bluuebunny/crossref_metadata_2025 huggingface dataset:
Are there disparities in the utilization of sentinel lymph node biopsies in patients with breast cancer?
Authors: Radhakrishnan Archana , Silverman Paula , Shenk Robert R. , Thompson Cheryl L.
Published: February 2017

117

Background: Racial disparities in outcomes continue to persist amongst breast cancer (BC) patients (pts). Standard of care for the surgical evaluation of early BC has changed from axillary lymph node dissection being recommended for axillary staging to sentinel lymph node biopsy (SLNB) for clinically node-negative pts. SLNB, however, can be deferred if findings would not alter treatment plans. The goal of this study is to determine if SLNB rates differ by race, age, insurer, community vs academic setting or surgeon. Causes contributing to disparities will be considered. Methods: Pts undergoing primary surgery for early stage BC from 2010-2011 at our academic teaching hospital and two affiliated community medical centers were identified from the tumor registry. Data abstracted included demographics, insurance type, medical center and surgeon. For pts without SLNB, clinical information was confirmed with medical record review. Unadjusted comparison of factors for pts who did and did not have SLNB was evaluated with a t-test or chi square test. Logistic regression modeling assessed significance of demographic and clinical factors predicting SLNB. Results: 499 pts were identified; 114 (23%) were black, 373 (75%) white, and 12 (2%) others/unknown race. SLNB was performed in 443 (89%) of total pts, without racial differences (86% of black and 89% of white pts (p=0.31) had SLNB). Average age of pts who had SLNB was younger (60.4) than those who did not (76.3) (p<0.01). As compared to those with managed care insurance (97%) or Medicaid (91%), only 78% of Medicare pts had SLNB (p<0.01). There was no statistical difference in SLNB rates between academic and community medical centers or by surgeon. Chart review determined that the standard of care was met in 55/56 pts who did not have SLNB; reasons for no SLNB include advanced age (range 79-95), in-breast recurrences, and positive nodes pre-operatively. Conclusions: Utilization rates of SLNB did not differ between black and white BC pts. Differences were seen based on age and insurer. Although only 89% of pts had SLNB, careful evaluation for reasons reveals medically appropriate treatment in almost all cases. These results suggest cautionary interpretation of large database findings.
Improved survival of patients with glioblastoma at NCI-designated clinical cancer centers.
Authors: Saria Marlon G. , Corle Courtney , Rush Toni , Kesari Santosh
Published: February 2017

122

Background: Glioblastomas are considered the most life-threatening central nervous system (CNS) tumors. With such a rapidly progressing disease resulting in low survival rates, it is no surprise that many of the factors related to first-course treatment regimens are also related to patient survival. There is a need to investigate treatment patterns and survival trends so that optimal care standards can be developed for patients diagnosed with this devastating disease. Methods: Patients diagnosed with glioblastoma between 1999-2008 were identified in the California Cancer Registry. Survival estimates were calculated using Kaplan-Meier method and hazard ratios were calculated using Cox proportional hazards model. Multiple logistic regressions were used to determine the relationships between location of treatment and a patient’s first-course treatment regimen after adjusting for gender, age, race, socioeconomic status, type of insurance, and year of diagnosis. Results: 8,527 patients diagnosed with glioblastoma were included in the analysis. Patients receiving surgery, radiation, and chemotherapy as a first-course treatment regimen had a 1-year survival of 62.5% (95% CI: 61.6-63.4) compared to patients receiving any other treatment combination with a 1-year survival rate of 24.3% (95% CI: 23.7-24.9) (p<0.0001). After adjusting for covariates, patients treated at National Cancer Institute-designated Clinical Cancer Centers (NCI-CCCs) were 1.31 (95% CI: 1.14-1.5) more likely to receive all three treatment options as a first-course regimen. Patients receiving care at NCI-CCCs had 11% increase in survival compared to patients receiving care elsewhere. Conclusions: Surgery, radiation, and chemotherapy given as a first-course treatment regimen for glioblastoma patients provide significant survival benefits and were more likely to be provided together at NCI-CCCs.
Improving breast-conserving surgery: A focus on margins.
Authors: Schnabel Freya Ruth , Schwartz Shira , Kiely Deirdre , Chun Jennifer
Published: February 2017

127

Background: Inadequate lumpectomy margins are associated with an increased risk of ipsilateral recurrence in patients undergoing breast conserving surgery for cancer. Multiple procedures are often required to achieve acceptable margins, increasing the burden to the patient and the health care system, and potentially delaying other adjuvant treatments. A novel device for intraoperative assessment of lumpectomy margins (MarginProbe) has been associated with a 25% reduction in the rate of positive margins at the conclusion of primary lumpectomy surgery. Our aim was to establish a baseline re-excision rate among surgeons and to initiate a follow up study to assess the impact of incorporating this new technology for intraoperative margin assessment. Methods: The NYU Langone Medical Center Breast Cancer Database was queried for patients who underwent breast conserving surgery including ≥ 1 re-excision procedure from 1/2010-1/2013. Variables of interest included re-excision rates, stage of disease, and additional margins taken at primary lumpectomy surgery. Statistical analyses included descriptive analyses and Pearson’s Chi-Square. