bluuebunny/crossref_metadata_2025 huggingface dataset:
Upstaging of head and neck cancers due to extranodal extension: An Indian study.
Authors: Joseph Deepa M. , Raut Sagar , Pasricha Rajesh , Gupta Sweety
Published: May 2019

e17553

Background: Latest AJCC staging has included extranodal extension (ENE) in nodal staging of head and neck cancers (HNC) in view of its prognostic significance. Presence of clinical ENE makes the disease N3b and the stage grouping will be stage IVB. This retrospective analysis was done with an objective to find out the percentage of patients with HNC getting upstaged because of ENE and their treatment outcome. Methods: A retrospective analysis of all HNC patients registered in our department from January 2018 to January 2019 were done to identify the presence of ENE and their staging. AJCC criteria was used for defining clinical and radiological ENE. The site, subsite, stage and presence of ENE were documented. Results: A total of 562 patients were registered with HNC. Among them 40 patients were identified to have ENE (7.1%). There were 35 males and 5 females. There were 17 cases with ca oropharynx, 13 oral cavity, four hypopharynx, three supraglottis, two glottis, and one maxillary carcinoma. Tumour size varied from 1.5 cm to 8 cm with an average of 4.9cm. Majority of the patient had a T4a disease, with 18 patients in the category. T stage varied from T1 – 1, T2 – 7, T3 – 7, T4b – 6, missing data – 1. 33 patients had clinically documented ENE and six were radiological and one patient had pathological ENE. Nine had skin involvement and the rest (24) had either muscle invasion or soft tissue involvement. Various treatment approaches were tried. Two patients received neoadjuvant chemotherapy (NACT) followed by chemoradiation (CTRT). On treatment at present. One NACT followed by surgery and later CTRT. Developed recurrence. Four patients received palliative chemotherapy, but developed progressive disease (PD), on best supportive care (BSC). Nine patients received palliative radiotherapy, six patients are on treatment and one had PD. Five patients received radical CTRT, 5 on treatment and one had PD. One received palliative RT followed by palliative chemo, but developed PD. 13 patients are on treatment and rest of the patients are either dead, lost to follow up or on BSC. Conclusions: Majority of the patients with ENE had a T4a disease. No special site predilection was identified. Various treatment modalities tried but none of them produced any significant difference in outcome. In conclusion, patients with ENE had a poor prognosis irrespective of the treatment modality selected.
Changes in the proportion of squamous cell carcinoma in head and neck cancer in the United States and Canada, 1995-2015.
Authors: Gaubatz Matthew , Bukatko Aleksandr R , Polednik Katherine M. , Simpson Matthew C , Adjei Boakye Eric , Mohammed Kahee A , Osazuwa-Peters Nosayaba
Published: May 2019

e17554

Background: There has been a shift in the epidemiologic landscape of head and neck cancer (HNC) with decreasing incidence of tobacco-related and increasing incidence of human papillomavirus (HPV)-related HNC. While it is often reported that ≥ 90% of HNC is considered squamous cell carcinoma (SCC), there is an apparent lack of recent population-based data to support this claim. This study aimed to estimate the current proportion and evaluate change in the proportion of SCC in HNC diagnoses in North America (United States and Canada) from 1995 to 2015. Methods: We queried the North American Association of Central Cancer Registries (NAACCR) database for HNC cases that were of either squamous (SQ) (ICD-0-3: 8050-8089) or squamous plus unspecified epithelial (SQE) (ICD-0-3:8010-8089) origin in the United States and Canada ( n = 1,054,409). All HNC included in the analysis were microscopically confirmed, malignant head and neck primary tumor sites of the oral cavity, nasopharynx, hypopharynx, oropharynx, nasal cavity, and larynx. Sub-analyses were conducted across more extensive cohort restriction combinations (country specific, registry specific, and primary sequence of cancer). Results: The overall proportion of SCC in HNC in North America from 1995-2015 was 81.7% (95% CI: 81.7 – 81.8) for SQ and 84.9% (95% CI: 84.8 – 85.0) for SQE. The proportion of SCC in HNC peaked in 2015 with 83.3% (95% CI: 83.0 – 83.6) for SQ and 85.9% (95% CI: 85.6 – 86.2) for SQE; and was lowest in 2005 with 80.7% (95% CI: 80.4 – 81.1) for SQ and 84.3% (95% CI: 83.9 – 84.6) for SQE. In the time period of this study (1995 – 2015), there were no years for which SQ or SQE made up 90% or more of HNC for any of the HNC cohorts. Conclusions: The changing landscape of HNC risk factors in the United States and Canada warrants re-evaluation and update of HNC epidemiological literature with regards to the proportion of SCC in HNC.
Cumulative odds of increased comorbid score in head and neck cancer.
Authors: Polednik Katherine M. , Bukatko Aleksandr R , Gaubatz Matthew , Simpson Matthew C , Adjei Boakye Eric , Mohammed Kahee A , Osazuwa-Peters Nosayaba
Published: May 2019

e17555

Background: Survival of head and neck cancer is impacted by known clinical factors, including anatomic subsite, stage of presentation, and treatment modality. An important clinical factor less explored is comorbidity burden. While it is known that a greater comorbidity burden is prognostic for poorer outcomes, it is unclear how the odds of presenting with increased comorbidity score is associated with head and neck cancer anatomic subsite. This study aimed at estimating the cumulative odds of increased comorbidity in head and neck cancer based on anatomic subsites. Methods: Data queried from National Cancer Database (2004-2015). Study sample (N = 328,504) consisted of Stage I-IV, Head and neck Squamous Cell Carcinoma (HNSCC) patients, with no missing demographic variables (age, sex, race, insurance status, local income, local population density). Multivariable cumulative logit model was used to estimate outcome of interest: odds of higher Charlson-Deyo comorbid condition score(CDCC) at HNSCC diagnosis. Results: Compared to patients diagnosed with oropharyngeal cancer (mostly HPV-related HNSCC), patients diagnosed with more tobacco-related HNSCC, such as laryngeal cancer (aOR: 1.69, 95% CI: 1.65-1.73), hypopharyngeal cancer (aOR: 1.33, 95% CI: 1.28-1.38), oral cavity (aOR: 1.26, 95% CI: 1.23-1.29), and sinonasal cancer (aOR: 1.12, 95% CI: 1.06-1.19) had greater odds of presenting with a higher CDCC. Patients with nasopharyngeal cancer did not statistically differ from oropharyngeal patients in odds of higher CDCC presentation. Conclusions: Patients diagnosed with cancers of larynx, hypopharynx and oral cavity (typically associated with tobacco and alcohol use) present with greater comorbid burden compared to patients diagnosed with oropharyngeal cancer (typically associated with HPV). It is important that the role of comorbidity burden be recognized in head and neck cancer prognostication.
Unhealthy alcohol use and toxicity of concurrent chemoradiation for head and neck cancer.
Authors: Graf Solomon A. , Wheat Chelle L. , Frost Madeline C. , Sigel Keith , Zeliadt Steven B. , Williams Emily C.
Published: May 2019

e17559

Background: Unhealthy alcohol use (UAU) is an important risk factor for development head and neck squamous cell carcinoma (HNSCC), but any effect on treatment outcomes is not well understood. The Veterans Health Administration (VHA) annually screens outpatients for UAU with the validated Alcohol Use Disorders Identification Test Consumption (AUDIT-C). Methods: Using national VHA data we retrospectively identified patients administered upfront radiation with concurrent systemic therapy (chemo- and/or immuno- therapy) for stage III-IVb HNSCC diagnosed 2008 –2017 and included males with a prior-year AUDIT-C. Regression models were fit to assess associations between AUDIT-C risk groups [low-level use (score 1-3), moderate UAU (4-7), severe UAU (≥ 8)] and treatment toxicity. Models were adjusted for a priori defined covariates including smoking and variables related to demographics, comorbidities, and cancer diagnosis and treatment. Results: Among 3,094 patients, 46.7% screened positive for UAU: 23.9% with moderate UAU and 22.9% with severe UAU. Compared to patients with low-level alcohol use, those with severe UAU were younger (mean age 65 vs 67 years) and more frequently active smokers (63.4% vs 36.2%) and underweight (11.2% vs 3.5%) ( p for all comparisons < 0.05). There was no significant difference between alcohol use groups in race/ethnicity, cancer stage, or systemic treatment agent used. In adjusted models, severe UAU was associated with lower risk of nausea [adjusted odds ratio (AOR) 0.63, 95% CI 0.47 – 0.84], ED visits (AOR 0.79, CI 0.63 – 0.99), and hospitalizations during treatment (AOR 0.78, CI 0.62 – 0.98). UAU was not associated with a composite measure of complications of infection or organ damage (AOR 0.94, CI 0.74 – 1.20), severe weight loss (AOR 0.83, CI 0.66 – 1.05), or mortality within 100 days of completing treatment (AOR 1.01, CI 0.62 – 1.66). Conclusions: In this large cohort of male patients in the VHA treated for locoregionally advanced HNSCC with concurrent chemoradiation, moderate and severe UAU is common. UAU is not associated with increased toxicity of treatment, and future research is required to define its place in treatment selection, supportive care, and counseling.
Impact of systemic treatment associated to radiotherapy on quality of life in locally advanced head and neck cancer patients in Brazil: Prospective real-world data study.
Authors: Santos Marcos Antonio , Oliveira e Silva Luis Felipe , Kohler Hugo Fontan , Curioni Otavio , Vilela Ricardo Alencar , Fang Marcel , Lima Carmen Silvia Passos , Gomes João Pedro Perez , Chaves Aline Lauda Freitas , Pulido Jose Zago , Trindade Karine , Araujo Mauricio C. , Obst Fernando , Brollo Janaina , Ferreira Ediane , Kowalski Luiz Paulo , Domenge Christian
Published: May 2019

e17563

Background: the purpose of this study was to compare quality of life (QoL) and overall survival (OS) in patients with locally advanced head and neck cancer treated with radiotherapy only (RT), chemoradiotherapy with cisplatin (CT-RT) or RT with cetuximab (CET-RT). Methods: in this real-world, multi-institutional and prospective study, QoL outcomes were assessed using EORTC QLQ-C30 and QLQ-H&N43 questionnaires. Patients were treated according to each participating institution’s protocol. The Item Response Theory was used to generate a global QoL score, based on the 71 questions of both forms. Questionnaires were completed before treatment and every three months, thereafter. Survival was calculated using the Kaplan-Meyer method, and groups were compared by the log-rank test. The impact of the treatment modalities on QoL was analyzed using multivariate regression analyses. Results: Six hundred and twenty-six patients, with tumors located at the oral cavity (36%), oropharynx (30%), larynx (21%), hypopharynx (9%) and nasopharynx (4%) were included. Median follow up was 10.2 months. RT was delivered to 39% of the patients while 58% received CT-RT and 3% received CET-RT. Patients submitted to surgery were not included. OS was higher when systemic treatment was added to RT (median OS CET-RT: 21.9 months and CT-RT: 24.3 months, versus 14.2 months with RT, p < 0.05). A decrease in QoL during treatment was observed in all patients’ groups, but CT-RT had a statistically significant negative impact on QoL when compared to CET-RT (p = 0.02). An important limitation of the study is the low number of patients that received this last treatment modality, what is, probably, a result of local policies on reimbursement. Other factors that influenced QoL were alcohol consumption (better QoL for patients with no history of chronic alcohol consumption, p = 0.007) and radiotherapy technique (better QoL for patients treated with intensity-modulated RT, when compared to conformal RT, p < 0.001). Conclusions: We observed, as expected, better OS with systemic therapy, when associated to RT. A decrease in QoL was detected, as well, during treatment, but a less pronounced decrease was seen in patients receiving CET-RT, when compared to CT-RT. More studies are needed to confirm the QoL improvement in patients submitted to this last treatment approach.
Single institution preliminary analysis of geriatric head and neck squamous carcinomas treated with modulated radiotherapy.
Authors: Basu Trinanjan , Karpe Ashay , Kendre Pradip , Bhaskar Pradeep , Sharnanghat Vijay , Gawde Sachin , Kasat Amrita , Raina Priyanka , Behera Neelam
Published: May 2019

e17566

Background: Geriatric head and neck squamous carcinomas (GHNC) treatment remains challenging due to multiple patient and treatment related factors. We analysed preliminary data for fifty HNC patients beyond 70 years of age treated by modulated radiotherapy (MRT). Methods: There were 50 patients (M:46,F:4) with median age of 78 years (70-96) treated by MRT at our centre. They were analysed for efficacy and acute side effects. Besides demographic and disease related parameters compliance to treatment, rate of hospitalisation, dependency of WHO ladder 3 analgesia and early clinico-radiological outcomes were analysed. Results: The median follow up was 10 months. 65% patients were locally advanced stage and 65% received radical MRT. For radical MRT the dose ranged between 66-70 Gy in 30-33 fractions and 5 patients received palliative MRT. 83% completed intended treatment with 30% had MRT interruptions. 48% patients required hospitalisation. 60% had comorbidities with 35% two or more types. 3 patients had concurrent chemotherapy and 48% had hospitalisation and 60% had feeding tubes.65% and 30% had post MRT endoscopic evaluation and imaging respectively. Among them 80% are loco-regionally controlled. 30% patients are long term (more than 3 months) tube dependent and morphine dependent. There were 5 deaths while on MRT both due to associated cardiac and pulmonary comorbidities. 40% and 65% of palliative and radical MRT patients respectively had complete response post MRT. All patients underwent psychological counselling and dietician evaluation. The median G8 screening score was 15. Conclusions: GHNC are a unique group with its own challenge. In specialised setting and with MRT treatment compliance and effective outcome is highly promising. Non disease related concerns like alteration in daily quality of life (QOL), social engagement related issues, age related dementia and end of life care emerged as prominent issues beyond disease control.
Factors associated with non-completion of radiation therapy (RT) or radiochemotherapy (RTCT) in head and neck squamous cell carcinoma (HNSCC): A prospective study.
Authors: Clatot Florian , Lebret Lucie , Rigal Olivier , Lefebvre Laureline , Dandoy Simon , Cabourg Marine , Moldovan Cristian , Veresezan Ovidiu , Thery Jean Christophe , Petrau Camille , Lebreton Mathilde , Guérault Fanny , Ebran Mélanie , Gouley-Toutain Céline , Bon-Mardion Nicolas , Bastit Vianney , Di Fiore Frédéric , Dubray Bernard M. , Lequesne Justine , Thureau Sébastien
Published: May 2019

e17568

Background: Although numerous factors have been reported to increase RT/RTCT toxicity, identification of patients with high risk of toxicities is lacking. Methods: The monocentric NutriNeck study (NCT02900963) recruited all HNSCC patients between 2014 and 2018 treated by RT or RTCT. Patients fed by enteral nutrition before RT initiation were excluded. All clinical and biological, planned RT or RTCT parameters were collected at baseline. A daily monitoring of the weight and a weekly evaluation of clinical, biological and food intake during RT/RTCT were performed. A nutritional intervention by enteral feeding was systematically proposed in case of 2 kg weight loss under treatment. Complete treatment was defined as full planned RT doses without more than 3 days interruption, and full planned doses of cisplatin and cetuximab if indicated. Primary endpoint assessed factors associated with non-completion of the planned treatment. Secondary endpoint assessed factors associated with use of enteral nutrition during treatment. A p value < 0.01 was considered significant. Results: Among the 249 HNSCC patients included, 118 (47%) were treated by RT and 131 (53%) by RTCT. 63 patients (25%) did not complete treatment: 3/118 (2.5%) in the RT group compared to 60/131 (45.8%) the RTCT group, p < 0.0001. Median weight lost during treatment (7 vs 3.8 kg, p < 0.0001) and grade 3 toxicities (53 vs 33%, p = 0.006) were more frequent in patients with incomplete RT/RTCT. Nutritional intervention was performed in 111 patients: 28 (23.7%) with RT and 83 (62.6%) with RTCT (p < 0.0001). Week 4 was associated with the higher rate of enteral nutrition initiation in both RT and RTCT groups. Among RTCT group, weight loss during treatment (OR 1.2 for each kg, p < 0.0001) and use of enteral feeding (OR 2.7, p = 0.005) were associated with incomplete treatment in multivariate analysis. Of note, 48 patients refused enteral nutrition while indicated, they had comparable grade 3 toxicities and weight loss during treatment compared to the 111 patients who accepted enteral nutrition. Conclusions: Incomplete treatment is overwhelmingly associated with RTCT rather than RT. Baseline clinical, biological features or treatment volume/dose are not associated with incomplete treatment. Enteral nutrition initiated during treatment is poorly efficient.
Incidence of severe late toxicities of head and neck squamous cell cancer (HNSCC) treatment in the era of intensity modulated radiotherapy (IMRT).
Authors: Eziokwu Akaolisa Samuel , Koyfman Shlomo A. , Reddy Chandana A. , Matia Brian , Woody Neil McIver , Joshi Nikhil Purushottam , Burkey Brian B. , Scharpf Joseph , Lamarre Eric , Prendes Brandon , Lorenz Robert , Ku Jamie , Adelstein David J. , Geiger Jessica Lyn
Published: May 2019

