bluuebunny/crossref_metadata_2025 huggingface dataset:
A novel global health fellowship elective in oncology in Rwanda: A multi-faceted model in education.
Authors: Lansigan Frederick , Costa Cristiana A. , Mpanumusingo Egide , Kigonya Catherine , Butonzi John , Sebahungu Fidel , Shyirambere Cyprien , Mpunga Tharcisse , Haley Jennifer , Figueroa Kurt , Park Paul , Davis Thomas H. , Chamberlin Mary D.
Published: September 2018

e18086

Background: Despite the rising burden of cancer, opportunities for global health education (GHE) at the fellowship level are lacking in hematology and oncology (HO). The Geisel School of Medicine at Dartmouth (GSMD) is pioneering a supervised one-month elective in Rwanda for HO fellows enrolled in U.S. programs. The goals are to expose fellows to a wider spectrum of disease states, improve clinical acumen, cultural sensitivity, and learn about health delivery in low-resource countries, while providing educational support for the local staff in a multidirectional learning paradigm. Methods: In partnership with the Rwandan Ministry of Health (MOH) and Partners in Health (PIH), GSMD created a one month elective rotation at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda. HO Fellows with an interest in GHE apply to work in the outpatient clinic and inpatient wards in at BCCOE under direct supervision by GSMD faculty to provide input on cancer management including diagnosis, treatment, and chemotherapy administration. Fellows and attendings give lectures to hospital faculty and staff on topics requested by the leadership of BCCOE and participate in weekly telemedicine tumor boards. Fellows are evaluated using ACGME clinical competencies. Feedback from the Rwandan staff is obtained through customized evaluations. Results: The HO fellow gained exposure to advanced cancers including HIV-related malignancies, rare sarcomas and gestational trophoblastic disease, adhered to locally developed staging and treatment pathways, and gained confidence in guiding medical decisions. Fellows and faculty gave didactic presentations and provided bedside teaching. The local MOH and PIH staff gained new insight about approaches to management of complex disease states. This program promoted a multidirectional exchange of ideas related to patient care, disease states, and collaborative research projects. Conclusions: The institution of a global health fellowship elective in oncology has measurable benefits to HO fellows, cancer care providers in Rwanda and American faculty sub-specialists. This novel educational program will help to bridge the gap in global health disparities in a multifaceted approach.
Effects of patient navigation on satisfaction with cancer care: A systematic review.
Authors: Jean-Pierre Pascal
Published: September 2018

e18088

Background: Patient navigation (PN) is a model of health care coordination designed to ameliorate health disparities by reducing barriers to achieving optimal health outcomes. Systematic reviews that evaluate whether PN is associated with higher patient satisfaction with cancer care are lacking. Methods: We conducted a systematic review to synthesize evidence of comparative studies evaluating the effectiveness of PN programs to improve satisfaction with cancer-related care. We included studies reported in English that: 1) evaluated a PN intervention designed to increase satisfaction with cancer care; and 2) involved a randomized controlled trial (RCT) or observational design. We abstracted data from studies using standardized forms, and evaluated these studies for methodological quality. Data were summarized qualitatively and synthesized under a random effects model. Results: The initial search yielded 831 citations, of which 3 RCTs and 6 observational studies met inclusion criteria. These nine studies involving 4,200 surveyed patients revealed either a neutral or positive effect in patient satisfaction in the majority of studies of PN and cancer-related care. However, only 5 studies (1 RCT and 4 observational) had adequate datato include in the meta-analysis. Methodological quality of eight of the included studies ranged from weak to moderate to strong, with half rated as weak. Findings of the RCT showed a statistically significant increase in satisfaction with cancer care involving PN [standardized mean difference (SMD) = 2.30; 95% Confidence Interval (CI): 1.79, 2.80, p < .001]. Pooled results from non-RCTs showed no significant association between PN and satisfaction with cancer-related care (SMD = 0.39; 95% CI: -0.02, 0.80, p = .06). Conclusions: More systematic reviews are needed to characterize the relationship between PN and satisfaction with cancer-related care across the cancer care continuum and across different types of cancer.
Treatment related mortality (TRM) for AML pts managed at a non-transplant, safety net hospital.
Authors: Goparaju Krishna , O'Brien Timothy E.
Published: September 2018

e18092

Background: Induction treatment for AML is associated with severe, life threatening toxicities. An accepted criterion for TRM is the 4 week mortality rate. A recent 18 yr study of AML pts treated with 3+7 induction regimens at SWOG institutions revealed an overall TRM at 4 weeks of 11%. Management of AML pts at non-transplant centers is controversial due to concerns over lower volumes, possibly leading to excess TRM. Over a 15-year period TRM was evaluated at a safety net, non-transplant center and compared to a national benchmark. Adherence to national guidelines for diagnostic testing was also assessed. Methods: MetroHealth Medical Center is a safety net hospital with a mission statement requiring all pts to be seen regardless of their ability to pay. Using tumor registry data, all cases of AML from 2001- 2016 were identified. Demographic data, 4 week TRM and compliance with standard diagnostic evaluation per NCCN guidelines were assessed.. Results: 67 cases were identified; average age was 59 (25-89), with equal distribution in gender. 73% were Caucasian, 18% African American, 4.5% Asian and 4.5% Hispanic. All but one (who went into hospice) had standard diagnostic tests sent (flow cytometry, cytogenetics and, for those with normal karyotyping, all had molecular testing for FLT-3 ITD, NPM-1, CEPBA and c-kit). Of the 67 patients, 5 received azacitadine, 2 received decitabine and 12 did not get treated due to co-morbidities and/or poor performance status. 48 patients received induction chemotherapy, of which 5 had APL appropriate therapies and the rest (43) received 3+7 induction regimens. For these 48 pts the 4 week mortality was 10%. Of those who received induction chemotherapy, 27% had favorable, 23% intermediate and 50% had poor risk molecular studies. Conclusions: A 15 yr review of outcomes during AML induction at a non-transplant, safety net institution revealed a TRM rate similar to a national benchmark, in spite of a relatively high percentage of poor risk cases. There was also good adherence to national diagnostic standards. Given the potential changes in the US healthcare delivery system which may result in more pts being seen at safety net institutions, these findings may have implications for future allocation of care.
New and emerging therapies for relapse/refractory multiple myeloma: Impact of education on practice behaviors.
Authors: Roc Anne , Turell Wendy , Dingli David
Published: September 2018

