51,276/QALY gained compared with No screen, depends on different antiviral therapies. Screen all was the most cost effective, while Screen Imm was ruled out due to extended dominance (ED) by No Screen and Screen all. Conclusions: HBV screening before ADJ for BC patients would prevent a significant number of reactivations, and is likely be cost effective. [Table: see text]
Impact of advance directive (AD) completion among patients with metastatic cancer treated at an academic medical center.
Authors: Kapadia Nirav S. , Snide Jennifer , Gelb Daniel J , Schlosser Evelyn
Published: February 2017

114

Background: Between February and September 2013, AD documentation for oncology patients across Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) increased from 36% to 48%. However, it remains unclear whether AD completion itself is associated with other indicators of quality care. Methods: Using the tumor registry and National Death Index patient data, we examined a cohort of deceased NCCC patients diagnosed with metastatic disease between April 1, 2011 and October 31, 2013. To account for unmeasured care provided outside of NCCC, only patients with at least two NCCC visits, one of which occurred within the last six months of life, were included. Individual patient electronic medical record data were then linked to the registry data and multivariable regression was performed to determine the effect of AD completion on end-of-life quality metrics. Results: The cohort consisted of 225 patients, 182 (81%) of whom had an advance directive on file and 43 (19%) who did not. There were no significant differences in the age, gender or cancer diagnosis between the two groups. Patients with an AD had shorter commutes to the medical center (mean 42 vs 58 minutes, p<0.01) and more visits with cancer center providers (median 11.5 vs. 4.0, p=0.03). Palliative Care consulted with 73% of patients with an AD, versus 28% of patients without an AD (p<0.01). Completion of an AD did not decrease the likelihood of hospital death (OR 0.90, 95% CI 0.33-2.49), intensive care unit (ICU) death (OR 0.83, 0.19-3.66), hospital admission in the last 30 days of life (OR 0.94, 0.40-2.21), or ICU admission in the last 30 days of life (OR 1.30, 0.37-4.55). Patients with an AD were twice as likely to receive hospice referrals (OR 2.04, 0.73-5.68) and 70% less likely to visit the emergency department in the last 30 days of life compared with patients without an AD on file (OR 0.28, 0.06-1.40), although these trends were not statistically significant. Conclusions: For patients with metastatic cancer, an advance directive was associated with increased use of palliative care, though not with other measures of quality care. In an attempt to improve the cancer care provided at the end of life, we must expand our strategies beyond the use of an AD.
Can protocol development improve breast cancer and breast surgery quality measures?
Authors: Samiian Laila , Rivera-Fernandez Ricardo , Puckett Katherine , Patrick Jilma , Chesire David
Published: February 2017

119

Background: Since 2009, UF Health Jacksonville has made significant changes in the Breast Cancer Program. These changes spanned across multiple specialties and have focused on creating protocols, guidelines, checklists, and policies for the management of breast cancer. This study evaluated the effect of standardized institutional protocols on breast cancer quality measures. Methods: Tumor registry was used to identify 350 patients who were diagnosed and treated at UF Health Jacksonville for breast cancer from 2006-2012 (Stage 0-III excluding LCIS). A retrospective review of electronic health records was performed to compare the achievement of quality measures 2 years before program development (6/2006 – 6/2008) to that of 2 years after program development (6/2010 -6/2012). Results: There were significant improvements in breast cancer diagnosis and surgical treatment quality measures after establishment of standardized protocols. Performance of pre-surgical needle biopsies regardless of diagnostic outcome (90% vs. 96%, p=0.02), and diagnosis of carcinoma via needle biopsy (50% vs. 87%, p=0.04) both showed significant improvement. More patients underwent sentinel lymph node biopsy post-protocol (43% vs. 68%, p<0.001). There was improvement in surgical specimen orientation (58% vs. 88%, p<0.001), and image confirmation of the specimen post-protocol (86% vs. 97%, p=0.01). There was a reduction of second or additional operations (44% vs. 26%, p=0.004), which included a significant reduction in lumpectomy re-excisions for margins (30% vs. 14%, p=0.003). There was a non-significant improvement in attempted (64% vs. 71%, p=0.17), and successful breast conservation surgery (57% vs. 65%, p=0.10). There were no significant changes in the rates of recommendation for adjuvant radiation, endocrine, or chemotherapy. There was no improvement in patient adherence to the recommended adjuvant therapy based on protocol implementation. Conclusions: Implementation of standardized institutional protocols can significantly increase achievement of quality measures in breast cancer diagnosis and surgery. However, these protocols did not have a significant effect on systemic therapy or radiation therapy quality measures.
Clinical documentation improvement as a quality metric in oncology.
Authors: Farber Jeffrey Ian , Holcombe Randall F.
Published: February 2017

