bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcome of wire localized lumpectomies for nonpalpable breast lesion following neoadjuvant chemotherapy.
Authors: Khan Samreen umer , Zaidi Syed Adil Asif , Feroza Zoona , Fiaz Sohaib adil , Khan Huma Majeed , Chaudhary Mohammad Zulqarnain , Khan Amina Iqbal
Published: February 2017

96

Background: Wire localized lumpectomies for non-palpable breast lesions is not yet a widespread practice in Pakistan. Shaukat Khanum Memorial Hospital is one of the few centers practicing this technique. It remains an effective and cost efficient procedure .The aim of this study is to evaluate wire-guided localization for nonpalpable breast cancer following neoadjuvant chemotherapy focusing on post-operative outcome and survival rate. Methods: It is retrospective analysis of consecutive series of patients treated at SKMH with BCS after wire localization for nonpalpable breast cancer following neoadjuvant chemotherapy from August 2005 to December 2011.The records were reviewed for patient, radiological, histological and surgical characteristics. The tumor volume analysis was calculated according to the Krekel et al method. Data was analyzed using SPSS (Version 19). Kaplan Meier curves were used to conduct survival analysis with respect to stage at presentation and pathological response to therapy. Results: A total of 195 patients were reviewed. The rate of positive margins; taken as less than 2mm, following initial BCT was 9.7%. Out of the 19 patients with positive margins 13 had re-excision of margins and 2 had completion surgery. One patient refused completion surgery. The rate of local recurrence was 6.6% and distal recurrence 17.9%.Out of 49 patients with recurrence 6 patients (12.24%) had both loco-regional and distal recurrence. The median resection ratio was 16.39. The median survival was 44 months (SD 17.162). There was a significant survival benefit (p = 0.03) in patients presenting at an early clinical stage whereas some clinic yet statistically non-significant survival advantage in patients undergoing surgery following complete radiological response after chemotherapy. Conclusions: Wire localized lumpectomies in post neoadjuvant chemotherapy patients at our institution has a low recurrence rate and an internationally acceptable re-excision rate. The size of the specimen can be optimized further. Early detection and management remains the mainstay of treatment for breast cancer. Patient education and screening are goals that are yet to be achieved on the grand scale in Pakistan.
Assessment for residual nodal disease after neoadjuvant chemotherapy with image-guided surgery.
Authors: Caudle Abigail Suzanne , Yang Wei Tse , Mittendorf Elizabeth Ann , Black Dalliah MaShon , Gilcrease Michael , Bedrosian Isabelle , Hobbs Brian P , Candelaria Rosalind P , Babiera Gildy , Dogan Basak , Santiago Lumarie , Hunt Kelly , Krishnamurthy Savitri , Kuerer Henry Mark
Published: February 2017

99

Background: Staging of breast cancer patients is enhanced by axillary ultrasound (US) and needle biopsy of abnormal lymph nodes (LN). When clips are placed in sampled metastatic LNs, they can be evaluated for nodal response to neoadjuvant chemotherapy (NCT). The goals of this study were to determine if pathologic changes in clipped LNs reflect nodal response to NCT and if targeted axillary dissection (TAD), which includes sentinel lymph node dissection (SLND) in addition to selective localization and removal of clipped LNs, could increase the accuracy of nodal assessment. Methods: This prospective study included patients with US-identified axillary metastases confirmed by needle biopsy with a clip placed in the sampled LN. After NCT, patients underwent axillary lymphadenectomy (ALND) with x-ray of the axillary contents to identify the clip-containing LN. In 38 patients, the clipped LN was selectively removed using wire (n=2) or I125seed localization (n=36) before ALND was performed. Five patients did not undergo ALND. The pathologic findings of the clipped LN were reported separately from the other nodes. Results: Ninety node positive patients were enrolled. Forty (44%) had a complete nodal response to NCT and 50 (56%) had residual disease. Pathologic evaluation of the clipped LN revealed metastases in 47/50 patients with residual disease, resulting in a false negative rate (FNR) of 6% (95% CI 1.3-16.6). In 52 patients who underwent SLND, the clipped LN was not a SLN in 23% (n=12). Thirty-one of these patients had residual disease; metastases were not seen in SLNs in 5 cases resulting in a FNR for SLND alone of 16% (95% CI 5.4-34). Evaluation of the clipped LN in addition to SLND improved the FNR to 3% (1/31, 95% CI 0.1-17). Thirty-one patients underwent TAD while an additional 7 had localization and selective removal of the clipped LN without SLND with one false negative result. Conclusions: US-guided marking of LNs with documented metastatic disease allows for their selective removal and improved pathologic evaluation for residual nodal disease. The FNR of SLND can be reduced by ensuring removal and evaluation of the clipped LN. TAD is technically feasible and allows for improved assessment of nodal response after NCT.
Alleviating financial burden for cancer patients in clinical trials.
Authors: Nipp Ryan David , Powell Elizabeth , Finkelstein Daniel , Winkfield Karen Marie , Percac-Lima Sanja , Chabner Bruce Allan , Moy Beverly
Published: February 2017