e18096

Background: Newly approved and emerging agents with novel mechanisms of action present unique challenges to treating patients with relapsed/refractory multiple myeloma (RRMM), including keeping abreast of rapid and ever-aggregating data on their safety, tolerability and efficacy. To address these challenges, an education activity focused on new and emerging therapies for RRMM was developed and learner responses were evaluated to determine the impact of education. Methods: A live-online 1-hour video panel discussion with slides, polling, and live questions was produced in 2016 and made available on-demand at OMedLive.com for 6 months. Survey responses (pre-, post-, 8 weeks post-activity), polling responses, and live questions asked were tracked to measure engagement, lessons learned, and additional education gaps. Results: 51 of 288 learners completed all pre/post/follow-up surveys, 67% of which reported the activity positively impacted patient experience or outcome and 61% reported it positively impacted their clinical practice. These learners reported improvements in their ability to: assess the relative safety and efficacy of emerging agents (50%), differentiate available agents and their relative efficacy (50% with proteasome inhibitors, 39% with monoclonal antibodies), see the potential benefit of HDAC inhibitors (35%), use combination regimens (29%), and adjust treatments for patients who’ve experienced disease progression (29%). As the result of education, 95 of 288 learners reported commitments to change in regards to: medical/practice knowledge (95%), care attitudes (89%), practice behavior (76%), and patient clinical outcomes (81%). Learners also demonstrated improved competence via a case scenario which required identifying the optimal next step for a patient with biochemical progression, and improved knowledge on the characteristics of daratumumab, elotuzumab, and selinexor. Conclusions: New and emerging therapies promise to improve the lives of patients with RRMM, but complicates the already difficult task of managing the disease. Ongoing education on RRMM is recommended and can yield immediate and sustained gains in knowledge, competence, and performance.
Association of diabetes with colorectal cancer treatment and outcomes.
Authors: Iyengar Arjun , Gold Heather Taffet , Nicholson Joseph , Becker Daniel Jacob
Published: September 2018

e18112

Background: Diabetes mellitus (DM) is associated with an increased incidence of colorectal cancer, but the impact of diabetes on colorectal cancer (CRC) prognosis and treatment patterns remains unknown. As outcomes in both CRC and DM have improved, appropriate co-management of the two diseases has become a priority to help patients live longer and healthier. Methods: A systematic search of PubMed, Embase, and CINAHL databases was performed to evaluate/assess the association of diabetes with colon cancer treatment patterns and outcomes, including recurrence rates (RR), disease free survival (DFS), colon cancer-specific (CSM) and all-cause mortality (ACM). We included English language peer-reviewed studies through November 2016 following the preferred reporting items of systematic reviews and meta-analyses (PRISMA) method. We applied STROBE quality criteria and conducted a random-effects meta-analysis. An inconsistency index (I2) was used to estimate the heterogeneity between studies. Results: After reviewing 2,611 reports, 35 studies were included that described an association of DM with CRC treatment patterns or outcomes. A meta-analysis of 14 studies that assessed (ACM) among 146,129 patients demonstrated an increased risk for ACM for CRC patients with DM (OR 1.28, 95% CI 1.16-1.42, I2 = 80%, P < .00001). No statistical significance was found in comparing 4 studies that looked at CSM (OR 0.91, 95% CI .72-1.14, I2 = 89%, P = 0.42). Analysis of 4 studies that assessed DFS found lower DFS in patients with DM (OR 1.75, 95% CI 1.33-2.31, I = 3%, P < .0001). Aggregating 3 studies that evaluated RFS demonstrated no clear association of DM and RFS(OR 1.12, CI 95% 0.91-1.38, I = 64%, P = .27). No consistent treatment discrepancies were noted in 6 studies that assessed the impact of DM on various CRC treatment modalities (receipt of surgery, chemotherapy, radiation). Conclusions: CRC patients with diabetes are at a greater risk for ACM and have worse DFS compared to those without DM. Analysis was limited due to study heterogeneity. We did not find consistent evidence that CRC is treated differently in patients with DM. Further study is warranted to clarify the mechanism of poor outcomes in CRC patients with DM and to improve survival.
Precision oncology experience at a tertiary care center.
Authors: Sadaps Meena , Funchain Pauline , Grivas Petros , Estfan Bassam N. , Abraham Jame , Stevenson James , Pennell Nathan A. , Khorana Alok A. , Bolwell Brian James , Sohal Davendra
Published: September 2018