e17570

Background: IMRT for HNSCC limits exposure to critical nearby structures thereby reducing toxicities. Real world data on toxicities after long term follow-up post IMRT for HNSCC are lacking. This study assessed the incidence of late toxicities in patients with HNSCC within 5 years post-treatment with definitive IMRT (d-IMRT). Methods: This is a retrospective, IRB approved, single-institution review of patients (pts) with stage I-IVB HNSCC treated with d-IMRT +/- chemotherapy between 2009 and 2013. The primary outcomes were incidence of severe late toxicities (dysphagia requiring esophageal stricture dilation, physician-reported grade 2 or worse neck fibrosis and xerostomia) occurring 3 months or more after completion of IMRT; feeding tube (FT) dependence within 1st year of IMRT completion, and FT dependence beyond 1st year post IMRT. Toxicities were deemed acute if they occurred during IMRT and up to 90 days post IMRT. Results: 274 pts, median age 59 years (38 – 82.9), were identified. 67.6% were HPV positive, 10.5% HPV negative and HPV status was unknown in 21.9%. Site of disease was oropharynx in 70%, larynx in 25% and hypopharynx in 4%. 206 pts (75.2%) received d-IMRT alone, 37 (13.5%) had definitive concurrent chemoradiation – mostly with cisplatin (58%), and 31 (11.3%) received adjuvant IMRT. Of the 243 pts treated with d-IMRT +/- chemotherapy, 80 (32.9%) required FT during RT due to grade 2 or worse acute dysphagia. Excluding 11 pts with disease recurrence or new HNSCC diagnosis, FT dependence at any time from 3 months to one year post IMRT occurred in 22 of 232 pts (9.48%), while FT dependence beyond 1st year post IMRT occurred in 8 pts (3.4%). 11 pts (4.7%) required stricture dilation for late dysphagia. Late grade 2 or worse fibrosis and xerostomia occurred in 7 (3.0%) and 89 (38.4%) pts, respectively. Conclusions: Our study suggests that except for xerostomia, severe late toxicities after definitive IMRT for HNSCC is likely uncommon. Prospective studies with late IMRT toxicities and their impact on quality of life (QoL) as endpoints are warranted.
Satisfaction survey from an innovative cancer care delivery model (Pendharkar model), creating access at scale: An outcome research.
Authors: Tripathi Chandramauli , Pendharkar Dinesh , Saitya Bhure Singh
Published: May 2019

e18002

Background: With the aim of empowering alternate oncology workforce, to resolve the issue of access, a unique cancer care delivery model (Pendharkar model) was launched in 4 states of India, spread across 125 districts with population coverage of around 210 million. The model has established nodal cancer units in every government run district hospital and created a point of contact for cancer- a physician-medical officer. Hundreds of patients have been seen by these hospital in last four years. The aim of this analysis was to survey the patient population attending and their satisfaction level. Methods: An elaborate survey was conducted amongst patients coming to district hospital. It sought information on satisfaction, choices. The written responses were sought, and data analysed. Results: Overall.186 patients were surveyed. Nearly 62 % of the patients had visited hospital multiple times before. Referral pattern showed that about 7 % of the patients were referred by other patients who were treated here, 62 % of the patients were referred by other medical professional, including nearby cancer hospitals and specialists. More than half of the patients (54.1) had taken cancer treatment outside district hospital, at some point of time. On question of comparison of service 65 % felt services to be better in government run setup, the time to start of therapy was much faster (74%).The time given by the doctor to the patient was satisfactory, highly appreciated by 97% of the respondents. Ease of accessibility of the staff was positively accepted by 100 %. All were happy with the level of communication by the doctors and nursing staff. Chemotherapy experience was better in district hospital set up for 58 % of the patients. More than 95% rated nursing services of high quality and all were happy with the behaviour of nurses. 80% were interested in continuing chemotherapy in same government hospital. Majority said that they are happy with their decision of taking chemotherapy in district hospital and would definitely refer other patients here. Conclusions: The survey strongly favours the model of empowerment of alternate oncology workforce in government run district hospital, and achieves high level of satisfaction amongst cancer patients.
Patients’ perspectives and outcomes on an oral chemotherapy education and electronic monitoring program.
Authors: Tocci Noah Xavier , Doolin Jim , Roberts Daniel Aaron , Cibotti Christina , Hartwell Rebekah A , Espiritu Jennifer , Devlin Scott M , Dowling Holly , Trillo Kelsey , Yenulevich Mary , Zerillo Jessica A. , Shea Meghan
Published: May 2019

e18007

Background: Patients on oral chemotherapy (OC) often lack consistent education and monitoring, risking toxicity and poor adherence. We developed an OC management program including education and an online tool for active outreach. Methods: In November 2017, we initiated pharmacist-led education for patients newly prescribed OC at a community practice and in the gastrointestinal oncology group at an academic medical center (AMC). An online tool assessing adherence, symptoms, and financial toxicity was emailed to patients three days after starting OC. Non-responders were contacted for phone interviews. A random sample of 28 patients newly started on OC at both sites before the intervention in 2017 was analyzed at baseline. A retrospective chart analysis was done to collect time to symptom assessment, identification and action. A report generated date of first emergency department (ED) visit or hospitalization within the AMC. We conducted a Mann Whitney U-Test, using a one-sided p value of 0.025 with Bonferroni correction. Results: Sixty-nine of 106 eligible patients (66%) received education, of whom 36 (52.1%) received the online tool, and 13 (36.1%) responded. There was a significant difference between the intervention and baseline median times to first new/worsening symptoms (p = 0.0105) but otherwise there were no outcome improvements. Eight of 23 patients who did not respond to the electronic tool were interviewed and indicated that their illness impeded their ability to check email (n = 2), and that they never check email (n = 2). Conclusions: This OC management program improved time to detect new/worsening symptoms and could potentially improve outcomes after further patient accrual. Future investigation should examine ways to improve patient responsiveness to electronic patient-reported symptom tools. [Table: see text]
Association between the variation in hospital beds and inpatient chemo/radiotherapy for breast cancer: A retrospective study using the Japanese Diagnosis Procedure Combination database of over 500K records.
Authors: Ogiya Rin , Matsumoto Haruki , Matsuda Shinya
Published: May 2019

e18008

Background: Chemo/radiotherapy for breast cancer patients does not require hospitalization in most cases. We investigated the relationship between the proportion of hospitalization for chemo/radiotherapy over total hospitalization among breast cancer cases (inpatient chemo/radiotherapy rate) and the number of hospital beds per capita using the national database in Japan. Methods: We conducted a retrospective observational study using Diagnosis Procedure Combination (DPC) database and National survey database from April 2012 to March 2016. We aggregated hospital-level data into prefecture-level data and classified the 47 prefectures into quintiles based on the number of hospital beds per capita (9-10 prefectures per quintile). Generalized estimating equations (GEE) were used for examining the relationship between the number of hospital beds and inpatient chemo/radiotherapy rate (discretionary setting) or the number of surgical operations (imperative setting). Results: Over the five-year study period, there were 561,165 records for hospitalization for breast cancer cases. The inpatient chemo/radiotherapy rate at each prefecture varied, ranging from 2.6% to 61.8% in 2016. The inpatient chemo/radiotherapy rate was significantly higher in the second highest and the highest quintile by 11.7% (95% CI 4.0-19.5%, P = 0.003) and 9.6% (95% CI 1.8-17.4%, P = 0.015), respectively, compared with the middle quintile. There was no significant difference between the lowest, second lowest and middle quintile. On the contrary, there was no significant difference in the number of surgical operations for breast cancer per capita between each quintile and middle quintile. Conclusions: We found that higher hospital beds associated with more chemo/radiotherapy in the inpatient setting. This study is a starting point for the discussion on the employment support for people with cancer and the economical utilization of the limited medical resource in the oncology field. The further studies evaluating the association between health resource and the other type of procedures are warranted.
Feasibility of mobile-deployed care management based on standardized ePRO and computer-interpretable-guideline engine for lymphoma patients.
Authors: Zhang Tingting , Song Yuqin , Ying Zhi Tao , Ping Lingyan , Zhang Chen , Xie Yan , Liu Weiping , Lin Ningjing , Tu Meifeng , Deng Lijuan , Hong Lingling , Zhu Jun
Published: May 2019

e18010

Background: To effectively assist lymphoma patients and their care-givers after their hospital discharge, a standard follow-up guideline for lymphoma patients was designed and encoded through a computer-interpret-able-guideline (CiG) engine and deployed through mobile-Web and mobile-Apps to ensure continuous care throughout the treatment and recovery processes. Methods: Scheduled tasks including ePRO questionnaires and requests for test results were sent for completion, and a virtual care management team was assigned to ensure compliance and respond to automatic triggered alerts. Attending oncologists also were given mobile-Apps to access the patients’ securely uploaded records and consult remotely to manage side-effects manifested after discharge. The out-of-hospital record management and care coordination enabled the adjustment of individual treatment plans and the optimization of clinical resources utilization. Results: During 2018, 1012 patients or their caregivers interacted with our team through the mobile platform after discharge. Out of these, 856 individual patients uploaded enough information to be initiated in the mobile follow-up program. Approximately 30% of these patients were Beijing residents while the rest came from all over China. Close to half of these patients had follow-up tests done in other 387 hospitals or 52 clinics. Based on ePRO questionnaires submitted, 218 patients had 616 side-effect-symptom alerts triggered and followed up, in addition to patient-initiated mobile consultation with their attending oncologists. Lab results especially white blood cell counts, platelet counts, and neutrophil counts, contributed to the majority of test alerts managed by our team. Analysis of the thousands anonymized questions identified clinical processes in need of optimization. A new patient education manual addressing frequently asked questions, and new processes such as chemo-regime scheduling were put in place. Conclusions: We have demonstrated the feasibility of a mobile-deployed care management process after discharge for lymphoma patients and their caregivers. We have initiated retrospective studies of impacts on our patients’ treatment compliance and quality of life. A randomized clinical trial in six cancer types assessing the value of such an approach is also under planning.
Identifying cancer patients’ care needs after discharge hospital using health claim data linked with Hospital-based Cancer Registry data in Japan.
Authors: Okuyama Ayako , Takemura Yukie , Higashi Takahiro
Published: May 2019