10

Background: Financial barriers may prevent cancer patients from enrolling into clinical trials. This financial burden has yet to be fully explored. The goal of this study is to establish the feasibility of a financial assistance program for cancer patients enrolled in clinical trials and to analyze patient characteristics associated with financial aid requests. Methods: We performed a cross-sectional analysis of cancer clinical trial patients who registered for a financial assistance program at a tertiary cancer center. This program is designed to fund non-clinical expenses related to clinical trial participation (e.g. travel, lodging). Patients were referred to the program by their provider and enrolled if they expressed interest. After registration, applicants were required to request reimbursement monthly in order to receive funding. Descriptive statistics and univariate analyses compared characteristics of patients who requested funding vs. those who did not. Results: From November 2013 to April 2014, a total of 86 participants enrolled into the financial assistance program; 43 received funds and 43 did not. Most patients were <65 years old (73%), female (70%), white (86%), married (67%), and enrolled in a phase 1 trial (69%). Patients with lower incomes were more likely to request funds than those with incomes > $75,000 (61% vs. 38%, p=0.01). Patients currently employed were more likely to pursue funds than disabled or unemployed patients (58% vs. 21%, p<0.01). Out-of-state patients were more likely to ask for funds than in-state patients (64% vs.19%, p<0.01). Patients who requested funds were less likely to have disease progression after enrollment than those who did not request funds (19% vs. 42%, p=0.03). Conclusions: Enrolling clinical trial participants onto a financial assistance program is both feasible and informative. The patients who requested financial aid in our program were more likely to have lower incomes, remain employed, and reside out of state. Those who requested funding were less likely to have disease progression after program enrollment. Future efforts should continue to explore and improve interventions aimed to alleviate the financial burden experienced by cancer patients enrolled in clinical trials.
Assessment of single screening questions for dysphagia for routine clinical use in a tertiary care practice.
Authors: Brown Catherine , Vennettilli Ashlee , Patel Deval , Zeman Katherine Zora , Lau Anthea , Kuang Qin , Boyd Kevin , Cella David , Mackay Helen , Darling Gail Elizabeth , Wong Rebecca , Xu Wei , Liu Geoffrey , Howell Doris
Published: February 2017

102

Background: Dysphagia is a common symptom among esophageal cancer patients. However, there is neither a validated PROMIS tool nor a validated PRO-CTCAE tool for this symptom. Clinically, obtaining patient-reported data on this symptom systematically in specific disease sites is important, but keeping the patient survey burden low means that this may be best done using a screening question first. The goal of this study was to assess the performance of such a screening question when compared to a more standard tool for measuring dysphagia, FACT-E, in a esophageal cancer outpatient clinic setting. Methods: Adult esophageal cancer patients seen at the Princess Margaret Cancer Centre between 2012-2014 were all seen by a multidisciplinary practice. Patients completed the FACT-E and screening symptom surveys at regular timepoints. The time point where the most severe set of symptoms was present for each patient was analyzed and severity of symptoms was compared against two 5-level screeners ("How are you currently eating?" (screener 1) and "I can swallow naturally and easily" (screener 2). Prevalence of symptoms, sensitivity (Se) and specificity (Sp) of the screeners was assessed. Complete data was available and analyzed in 173 (87%) of 199 patients. Results: Mean age (range) was 64 (23-89) and 75% were male. Prevalence of moderate to severe difficulty swallowing solid, soft, liquid foods and choking was 31%, 10%, 7%, 4% respectively. 34% of patients experienced at least one moderate to severe symptom of dysphagia. Screener 1 had a Se of 84% and Sp of 79% when using any moderate or severe swallowing problem as the reference. The Se and Sp of screener 2 was 51% and 87%, respectively. Conclusions: Up to a third of esophageal cancer patients experience moderate to severe symptoms of dysphagia. Screener 1 had the better performance as a screening tool. High completion rates in this practice suggest that routine systematic collection of such data is feasible, and perceived to be important to patients. Practice level projects can improve the quality of measuring symptoms. In the future we will be testing the role of mobile and computer technology for the routine collection of dysphagia and other symptoms in this practice setting.
Value of phase II pathway in the ambulatory care setting.
Authors: Schaub Diane , Rebello Elizabeth
Published: February 2017

115

Background: The aim of the project was to decrease PACU (Post Anesthesia Care Unit) time by implementing a Phase II pathway for patients undergoing port-a-cath placement under Monitored Anesthesia Care in the Ambulatory Setting. Methods: The process improvement interventions were centered on eliminating unnecessary patient care processes and increasing patient flow and consisted of: patient and healthcare provider education, phase II unit utilizing existing bed space, revised charting template in the PACU. Queries of our AIMS database for port-a-cath cases performed between January 1, 2012 and February 28, 2013 (pre-intervention) and then between May 1, 2013 and May31, 2014 (post-intervention) were obtained. March 1, 2013 to May 1, 2013 was a transition period used to implement the process. Only cases performed under monitored anesthesia care were included. Cases with a PACU length of stay greater than 200 minutes were excluded from the study as these patients were no longer fast track. Descriptive statistics were used to summarize PACU length of stay pre/post-intervention. Scatter plots were used to show the variability in PACU length of stay and to illustrate the average trajectory of PACU length of stay over each time frame. A t-test was used to compare the average length of stay in the PACU, pre/post-intervention. Results: There were 917 pre-intervention cases and 362 post intervention cases. Trend of minutes spent in the PACU over time is illustrated (Figure 1). The average number of minutes in the PACU during the pre-intervention was 86.8. During the post-intervention, it was 67 minutes (Difference = 19.6 minutes; p-value < 0.001). Conclusions: As a result of implementing a phase II pathway for patients undergoing port-a-cath placement, there was a significant decrease in average time spent in the PACU. In addition, there was a decrease in the variation associated with PACU length of stay. The phase II pathway allowed a significant subgroup of this patient population to be less sedated after surgery and proceed directly to chemotherapy or their next scheduled appointment in the institution. Time and cost savings to the patient and the institution were additional benefits.
Construct a computer simulation model to replicate CT operations for decreasing delayed procedure starts.
Authors: Iyer Ranganath K. , Steele Joseph Rodgers , Tannir Habib , Venable Steve
Published: February 2017