123

Background: With the rapid pace of healthcare reimbursement transformation from a fee-for-service to a fee-for-value system, clinical documentation is increasingly recognized as a critical area of focus for quality improvement. Engaging busy physicians to improve their clinical documentation is a challenging endeavor. Many hospitals utilize clinical documentation improvement specialists to query physicians for more specific and comprehensive clinical documentation. In this paper, we will report on a novel, complementary, and replicable approach we utilized to improve clinical documentation in the medical oncology clinical service line at the Mount Sinai Hospital in New York City. Methods: We organized a team of stakeholder physicians, clinical documentation specialists, clinical informaticists, and data analysts in July 2013 to address a perceived gap in publicly-reported severity-adjusted quality metrics in medical oncology. We used University Health System Consortium data to conduct a detailed comparative analysis of the rates of coding for common and important secondary ICD-9 diagnoses on inpatient claims by base Diagnosis Related Group (DRG). A list of 34 diagnoses was targeted for improvement in the accuracy and specificity of clinical documentation. We then developed an electronic medical record tool to assist clinicians in real-time clinical documentation. We rolled out a new quality metric with monthly reporting on CC/MCC (complication or comorbidity and major complication or comorbidity) capture rates to departmental leadership, provided educational outreach to front-line providers and developed additional non-electronic reminder tools for provider use. Results: We increased the overall CC/MCC capture rate from 88% to 94% and the case mix index (CMI) for the chemotherapy base MS-DRG from 1.11 to 1.28 from March 2013 to March 2014. The capture rate remained the same (6) or increased (18) in 82% of the targeted diagnoses. Conclusions: Adding clinical documentation metrics to the existing quality infrastructure, supported with comparative analytical data and EMR tools, can drive sustainable improvements in clinical documentation which supports publicly-reported severity-adjusted quality measures.
Reduction of emergency department utilization via access to outpatient cancer care.
Authors: Bishop Kenneth D. , Fenton Mary Anne , Szymanski Tara , Begnoche Megan
Published: February 2017

128

Background: Emergency department (ED) utilization for non-emergent medical problems is an inefficient use of medical resources. During calendar year 2013, 224 RIH adult cancer patients presented to the RIH ED. Retrospective review indicated up to 50% of these ED visits were avoidable. Methods: This project was developed for the ASCO Quality Training Program. A multidisciplinary team was assembled to address ED utilization. Retrospective chart review of ED visits included time and reason for visit and primary tumor site. The team selected the Lung Cancer as the target group, developed a cause-and-effect analysis for ED visits, administered a patient survey, and implemented a series of Plan-Do-Study-Act (PDSA) cycles. The team implemented a patient education process of nurse sick-line symptom management and same-day sick visits at RIH CCC as well as developing a single-page patient “sick-line tool” with oncology nurse sick-line contact telephone numbers. A patient navigator introduced the sick-line tool at the first visit and its usage was reinforced at subsequent visits. Results: For RIH CCC lung cancer patients, a standardized symptom-control education process correlated with 30% decrease in ED visits for any presenting complaint (42 visits vs. 60 visits) and 32% decrease in ED visits with presenting complaint of pain (13 visits vs. 19 visits) during January/February 2014 compared to January/February 2013. We did not find significant differences between the proportion of ED visits during Cancer Center business hours, evenings, or weekends. Sick-line calls were found to increase by 53% during January 2014 compared to December 2013 with an additional 35% increase in February 2014. Conclusions: A standardized patient education process resulted in a significant decrease in ED visits, concurrent with an increase in outpatient sick-line utilization. This may reflect an improvement in efficiency of outpatient cancer patient care in a single-institution setting. Given other reports of increased ED utilization by lung cancer patients for similar presenting reasons, these improvements may be generalizable to other institutions.
Improving telephone management of patient clinical concerns.
Authors: Sudheendra Preeti , Gilbert Beth , Gillespie Dawna , Coniglio Mary , Evans Tracey L.
Published: February 2017