e18012

Background: In 2018, the 3rd Cancer Control Plan developed in Japan. This plan recommends that we should create a better society for cancer patients to keep living at their homes after leaving hospital. In order to grasp the continuous health care needs, we investigated independence degree of Activities of Daily Living (ADL) at the time of discharge for cancer patients by hospital types. Methods: We analyzed the health insurance claims database linked with the hospital-based cancer registry of 230 cancer care hospitals covered the period from October 2012 to December 2014. Data were abstracted from patients who 1) were diagnosed with breast, lung, liver, colorectal, stomach, pancreas, or prostate cancer in 2013; 2) were 20 years or older at the time of the diagnosis; and 3) received the first course or continuous treatment at the hospital. Ministry of Health, Labor and Welfare designates cancer care hospitals (DCCHs) to provide a high quality of cancer care. In each prefecture, one hospital is designated as Type 1 DCCH, and it has the role of supporting other DCCHs in that prefecture. Remaining DCCHs are Type 2 DCCHs. Hospitals which are not designated as DCCHs are categorized into other hospitals. We assessed the differences of patient’ ADL status by these hospital types. Results: We extracted 37,523 patients’ discharge data (8,271 from Type 1 DCCHs, 28,200 from Type 2 DCCHs, and 1,052 from other hospitals). The mean age (SD) at the time of diagnosis was 65.6 (11.7) at Type 1 DCCHs, 69.1 (11.0) at Type 2 DCCHs, and 70.0 (12.3) at other hospitals. The percentage of clinical stage IV in other hospitals (25.3%) was slightly higher than others (22.5%). In total, 16.2% of patients need all assistance for bathing, while only 3.5% of patients need all assistance for eating. More patients at other hospitals were need assistance for ADL compared to patients at DCCHs. For example, 10.6% of patients need all assistance for bathing in type 1 DCCHs, while 25.2% of patients need it in other hospitals. Conclusions: Many patients discharged in not DCCHs need more assistance for their daily living. We should take these situation into account when we provide appropriate support for cancer patients.
Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital: Focus on cardiovascular patients.
Authors: Bowers Reid Christian , Korman Sandra Tomany , Thompson Michael A. , Pant Manish Krishna , Sana Sherjeel , Sanchez Federico Augusto
Published: May 2019

e18014

Background: As part of a system wide implementation of Patient Blood Management (PBM), an Anemia Clinic program was implemented at St. Luke’s Medical Center, Advocate Aurora Health in Milwaukee, WI. Methods: September 2016 the Anemia Clinic started accepting referrals for management of non-cancer anemia, predominantly pre-operative cardiovascular surgery (CVS) Pts. Hgb thresholds were < 13 g/dL in men and < 12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte. Nutrient deficiency received appropriate supplementation. Pts with CKD or chronic disease were eligible to receive erythropoiesis stimulating agents. Results: PBM implementation 2015-2018 resulted in a drop in packed red blood cell (PRBC) usage during a surgical episode (Table). Of 508 CVS Pts pre-operatively anemic in 2018, 155 were referred to the Anemia Clinic and 353 were not. There was not a statistical difference between the referred and the non-referred for percentage of Pts who received PRBCs (65.4% vs. 70.3% Chi-Square p = 0.31). Of preoperatively anemic Pts who were transfused in 2018 an average of 2.23 PRBCs were used in the referred group vs. an average of 2.35 PRBCs in those in the not referred group (Poisson Means p = 0.49). Length of stay (LOS) in the referred group was a median 10d ( P25= 7d, P75 =15d) vs LOS in the non-referred group was a median 11d ( P25= 7d, P75 =20d). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges.. For 2018 through Nov. the referred group was observed to have LOS mgeo = 10.19 days vs LOS mgeo = 11.72 days (N = 141, O/E 0.87). The not referred group was observed to have a LOS mgeo = 12.45 days vs. an LOS mgeo = 10.65 days (N = 311, O/E 1.17). Conclusions: Referral to the Anemia Clinic as part of a broader program of PBM was associated with shorter LOS and a decrease in PRBC use. Implementation of PBM at our institution decreased PRBC use even in patients not referred to anemia clinic due to systematization of best practices. Implementation of our methods as the initial approach to general anemia referrals may increase access and efficiencies in the systemization and treatment of hematologic malignancies. [Table: see text]
Characteristics of medical oncologists participating in the Oncology Care Model.
Authors: Parikh Ravi Bharat , Bekelman Justin E. , Huang Qian , Martinez Joseph , Emanuel Ezekiel J. , Navathe Amol S.
Published: May 2019