132

Background: Patients scheduled to undergo computed tomography (CT) should be treated expeditiously and not delayed owing to a lack of either CT scanner capacity or available staff. Delayed scanning affects both patients and staff in several ways. First, patients are unhappy that they have to wait. Also, delayed scanning makes patient late for their next appointments or other events, which affects the downstream departments’ capability to operate effectively and efficiently. In addition, radiologists and their staff have to commit additional time and resources to processing patients on time. Finally, variability in the placement of patients reduces the scanner’s operating efficiency. The aim of this initiative is to optimize the appointment template using simulation software to reduce the rate of delayed CT procedures by 25% or more by the end of 2014. Methods: To further understand the CT queuing process, we hired 2 graduate students to create a simulation model using the data collected from the operations study. The simulation study modeled patients’ experience from their arrival to discharge and the steps were: (a) performed elemental analysis for each process; (b) cceated value stream map; (c) created high-level simulation model and “mini model” using operational data. The simulation models were presented to department leaders, who approved them. The models clearly showed that the time patients spent on the CT scanner was the bottleneck. Results: Changes in the CT area that have impacted on-time starts and average wait time include: (a) new fast-track for no interview patients and (b) changes in staffing hours. Progress and improvement include (a.) On-time delays decreased by 18% and (b.) a verage wait decreased by 8 minutes (19%). Conclusions: Discrete event simulation accounts for the probabilities and uncertainties associated with the processes and helps create a visual model of the work area. This adds confidence to decision makers’ ability to make decisions that have high impact. Also, the models can be used to test changes in the processes and study the impact on other processes without making true operational changes that could potentially waste resources and time.
Measuring baseline adherence to Choosing Wiselyrecommendations in regional oncology clinics: Challenges and strategies.
Authors: Kreizenbeck Karma L. , Hughes Erin E. , Egan Kathryn , Fedorenko Catherine R. , Mohedano Ada , Greer Benjamin E. , Demers Linette , Stewart F. Marc , Berkes Ken , Jafari Mehrdad , Jensen Barbara , Bredeson Chris , Rieke John , Smith Julie C. , Gunkel Mary , Guerrero Rose , Carlos Timothy , Ramsey Scott David
Published: February 2017

133

Background: ASCO launched the Choosing Wisely campaign to reduce the use of interventions lacking evidence of benefit to cancer patients, but implementation may be a challenge. This project develops a stakeholder-informed process to prioritize and implement the 2012 ASCO Choosing Wisely (CW) recommendations in oncology clinic settings. Methods: Medical directors from 6 network-affiliated oncology clinics in the Puget Sound region selected 2 CW measures for implementation: (1) No biomarkers/advanced imaging following early breast cancer treated for cure, and; (2) No colony stimulating factor use for low FN risk chemotherapy. Results: Adherence is measured with data from each clinic’s tumor registry, billing records, lab results, pathology reports, and clinic notes. Challenges to measuring baseline adherence included translating non-specific guidelines into discrete data elements (e.g. when does surveillance start?) or required measuring the absence of something, presenting quality control challenges to distinguish between adherence and missing data. Additional challenges are shown in the Table. To address these challenges, the team developed these strategies: (1) creation of specific data elements, (2) mapping clinics separately to the criteria and (3) employing methods such as Natural Language Processing to efficiently collect data from EMR. Conclusions: It is feasible to measure adherence to ASCO CW recommendations with data sources available at oncology clinics. Variability in data platforms among clinics is inherent to the current medical landscape and must be accounted for in successful implementation of cross-clinic programs. [Table: see text]
A fall prevention and detection project: Preliminary results.
Authors: De Marino Elvira , Chesta Cristina , Rugge Elisabetta , Ferrari Paola , Posca Teresa , Lattuada Sara , Torazzo Renata , Rossetti Sabrina , Di Cola Alessandra
Published: February 2017

142

Background: Falls often causes serious injury to cancer patients (PTS) and hospital costs account for two thirds of the total. Fall prevention and detection (FAPRE) project was planned to develop a new technology in three steps: first to identify potential high risk fallers (HRF) by Timed Up and Go (TUG) test; second to compare TUG with Conley Scale and third to hospitalize HRF in monitoring room equipped with a network of smart sensors that can identify person’s location, fall or lack of balance and posture connected by smartphone alerting watch nurse. Aim of this study is to describe general characteristic of HRF by TUG and to determine how new test instruments can identify them. Methods: A nurse performed TUG in ambulatory room equipped with pressure sensors on the floor (intelligent carpet), webcam, home gateway, WI-FI router and smartphone. PTS were required to sign informed consent. HRF were identified by TUG test >12 seconds. Results: From January to March a series of 99 consecutive PTS enter the trial, performance status ECOG < 2, age: median 73, range 34-87, 50 males and 49 females. All PTS underwent TUG and were evaluable. There were 11 hematologic (H) and 88 solid tumors (ST); 45/88 ST had metastatic disease; 97/99 were treating by chemotherapy, 2 by palliative care. Six PTS had brain metastasis and 9 bone; 33/99 had previous pathological fractures. Comorbidity: 14/99 diabetes and 33/99 hypertension 10/99 were taking psychoactive drugs, 22 were treated with opiate and 5 both. HRF identified by TUG were 44%; there were 27% H, 46% ST and 75% were older then 70 years. Previous pathological fracture in long bone were 14/33; bone metastasis (BM) 7/9; brain metastasis 3/6. HRF taking only psychoactive drugs were 5//10 and 17/22 opiate; 5/5 both. Conclusions: TUG detected HFR more frequently in ST, elderly with BM and previous long bone fractures treating by opiate and hypertension. Identify HRF by new integrated room automation FAPRE infrastructure seems a simple, reliable and manageable approach at preliminary data. Trial is ongoing and carrying on next step.
Do hospitals in a large metropolitan area utilize published breast cancer care practices and guidelines?
Authors: Tossas-Milligan Katherine Y. , Weldon Christine B. , Trosman Julia Rachel , Simon Melissa A. , Roggenkamp Betty , Gradishar William J. , Ansell David , Murphy Anne Marie
Published: February 2017

151

Background: Insufficient utilization of guideline and evidence based care practices contribute to the cancer crisis (IOM 2013). We examined utilization of published breast cancer (BC) care practices and guidelines at hospitals in a large metropolitan area. Methods: IRB approved web survey of all 35 hospitals in a large metro area that provide BC treatment. Using guidelines/recommendations (NCCN, NAPBC, ADA, IOM) and peer-reviewed literature (62 studies) we developed a survey on BC care practices. Results analyzed by simple frequencies and Fisher's exact test. Results: Response rate: 91% (32/35 sites). Care practices, included in the table, are utilized by < 50% of sites. Radiation oncologist preoperative consults (53%, 8/15) and offering indicated pre-operative chemo* (67%, 10/15) are associated with 15 sites that have high volume (67+/year, Chen CS 2008) BC surgeons, compared to 17 sites without high volume BC surgeons (12%, 2/17) and (24%, 4/17) respectively, p=0.02, p=0.03. Indicated supportive services, such as a dental checkups (ADA 2008), are more likely at sites with patient-centered written treatment plans (IOM 2011) (58%, 7/12) than at sites without written treatment plans (10%, 2/20), p=0.006. Conclusions: Low utilization of published care practices and guidelines is concerning and requires attention. Other metro areas and regions should be examined as our findings indicate that patients may have limited local choices of care that is up-to-date on published guidelines and practices. [Table: see text]
Improving quality of care by obtaining patient-reported outcomes (PRO)-CTCAE chemotoxicities using tablet technology in daycare (DC) waiting rooms.
Authors: Wang Tian Qi , Brown Catherine , Vennettilli Ashlee , Wong Lauren , Zarrin Aein , Dobriyal Aditi , Chen Linda , Pat Vivien , Ho Anthea , Ho Valerie , Xin Cindy , Solomon Hannah , Irwin Margaret , Gonos Christina , Merali Zahra , Xu Wei , Howell Doris , Liu Geoffrey
Published: February 2017

165

Background: In a busy chemo DC, any efficient means of tracking important chemotoxicities can improve quality of care. The study goal was to evaluate whether tablet technology available in a DC waiting room is able to capture prevalent and severe toxicities associated with chemotherapy using the patient reported outcome (PRO) - common toxicity criteria for adverse events (CTCAE). Methods: This cross-sectional PRO-CTCAE study of 160 adult solid/hematologic cancer outpatients of all stages, who were undergoing chemotherapy (CT), focused on common chemotoxicities captured using touchscreen tablets in the DC waiting room of Princess Margaret Cancer Centre (Toronto, CA). Individual health scores from the EQ-5D VAS tool and the prevalence of AEs experienced by cancer patients within the past seven days were captured. Symptoms that were listed as moderate to very severe were considered significant. Results: Across a wide range of tumours and patients on intravenous CT, the median age (range) was 56 (19-88) years; 38% were males.Patients reported a median (range) health score (100 = best health possible, 0 = worst) of 70 (4-100). The severity offiveprevalent, key side-effects of CT were tabulated (Table). 59% of patients felt their fatigue interfered significantly with their daily activities, and 30% felt decreased appetite interfered significantly. 32% experienced nausea occasionally to almost constantly. Conclusions: The common symptoms of CT were captured FEASIBLY, and found to be highly prevalent in this CT-treated population. Capturing additional symptom prevalence outside of the 7-day time frame may be important from a clinical standpoint. Administration of PRO-CTCAE instrument through tablet technology may be an excellent method to help collect such data systematically and reliably. Updated data on 300 patients will be presented at the meeting. [Table: see text]
Primary care provider (PCP) views on survivorship care plans (SCPs) generated by an electronic health record (EHR).
Authors: Tevaarwerk Amye , Donohue SarahMaria Hill , Buhr Kevin A , Hahn David , Sun Wenjun , Terhaar Abigail , Wiegmann Douglas , Sesto Mary E
Published: February 2017