137

Background: As the majority of oncology care is delivered in the ambulatory setting, patients and families require reliable and efficient ways to contact the care team with clinical concerns. The Abramson Cancer Center is comprised of 40 medical oncologists seeing over 100,000 annual outpatient visits. Press Ganey phone access satisfaction scores in the 12th percentile reflect patient dissatisfaction with phone communication. We initiated a pilot project to improve phone access. Methods: Baseline data was collected from 3 main sources of patient calls: intake office, administrative assistants, and triage RN’s. Over 2,000 patient calls were tallied during a one week period documenting: time of call; live answer vs voice mail; reason for call; whether and to whom the call was transferred. A subset analysis of calls related to symptom/medication management (SM) was performed via EMR audit to determine: time to call resolution (TTR), % resolved within 2 hours, % documented in the EMR, and % answered live. The TTR of patient SM calls and % resolved in < 2hrs were calculated by comparing the time of call receipt per log to the time of closed phone encounter in the EMR. The percent of calls documented was determined by comparing the call log to corresponding EMR encounters. The percent answered live was determined by review of the call log. As a pilot test of change, all calls in one of the practices were forwarded to a single source (intake office) to ensure live answer. The staff was educated to create an EMR encounter for each SM call and then route the encounter to a clinical pool (RN, APP and MD). An automated report enabled monitoring of key metrics. Results: The goals set for the pilot project were exceeded for 2 of the 3 performance metrics (Table). Conclusions: Within a complicated academic health system, we utilized our EMR and modified our phone triage system to streamline and reduce variation for management of SM calls. 62% of these calls were resolved within 2 hours, and the mean time to resolution of SM calls was reduced from 127 to 87 minutes. [Table: see text]
An assessment of neoadjuvant therapy for breast cancer and treatment wait times at the BC Cancer Agency Vancouver.
Authors: Adilman Rachel , Leonard Robyn , Poonja Zia , Simmons Christine E.
Published: February 2017

140

Background: Neoadjuvant therapy (NAT) is widely considered to be the standard of care for patients diagnosed with locally advanced breast cancer (LABC) or inflammatory breast cancer (IBC). NAT is also considered in patients with more aggressive subtypes (Her2+ or triple negative cancers). However, it remains unclear which patients are being considered for NAT, which patients are indeed receiving NAT, and how long the current wait times for chemotherapy and hormone therapy are in this patient population. This study was designed to characterize the breast cancer patients being referred to the BC Cancer Agency (BCCA) Vancouver’s NAT clinic, and to determine the average wait times for chemotherapy and hormone therapy in these patients. Methods: Between May 13th, 2013 and June 3rd, 2014, a total of 160 potential NAT candidates were seen at the BCCA Vancouver NAT clinic. Breast cancer characteristics and wait times for these patients were assessed prospectively using a secure database. Results: Of these 160 patients, 119 (74%) actually received NAT; 76.7% of these were deemed LABC patients (clinical stage IIB or III), and 6% were “window of opportunity” (WOP) patients (those considered for NAT due to long surgical wait times). NAT patient receptor status differed significantly from the receptor statuses of patients who did not receive NAT (p=0.006), with Her2+ and triple negative breast cancer patients being most likely to receive NAT. Seventy-eight percent of ER+Her2+, 86% of ER-Her2+, 67% of ER+Her2-, and 80% of triple negative patients received NAT. A total of 4 patients (2.5%) presented in clinic with metastatic disease and thus were not considered for NAT. The average wait time between when a patient was referred to the BCCA and when they commenced chemotherapy was 18.1 days (median: 16), while the average wait time to receive hormone therapy alone was 12.3 days (median: 10). Conclusions: These findings suggest a need to expedite screening and care for these high-risk breast cancer patients in order to characterize and treat the disease neoadjuvantly before it has metastasized. Strategies to reduce wait times in this breast cancer population are being further assessed.
Mobile solution for clinical research documentation.
Authors: Philip Lindsay , Grant Jasmine , Eggert Calven , Di Nardo Aaron , Sellmann Susanna , Cole Heather , Flynn-Post Marcia , Williams-Brennan Leslie , Degendorfer Pamela
Published: February 2017