e18118

Background: Precision oncology – use of tumor genomic profiling to guide therapies – is widely discussed but with limited real-world data. We have previously reported our prospective study on feasibility and clinical utility of routine somatic genomic testing of solid tumors [ J Natl Cancer Inst. 2015; 108(3)], and here we report our longitudinal experience, focusing on therapeutic impact. Methods: Records were reviewed for consecutive adult patients seen at Cleveland Clinic for a solid tumor malignancy without known curative options where tumor genomic profiling was ordered using FoundationOne™ (Cambridge, MA). Results were discussed at the Cleveland Clinic Genomics Tumor Board, and therapeutic recommendations were conveyed to the primary oncologist. Data for this cohort study approved by the Cleveland Clinic IRB included subsequent therapies and clinical outcomes. Results: From 2013 to 2016, 330 patients had tumor genomic testing ordered. Median age was 61 years (range, 24-94); 170 (51.5%) were female; 289 (87.6%) were Caucasian. Colorectal (21.5%), breast (17%), lung (16.1%), and pancreatobiliary (11.5%) cancers were the most common diagnoses. In 300 resulted cases, a median of 4 (0-20) alterations per specimen were noted; the most commonly altered genes were TP53 (n = 174), KRAS (n = 75), APC (n = 65), CDKN2A/B (n = 49), and PIK3CA/ PIK3R (n = 46). A specific therapy targeting an actionable alteration was recommended in 51% (153/300) of patients, and 11.7% (n = 35) received such therapy: 14 on clinical trials, 5 on-label, and 16 off-label. Most common targets for therapy were PIK3CA/PIK3R/PTEN (n = 7), HER2 (6), BRAF (3), EGFR (3), and ALK, FLT3, NTRK1 and RET (2 each). At last follow-up, of 35 patients receiving targeted therapy, best responses were: complete response (n = 1, 2.9%), partial response (n = 5, 14.3%), stable disease (n = 14, 40%), progressive disease (n = 11, 31.4%); data not available for 4 patients. Non-availability of clinical trials was a common reason for non-receipt of targeted therapy. Conclusions: Tumor genomic profiling influenced treatment in 11.7% of patients in this cohort, and 57% of those receiving targeted therapy experienced clinical benefit. These data can help guide real-world discussions of precision oncology.
Formal assessment of teamwork among cancer health care professionals in 3 large tertiary centers in Nigeria.
Authors: Ibraheem Abiola Falilat , Awolude Olutosin Alaba , Habeebu Myhammad-yaqub Murtazha , Sowunmi Anthonia Chima , Olaniyi Popoola Abiodun , Olopade Olufunmilayo I. , Polite Blase N.
Published: September 2018

e18126

Background: Cancer is fast becoming a common cause of death in developing world. Over the last decade, there have been strategies to bring quality cancer care to underserved patients around the world. In low-income countries, poor utilization of principles of teamwork is a major barrier to achieving quality services. The intent of this study is to assess teamwork as perceived by the health care workers caring for cancer patients Methods: We conducted a survey among health care professionals involved in cancer care in 3 tertiary centers in the southwestern part of Nigeria from July to November 2016. Respondents rated teamwork using the previously validated ÒSafety Attitudes QuestionnaireÓ. For this analysis we focused on the teamwork climate subscale. This subscale is scored on a scale of 0-100 with mean (SD) values,in US ambulatory population of 69.7 (17). We compared ratings by professionals using analysis of variance Results: Overall 373 professionals completed the survey: Physicians (47%), nurses (14%), pharmacists (6%) and others (33%). Some results are shown in table Conclusions: Cancer care is complex and depends on teamwork amongst health care professionals to achieve optimal outcomes. While overall teamwork scores was consistent with US ambulatory studies , there are important variations that provide targets for intervention. Physicians rated teamwork poorly both intra and inter professionally. Pharmacists rated inter professional teamwork with nurses particularly poorly. Further data on additional subscales of the instrument and by individual centers will be presented. Efforts to transform cancer care need to focus on building trust among the key stakeholders. This is true in developing world where there is a need to maximize the use of limited resources to improve patient outcomes. [Table: see text]
Evaluation of an online tool providing management guidance for adverse events associated with immune checkpoint inhibitors.
Authors: Marcello Krista , Obholz Kevin , Rosenthal Kristen , Weber Jeffrey S.
Published: September 2018

e18131

Background: Immune checkpoint inhibitors (ICIs) are altering the treatment paradigm in oncology; but many healthcare providers (HCPs) are still unfamiliar with ICIs and the unique associated immune-related adverse events (irAEs). An online tool was developed to give HCPs easy access to fair-balanced guidance and algorithms that extend beyond standard recommendations found in the respective product inserts. Methods: Tool users input patient symptoms, organ system affected, and the grade of the event along with their planned management strategy; they were then provided an expert recommendation to guide management of that specific irAE. Recommendations in the tool comprised algorithms developed from peer-reviewed studies and personal clinical experience of several experienced physicians. Case entries (collected from 11/9/16 through 1/17/17), variation of intended management with recommended management, and impact on practice were analyzed. Results: To date, 918 unique tool queries have been entered by HCPs. Cases of GI symptoms were most frequently (29% of all cases) entered into the tool (Table). The planned management of pulmonary- and endrocrine-related AEs differed from expert recommendations for the highest percentage of cases (53% and 65%, respectively). Overall, the intended management plans differed from expert recommendations in 49% of HCP tool queries. Most (93%) HCPs indicated that this online tool either changed their management plan or that their planned strategy was reinforced by using this tool. Conclusions: These data suggest that many HCPs are challenged to manage irAEs associated with ICIs and that an online tool can provide a resource to improve patient care and safety. A detailed analysis of the tool, including case entries and planned management vs expert recommendation for each irAE and grade will be presented. [Table: see text]
The Cancer Care Treatment Outcomes Ontology (CCTO): A computable ontology for profiling treatment outcomes of patients with solid tumors.
Authors: Lin Frank Po-Yen , Groza Tudor , Kocbek Simon , Antezana Erick , Epstein Richard J
Published: September 2018

e18137

Background: Systematic enhancement of knowledge about outcomes of cancer therapy is a central goal for oncology research, practice and audit. However, there is no resource standardizing the disparate vocabulary used to describe treatment outcomes, which prevents translating the data acquired into value-adding information for better cancer care. Methods: To build an application ontology that organizes high-level concepts describing treatment outcomes in solid tumors, provisionally named Cancer Care Treatment Outcomes (CCTO), we extracted all trial endpoints listed in ClinicalTrials.gov, queried it using the keyword ‘cancer’, followed by an expert appraisal. Term definitions and synonyms were automatically imported from the National Cancer Institute thesaurus, and extra terms were imported from Common Toxicity Criteria for Adverse Events. Logical relationships between concepts were represented by forward chaining rules, aiding conversion between concepts. The coverage of CCTO was tested against MEDLINE abstracts, and the applicability of 1825 rules was tested in a case of metastatic colon cancer (index case). Results: After removing duplicated terms from 54705 trial entries, an ontology (CCTO), holding 1145 terms and organized into 13 concept groups (including but not limited to efficacy, safety, and quality of life), was built. CCTO not only captures a comprehensive taxonomic hierarchy (through is_a relationships) but also an evaluative hierarchy ( is_assessed_by) to aid the acquisition of treatment outcome data. At least one CCTO term was mentioned in 29493 of 29951 (98%) MEDLINE abstracts on phase 1-3 cancer trials; concepts about efficacy were mentioned in 7208 (79%) phase 1, 15051 (92%) phase 2, and 3884 (86%) phase 3 trials. We show that, by applying the relationship rules in an expert system shell, the event sequence of the index case can be readily converted into a comprehensive profile that incorporates survival measures, treatment responses, and adverse events. Conclusions: CCTO efficiently captures and categorizes high-level concepts of treatment endpoints in oncologic practice and enables rapid profiling of clinical outcomes for cancer patients.
Prognostic significance of geriatric assessment.
Authors: Edwards Beatrice Jara-Almonte , Zhang Xiaotao , Sun Ming , Song Juhee , Dinney Colin P.N. , Popat Uday R. , Champlin Richard E. , Valero Vicente , Tripathy Debu , Hedberg Ann-Marie , Stroehlein John R
Published: September 2018

e18140

Background: More than 60% of cancer patients are older adults, and by 2020 the proportion of older adults with cancer will rise to 70%. Objective: To assess risk factors for overall survival (OS) in older cancer patients seen in a comprehensive cancer center. Methods: This is a single center, retrospective cohort study of older cancer patients (65 years of age and older). Patients receiving active cancer care underwent comprehensive geriatric assessment (including cognitive, mood, functional, nutritional, physical, and comorbidity assessment using validated scales). Hematologic, and solid tumors (urologic, breast, gastrointestinal cancers) were evaluated. Targeted interventions were implemented. Analysis: Univariate and multivariable Cox proportional hazards regression analysis were performed to identify factors associated with OS (SAS 9.4). Results: Among 304 eligible patients, the median follow-up was 12.7 months, 98 (32%) died, the median OS was 25.4 months. Median age is 78 years. Univariate analysis revealed known risk factors for mortality (advanced age [p = 0.004], and metastatic disease [p = 0.002]), functional impairment (ADL scores 0-4, p = 0.02), and major depression (p = 0.005). Comorbidity (p = 0.07) and functional impairment showed a marginal significance on OS. Factors with a univariate p-value less than 0.1 were considered in multivariable regression models. A final multivariable model included age group, cancer stage, functional impairment, and major depression. Risk factors for OS include major depression (HR 1.88 (95% CI, 1.12, 3.15), p-value = 0.02), functional impairment (HR 2.47 (95% C.I. 1.28, 4.74), p = 0.007), and metastatic disease (HR 2.2 (95% C.I. 1.30, 3.97), p = 0.004). Conclusions: Major depression and functional impairment were identified as risk factors for OS in older cancer patients. Prospective studies are recommended.
Temporal associations between prognostic indicators and overall survival after breast cancer.
Authors: Plichta Jennifer Kay , Thomas Samantha Marie , Fayanju Oluwadamilola Motunrayo , Rosenberger Laura Horst , Park Tristen Sinae , Hyslop Terry , Greenup Rachel Adams , Hwang Eun-Sil Shelley
Published: September 2018