e18017

Background: The Oncology Care Model (OCM) is Medicare’s first bundled payment program for patients with cancer. Because practices voluntarily enrolled in the OCM in 2016, there may be differences between OCM-participating and non-participating oncologists that impact the OCM’s generalizability. We examine baseline characteristics of OCM participants and markets with high OCM physician participation. Methods: In this cross-sectional study, we identified characteristics of US medical oncologists practicing in 2016 using a national telephone-verified physician database. We linked this data with Dartmouth Atlas and Medicare claims data to identify market characteristics of areas with high OCM participation. We used logistic regression to examine relationships between market characteristics and OCM participation. Results: Of 10428 US medical oncologists, 2605 (24.9%) were listed on an OCM-participating practice’s website. There were no differences in sex or medical training between OCM participants and non-participants, although OCM participants were younger. OCM participants were more likely to be affiliated with large, group, and urban practices that were not part of a health system (Table). Southwest, Southeast, and mid-Atlantic markets had higher OCM participation. Markets with high OCM physician participation had higher specialist density, Hospital Care Intensity Index, and acute care utilization at the end of life (all p < 0.001). Market penetration of Accountable Care Organizations (adjusted odds ratio [aOR] 4.65, 95% CI 3.31-6.56, p < 0.001) and Medicare Advantage (aOR 2.82, 95% CI 1.97-4.06, p < 0.001) were associated with higher OCM participation. Conclusions: We found differences in provider and practice demographics, care intensity, and prior exposure to alternative payment models between OCM-participants and non-participants. Differences in practice and market characteristics influence oncologists’ participation in alternative payment models and should be accounted for in Medicare’s OCM evaluation. [Table: see text]
Profile of cancer caregivers among adult Indian rural cancer patients: A prospective survey.
Authors: Pandey Avinash Vijay Kumar , Singh Anjana , Singh Shivkant
Published: May 2019

e18019

Background: There is lack of information regarding Cancer Caregivers who play predominant role in assisting patients during active treatment and follow –up in India. Aim: To identify profile of cancer caregivers Objectives: To identify, social, economic, familial variables of cancer caregivers of adult cancer patients by prospective survey/questionnaire. Methods: All consecutive individual adult (age≥18 years) patients diagnosed with cancer and registered in Medical Oncology OPD were enrolled for Cancer caregiver questionnaire based survey between July 2018 and October 2018.Primary caregiver was defined as person of first degree relative who has greatest responsibility of daily patient care. Patient was asked to name single preferred primary caregiver in case of multiple first degree relatives available. Results: Of 517 patients enrolled, 456 (88%) were rural.491 (95%) had primary caregivers, while 26(5%) had secondary caregivers only. 295(57%) had 3-4 caregivers, while 117 (23%) had 5-7 caregivers in predominantly joint family population (75%). Among primary caregivers, son 287 (58%) was the preferred choice, followed by brothers, 50 (10%). Only 61 (12%), chose female as primary caregivers. Only 36/281 (13%) married men and 71/215 (33%) married women chose their spouse as primary caregiver. 326 (63%) of primary caregivers had monthly income equivalent to $70-140, while 16% and 9% had between $140-280 and less than $70 respectively.131 (25%) of caregivers were graduate,186 (35%) passed secondary school, while only 25 (4.8%) were illiterate. Conclusions: Majority of rural Indian cancer patients have access to multiple caregivers. Young males are the preferred choice as primary caregiver. Primary caregivers are economically poor but literate.
Real-world assessment of practice efficiency with the introduction of subcutaneous rituximab.
Authors: Qiu Annie , Shapouri Sheila , Drill Esther N. , Schade Jake , Ravelo Arliene , Ni Ai , To Tu My , Dawson Keith Lamont , Matasar Matthew J.
Published: May 2019

e18025

Background: Rituximab (R), available as an intravenous (IV; R-IV) infusion or subcutaneous (SC; R-SC) injection, is used in the treatment of follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), and chronic lymphocytic leukemia (CLL). This study evaluated real-world practice efficiency changes associated with the adoption of R-SC by studying differences in chair time by route of administration. Methods: We conducted a retrospective analysis of practice care delivery measures before and after adoption of R-SC at Memorial Sloan Kettering Cancer Center (MSKCC). Data for patients (pts) with FL, DLBCL, or CLL receiving R-based therapy from September 2016 to September 2018 were extracted from the electronic medical record. A linear mixed effect multivariate model with random intercept was used to analyze the association between treatment type (R-IV vs R-SC) and chair time (defined as the difference in pt room-in and room-out times) in the year prior to and following R-SC adoption at MSKCC. Model covariates included treatment time and location, therapy type (monotherapy vs combination), and pt demographics. Given the prolonged infusion time, patients’ first dose of R-IV was excluded from the analysis. Results: Data were collected during 6744 visits (3018 visits prior to R-SC adoption and 3726 after) for 1503 pts receiving R. Pts receiving R-IV combination therapy had a mean chair time of 203 minutes (min); overall, R-SC injection reduced chair time by a mean of 92 min (p < 0.001 vs R-IV). Monotherapy, regardless of route, reduced chair time by a mean of 30 min (p < 0.001) compared with combination therapy, and mean chair time was further reduced by 39 min (p < 0.001) for R-SC pts receiving monotherapy. Reductions in chair time increased over time following initial adoption of R-SC (p = 0.042), and were greater at the lymphoma-specific site than multispecialty oncology infusion centers (p < 0.001). Conclusions: Adoption of R-SC results in substantial time savings for both the pt and health system as measured by reduced chair time and improved pt throughput. Given increasing constraints on infusion chair space, increased utilization of R-SC may improve practice efficiency and pt access to care.
Case discussion at cancer multidisciplinary meetings: What resourcing is required?
Authors: Mitchell Paul , Soon Jennifer , Kenny Joanne , Simons Katherine
Published: May 2019

