bluuebunny/crossref_metadata_2025 huggingface dataset:
Worry about recurrence and patient preferences for provider roles in collaborative breast cancer care.
Authors: Wallner Lauren P. , Janz Nancy K. , Li Yun , Friese Christopher Ryan , Ward Kevin C. , Hamilton Ann S. , Katz Steven J. , Hawley Sarah T.
Published: April 2017

158

Background: Prior studies have shown that worry about recurrence is a common problem during cancer treatment and survivorship and may be associated with symptom response and surveillance after primary treatment. However, whether worry about recurrence influences patient preferences for which provider to see for their continuing care remains unknown. Methods: A random sample of patients newly diagnosed with breast cancer in 2014-15 as reported to the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (N = 2,502, 70% response rate). Frequency of worry about recurrence was defined by asking women to indicate on a 5-pt scale how often they worried about their cancer coming back in the past month (not at all-always) and was then dichotomized as frequent worry (sometimes/often/almost always) vs. less worry (almost never/rarely). Patient preferences for which provider manages certain aspects of care after treatment were ascertained for: follow-up mammograms, screening for other cancers, general preventive care, and treatment of comorbidities. Response categories included primary care clinician (PCP), cancer doctors, either or both. The associations between patient-reported worry about recurrence with preferences for provider roles were assessed using multinomial logistic regression. Results: In this sample, 37% of women reported worrying frequently about recurrence. Controlling for patient and clinical factors, women who reported more frequent worry (vs. less worry) were more likely to prefer to see both clinicians (vs. PCP only) for mammograms (OR: 2.3, 95%CI: 1.5, 3.6), screening for other cancers (OR: 2.3, 95%CI: 1.5, 3.5), general preventive care (OR: 1.6, 95%CI: 1.1, 2.3) and comorbidity care (OR: 1.5, 95%CI: 1.03, 2.2). Conclusions: Frequent worry about recurrence was common in this sample of women with favorable prognosis breast cancer. More frequent worry about breast cancer recurrence was associated with stronger preferences for seeing both PCPs and oncologists for continuing care after treatment. Assessing and managing worry about recurrence early in survivorship may improve collaborative cancer care and reduce duplicated services after treatment.
Evidence-based guidance for peer review “best practices” in radiation oncology.
Authors: Brundage Michael Donald , O'Donnell Jennifer , Hart Margaret , Divanbeigi Lorella Divanbeigi , Gutierrez Eric , Ang Michelle , Murray Elizabeth , Warde Padraig Richard
Published: April 2017

180

Background: Peer review (PR) is an essential component of quality assurance in radiation oncology practice, endorsed by Canadian cancer agencies as a national standard of quality care. However, reported patterns of care studies indicate that PR practice varies considerably, including which contours (e.g., target volumes, organs at risk (OARs)), which dose parameters (e.g., OAR constraints, homogeneity criteria), which decision making points (e.g., decision to treat, selection of anatomical regions), and which treatment imaging parameters are included in the PR process. Both qualitative and quantitative evidence support the need for guidance on PR best practices. Here we report processes for the establishment of best-practice guidelines/minimal standards for PR. Methods: A comprehensive literature review was done to quantify PR findings for each of 3 cancer streams: head/neck, lung, and breast. This evidence summarized which aspects of radiotherapy plans were most frequently "flagged" at PR. A modified Delphi process was used to develop cancer site-specific PR guidance documents: appropriate stakeholders were first identified; a pre-meeting survey determined opinions on which plan elements are essential/important to review; a face-to-face meeting considered the evidence base and survey results to reach consensus. Parallel processes were conducted separately for each stream. Results: The literature findings were compiled to summarize the reported proportion of plans flagged by PR, and the nature of the flag (i.e. volumes, dose, OARs, other) for each cancer stream. Stakeholders included radiation oncologists, physicists, radiation therapists, and patients, specific to each stream. Draft guidance documents were created on the basis of stakeholder consensus regarding which components of PR were deemed essential; other important or “second tier” elements were also identified. Conclusions: Guidance documents including minimum standards for PR can be successfully created based on structured consensus development informed by available evidence. This guidance promises to reduce variation in PR thereby optimizing the efficiencies of PR processes, and increasing the quality of radiation treatment plans.
A priority educational program at Princess Margaret Cancer Centre.
Authors: Grant Jasmine , Sellmann Susanna , Gundry Julie , Degendorfer Pamela
Published: April 2017