e18144

Background: Breast oncologists have little guidance on predicting long term outcomes after interval survival. We aim to evaluate the association of overall survival (OS) with select factors at multiple time points. Methods: Women ages 18-80 with non-metastatic invasive breast cancer were identified from the NCDB (2004─2014). Using multivariate survival analysis, we estimated the association of OS with tumor and treatment factors for those with follow up surviving at least 2, 5, and 10y post-diagnosis. Results: 685598 women (median age 59) were identified; 573757 were alive with follow up at 2y, 254303 at 5y, and 18640 at 10y. The majority had early stage, hormone receptor (HR) +, invasive ductal carcinoma. 57% underwent lumpectomy; 49% received chemotherapy; 89% of lumpectomies received radiation (RT); and 83% of HR+ tumors received endocrine therapy (ET). Of those alive at 2y, improved OS was associated with ER+, PR+, chemotherapy, RT, and ET. Reduced OS was associated with higher cT/cN stage, grade, and mastectomy. Of those alive at 5y, improved OS was associated with chemotherapy, RT, and ET. Reduced OS was associated with higher cT/cN stage, grade, and mastectomy. Of those alive at 10y, reduced OS was associated with higher cT stage and grade. Conclusions: Tumor and treatment factors are associated with OS, but the association of some factors may change for women surviving at least 5y or 10y. These findings may contribute to more tailored prognostication for patients based on interval survival. [Table: see text]
Nonspecific tumor markers in the era of value based medicine: Role of CA 19-9 in the pelvic mass workup.
Authors: Underwood Jenny , Saeed Haleema , Chae Esther Y. , Hanna Rabbie Kriakoss
Published: September 2018

e18194

Background: When encountering a pelvic mass, CA 125 and CEA are usually obtained to evaluate for ovarian or colon cancer. The clinical importance of ordering a CA 19-9 level is unknown. Does it offer valuable information or merely add confusion and additional workup if elevated? Methods: 3,370 women were retrospectively identified via CPT codes for pelvic mass and CA 19-9. Initial analysis reviewed the subspecialty of the primary investigator using CA 19-9 in their initial workup, and its correlation to a gynecologic pathology. In the cases where an OBGYN was the primary investigator additional tumor markers, age, race, menopausal status, imaging, surgical interventions and final pathology were further analyzed. Results: Out of 3,370 women 982 had an abnormal CA 19-9. The distribution of subspecialties that utilized CA 19-9 in their initial work up was Hematology Oncology 31.6%, Internal Medicine 18.7%, Gastrointestinal 18.2%, Gynecology 9.2%, Surgery 8.8%, Emergency Medicine 5.7%, Transplant 4.9%, and Family Medicine 2.9%. Of the patients evaluated by Gynecology, 32.2 % were found to have elevated CA19-9 which led to additional work-up of the upper GI tract in 18.9% including MRI, and PET preoperatively. Further analysis revealed that there was no correlation between the elevation of CA 19-9 and whether the tumor was malignant or benign [p value = 0.45] even after being adjusted for: menopausal status, presence of endometriosis, or pathology including mucinous cell type. Conclusions: The majority of adnexal masses are benign; the main goal of diagnostic evaluation is to exclude malignancy. Value based medicine is implemented to help improve health care quality, and efficient utilization of health care resources. Based on this retrospective analysis the use of CA 19-9 in evaluation of a pelvic mass does not offer information that directly improves patient outcome, but rather correlates to the increased misuse of health care resources.
Real-world practice patterns in community U.S. oncology practices: A quality improvement approach in HER2-positive breast cancer.
Authors: Hurvitz Sara A. , Simone Laura C , Carter Jeffrey D , Mateka James JL , Moreo Kathleen , Sapir Tamar
Published: September 2018

e18196

Background: In breast cancer (BC), quality measures related to care coordination (CC), HER2 testing (testing) and use of HER2-targeted therapy (Tx), provide parameters for assessing care quality. We assessed the influence of quality improvement education (QIE) on alignment with BC quality indicators. Methods: 20 community oncologists participated in an IRB-approved QIE program. At baseline, 200 randomly selected charts of women with HER2+ invasive BC were retrospectively reviewed for adherence to quality measures pertaining to testing, Tx and CC. The cohort participated in accredited QIE activities for developing action plans for improvement. Follow-up chart reviews were completed 6 months after the QIE. Results: Patient and disease characteristics were generally similar across the 2 cohorts. At baseline, documentation of cancer staging was 90%, ECOG functional status assessment was 67% and cardiac testing was 33%. Treatment in the adjuvant setting was most common, followed by neoadjuvant, and metastatic. Documentation of CC varied greatly across specialties, and was highest for primary care physicians. At follow-up, randomly selected charts (n=60 to date) revealed increases in documentation of patient assessments and care coordination. A shift towards increased treatment in the neoadjuvant setting was also observed. Conclusions: QIE interventions that engaged oncology teams showed a positive impact on documentation across several parameters. A complete analysis of follow-up charts (n=200) will be presented. [Table: see text]
Internal medicine residents' perception of cancer prognosis.
Authors: Acoba Jared David , Belyea Loni
Published: September 2018