153

Background: As trial complexity increases, there is a growing need to facilitate rapid communication of trial data among members of the research and clinical care teams. Timeliness of investigator review and high quality data are critical to clinical trial documentation. Princess Margaret developed an electronic application that meets these needs, is integrated into a patient’s medical chart, and is accessible at the point of care on a mobile device. Methods: Focus groups were held with research staff to evaluate application and device needs. Device needs were usability, compatibility with the electronic patient record (EPR), and encryption ability, which were considered and a device was selected. Standard templates were developed for the informed consent process, clinical notes, vital signs, baseline symptoms, adverse events, and concomitant medications. Electronic source (eSource) was linked to an existing CTMS, the Clinical Research Record. eSource is accessible via the EPR, allows for electronic review and sign off by investigators, and allows data capture directly into the EPR from a mobile device. Results: A 4 month pilot was completed in December 2013 with 10 clinical research nurse coordinators (CRNCs) from 3 different treatment areas, enrolling 40 patients. The project continues to roll out and will be completely integrated by July 2014. CRNCs enter information at the point of care that is easily shared amongst research and clinical care teams; important safety information is available to all staff; investigators can sign off electronically; and data has an audit trail. Metrics collected over a two-month span demonstrate average investigator sign off is completed within 7 days, well under our established timelines of within a cycle of treatment. Conclusions: Enhancements were made within the system during the pilot to facilitate workflow as issues were identified. The system provides solutions for delayed documentation, the transfer of paper charts between team members, and investigator sign-off. This has allowed for tracking of metrics including the timeliness of documentation, review, and sign off; and quality improvements to documentation will be measured through internal quality assurance reviews.
Using tablet technology in routine patient-reported outcome measure surveys to improve cancer quality care: A patient acceptability assessment.
Authors: Pat Vivien , Brown Catherine , Vennettilli Ashlee , Zarrin Aein , Dobriyal Aditi , Chen Linda , Mirshams Maryam , Patel Deval , Hon Henrique , Irwin Margaret , Ho Anthea , Solomon Hannah , Tiessen Kyoko , Mahler Mary , Ho Valerie , Thai Henry , Eng Lawson , Xu Wei , Howell Doris , Liu Geoffrey
Published: February 2017

155

Background: Patient-reported outcome measure (PROM) surveys are a tool used to collect information about clinically-relevant symptoms in patients. Touch-screen technology has been previously identified as a feasible and effective method of routinely capturing PROMs.Our aim was to evaluate cancer patients’ acceptance and perception of usefulness of tablet technology as a means of communicating PROMs to healthcare providers during delivery of quality care. Methods: 337 adult cancer patients across all outpatient clinics and disease sites at Toronto’s Princess Margaret Cancer Centre (PMCC) completed PROMs surveys using touch-screen technology. Acceptance and feasibility of completing the tablet-based PROMs data on a routine basis were also assessed. Results: The study population consisted of 45% males; median age 59 (19-91) years; 75% Caucasian, and 48% had a post-secondary degree.20% had lung cancer, 20% genitourinary, 16% breast, 16% lymphoma, 11% gastrointestinal, 7% gynecologic, and 7% head/neck. 88% were happy to complete the survey on a touch-screen tablet and 65% of these were willing to complete such surveys routinely. 86% did not find it time-consuming. Only 2% found that the completion of surveys made their clinic visit more difficult. Of the 72% that thought the survey was a useful means to inform the clinician of how they felt physically and emotionally, only 81% were willing to complete the survey at every visit. Conclusions: Tablet-technology was found to be an acceptable tool for survey administration, however, not on a routine basis. While the majority of patients found PROMs to be clinically important, almost 20% did not want to fill it in regularly at every visit. Current mixed-methods analysis is being utilized to help discern whether this discrepancy is related to the tablet technology or survey burden.
A strategic roadmap for oncology electronic medical records (EMRs) in Ontario’s complex multiregional health care system.
Authors: Kukreti Vishal , Yardley Tim , Derman Yaron , Kennedy Margaret , Dhoot Rummy , Melamed Saul , Gilks John
Published: February 2017

159

Background: Ontario’s cancer system comprises 14 regions; from large and sparsely populated to dense urban areas. Each region, and the hospitals within it, is responsible for its own IT solutions to support oncology. In 2011 Oncology EMRs in 4 regions were funded as there are no oncology specific Health Information Systems (HIS). Cancer Care Ontario (CCO) also obtained funding to develop standards, and a roadmap for their use, from eHealth Ontario. Methods: Early work focused on establishing standards based on the integrated patient cancer journey. Work-streams included functional standards, an interoperability framework for CCO tools and provincial assets and information standards to be supported through EMRs. These were evaluated through internal and external review and validation processes. The strategic IT roadmap was developed via interviews with leaders in the clinical, management and IT domains to obtain input on how the standards might be used and what role CCO should play. Results of the consultations were consolidated into key themes and validated through a facilitated workshop with an expert panel. Results: Standards can be incorporated into EMRs in a consistent way by basing the design around the patient journey and by working with the point of care tools that clinicians need to support accurate, timely and relevant data at each stage of the patient journey. This approach is location and vendor neutral. Focusing on the data needed at point of care provides insight into reporting needs and how data can be exchanged between systems; directly, via a provincial repository or via CCO provided tools. CCO’s role should be to provide support to the regions through standards and advocacy with stakeholders rather than development of tools. Conclusions: Oncology has unique IT needs that may not be fully incorporated in hospital wide IT strategic plans or decisions. The standards and roadmap provide a basis for oncology programs to ensure that IT decisions meet their needs. The role of CCO should evolve toward strategic counsel and advocacy rather than provision of IT tools.
Development of an algorithm to identify metastatic prostate cancer in electronic medical records using natural language processing.
Authors: Wallner Lauren P. , Dibello Julia R. , Li Bonnie H. , Zheng Chengyi , Yu Wei , Weinmann Sheila , Richert-Boe Kathryn E. , Ritzwoller Debra P. , VanDenEeden Stephen K. , Jacobsen Steven J.
Published: February 2017

164

Background: Prostate cancer patients who develop metastases are a difficult population to identify through administrative diagnostic codes, due to their protracted time to metastases, limited survival and the inconsistent use of specific codes. As a result, research that is needed to inform the delivery of high-quality care in this setting is limited. Therefore, the goal of this study was to develop an algorithm, which utilizes EMR data to identify men who progress to metastatic prostate cancer after diagnosis using natural language processing (NLP). Methods: An electronic algorithm was developed to search unstructured text using NLP to identify progression to metastases among men with a diagnosis of prostate cancer between 1992 and 2010 in a large, diverse cohort of men who were part of an ongoing study focused on prostate cancer mortality. A training set of 449 men who were diagnosed as early stage prostate cancer was used for development. Pathology, radiology and clinic notes were searched from diagnosis until death or loss to follow-up. Pathology reports were searched for mention of adenocarcinoma in the metastatic lesion, radiology reports were searched for abnormal findings consistent with metastases, and clinic notes were searched for mentions of increasing pain or narcotic use related to metastases. Each NLP component was validated against manual review of the corresponding records. Results: Of the 449 men in the training set, 40 (8.9%) were found to have metastatic prostate cancer. The majority of cases had evidence of metastases in their clinic notes (98%). Radiology reports identified 18% of cases, and pathology reports identified 5%. Of the 40 cases identified, 25% did not have a corresponding ICD-9 codes for metastatic cancer. However, 7.5% used ADT, 37.5% had increasing oncology visits and 22.5% had rapidly rising PSA levels. Conclusions: Our results suggest that NLP can be used to identify men with metastatic prostate cancer in the EMR more accurately than diagnosis codes alone. The automated identification of patients with metastatic cancer facilitates quality of care research in this setting to ensure the delivery of appropriate and high-quality care.
Supportive care plans: Harnessing technology and patient-reported outcomes to drive quality care across the cancer continuum.
Authors: Brant Jeannine , Stricker Carrie Tompkins , Jacobsen Paul B.
Published: February 2017

167

Background: Cancer care is increasingly complex. Clinicians lack time to stay current on evolving evidence and resources to implement quality standards. Health information technology solutions have proliferated, including electronic patient-reported outcome (ePRO) and care pathway technologies, but adoption has been slow. The goal of this study is to explore feasibility, usability, and acceptability of incorporating a novel supportive care planning technology into clinic workflow. The On Q Care Planning System (CPS) collects ePRO and clinical data to generate a personalized supportive care plan aligned with quality care standards and current evidence. Plans promote self-management and patient-provider communication. Methods: Prospective, multi-center pilot study at 2 NCI-affiliated centers (a comprehensive community cancer program [NCCCP] in the Western U.S., and a NCI-designated comprehensive cancer center [NCCC] in the Southeastern U.S.). 100 patients and their providers will participate; 50 women with gynecological cancers on chemotherapy; 50 women post-active treatment for breast cancer. Patients complete an ePRO assessment and are given an electronically generated, personalized supportive care plan by their providers during office visit(s) over a 3-month period. Study outcomes evaluated at baseline and 6 weeks include feasibility/usability of the platform (patient/provider, post-test only; surveys/platform statistics), patient satisfaction with care (pre/post-test; CG-CAHPS), and adherence to care plan recommendations (post-test survey). Results: To date, 10 patients have enrolled at the NCCCP and 7 completed baseline and 6 week measures; 5 at the NCCC have completed baseline measures. Four providers each at the NCCCP and the NCCC are scheduled for post-test assessments. Updated enrollment and results will be presented at the meeting. Conclusions: The On Q CPS is a novel supportive care planning technology developed to improve care processes and patient outcomes through the delivery of personalized electronic care plans. Feasibility, usability, acceptability, satisfaction and exploratory outcome data will be presented.
Measuring adherence to 2012 Choosing Wisely recommendations: SEER Registry linked with health plan data.
Authors: Kreizenbeck Karma L. , Fedorenko Catherine R. , Hughes Erin E. , Shoemaker Joshua , Lucas Oscar , Chauhan Rakesh T , Ramsey Scott David
Published: February 2017

178

Background: The ASCO Choosing Wisely campaign aims to reduce the use of interventions that lack evidence of benefit in cancer care. This project characterized adherence to the 2012 ASCO Choosing WiselyRecommendations by linking health plan claims data to a regional cancer registry in order to identify areas for research interventions to improve adherence. Methods: Surveillance, Epidemiology, and End Results (SEER) records for patients diagnosed with cancer in Western Washington state between 2007 and 2013 were linked with enrollment and claims from a large regional commercial insurance plan. Using claims and SEER records, algorithms were developed to characterize each Choosing Wisely measure. Results: For the 5 recommendations measured, adherence rates were as follows: (see Table). Conclusions: Using algorithms involving insurance claims and cancer registry records, we found variable adherence to the 2012 ASCO Choosing Wisely recommendations. While 100% adherence is not expected due to limitations of claims data, such records may be useful to identify areas for intervention and estimating potential savings from improved adherence. [Table: see text]
NCI Community Cancer Centers Program (NCCCP): Percent improvement in guideline-concordant breast and colon cancer care for disparate patient populations.
Authors: Spain Pamela , Teixeira-Poit Stephanie , Halpern Michael T. , Castro Kathleen M. , Prabhu Das Irene , Clauser Steven
Published: February 2017

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Background: The NCI Community Cancer Center Program (NCCCP) pilot launched in 2007 to improve quality and reduce disparities in patients receiving care in community hospital-based cancer centers. This study assessed the percent improvement in guideline-concordant cancer care since NCCCP initiation, overall and for disparate patient populations. Methods: We conducted a retrospective analysis of patients diagnosed and receiving treatment at one of 12 NCCCP sites. We compared percent improvement in concordance for NQF-approved quality measures: 3 breast (BCS-radiation following breast conserving surgery; HT-hormonal therapy; and MAC-multi-agent chemotherapy) and 2 colon (12RLN-12 regional lymph nodes examined during surgery; and ACT-adjuvant chemotherapy). Sample included patients diagnosed 2006 to 2007 (baseline, or pre-NCCCP) and 2008 to 2013 (NCCCP). Percent improvement was defined as the difference in concordance between baseline and NCCCP periods divided by baseline concordance. Results: Between baseline and NCCCP periods, improvement was noted for all 5 measures. The HT concordance rate improved by 55.1% (from 58.2% to 90.3%). For all breast measures, Black patients showed significantly larger than average percent improvement (p<.05). For BCS and ACT, Medicaid and uninsured patients showed significantly larger than average percent improvement (p<.05). Larger than average improvement was also noted in hospitals in high-poverty markets and in markets with few physicians. Conclusions: The percent of patients receiving guideline concordant breast or colon cancer care increased significantly since Program initiation, particularly among certain disparate patient subgroups. Future analyses will examine issues of disparities in timeliness of treatment.Funded by NCI Contract HHSN261200800001E. [Table: see text]
Equity of access: Consent interpretation program at Princess Margaret Cancer Centre (PM) in Canada.
Authors: Grant Jasmine , Philip Lindsay , Eagan Grace , Abraham Elizabeth , Degendorfer Pamela , Oza Amit M.
Published: February 2017

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Background: Toronto is a multicultural city with over 160 languages spoken by patients. Since 2010, institutional policy requires that professional medical interpreters are used when obtaining informed consent from patients with limited English proficiency (LEP). The availability and cost of these interpreters can be a deterrent for clinical trial participation, particularly when funding is limited. In order to ensure that patients facing language barriers have equitable access to trials, to protect the rights and safety of LEP patients involved in trials, and to improve patient outcomes, adherence to this policy needs to be ensured. Methods: Through a collaboration with the PM Cancer Clinical Research Unit (CCRU) and Interpretation and Translation Services (ITS) supported by the Princess Margaret Cancer Foundation, a 6-month pilot was initiated with full access to interpretation services for all trial patients in November 2012. The CCRU provided training to interpreters on clinical trials and GCP and interpreters reviewed template consent forms provided by ethics boards to cut back on preparation time and costs when delivering a sight translation of study specific consent forms. Trials staff were trained on the process and given badge tags with instructions. Metrics were collected to monitor the use of professional interpreters. Results: Utilization of professional interpreters in trials increased by 16% during the 6-month pilot and 286 requests have been logged to date. Staff were surveyed and indicate this has streamlined the consent process with 83% of respondents saying the new process is easy/very easy. Care providers feel this has allowed them to approach more patients than before this project. Conclusions: This project ensures that accurate information is provided to all patients contemplating participating in or already enrolled in trials, that all patients have the same level of access to treatment, and that there is equity of access for all patients irrespective of their English proficiency. The increased use of professional interpreters in consent discussions indicates better adherence to policy which has allowed the pilot to continue for another year.
The Morbidity and Mortality Conference (MMC) in Oncology: A patient safety and root cause analysis (RCA)-driven approach at the Cleveland Clinic Taussig Cancer Institute (TCI).
Authors: Goodman Lindsey Martin , Moeller Machelle , Guthrie Amy E. , Earl Marc A. , Pennell Nathan A. , Gilligan Timothy D. , Stevenson James
Published: February 2017

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Background: MMC has been traditionally viewed as an educational tool. However, negative associations with MMC include emphasis on individual error and assigning blame, with little attention to improving patient safety and quality of care. MMC at the TCI has been designed to provide an opportunity to discuss MMC cases in an open, non-judgmental setting. Methods: Since September 2013, a monthly MMC, open to all caregivers, not just physicians, has been held as part of CME certified oncology grand rounds. Two cases are discussed per session and are obtained from nursing, pharmacy, and physician recommendation through the hospital Safety Event Reporting System or direct communication. Fellows investigate and present cases with patient and provider information de-identified to assure the discussion occurs in a blame-free setting. RCA is performed to determine action items. Process and safety improvements are recommended where applicable. Ongoing follow-up and improvement tracking is reported at future MMCs. The MMC governance committee, composed of the TCI quality officer, quality director, fellow representative, and a multi-disciplinary group of providers, meets quarterly to review cases and follow up action items under the guidance of the TCI MMC charter. The MMC governance committee reports to the TCI Quality Steering Committee. Results: Cases reviewed to date include chemotherapy dosing/administration errors (23%), hospital acquired medical complications (31%), communication breakdown between caregivers (15%), and end of life care (31%). An average of 3.5 action items has resulted from each case with 75% addressed within 90 days. Physician attendance is 59% higher and 23% more physicians report that they are very likely to change their practice behaviors from MMC than other grand rounds presentations. Conclusions: A patient safety driven MMC, delivered in an open setting, can be an effective tool to improve quality of care and caregiver communication in a large academic cancer center. High provider attendance and survey feedback reflects engagement in the process and will be essential to sustaining a meaningful and productive MMC.
Examining health beliefs: Why mastectomies are on the rise.
Authors: Covelli Andrea Marie , Baxter Nancy N. , Fitch Margaret , Wright Frances Catriona
Published: February 2017

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Background: Rates of unilateral (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. To understand this increase we sought the perspectives of patients who chose UM+/-CPM and treating surgeons. Methods: Applying the Health-Belief Model, we completed a qualitative study examining the surgeon’s practice and patient’s decision-making that resulted in the choice for mastectomy. Purposive sampling identified women across Toronto, Canada who were candidates for breast conserving therapy (BCT) but underwent UM+/-CPM. Academic and community breast surgeons from across Ontario, Canada and the United States were also recruited. Data were collected through semi-structured interviews, this continued until data saturation was reached. Constant comparative analysis identified key ideas. Results: 29 patients and 45 surgeons completed interviews. The dominant theme was a ‘misperceived threat’. Despite surgeons describing the high survivability of ESBC, patients greatly overestimated the threat of ESBC and strived to eliminate this threat by choosing mastectomy. Surgeons described BCT and UM as equivalent treatment options for ESBC, and often recommended BCT. In this average-risk population CPM was discouraged by the surgeons describing no survival advantage; despite this, women requested UM+CPM. Personal cancer experiences with family and friends were extremely influential in women’s request for UM+/-CPM. Previous negative experiences translated into an overestimated risk of recurrence, contralateral cancer, metastasisand subsequent death. Despite evidence-based consultations, patients misperceived the risks and severity of ESBC, and believed that by choosing UM+/-CPM they would live longer. Most women did not perceive any risks of undergoing mastectomy, yet many had ongoing issues with disturbed skin sensation, cosmesis and body image. Conclusions: A previous cancer experience was influential in the choice for UM+CPM. Despite surgeons counseling otherwise, women greatly overestimated the risk of ESBC and misperceived the benefits of mastectomy. Improved discussion of patient sources of information and fears around survival would benefit surgical consultations.