189

Background: The clinical research environment is consistently evolving with new methodology, complexity and regulatory stringency. With this evolution, the need for a well-educated clinical research team is critical. There are approximately 300 clinical research staff at Princess Margaret, 100 Principal investigators. The Cancer Clinical Research Unit (CCRU) is a support department within the Princess Margaret Cancer Program and provides two dedicated staff to implement and facilitate clinical research education across the program. Methods: CCRU Education currently offers 50 unique education sessions with an average of 45 sessions per quarter. Starting in 2010, 9275 attendees have attended 892 CCRU in-class sessions. Since 2015, 224 sessions have been attended by 25 sites through teleconference. The CCRU has implemented an “Orientation Pathway” for new clinical research staff to provide clear guidance on mandatory research training activities, as well as role and task-specific training activities. In 2016, CCRU has included more workshop-style courses, providing scenario-based learning models. The CCRU uses a blend of online, in-class, and case-based learning sessions to promote critical thinking and stimulate vibrant group discussion. Interactive sessions and evaluation ensure learning needs are met. Results: Since implementing the interactive sessions, and the Orientation Pathways, the CCRU Quality Assurance department has seen a reduction of insufficient documentation findings. To measure this, the total number of Quality Assurance Review (QAR) findings on insufficient and/or incomplete documentation of the consent process was averaged and compared in 2014 and 2015 and a 25% decrease was noted. In addition, staff feedback is regularly collected through an online methods and is reviewed by the CCRU Quality-Education committee for training quality improvement. Conclusions: Positive staff feedback and a reduction of QAR findings has encouraged CCRU Education to continue creating workshop-based training sessions that are interactive, timely and effective. Efforts will continue to include CCRU-QA findings in the development of new course content to ensure staff are well trained and overall quality continues to improve.
Multidisciplinary cancer conferences as a forum for early identification of patients who can benefit from a palliative approach to care: INTEGRATE quality improvement project.
Authors: Wright Frances Catriona , Buchman Sandy , MacKinnon Marnie , Arthurs Erin , Rajmohan Yanchini
Published: April 2017

196

Background: Introducing palliative care early in the cancer journey results in a better quality of life, less aggressive care and longer survival compared to patients receiving standard care. The INTEGRATE project goal is to identify and manage patients who may benefit from palliative care earlier in their care. Multidisciplinary cancer conferences (MCCs) are scheduled meetings for oncology teams to prospectively discuss patient diagnostic tests and treatment options. In this study, we tested whether MCCs could be used as a forum to identify patients using the UK Gold Standards Framework Surprise Question (Would you be surprised if this person died within the next year?). Methods: Cancer centres volunteered to participate in a pilot project to test the efficacy of the Surprise Question at MCCs and implement a palliative model of care. Prior to initiation, a survey was completed to identify provider comfort in providing palliative care. All sites received primary level palliative care education by completing Pallium Canada’s LEAP Oncology module. Identified patients received Advance Care Planning, symptom management, referrals and standardized reporting to primary care. Results: A baseline survey showed over 50% of providers had no palliative care training. 157 providers participated in LEAP Oncology. Three MCC disease sites (Lung, GI and CNS) are participating in 3 academic and 1 non-academic cancer centres. Implementation of the Surprise Question began in February 2015 and by August 2016, 300 patients were identified out of 1086 total reviewed patients. At the CNS MCC, 100% of all glioblastoma patients were identified. The Lung and GI sites had lower identification rates (19% and 19%, respectively). Identified patients will have their healthcare utilization (community referrals, billing patterns, etc.) analyzed and final results will be synthesized by project completion in January 2017. Conclusions: MCCs appear to be an excellent forum for identifying patients who may benefit from a palliative approach to care within CNS, Lung and GI site groups. Further analysis will inform broader palliative care recommendations in Ontario.
Costs of potentially preventable emergency department use during cancer treatment: A regional study.
Authors: Panattoni Laura , Fedorenko Catherine R. , Kreizenbeck Karma L. , Greenlee Stuart , Walker Julia Rose , Greenwood-Hickman Mikael Anne , Barger Sarah , Rieke John Whitelaw , Conklin Ted , Chance Sharon , Eaton Keith D. , Guerrero Rose , Gunkel Mary , Martins Renato G. , Moorhouse Marilyn , Smith Bruce , Lyman Gary H. , Ramsey Scott David
Published: April 2017

2

Background: There is growing recognition that many emergency department (ED) visits during cancer treatment may be related to poorly controlled disease or treatment-related symptoms and could be prevented. An RCT using the Symptom Tracking and Reporting (STAR) tool for proactive symptom management decreased the percentage of patients admitted to the ED (34% vs. 41%; p=0.02). Little is known about the costs of potentially preventable ED visits in a community setting. This study examined the number and costs of ED visits and their associated diagnoses. Methods: Cancer registry records for patients in Western Washington from 2011 to 2015 were linked with claims from two regional commercial insurers. Patients diagnosed with a solid tumor and treated with chemotherapy or radiation were selected. All ED utilization was tracked for 1 year after the start of treatment. ED-related diagnoses codes were labeled “Potentially Preventable” (PP) if they mapped to the 13 symptom categories targeted by STAR (e.g. pain, nausea) and non-PP otherwise. Costs of ED visits were inflation-adjusted and include claims with ED-related procedure, revenue, and place of service codes. All subsequent inpatient costs were excluded, likely under-estimating total costs. Results: Of the 7,075 eligible patients, 2,543 (35.9%) visited the ED an average of 1.79 times. Pain (720 visits), Dyspnea (279 visits), and Nausea (232 visits) were the most common potentially preventable diagnoses; Hypertension (506 visits), Fever (230 visits), and Diabetes (215 visits) were the most common non-PP diagnoses. $1,134,254 (25.2% of the total ED costs) was spent on PP ED visits. Of PP ED visits 20.3% (178/875) resulted in an inpatient stay. Conclusions: In our community setting, at least one quarter of ED costs were potentially the result of poor symptom management. An investment in better symptom management has a significant opportunity to both improve cancer care and lower total costs.[Table: see text]
Nutritional intervention in high-risk patients receiving radiation for a broad spectrum of tumor types.
Authors: Hertel Chelsea , Harandi Amir , Connery Cliff P. , Papadopoulos Dimitrios ,   Dyson Center for Cancer Care
Published: April 2017

203

Background: Malnutrition is very common in patients receiving radiation therapy. This can result in significant weight loss, decreased functioning, depression, increased mortality, and dramatic declines in quality of life during and after treatment. Targeting patients at risk with nutritional counseling and progressive intervention can have important clinical implications. Methods: A total of 106 patients at a hospital-based cancer center getting radiation for a wide spectrum of cancers (breast, lung, gastrointestinal, genitourinary, and other types) were evaluated for individualized nutritional counseling and education. Patients with identified risk factors were deemed to be at high risk by nursing staff if meeting pre-specified criteria for weight loss ( > 2.5%), body mass index < 18.5%, and/or gastrointestinal symptoms (poor appetite, diarrhea, or constipation affecting quality of life). After high risk patients were identified by a nursing staff triage questionnaire, an automatic computer generated referral was made to the nutritionist. Results: Prior to the institution of this protocol, 13.7% of patients getting radiation therapy were noted to be at high risk and not receiving any nutritional intervention during their course of radiotherapy. However, after the initiation of adequate screening by nursing staff triggering a nutrition referral, the percentage of high risk patients without an associated nutrition consult declined to 1.1%. Conclusions: This study conveys important information for having a systemic screening process in place to identify those at risk for progressive malnutrition while getting radiotherapy for a broad spectrum of tumor types.
Association of surgical quality metrics and hospital-level overall survival for patients with head and neck squamous cell carcinoma.
Authors: Schoppy David W. , Ma Yifei , Rhoads Kim Felder , Chen Michelle M , Nussenbaum Brian , Orosco Ryan K. , Rosenthal Eben Lloyd , Divi Vasu
Published: April 2017

206

Background: Both negative margins and lymph node yields ≥ 18 from neck dissections in patients with head and neck mucosal squamous cell carcinomas (SCC) have been correlated with improved overall survival. It is unclear whether these patient-level metrics are applicable at the hospital level, and what compliance rates hospitals would need to achieve to show an improvement in survival. Methods: The National Cancer Database (NCDB) was used to identify patients who underwent primary surgery that included a neck dissection for mucosal SCC of the oral cavity, oropharynx, larynx, and hypopharynx. The percentage of patients at each institution with negative margins on primary resection and lymph node yields ≥ 18 from a neck dissection was quantified. A multivariate Cox proportional hazard regression was used to determine the association between hospital compliance rates with these metrics and overall survival. Results: There were 65,097 patients at 1,087 hospitals in the NCDB who underwent a neck dissection for mucosal SCC of the head and neck. A total of 221 hospitals (20%) had lymph node yields of 18 or higher in ≥ 80% of patients, and 137 hospitals (12.6%) achieved negative margins in ≥ 90% of patients. Patients treated at hospitals that attained the combined quality metric of ≥ 80% compliance rate with lymph node counts and a ≥ 90% compliance rate with negative margins, showed a significant improvement in overall survival (hazard ratio [HR] 0.93; 95% CI 0.89 to 0.98). This benefit in survival was independent of the patient level improvement seen from having negative margins (HR 0.73; 95% CI 0.70 to 0.75) and a lymph node count ≥ 18 (HR 0.85; 95% CI 0.83 to 0.88). Treatment at high volume or academic teaching hospitals was not independently associated with improved survival once the model controlled for margin status and lymph node count. Conclusions: Patients with head and neck mucosal SCC experience better survival when treated at hospitals achieving a combined quality metric based on lymph node counts and negative margin rates. National tracking of these modifiable quality metrics may identify facilities that would benefit from quality improvement measures.
Reliability of administrative data for evaluating the quality of systemic treatment for cancer.
Authors: Powis Melanie Lynn , Taback Nathan , Diong Christina , Enright Katherine , Booth Christopher M. , Trudeau Maureen E. , Krzyzanowska Monika K.
Published: April 2017