e18214

Background: Cancer is the second leading cause of death in the US. Many internal medicine physicians feel uncomfortable having to prognosticate, however oncology patients often ask this of them. The inability to provide an accurate prognosis could lead a patient to make a treatment decision incongruent with their true wishes. We conducted this study to assess resident and attending physicians’ knowledge of cancer prognosis. Methods: We conducted a prospective cross-sectional study to assess internal medicine resident and attending physician knowledge of median survival for seven different oncologic case scenarios. We asked participants to choose a median survival of: (a) ≤6 mo, (b) 10-12 mo, (c) 24-36 mo, or (d) 48-60 mo for each scenario. Residents were asked to identify the source(s) of information that most significantly influenced their choices. All internal medicine residents and attending physicians affiliated with the University of Hawaii Internal Medicine Residency Program were invited to participate. Results: A total of 67 of 85 surveys were completed, representing 41 residents and 26 attending physicians. Overall, the respondents correctly estimated median survival 42.6% of the time. The respondents underestimated more often than overestimated median survival (46.3% vs 14.9%, p = 0.0001). Survival in colon and pancreatic cancer were most often underestimated (61% and 53%, respectively). We found no statistically significant difference between resident and attending physician responses. Of the residents who underestimated survival, 73% sited inpatient experience as influencing their oncologic knowledge. Conclusions: Internal medicine residents and attending physicians correctly estimate median survival of cancer patients less than 50% of the time and often underestimate survival. Inpatient rotations, where residents care for the oncologic patients experiencing significant complications of their cancer and treatment, may be giving them an unbalanced perspective on cancer prognosis. Improving oncologic education to provide a more balanced perspective may be critical in improving perception of prognosis so that patients can be provided with accurate information when trying to make critical treatment decisions.
Concordance rates of provider selected pathway decisions to actual delivered therapy.
Authors: Shamah Corey J.
Published: September 2018

e18220

Background: In November 2014, Aurora Cancer Care (ACC) adopted a new software package called Via Oncology (Via). It is a software driven, algorithmic, decision support tool. Via's goal is to help providers make the best decision in the treatment plan for patient care. Eligible clinical trials are the preferred therapy choice. If not available, treatment choices are then ranked by efficacy, toxicity, then cost. Its use has been mandated for every patIent visit in the department of Medical Oncology. ACC has 19 sites of service. While our current electronic medical record (EMR) and Via do communicate, it is limited to demographics and sending a link of the selected pathway from Via to the EMR. However, this link does not need to be selected in the EMR and another treatment could be selected. Our group does not penalize for off-pathway decisions, but it is possible that providers are selecting one protocol in Via to count as "on-pathway", and entering another treatment plan in the EMR. The goal of this study was to determine the concordance of stated pathway on Via and the actual ordered therapy in the EMR. Methods: One month of pathway decisions for a large, hospital based, multisite oncology group were obtained. Those decisions in Via that were recorded as new "on-pathway" treatment decisions were manually audited in the EMR to determine if there was concordance. If discordant decisions were corrected on a subsequent visit, it was felt that there was likely a mitigating circumstance and these decisions were not included in the final analysis. Results: Over one month, our 39 oncologist made 1534 new decisions for patients. Of these, 368 were "on-pathway" in Via. There was concordance of 319 (87%) to our EMR. The discordant charts were mostly due to differing drugs (19), dosing schedule (8), drug omitted (7), never given (7), additional drug (2). Conclusions: Despite the mandated use to two mostly independent software systems, agreement was high among patient records. Further integration of these systems will likely result in even greater concordance.
Designing comprehensive patient and family centered oncology care to achieve value based quality outcomes: Lessons learned from the field in creating sustainable change.
Authors: Harris Tamira , Wilfong Lalan S.
Published: September 2018

e18225

Background: Of all clinical specialties cancer care is often thought of as one of the most patient and family centered due to the nature of the disease and course of treatment. Traditionally a strong relationship is held among the physicians, office practice staff and patients and family. Cancer care requires multidisciplinary collaboration and alignment for the optimized patient experience. Comparatively speaking this has been the case. The office based oncology care team has worked side by side to move the patient through the system during various treatments and settings. Most often the relationships and bonds that are formed are long lasting as cancer is a life changing experience. Opportunities for change however do exist and are needed in today’s increasingly complex healthcare environment. As demographics shift, and treatment methodologies continue to be discovered costs have escalated giving rise to the need to evaluate different care delivery models such as value based care. The Centers for Medicaid and Medicare Innovation Center (CMMI) Oncology Care Model (OCM) initiative has addressed this in their 5 year OCM pilot. Methods: Using qualitative and six sigma lean techniques practices redesigned patient throughput and experience based on data from gap analysis assessments, observation and collaboration. Results: The session will highlight lessons learned from the practice setting in initiating the changes required to meet CMS objectives and change the face of oncology care. Learn how practices designed patient navigation, created care team huddles, designed technology that facilities decision making, identified new models and partnerships for care, and standardized approaches across practice sites among other successes. Conclusions: This interactive session will explore what worked well, what physicians would change, and next steps planned.
Effect of follow-up appointments and admission unit on readmissions in patient with cancer on chemotherapy: A tertiary center experience.
Authors: Abdel Rahman Zaid , Philip Joyce , Mohtadi Omar , Kahlon Pushpinderdeep Singh , Donthireddy Vijaya
Published: September 2018

e18239

Background: Readmissions are a huge burden on patients and organizations, especially in light of the newly emerging bundled payment systems. Many interventions have been proposed to reduce readmissions, including admitting patients to a cancer-specific unit (CSU) and scheduling follow-up appointments after discharge. Methods: We conducted a retrospective cohort study to identify the effect of admission unit and follow-up appointments on readmissions within 30 days among cancer patients receiving outpatient chemotherapy. We included unplanned admissions between July and October 2016 at Henry Ford Hospital. Results: There were 232 inpatient admissions. Of those, 73 (31%) were readmitted. The number of admissions to the CSU was 100 (43%) compared to 132 admissions (57%) to other general practice units (GPUs). Mean length of stay was 5.8 (1-29) days and 3.8 (1-30) days, respectively. Most common malignancies were hematological (27% and 22%) and gastrointestinal (26% and 19%). The most common reasons for admissions were infections (29% and 28%) and pain management (19% and 12%). Of patients who were admitted to the CSU, 24 (24%) were readmitted compared to 49 (37%) for other GPUs, OR 0.53 (95% CI:0.3-0.95, p = 0.033). Readmission rates were also calculated based on the type of appointment scheduled within 30 days of discharge (Primary care (PCP) and oncology, PCP only, Oncology only and neither). Odds ratios of readmission were calculated for the last three categories in comparison to having both appointments. Of admissions that had both appointments, 15 (23%) had a readmission within 30 days. Of admissions that had oncology only appointments, 39 (33%) had a readmission; OR 1.6 (95% CI: 0.8 to 3.3, p = 0.15). Of admissions that had a PCP only appointment, 6 (42%) had a readmission; OR 2.5 (95% CI: 0.7 to 8.3, p = 0.13) and of admissions that had neither appointments, 12 (57%) had a readmission; OR 4.4 (95% CI 1.6 to 12.6, p = 0.0049). Conclusions: Care for cancer patients is challenging as they carry a high risk of readmission, admitting cancer patients to cancer-specific units significantly reduces that risk. Having no follow-up appointments carries a high risk of readmission.
Cardiotoxicity of tyrosine kinase inhibitors among veterans diagnosed with renal cell carcinoma.
Authors: Lynch Kristine E. , Lynch Julie Ann , Efimova Olga , Chang Jiwon , Berse Brygida , Rivera Donna , Becker Daniel Jacob , DuVall Scott L. , Filipski Kelly Kristin
Published: September 2018

e18248

Background: Renal cell carcinoma (RCC) accounts for 3% of cancers diagnosed in the Department of Veterans Affairs (VA). Each year, 15% of the 1,600 veterans diagnosed with RCC have advanced disease. Until a decade ago, there were few non-surgical treatments for advanced RCC. Approval of multi-targeted tyrosine kinase inhibitors (TKIs), sorafenib, sunitinib, and pazopanib significantly improved outcomes for patients. However, several studies demonstrated increased risk of congestive heart failure, stroke, and thromboembolic events in patients treated with TKIs. We sought to understand whether veterans, who have a high prevalence of comorbidities, have increased risk of cardiac events following TKI treatment. Methods: This was a retrospective study of patients diagnosed with advanced RCC from 2006 to 2015. The outcome variable was whether the patient had congestive heart failure, cardiomyopathy, acute myocardial infarction, stroke, or cardiovascular related death after initiation of at least one TKI. Clinical, demographic, and pharmacy data came from the VA Central Cancer Registry and Corporate Data Warehouse. Patient characteristics across treatments were evaluated using chi square tests, t-tests and ANOVAs, as appropriate. We used multivariate logistic regression to determine the likelihood of cardiac event in patients treated with TKIs. Results: We identified 3,510 patients eligible for treatment who did not have a prior cardiac event. Overall, 1,840 patients were treated with at least one TKI prior to any cardiac event: 953 (27.1%) were treated with only sunitinib, 179 (5.1%) with sorafinib, 289 (8.2%) with pazopanib, and 419 (11.9%) treated with a combination. There were 909 who had a cardiac event (25.9% of all patients). Only 259 (28.49%) were treated with a TKI. On multivariate analysis, statistically significant predictors of a cardiac event were having diagnoses of dyslipidemia (Odds ratio [OR] 2.1, 95% confidence interval [CI] 1.7-2.5) or diabetes (OR 1.5, 95% CI 1.3-1.8). Patients treated with TKIs had a lower likelihood of a cardiac event (OR 0.3, CI 0.2-0.3). Conclusions: Among veterans, treatment with TKIs do not pose as great a risk for cardiac events as underlying comorbid diagnoses.
Pulmonary embolism prophylaxis in solid tumors: Exploring a paradigm shift.
Authors: Hakim Nausheen Naila , Marconcini Luiz Antonio Liarte , Vazquez Martinez Mariola A. , Rivas Doris Maria , Trotta Christina , Carter Jordan Spencer , Perimbeti Stuthi , Lee William May , Niphadkar Seema , Nandi Neilanjan , Ward Kristine Marie , Jain Maneesh Rajiv , Styler Michael
Published: September 2018