168

Background: SCPs may address inadequate provider-to-provider communication but PCP views regarding EHR-generated SCPs have not been assessed. A multiple choice survey was used to evaluate an EHR-generated SCP for appropriate content, length, perceived accuracy, need for updates and preferred method of delivery (the Clinican survEy of Care Plan [ChECkuP]). Methods: PCPs were recruited from the Wisconsin Research and Education Network (WREN), a cohort of family practitioners working in urban and rural Wisconsin. WREN practitioners were e-mailed and invited to participate if they currently saw patients with a breast cancer history. PCPs were provided a sample 10-page EHR-generated SCP and completed the ChECkuP at one time point. Results: 36 PCPs participated in Summer 2014. Most PCPs reported the sample EHR-generated SCP as accurate (75%), easy to use (58%) and useful in coordinating care (75%). Few felt using SCPs would disrupt their clinic workflow (11%) or that SCP use would take too much time (14%). Most (75%) preferred receiving SCPs via EHR, vs paper (36%), having the patient provide (19%) or viewing the SCP on an external website (6%). Most deemed consistent provision (69%) and standard location (78%) important. With regards to timing, 42% reported desiring an SCP immediately after completion of primary treatment. However, PCPs requested some changes: 33% requested a shorter SCP (ideally 1-3 pages) and 53% advocated for SCPs specifically written for PCPs rather than producing one document for both PCP and survivor. Also, most (53%) felt that SCPs should be updated based on information changes rather than on a regular schedule, including changes to screening guidelines (100%), late or long term side effects (89%) and followup recommendations (95%). Conclusions: PCPs regarded EHR-generated SCPs as useful in coordinating care between oncologists and primary care. PCPs desired a standardized SCP accessible within the EHR. EHR-generated SCP content, length and layout will be revised based on the feedback provided. Clinical trial information: OS12122.
Can we accurately identify chemotherapy-related acute care visits in administrative data?
Authors: Krzyzanowska Monika K. , Enright Katherine , Moineddin Rahim , Yun Lingsong , Ghannam Mohammed , Grunfeld Eva
Published: February 2017

185

Background: Administrative data is increasingly being used to study treatment related complications that lead to acute care visits such as emergency department visits or hospitalizations (ED+H). We evaluated the accuracy of diagnosis codes for identifying chemotherapy related acute care visits (CRVs) among women with breast cancer. Methods: We prospectively developed algorithms to identify CRVs from administrative data in women receiving adjuvant chemotherapy for breast cancer in Ontario, Canada. Sensitivity (SN) and specificity (SP) were calculated for 3 scenarios: chemotherapy related ED visit, chemotherapy related H, and febrile neutropenia (FN) related visit using the chart as the gold standard. Since there is no specific diagnosis code for FN, three definitions of FN were considered: general (defined as fever or infection or neutropenia as main reason for visit), moderate (neutropenia as main reason for visit) or strict (fever or infection plus neutropenia). The population based cohort was generated by linking several health databases to identify women who had at least one ED+H during adjuvant chemotherapy for breast cancer between 2007-2009. The validation cohort consisted of 490 randomly selected cases from this cohort. Results: The population-based cohort consisted of 8,359 patients of whom 43.4% had at least one ED+H including 1,496 women who had multiple visits resulting in 6,293 unique ED+H. Of these, 73.1% were considered CRVs based on our algorithm. The algorithm performed well in identifying CRVs that included an H either from ED (SN 90%, SP 100%) or directly from home (SN 91%, SP 93%) but less well for ED visits that did not result in H (SN 65%, SP 80%). Depending on which FN algorithm was used, 1.4-24% of visits were considered FN related. The general FN algorithm had excellent SN regardless of whether the visit involved H (94-98%) but SP was moderate (66-80%). The strict FN algorithm had good SP (78-99%) but SN was highly variable (13-89%). The moderate FN algorithm provided the best tradeoff between SN (69-97%) and SP (76-98%). Conclusions: CRVs can be identified from administrative data with reasonable confidence, obviating the need for chart abstraction to evaluate chemotherapy related serious events.
Impact of care at NCI Comprehensive Cancer Centers (NCICCC) on cancer outcome: Results from a population-based study.
Authors: Wolfson Julie Anna , Sun Can-Lan , Kang Tongjun , Wyatt Laura , Hurria Arti , Bhatia Smita
Published: February 2017