208

Background: There is ongoing interest in leveraging administrative data to examine quality but methodological concerns persist. We evaluated the reliability of a previously established panel of administrative data derived quality measures for systemic cancer treatment. Methods: The study cohort consisted of women diagnosed with early stage (stage I-III) breast cancer (ESBC) in Ontario, Canada, in 2010. Performance on 11 quality indicators evaluated using deterministically linked healthcare administrative databases has been reported previously. The sensitivity and specificity of these 11 indicators were examined using the chart as the gold standard. Results: The administrative cohort consisted of 6,795 women with ESBC from which a validation cohort of 705 patients was randomly selected from among patients who underwent cancer surgery at one of five hospitals chosen to balance feasibility and institutional characteristics.Sensitivity and specificity varied by indicator (Table). Reliability of some indicators may have been affected by suboptimal chart documentation in instances where care spanned multiple settings or the medical record was fragmented, or where the number of eligible patients for that indicator was low. Conclusions: Administrative data can be used to evaluate quality of systemic cancer therapy but understanding the reliability characteristics of individual indicators is essential to inform their appropriate use and interpretation. [Table: see text]
Implementing routine assessment of patient-reported outcomes in cancer care.
Authors: Mooney Kathi , Biber Joshua , Hess Rachel , Weeks Howard , Sweetenham John W.
Published: April 2017

229

Background: Value based cancer care includes measurement of value to the patient. Patient reported outcomes (PRO) are central to assessing outcomes of cancer care but systematically measuring them creates adoption and work flow issues. We report the Huntsman Cancer Institute’s (HCI) experience implementing routine collection of PROs. Methods: Patients on a quarterly basis either prior to a scheduled visit via email or at the visit via tablet, complete 5 PROMIS measures (fatigue, pain interference, anxiety, depression and physical function) administered in computer-assisted test (CAT) format. Patients also complete a current health visual analog scale and general health question. Data are automatically and seamlessly populated to the electronic health record (EHR) for clinician review at the visit and are stored within the data warehouse. Results: Roll-out began sequentially to all HCI oncology outpatient clinics in July 2016, with a new clinic added every 2 weeks. To date PRO assessment is operational in every HCI clinic with over 9,800 assessments completed by 8,600 patients. Most assessments have been completed in the clinic as at-home completion was a recent option. Time to complete assessments average 5 minutes. Findings to date demonstrate that HCI patients are within average norms for cancer patients on the measures. Approximately 3% of depression assessments were at an elevated level and automatically routed to social work for follow-up. Initial assessments will serve as the basis for tracking quality improvement initiatives in the future. Missed assessments were common during initial startup. Completion was more likely when the clinicians valued having the data during the clinic visit and made it an expectation for collection by front end staff at visit registration. Conclusions: Technology-aided patient reported outcomes can be systematically and successfully collected during outpatient care, with triage of scores beyond acceptable thresholds for follow-up. Baseline scores will serve to evaluate improvements in care over time. Critical to success are clinical champions who value and understand the scoring and interpretation of patient reported data and make staff facilitation of data collection an expectation.
A natural language processing algorithm to measure quality prostate cancer care.
Authors: Hernandez-Boussard Tina , Kourdis Panagiotis , Dulal Rajendra , Ferrari Michelle , Henry Solomon , Seto Tina , McDonald Kathryn , Blayney Douglas W. , Brooks James D.
Published: April 2017

232

Background: Electronic health records (EHRs) are a widely adopted but underutilized source of data for systematic assessment of healthcare quality. Barriers for use of this data source include its vast complexity, lack of structure, and the lack of use of standardized vocabulary and terminology by clinicians. This project aims to develop generalizable algorithms to extract useful knowledge regarding prostate cancer quality metrics from EHRs. Methods: We used EHR ICD-9/10 codes to identify prostate cancer patients receiving care at our academic medical center. Patients were confirmed in the California Cancer Registry (CCR), which provided data on tumor characteristics, treatment data, treatment outcomes and survival. We focused on three potential pretreatment process quality measures, which included documentation within 6 months prior to initial treatment of prostate-specific antigen (PSA), digital rectal exam (DRE) performance, and Gleason score. Each quality metric was defined using target terms and concepts to extract from the EHRs. Terms were mapped to a standardized medical vocabulary or ontology, enabling us to represent the metric elements by a concept domain and its permissible values. The structured representation of the quality metric included rules that accounted for the temporal order of the metric components. Our algorithms used natural language processing for free text annotation and negation, to ensure terms such as ‘DRE deferred’ are appropriately categorized. Results: We identified 2,123 patients receiving prostate cancer treatment between 2008-2016, of whom 1413 (67%) were matched in the CCR. We compared accuracy of our data mining algorithm, a random sample of manual chart review, and the CCR. (See Table.) Conclusions: EHR systems can be used to assess and report quality metrics systematically, efficiently, and with high accuracy. The development of such systems can improve and reduce the burden of quality reporting and potentially reduce costs of measuring quality metrics through automation. [Table: see text]
Treatment sequences in non-small cell lung cancer in the United States from 2014-2016.
Authors: Hess Lisa M. , Cui Zhanglin Lin , Li Xiaohong , Beyrer Julie , Oton Ana Belen
Published: April 2017