e18252

Background: Studies have found higher risk of development of pulmonary embolism (PE) in those with metastatic disease within the first year of diagnosis, predominantly in pancreatic cancer. Therapeutic anticoagulation is consequently recommended in pancreatic cancer. We thus hypothesized that the rate of PE would be highest in pancreatic cancer compared to other solid tumors. Methods: We queried the Nationwide Inpatient Sample between 1999-2014 using the ICD-9 codes for PE in association with the following solid tumor types: esophageal, colorectal, lung, stomach, breast, pancreatic, liver and small intestine. The primary diagnosis was the type of solid tumor and the secondary diagnosis was PE. Chi-square analysis was used to to analyze for the independence of two variables. Results: From 1999-2014 there was a total of 16,473 cases of PE in solid tumors. 1.9% of the pancreatic cancer admissions developed a PE, followed by 1.7%, 0.9% and 0.8% for lung, liver, and colorectal, respectively (p > 0.05). Overall mortality rate for PE in pancreatic, lung, and colorectal cancers decreased from 32% in 1999 to 15% in 2014. Conclusions: Earlier detection due to improved diagnostic modalities may have contributed to the decrease in overall mortality rate observed in lung, liver, and colorectal cancers diagnosed with PE from 1999-2014. The highest rate of admissions associated with PE was seen in pancreatic cancer: however the differences between the four cancers were not statistically significant. Future studies should focus on observational prospective data monitoring solid malignancies for PE. If the prevalence of PE is indeed similar in different types of cancers, we should consider the addition of therapeutic anticoagulation to the current recommendations.
Implementation of the IOM 13 point care plan by Oncology Care Model (OCM) practices.
Authors: Fargnoli Brenton , Jaffe Natasha , Bauer-Levey Nick , Cowing Keith , Schneider Joanne , Parulkar Rohit , Lee DJ , Harary Ovadia , Holleran Ryan , Zhang Sen , Revol Cindy , Tran Dan , Shah Robin , Abernethy Amy Pickar , Kolodziej Michael A.
Published: September 2018

e18279

Background: The completion of the IOM 13 point care plan is mandatory for all patients enrolled in the OCM. We built an integrated care plan into the electronic medical record, with 9 points being auto-populated by data documented elsewhere in the EMR and 4 points requiring completion by the caregiver. We report on preliminary experience with care plan completion. Methods: Of the 190 practices selected by CMMI for the OCM, 32 practices utilized the embedded care plan. Patient eligibility for the OCM was determined by identification of a qualifying episode by an electronic algorithm. Initiation of a care plan was determined by physician completion of any field in the care plan field. Completion of the care plan was defined by the act of printing and distributing the care plan to the patient. Correlations between number of eligible patients and completion rates were calculated using Pearson’s product moment correlation coefficient (r). P-values were calculated using a t-distribution and null hypothesis of 0. Results: Over the first 6 months, 15,705 patients were identified as eligible for the OCM. At these practices, 69% (10,851) of patients had care plans initiated (range 0-100%) and 34% (5,290) had a care plan printed (range 0-100%). Within the care plans initiated, 53% (5,711) had the advance directive field completed (range 0-87%). There was no correlation between percent of care plans initiated or percent of care plans printed and number of eligible patients in the practice (r = -0.16, p = 0.51 and r = -0.13, p = 0.44); likewise, advance directive field completion percent was not correlated with the number of eligible patients (r = -0.16, p = 0.37). Conclusions: Completion of the IOM care plan has proven challenging for practices in the OCM irrespective of practice size. This suggests technological solutions represent only one component needed for success in this component of the OCM.
Neutropenia related hospitalization risk in lung cancer patients with chemotherapy.
Authors: Ma Qinli , Agiro Abiy , Acheson Anupama Kurup , Wu Sze-Jung , Patt Debra A. , Barron John , Rosenberg Alan , Schilsky Richard L. , Lyman Gary H.
Published: September 2018

e18290

Background: We sought to describe outcomes following granulocyte-colony stimulating factor (G-CSF) prophylaxis in patients with lung cancer receiving chemotherapy regimens with low to intermediate risk for inducing neutropenia related hospitalization. Methods: We identified 11,233 lung cancer (all histologies) patients ≥ 18 years from 14 commercial US health plans. All patients received first cycle chemotherapy during 2008–2013. 5,423 patients received one of the 3 regimens: carboplatin and paclitaxel, cisplatin and etoposide, carboplatin and etoposide. Primary prophylaxis (PP) was defined as G-CSF administration within 5 days of chemotherapy. Outcome was neutropenia, fever, or infection-related hospitalization within 21 days. Regression and number-needed-to-treat (NNT) analyses were used. Results: A total of 11,233 patients received any chemotherapy (21.2% PP), were older (median years 64 PP; 64 no PP) and had at least 1 non-cancer comorbidity (79.8% PP; 77.9% no PP). About 2,776 patients received Carbo/Paclitaxel (13.9% PP), 1,356 patients received Cisp/Etop (23% PP) and 1,291 patients received Carbo/Etop (45.8% PP) regimens. PP was associated with lower risk of neutropenia related hospitalization for any chemotherapy (4.7% PP; 7.5% no PP; odds ratio [OR] 0.61; 95% CI 0.49 – 0.74), for Cisp/Etop (5.1% PP; 8.8% no PP; OR 0.56; 95% CI 0.32 – 0.97) and Carbo/Etop (5.6% PP; 11% no PP; OR 0.48; 95% CI 0.31 – 0.73), but not Carbo/Paclitaxel (5.7% PP; 6.7% no PP; OR 0.84; 95% CI 0.53 – 1.32) regimens. Based on NNT, the total cost of PP for 36 patients with any chemotherapy regimen to avoid one hospitalization would be $128,952 (mean hospitalization cost = $11,900, Standard Deviation [SD] = $9,541). For 28 patients with Cisp/Etop, it would be $101,920 (mean hospitalization cost = $16,957, SD = $16,135). For 19 patients with Carbo/Etop, it would be $63,270 (mean hospitalization cost = $11,356, SD = $6,949). Conclusions: Primary G-CSF prophylaxis was associated with some benefit in lowering neutropenia-related hospitalization in patients with lung cancer receiving Cisp/Etop and Carbo/Etop regimens, although the cost to treat patients remains high. Future studies need to examine the value of continued G-CSF use in subsequent cycles.