188

Background: Despite advances in therapy and supportive care, prognosis for certain cancers remains poor. Rigorous processes ensure quality of research, clinical care and education at NCICCC. However, impact of site of care on survival and access to NCICCC for vulnerable subpopulations (race/ethnicity, payor) remains unstudied. Methods: We constructed a population-based cohort of 53,618 patients diagnosed between 22y-65y with adult-onset cancers and reported to LA County cancer registry between 1998-2008. Geographic Information Systems (ArcGIS) was used for geospatial analysis. Results: Across multiple diagnoses, patients at NCICCC showed superior 5y overall survival (OS) as compared to those at community sites (Breast [n=31,770]: 89% vs. 86%, p<0.01; Lung [n=10,855]: 28% vs. 17%, p<0.01; Hepatobiliary [n=4,296]: 34% vs. 19%, p<0.01; Gastric [n=2,678] 32% vs. 22%, p<0.01; Pancreas [n=2,326]: 13% vs. 6%, p<0.01; Oral [n=1,838]: 68% vs. 59%, p=0.01). Adjusting for clinical (age, stage, gender) and sociodemographic (race/ ethnicity, payor, socioeconomic status [SES]) characteristics, multivariable Cox regression revealed an increased risk of mortality in patients receiving care at non-NCICCC sites: Breast: hazard ratio (HR)=1.2, p<0.01; Lung: HR=1.5, p<0.01; Hepatobiliary: HR=1.4, p<0.01; Gastric: HR=1.4, p<0.01; Pancreas (n=2,326), HR=1.5, p<0.01; Oral: HR=1.3, p=0.05. Overall 7% of patients were seen at NCICCC (range 4-16%, p<0.01). Multivariable logistic regression adjusting for clinical characteristics revealed that low SES (OR range across diagnoses: 0.4-0.5, p<0.01), public (OR 0.4-0.9, p<0.03) or no (OR 0.1-0.7, p<0.04) insurance, African-American race (OR 0.4-0.6, p<0.03) or Hispanic ethnicity (OR 0.5-0.7, p<0.02), and residing > 9 miles from nearest NCICCC (OR 0.5-0.9, p<0.01) decreased likelihood of care at NCICCC. Conclusions: Population-based data reveal superior OS among adult-onset cancer patients receiving care at NCICCC. Patients without private insurance, from low SES, African-American and Hispanic backgrounds or living more than 9 miles from an NCICCC, are less likely to use NCICCC. Barriers to care at NCICCC are currently being explored.
Medicare Part D low-income subsidy and disparities in breast cancer treatment.
Authors: Biggers Alana , Neuner Joan , Smith Elizabeth , Charlson John A. , Pezzin Liliana , Laud Purushottam
Published: February 2017

2

Background: Breast cancer outcomes are worse among black than white women, but the role of income and out-of-pocket costs (OOPCs) in these disparities is understudied. The Medicare D program provided medication insurance for older women and also included a low-income subsidy (LIS) which eliminated or reduced OOPCs among women with low assets and limited income (based on federal poverty level). We examined differences in adherence to HT by race/ethnicity among a Medicare D population, hypothesizing that LIS might reduce racial disparities in HT adherence. Methods: With data collected from a national sample of women enrolled in Medicare Parts A, B, and D, we identified Medicare Part D enrollees ≥65 years diagnosed with breast cancer who underwent mastectomy or breast conserving surgery in 2006-07 and received either tamoxifen or an AI (anastrozole, letrozole, or exemestane) within one year of surgery. Nonadherence rates (medication possession rate of >0.80) were calculated by race and LIS status for each year after first fill up through December 2011. The association of race with HT adherence was examined in unadjusted Chi-square analyses and in regression models adjusted for age, comorbidity, chemotherapy use, and zip code level- income and education. All models utilized GEE to account for within-patient clustering. Results: Among a sample of 23,299 women (50.6% age 65-74, 40.9% age 75-84), 27.2% received LIS. LIS (but not AI use) varied substantially by race, so that 20.6% of white women and 69.7% of black women received the subsidy. In the first year of therapy, differences in adherence by race were statistically significant, but small (64.2% for white, 63.2% for black and 66.7% for Hispanic). Adherence dropped during years 2-3 of the study, but reductions were much smaller among LIS recipients. Results were confirmed in adjusted models. Conclusions: Enrollment in the Medicare D LIS was high among black and Hispanic breast cancer patients, and disparities in adherence to breast cancer HT among these women were small and remained so over three years. Our study offers important information about the role of medication subsidies and SES in adherence, and suggests their potential to reduce the breast cancer outcomes gap by race.
The role of nursing in obtaining a three-generation familial cancer history intake tool (FCHT) and the care of patients with hereditary gastrointestinal syndromes.
Authors: Fontes-Borts Lucia , Safran Howard , Perez Kimberly
Published: February 2017

216

Background: Of patients diagnosed with colorectal cancer, 5-10% of all cancers are associated with hereditary cancer syndromes. Since hereditary gastrointestinal cancer syndromes convey a markedly increased risk for developing cancer, identification of affected families is important. Studies have found that clinicians are unlikely to adequately or routinely collect family history information on their patients. This study assessed the implementation of a validated three-generation family history intake tool by an advanced practiced nurse practitioner (APNP) and the impact on clinical practice at a mid-size academic affiliated Medical Oncology practice. Methods: From September 2013 to January 2014, 100 patients with the diagnosis of colorectal cancer were assessed after a clinic session with a physician by an APNP. The APNP utilized a validated 3 - generation family history tool. Information regarding age, sex, education, annual income, family ethnicity, diet, exercise and previous genetic testing was also collected. Data collected was then analyzed to assess risk of hereditary syndrome. A chart review of the patients was performed to analyze microsatellite instability testing and prior genetic counseling referrals. Results: Of the 100 screened, 93 patients were evaluable. There were 52 males: 39 female participants with a median age of 60.71 years (range 28-90). The implementation of FCHT was associated with an increase in identification of individuals at risk; 16 (17.2%) patients reported a diagnosis of CRC at age less than 50. The rate of referrals for genetic evaluation tripled after the implementation of the FCHT (6.5% to 16.3%). Of the 17 referred, five had been referred prior to implementation of the FCHT. Conclusions: Institution of a separate session with an APNP to assess family history resulted in a 3-fold increase in rates of detection of patients with high risk for hereditary cancer syndromes associated with colorectal cancer.This study demonstrates that APNP’s are well positioned to promote preventative health by engaging in family history intake and genetic assessment referral.
Quality and value-focused albumin-bound paclitaxel decision support for pancreatic, lung, and breast cancer in southeastern United States.
Authors: Baranwal Anmol , Hrushesky William J. , Huff Dinah Faith Q. , Shimp William S. , Mamgain Avinash , Fishman Marc L. , Bobolts Laura Rose , Schorer Anna E. , Kogler Jurgen , Davis Sharon , Armitage Melissa , Bennett Charles L.
Published: February 2017