237

Background: A number of important advancements in the treatment of metastatic non-small cell lung cancer (mNSCLC) have increased and diversified options for improved patient care based on individual characteristics. The ability to tailor therapy increases the challenges related to appropriate treatment sequencing. This study was designed to describe these emerging treatment patterns following the approval of novel targeted agents. Methods: Flatiron Health OncoEMR, a nationally-representative electronic medical records database in the US, was used to evaluate treatment patterns by histology (squamous and nonsquamous). Eligible patients were 18+ years of age who initiated 2ndline therapy for mNSCLC from Dec 2014-Jul 2016. Descriptive statistics were used to characterize the clinical and demographic characteristics of the study population, treatments used by line of therapy, and treatment sequencing. Analyses were conducted using SAS version 9.2. Results: A total of 3498 eligible patients were included in this study: 51.3% male; mean age 66.6 years; 65% white; 25% squamous/70.7% nonsquamous (4.3% not specified); and 93% were treated at community practices. ALK testing was performed on 20.0%/74.8%, EGFR testing on 21.5%/79.8%, and PDL-1 on 8.6%/9.7% of patients with squamous/nonsquamous tumors, respectively. Single-agent PDL-1 inhibitors were used by 54.2% of squamous and 35.2% of nonsquamous patients in the 2nd-line setting; however, there were more than 35 (squamous) and 64 (nonsquamous) unique first-line regimens prior to single-agent PDL-1 treatment. Other 2nd-line regimens included pemetrexed (24.9% of nonsquamous patients) and gemcitabine (18.4% of squamous patients), which were preceded by 70 and 48 unique first-line regimens, respectively. Conclusions: There is interest in understanding treatment sequencing to identify the optimal sequence of care for patients with NSCLC; however, there was considerable heterogeneity in sequencing. Since few patients follow any similar trajectory of care, comparative effectiveness research will be challenged to appropriately balance groups due to insufficient patient numbers in any specific treatment sequence.
Development of cancer care episodes to measure costs for breast, colorectal, and non-small cell lung cancer.
Authors: Fedorenko Catherine R. , Kreizenbeck Karma L. , Panattoni Laura , Walker Julia Rose , McDermott Cara L. , Greenwood-Hickman Mikael Anne , Lyman Gary H. , Conklin Ted , Smith Bruce , Barger Sarah , Ramsey Scott David
Published: April 2017

29

Background: Cancer care costs are rising, creating concerns about affordability. As a result, delivery systems are creating alternative payment structures to lower costs while maintaining or improving quality. As cancer care delivery often involves multiple provider systems, measuring cost may be difficult. In response, using commercial insurance claims linked to cancer registry records, we constructed broadly applicable, reproducible, clinically relevant episodes to measure costs. Methods: Cancer registry records for patients diagnosed in Western Washington from January 2007-June 2016 were linked with claims from two regional commercial insurers. Patients are age 18+, diagnosed with breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) and enrolled with a single insurance plan. With oncologist input, we constructed three care phases: diagnosis (30 days before diagnosis to first treatment), initial treatment (first treatment through first 4 month treatment gap), and end of life (last 30 days). Costs include all claims paid within the phase (2016 inflation adjusted). Supportive care includes colony-stimulating factors, blood transfusions, antibiotics, antivirals, antifungals, and antiemetics. Results: This study included 8,727 patients at diagnosis, 7,686 during treatment, and 1,736 at end of life. Diagnosis phase averaged 54 days and cost $6,936 (SD $11,761, median $4,021). Treatment averaged 126 days, with costs of $61,148 (SD $75,432, median $35,750). Average end-of-life costs were $15,829 (SD $30,222, median $2,347). The table below provides an example of the variation in costs during the treatment phase using local-stage tumors. Conclusions: Clinically relevant episodes of care and cost measures can be constructed using claims-registry data. This allows for identification of high-cost care categories and areas with large-cost variability, which may be helpful when designing value-based reimbursement programs or identifying areas for potential cost-reduction.[Table: see text]
Toxicity of high-dose interferon for high-risk melanoma in Ontario: A population-based study of health services use.
Authors: Hanna Timothy P. , Baetz Tara D. , Xu Jianfeng , Miao Qun , Earle Craig , Peng Yingwei , Booth Christopher M. , Petrella Teresa M. , McKay Douglas , Nguyen Paul , Langley Hugh , Eisenhauer Elizabeth A.
Published: April 2017