e18026

Background: Discussion of cancer cases at multi-disciplinary meetings (MDMs) is expected standard care in Australia. To our knowledge there are no local, and few international, data on the resourcing required for MDMs. Methods: Data covering 12 months of MDM activity at Austin Health, Victoria, were obtained retrospectively. Prospective data were also collected over 4 weeks focusing on time required for preparation and post-meeting activities. Capital, maintenance and general overhead costs were not included. Results: MDMs covered 15 tumour areas: 11 solid tumour, one lymphoma and 3 haematological. Over 12 months 452 MDMs were held, discussing 5943 patients with highest case volume for hepatoma (1243), breast (1084) and hepato-biliary (HPB, 679). On average 12 cases (range 3.5 – 38.3) were discussed per meeting, with average 3.8 minutes spent per case. An average of 3 imaging studies were reviewed per case and 60% of cases in the high volume MDMs required access to external imaging. Imaging consultants spent an average of 2.9 minutes preparation per imaging study, registrars 5.2 minutes and external imaging required 7.8 minutes per study. Pathologists spent an average of 6.8 minutes preparation per case, which rose to 9.4 minutes for external cases (making up between 3% - 30% of cases per MDM). Pathology administration time was 53 minutes per meeting. The mean cost of medical staff was AUD 1617 per meeting (range $532-$2860), and 78% of the cost was for consultant medical staff. The mean cost for diagnostic staff attendance was $216, and preparation $327. MDM and pathology administrative costs were $273. The MDMs with the highest annual total costs were breast, lung and HPB ($152,904 - $207,289). The overall mean cost for a meeting varied between $847 - $4080. The cost per case discussed varied from $106 - $422, with generally lower per-case costs for the high case volume MDMs. The average per case cost was $255. Conclusions: Data on staff time and costs associated with conducting cancer MDMs were able to be obtained. The average cost per case discussed was $255 (USD 184). These data may be useful in planning to extend MDM discussion to include a higher proportion of cancer cases and in seeking additional funding.
Staging the development and implementation of a Coordinated Cancer Care Model using risk-based survivorship care: A deliberative discussion among multiple stakeholders.
Authors: Tremblay Dominique , Bilodeau Karine , Prady Catherine , Touati Nassera
Published: May 2019

e18027

Background: Risk-based survivorship care has become one of the best practices care recommended by the Institute of Medicine. It involves coordinated follow-up services based on the risk of long-term and late effects, cancer recurrence and an individualised care plan. Risk-based care requires specific knowledge about cancer histology, treatments, and potential consequences of cancer and its treatment to guide surveillance, screening and counseling. Diagnostic and treatment details and their associated health risks may not be known by survivors or their multiple care providers. Implementing risk-based survivorship care is often challenging for providers. This presentation report on a deliberative workshop on the development and planning of a risk-based survivorship care model. Methods: The deliberative workshop is part of a larger study in two regional cancer networks in Quebec, selected for there differences (geographic location, population size, academic mandate). A total of 25 key informants (researchers, managers, family physicians, oncologists, cancer survivors, nurses, social workers) participated into the workshop on October 2nd, 2018. Deliberative discussion between local stakeholders followed by videoconference, getting together stakeholders from both networks was drawn from Gupta et al 3 steps: 1) identify the problem; 2) develop the innovation; 3) design the pilot test. Results: Although the context of the network was different, main issues were similar: 1) there is no common understanding of the concept “risk-based survivorship care”, either for survivors, primary care providers and cancer specialist; 2) “silo functioning” within and between teams is a main barriers to ensure care coordination based on risk assessment; 3) organizational assets should be formalized to insure safe coordination of survivorship care based on cancer risk assessment. Conclusions: Given the recognized importance of risk-based survivorship care and implementation challenges, deliberative discussions may provide a useful lens to inform translation of this model into real practices and guide empirical studies.
Development of a patient-oriented navigation model for lung cancer patients.
Authors: Holmberg Christine , Gödde Kathrin , Fuegemann Hella , Mueller-Nordhorn Jacqueline , Rieckmann Nina , Goerling Ute
Published: May 2019

e18033

Background: Patient navigation is seen to support and enable patient-oriented, optimal care both in palliative and in screening settings. However, the evidence remains inconclusive on what patient groups are best targeted by navigation and what may be improved by such a care model. Lung cancer patients are at particular risk for sub-optimal care because they face complex care trajectories due to severe and rapid disease progression and accompanying comorbidity. Methods: To develop a navigation model for lung cancer, we conducted a mixed-methods study to investigate who may be at risk of receiving sub-optimal care in the German health care setting. To capture the patient perspective a longitudinal qualitative component was included with patients (N = 20) assessed at three dtime points. In addition, a secondary data analysis of cancer registry data of a comprehensive cancer center was conducted and a repository of patient support offers gathered. Results of the study components were integrated to develop a patient-oriented navigation model. Results: Secondary data analysis showed that medical care functioned according to tumor board recommendations. Patient data revealed institutional barriers that conflict with individual needs and preferences. A lack of contact persons, information provision as well as bureaucratic difficulties were identified. Patients without a social network seem particularly in need for support. Identification of regional support offers shows that there are resources available to meet some of these needs. However, knowledge on such offers was not common among patients and caregivers. Navigators should provide practical support, give advice on social care issues and refer to existing support offers. Conclusions: Social networks crucial. Patients lack knowledge to use available resources. Navigation needs to be implemented within existing care structures to reach patients.