246

Background: Albumin-bound paclitaxel is FDA approved as single agent for breast cancer, in combination with carboplatin for non-small cell lung cancer (NSCLC), and with gemcitabine for pancreatic cancer. Oncology Analytics (OA) is a cancer care decision support group comprised of board-certified oncologists, interacting with more than 2,800 cancer doctors in the Southeastern U.S. We have been making oncologists aware of comparative efficacy data, and the relative values of albumin-bound paclitaxel vs other taxanes. We hypothesized our work has impacted albumin-bound paclitaxel use in these diagnoses with improved cost effective care and value enhancement. Methods: We analyzed all albumin-bound paclitaxel requests for FDA approved indications from April 2013 to June 2014. Requests withdrawn by the treating oncologist after OA consultation were compared with albumin-bound paclitaxel persistence over these five consecutive quarters. Financial outcomes of voluntary oncologist withdrawal of albumin-bound paclitaxel-based therapy in favor of another taxane were calculated as per standard Medicare reimbursement rates. Results: Over the entire 15 month span, we received a total of 265 evaluable albumin-bound paclitaxel requests, on a total of 181 patients. Ninety-two percent (155/168) of requests for albumin-bound paclitaxel with gemcitabine in pancreatic cancer were automatically approved by Oncology Analytics’ web based software. One third each of the requests for breast cancer (12/37, 32.43%) and NSCLC (21/60, 35%) were withdrawn by the requesting MD after OA consultation. Changing albumin-bound paclitaxel to another taxane reduced pharmaceutical costs by approximately $1,124,115 for these 15 months, or $74,941.00 monthly. Conclusions: When paclitaxel or docetaxel are safe and effective alternatives to albumin-bound paclitaxel, OA consultation enhances cancer care quality and value.
Augmentation of cancer outcomes through safe transitions.
Authors: Hiremath Adarsh , Manzano Joanna-Grace , Halm Josiah , Farroni Jeff
Published: February 2017

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Background: Policymakers have identified 30-day readmissions as an important quality indicator of poor care or coordination of care. Among cancer centers, there is no benchmark data in terms of readmission rates or recommendations in terms of risk adjustment models. Methods: Retrospective data analysis to estimate baseline readmission rate and identify risk factors. Interventions: (1)admitting to single floor, (2) twice weekly interdisciplinary meetings with using risk assessment tool–Cancer Outcomes Augmented through Safe Transitions (COAST) tool, and (3) re-evaluate readmission rate post intervention at 6 months and 1 year. Results: Unplanned readmission rate on the Hospitalist Service at MD Anderson was 21.5% at baseline. After 6 months of interventions, our readmission rate over 6 months was 23.3%. Age 45-65, having Medicare insurance, and being discharged to hospice were protective of a readmission. Distant metastases and having more comorbidities were associated with increased risk for readmission. Readmitted patients have a greater length of stay (7 days) and a higher average cost of inpatient stay ($20.3K vs. 17.9K). The median days to readmission was 11 days. Top comorbidities: hypertension, fluid and electrolyte disorders, anemia, diabetes mellitus, and abnormal weight loss. Top reasons: metastatic disease, biliary tract disease, GI hemorrhage, intestinal obstruction, septicemia, renal failure. Conclusions: Our project has provided insight into the rates and risk factors for readmission in oncology hospitalist service in a tertiary cancer center. The development of web-based COAST risk assessment tool is expected to give an improved understanding of our patient population. Although our readmission rates have not shown decrease over the 6 months after our interventions, this means that more interventions and more time may be necessary to impact readmission rates of services dealing with complex cancer patients. Additionally, a proportion of these unplanned readmissions in cancer patients may not be preventable. Benchmark data we have presented and that we continue to collect will help inform recommendations for effective transitions of care, patient safety practices as well as strategies for reducing readmission rates in cancer centers.
Improving the safe delivery of systemic treatment by assessing concordance with labeling guidelines.
Authors: Vu Kathy , Simanovski Vicky , Kaizer Leonard , Green Esther , Hertz Sherrie , Rae Erin , Krzyzanowska Monika K. , Ahmad Noor
Published: February 2017

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Background: Improper labeling of medication may lead to errors. In 2009, Cancer Care Ontario published Key Components of Chemotherapy Labeling, with recommendations for the necessary components and formatting of intravenous chemotherapy labels. A jurisdiction-wide evaluation for concordance occurred in 2011. Results were shared, improvement efforts were supported through a provincial quality network, and a re-evaluation was conducted in the fall of 2013. Methods: Three defined chemotherapy labels were evaluated at baseline and after improvement strategies were implemented at each of Ontario’s 77 hospitals providing systemic treatment. Labels were reviewed centrally and awarded points for concordance for each of 15 guideline-specified criteria. Results: The provincial average overall score for concordance increased from 59% to 80% (p<0.001). Improvement was seen for 12 of the 15 criteria evaluated and for 64 of the 77 facilities. The greatest increase in overall score by a facility was 53.4%. The greatest overall improvement in score for an individual component was 67% (TALLman lettering). The scores of 2 components were unchanged, as 100% concordance was achieved on both the baseline and re-evaluation. Conclusions: Improvement in concordance to chemotherapy labeling guidelines was observed following the implementation of a measurement strategy and improvement plans. This approach is one component of a larger strategy to promote a culture of safety in chemotherapy delivery in Ontario. [Table: see text]
Assessing the validity of using claims data compared to medical chart reviews for measuring care quality in Japan.
Authors: Nakamoto Nana , Nakamura Fumiaki , Higashi Takahiro , Iwamoto Momoko , Amano Asuka , Hirayasu Masako , Higa Hatsue , Asato Kuniko , Aoki Kazuo , Masuda Masato
Published: February 2017

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Background: Health insurance claims data have been used extensively as a less labor-intensive method of collecting data than medical record reviews, which are the preferred source of data collection in most medical studies. Although recent reports have raised questions about its validity of use in measuring care quality, validity of using claims data may differ by health systems and should therefore be assessed by country. We aimed to test the validity of using claims data in Japan by comparing quality performance scores obtained from claims data to those derived from medical record reviews. Methods: We reviewed medical records from Apr 2013 to Apr 2014 of gastric and colorectal cancer patients who were diagnosed in 2011 from 4 cancer care hospitals in Okinawa. We calculated the proportion of patients who received adjuvant chemotherapy for gastric and colorectal cancer using claims data, and compared the results with those obtained from medical record reviews. Chart reviews were performed by certified tumor registrars. We used kappa coefficients to measure the level of agreement between claims data and medical record reviews. Results: Analysis using claims data resulted in 14 Stage II and III gastric cancer patients who had undergone surgery, with 50% receiving adjuvant chemotherapy; whereas medical record reviews resulted in 19 patients, 94.7% of whom either received or had a clinically valid rationale for not undergoing adjuvant therapy. For colorectal patients, claims data resulted in 48.5% of 68 surgical stage III colorectal patients receiving adjuvant therapy, compared to 74.4% of 78 patients using medical record reviews who either received adjuvant therapy or had a valid reason for not undergoing therapy. Agreement between claims data and chart reviews was low (kappa=0.14) for gastric cancer, but fair (kappa =0.37) for colorectal cancer. Conclusions: Our analysis showed that use of claims data may greatly underestimate quality performance measures if they are not compensated by medical record reviews. Claims data alone cannot capture a large proportion of patients who either choose not to, or has a clinically valid reason for not undergoing standard care.
Reporting on quality indicators in renal cell carcinoma: Proportion of metastatic patients who initially commence on full-dose targeted therapy.
Authors: Wood Lori , Heng Daniel Yick Chin , Knox Jennifer J. , Bjarnason Georg A. , Kollmannsberger Christian K. , Kapoor Anil , Hotte Sebastien J. , Vanhuyse Marie , Czaykowski Piotr , Soulieres Denis , Finelli Antonio , Liu Zhihui
Published: February 2017

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Background: Measuring quality of care is required to improve patient outcomes. There are 23 established Quality Indicators in Renal Cell Carcinoma (RCC) (Wood LA et al, JOP 2013) including initiating targeted therapy (TT) at full dose. It is recognized that the dose of TT is important to optimize clinical outcomes. Methods: The Canadian Kidney Cancer Information System (CKCis) is a prospectively maintained database of RCC pts from 14 Canadian academic centers. CKCis data was used to determine the use of TT in metastatic pts, the initial dose in the first line setting, and factors influencing whether pts initiated full dose TT. Descriptive statistics were performed to characterize current practices and a multivariate logistic regression was performed to assess predictors of initiating full dose TT. Results: Between 2006 and 2014, 560 pts received first-line TT and make up the study cohort. 92% received VEGF TT (81% sunitinib; 9% pazopanib; 2% sorafenib) and 8% received mTOR TT (5% everolimus; 3% temsirolimus). All pts receiving mTOR inhibitors received full dose and are excluded from further analysis. Full dose VEGF TT was initiated in 87% on sunitinib, 78% on pazopanib, and 92% on sorafenib. The sunitinib schedule was 4/2 in 81%, 2/1 in 12%, and other in 7%. Pts were less likely to initiate full dose TT if they were older (OR: 1.10, 95% CI 1.06-1.15), female (OR: 2.23, 95% CI 1.09-4.55) or had a worse ECOG PS (2,3,4 vs 0,1) (OR: 2.30, 95% CI 0.95-5.59). Data on initial versus final dose of TT will also be presented. Conclusions: Maximizing exposure to TT is important in metastatic RCC which is why initiating full dose TT was prioritized as a key QI in RCC. In this study, 87% of pts were initiated on full dose VEGF TT in the first line setting, and 100% of pts on mTOR TT which is higher than predicted. Those less likely to start on full dose VEGF TT were older, female and had a lower ECOG PS. The gender discrepancy will be explored in future studies.