31

Background: While High-Dose Interferon (HDIFN) is the sole approved adjuvant systemic treatment for melanoma in Ontario and many other jurisdictions, it is toxic, of modest benefit, and costly. We sought to assess the population-level impact of toxicity, particularly neuro-psychiatric toxicity. This can inform value assessment for the adjuvant treatment of melanoma. Methods: This was a retrospective population-based registry study of all patients with melanoma receiving adjuvant HDIFN in Ontario 2008-2012. HDIFN receipt was determined from provincial drug-funding data. Toxicity was investigated through health services use compatible with HDIFN toxicity (e.g. mental health physician billings). Associations between early HDIFN discontinuation and health services use were examined. Using stage data reported from cancer centers on a subset of patients, propensity matched analysis compared utilization in stage IIB-IIIC patients that did and did not receive HDIFN. Results: Of 718 patients receiving HDIFN, 12% were ≥65 years, 83% had little or no comorbidity. One third had ≥1 toxicity-associated utilization within one year of starting HDIFN. 364/420 (87%) of utilization was mental health-related: 54% were family practitioner visits, 39% psychiatrist visits. Early drug discontinuation was more likely with pre-existing mental health issues in multivariable analysis (OR 2.0 (1.1,3.4)). In propensity matched analysis, HDIFN patients were more likely than untreated matched controls to have mental health utilization (51% vs. 42%, p=0.01) between 1 year pre-melanoma diagnosis to 2 years post. Conclusions: Mental health services use is common among stage IIB-IIIC patients with melanoma, especially with HDIFN. This emphasizes an important survivorship issue for these patients, and for those receiving HDIFN, and impacts the value of care. Pre-treatment mental health services use is associated with treatment discontinuation. This is important when contemplating the value of HDIFN use for individual patients. For those receiving HDIFN, optimal support must include mental health care.
Radiation therapist (RT) perceptions and practices related to safety culture (SC) and error reporting in radiation oncology.
Authors: Hashemi David , Woodhouse Kristina Demas , Monzon Brian , Rosenthal Seth A. , Vapiwala Neha
Published: April 2017

42

Background: The delivery of radiotherapy is complex and demands careful management, high vigilance, and precise coordination of clinical personnel. RTs are at the frontline and are often first to discover or report an error. However, few studies have examined RT patient safety practices. We conducted a national survey to explore the attitudes, training, and experiences of RTs related to safety in radiation oncology. Methods: In 2016, an electronic survey was sent in June and July to a random sample of 1,500 RTs (~10% of licensed RTs in the US). The survey assessed department SC, error reporting, knowledge, and practices. Questions were multiple choice or recorded on a 5-point Likert scale. Results were summarized using descriptive statistics and analyzed using multivariate logistic regression. Results: A total of 702 RTs from 48 states (47% response rate) completed the survey. Respondents represented a broad distribution across practice and geographic settings with varying levels of work experience (see table). Most RTs gave their department a “Patient Safety Grade” of Excellent (61%) or Very Good (32%), especially if they had an Incident Learning System (ILS) (OR: 2.0). Most departments (58%) had an ILS; however 59% of RTs had not reported an event in the previous year. When an error occurred but did not result in patient harm, 39% of RTs said they would report it and 37% said they would not. Bullying was reported among 17% of respondents; 40% reported that burnout, stress, and anxiety negatively impacted their ability to effectively treat patients. RTs reported errors were more likely to occur with longer work days (>8hrs) and poor multidisciplinary communication during handoffs and transitions. Most (62%) reported they could benefit from additional patient safety education and training, indicating significant interest in this topic. Conclusions: The majority of RTs reported excellent SC practices within their treatment facilities. Most facilities had systems in place to report errors. The obstacles identified, the results of this study may inform future educational efforts and safety initiatives directed towards RTs and should help increase awareness of patient SC in radiation oncology.
Improving oral chemotherapy adverse event reporting: Listening to pediatric oncology patients and parents.
Authors: Zerillo Jessica A. , Barysauskas Constance , Catalano Paul J. , Jacobson Joseph O. , Billett Amy
Published: April 2017

45

Background: Medication-related adverse events and near misses are underreported, particularly in the ambulatory setting. Our aim was to assess pediatric oncology parent and patient-reported oral chemotherapy errors and near misses. Methods: A survey of parent and patient-reported oral chemotherapy errors and near misses over the past month was developed and validated in a subgroup and administered to parents/patients at an academic pediatric hematology-oncology clinic. Parents and patients were included if the patient received any commercially available oral chemotherapy agent within the past month, dispensed by an onsite retail pharmacy, and agreed to participate. Results: Forty-eight of 69 parents and 11 of 17 patients responded (ten from the same household). Fifteen of 59 respondents (25%) reported at least one event, miss, or error (twelve (25%) parents and three (27%) patients). Of five events described by parents and patients of the same household, one was co-reported. Of the errors that occurred in the home, the most common were missed (n=5, 8%) and late (n=3, 5%) doses. Forty-six percent of respondents did not report events to the medical team. Two respondents perceived minor harm as a result of the event. Conclusions: Patients and parents are willing to share information about oral chemotherapy-related adverse events and near misses. Twenty-five percent of respondents noted an oral chemotherapy event, near miss, or error over the preceding month. Importantly, many of these events were unreported to care teams. Missed doses were the most common safety event, and interventions should target this need.[Table: see text]
Reviewing systemic treatment regimens to reduce unintentional errors.
Authors: Crespo Andrea , Redwood Erin , Vu Kathy , Kukreti Vishal
Published: April 2017

51

Background: Use of systemic treatment computerized prescriber order entry (ST CPOE) and pre-printed orders (PPO) are proven error reduction measures. Such systems are not failsafe, as regimen development depends on cognitive input at critical points and is susceptible to human error. No known guidance currently exists in oncology to ensure regimens are of high quality and built as intended. The purpose of this initiative was to improve the quality of oncology regimens in Ontario. Methods: A review of 35 centres, representing 75 treatment centres in a hub-and-spoke model, was conducted for all active regimens (PPO and CPOE) to ensure they were built as intended, with respect to drugs and doses. Centres completed an exploratory survey to report any unintentional discrepancies and existing maintenance review processes. The survey collected centre demographics and contained descriptive questions to document details of the regimen review and maintenance processes. Results: The review yielded an 86% response rate (12 regional and 18 community cancer centres). Upwards of 700 regimens were reviewed by a multidisciplinary team at each participating centre. Unintentional discrepancies were reported by 7 of the 30 (23%) centres (range of 2 – 141 per centre); types and examples are presented in the Table. Only 2 of 30 centres (7%) had an established regimen maintenance process. Conclusions: The review identified unintentional discrepancies and, due to the potential for patient harm, corrective action has been taken. There is a need for guidance and adoption of a standardized approach in order to sustain a high-quality regimen build and review process across the province. Consensus-based recommendations for ST CPOE and PPO regimen development and maintenance have been developed. Identified discrepancies have been amended and maintenance review processes are now implemented to improve the quality and safety of systemic treatment delivery. [Table: see text]
Improving documentation of surrogate decision makers in medical oncology clinic.
Authors: Wong Melisa L. , Borno Hala , Mahajan Reena , Bischoff Kara E. , Calton Brook , Bergsland Emily K. , Kim Won , Aggarwal Rahul Raj , Tsai Katy K. , Cinar Pelin
Published: April 2017

63

Background: Advance care planning (ACP) is an important component of high quality care for cancer patients. A measurable and early step in the ACP process is for patients to identify a surrogate decision maker and document this information in the medical record. Methods: To improve documentation of surrogate decision makers for stage IV cancer patients, we designed a hematology/oncology fellow-led multidisciplinary quality improvement (QI) initiative including: 1) ACP education for fellows, 2) ACP patient education materials and online resources, and 3) standardized note templates for surrogate documentation. We aimed to document surrogate decision makers or discussions for > 50% of stage IV cancer outpatients evaluated by a fellow cumulatively over the 2016-2017 academic year. Patients seen for second opinion visits were excluded. Audit and feedback of individual fellow and group results were conducted twice a month. During each audit period, we randomly selected 2 medical oncology clinic sessions per outpatient fellow and reviewed all new patient and follow-up notes for surrogate decision maker documentation. Results: Prior to implementation, baseline surrogate decision maker documentation by fellows was 2% (1 out of 55 stage IV cancer patients seen during 2 randomly selected clinic sessions per outpatient fellow from January to March 2016). Since implementation in July 2016, 20 fellows have participated during outpatient rotations. During randomly selected clinic sessions from July to October 2016, 156 eligible stage IV cancer patients were evaluated by fellows. Surrogate decision makers or discussions were documented for 64 patients (41%). Overall, fellows felt comfortable discussing surrogate decision making with patients but often forgot to address it during the visit. Conclusions: Our fellow-led QI initiative improved surrogate decision maker documentation for stage IV cancer patients from 2% to 41%. A centralized ACP navigator (which includes a surrogate decision maker section) was recently added to our electronic medical record. As part of the ongoing efforts to achieve our cumulative goal, we will leverage this new feature to engage clinic staff in documentation of surrogate decision making as well.
Real-world treatment patterns and characteristics in patients with chronic lymphocytic leukemia.
Authors: Schenkel Brad , Rider Alex , Macomson Brian , Hallworth Pam
Published: April 2017

65

Background: CLL is the most prevalent form of adult leukemia. In recent years, there have been a number of newly approved therapies for the management of patients with CLL in both the 1st line (1L) and relapsed/refractory settings, including ibrutinib (approved for 1L CLL, March 2016). Methods: USphysicians involved in CLL treatment decision-making were recruited into the Adelphi CLL Disease Specific Programme (February-May 2016). Physicians completed record forms on consecutively presenting patients > 18 years currently on active CLL treatment. Descriptive statistics analyzed demographics, clinical characteristics, and antineoplastic treatment patterns. Results: 700 patients diagnosed with CLL for an average of 3.0 years were captured. Patients’ mean age was 68.3 years, 53% were male, 75% were Caucasian, 25% had 17p deletion, and 55% were Medicare insured. Of the 81 physicians, 35% were based in an academic hospital setting, 51% in a non-academic hospital setting, 4% in both, and 9% were office-based. Within the overall cohort, BR was the most common 1L regimen (25%), while ibrutinib was the most common 2nd line (2L) regimen (42%). Among patients with 17p deletion, BR was the most common 1L regimen (25%) and ibrutinib was the most common 2L regimen (50%). Older patients ( ≥ 65) were most likely to receive BR at 1L (28%), while 1L younger patients ( < 65) received FCR (24%). Conclusions: This analysis of real world treatment patterns identified BR, FCR, and ibrutinib as the most common 1L regimens in US CLL patients. Ibrutinib, BR, and idelalisib + rituximab were the most common 2L regimens. Choice of therapy varied depending on age and 17p deletion status. For example, FCR was more frequently used as 1L therapy in patients < 65 years, and the proportion of ibrutinib use as 1L therapy was higher in those with 17p deletion. [Table: see text]
Administration of the ASCO Pain Survey to identify patient education deficiencies in patients with cancer.
Authors: Hagmann Chelsea , Ma Joseph , Cramer Arlene , Russell Michelle , Dullea Alexandra , Cohen-Arazi Yael , Roeland Eric
Published: April 2017

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Background: The Doris Howell Palliative Care (PC) Outpatient Consultation Service consists of a multidisciplinary team. Reasons for consultation include pain management, treatment of other physical symptoms, education about non-drug options for pain, and advanced care planning. To assess methods used for patient education, the PC team administered the ASCO pain survey to those prescribed opioid pain medications. Methods: The survey was a 26-item questionnaire evaluating patient education content communicated by a provider to a patient during a routine clinic visit. Twenty surveys were completed anonymously. After survey review, the outpatient PC team developed an intervention to address patient education concerns. The intervention consisted of written and verbal instructions on pain medication management reviewed by the PC nurse with the patient and/or caregiver at the end of the outpatient visit. Another twenty surveys were completed anonymously with patients after intervention implementation. Time required to complete the intervention was less than two minutes per patient. The Fisher’s exact test was used to analyze the differences between surveys completed with or without the intervention. Results: The majority of patients stated that his/her provider adequately explained the use (n = 40, 100%), side effects (n = 37, 93%), and storage (n = 32, 80%) of pain medications, regardless of the intervention. Both groups also indicated that the provider and/or nurse adequately explained the risks associated with medical history (n = 34, 85%) and other medications while taking pain medications (n = 33, 83%). The intervention did increase understanding to avoid sharing pain medications (75% vs. 85%, p < 0.05) and to use a lock box to secure pain medications (45% vs. 60%, p < 0.05). Additionally, asking patients if family members have a history of alcohol or substance abuse was also significant (p < 0.05). Conclusions: Written and verbal instructions as an intervention improved patient understanding to avoid sharing pain medications and to secure pain medications in a lock box.
Pharmaceutical assistance foundations in the financing of cancer care.
Authors: Mitchell Aaron Philip
Published: April 2017

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Background: The rising cost of cancer drugs may make treatment unaffordable for some patients. Patients often rely on drug manufacturer-administered Pharmaceutical Assistance Programs (PAPs) to obtain drugs at reduced or no cost. The overall impact of PAPs on cancer care delivery is unknown. Methods: We identified all patients obtaining cancer drugs across an academically affiliated, integrated health system in the state of North Carolina during 2014. The proportion of patients receiving PAP assistance, and the retail value of the assistance, were quantified for each oncology drug. Cancer drugs were analyzed with respect to route of administration. Results: 215 unique patients submitted a total of 478 successful PAP requests for cancer drugs. The majority of the retail value of drugs obtained was for oral cancer drugs, particularly targeted therapies including tyrosine kinase inhibitors. Among all cancer patients who received medical treatment, 5.5% required PAP assistance, whereas 10.6% receiving an oral agent required PAP assistance (Table). The proportion receiving PAP assistance varied substantially by drug, ranging from <1% of patients (e.g., carboplatin, methotrexate) to 50% of patients (e.g., ponatinib, temsirolimus). Patients obtained a total of $1,556,575 of imatinib and $1,449,633 of dasatinib, which were the two drugs with the highest aggregate retail value. 40% of PAP-utilizing patients were uninsured, 26% had Medicaid coverage, 20% had Medicare coverage, and 14% were commercially insured. Conclusions: A substantial proportion of patients with cancer receive private charitable assistance through PAPs in order to obtain standard-of-care treatments. In particular, a disproportionate share of patients treated with orally-available cancer drugs require PAP assistance. This includes patients with federal and private insurance, suggesting an inability of patients to meet cost-sharing requirements. [Table: see text]
Determining needs for nonmedical support during cancer care.
Authors: Neuss Michael N. , Shyr Yu , Washburn Anne , Elliott Stephanie L , Carson Kristin , Carson Kate , Friedman Debra L.
Published: April 2017

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Background: The need for supportive care services during cancer treatment appears obvious but ranges from 7 to 100% are reported. (McMurray 2001) (Soothill K, 2001). The Commission on Cancer (CoC) requires programs to assess these needs. We report on the rates of identified needs and our survey methodology. Methods: VICC members developed a 41 element survey to assess financial, emotional, and educational needs. Surveys were made available to patients with instructions, but no facilitators (Method 1). Then the same surveys were personally given to patients by two trained research coordinators who randomly selected, instructed and helped patients to complete the survey (Method 2). We report the responses using the two study methodologies. The difference between the two studies was examined using the two-sided chi-square test. Results: Results are presented in Table below. Conclusions: The rate of self-reported need for supportive and educational services in our study was small, but a meaningful minority of patients require assistance with supportive care. Simple unsupervised surveys led to results which were very similar to those supported by more complex and expensive methodologies. These data will inform the design of future survey methodology as well as intervention targets for patient navigators. [Table: see text]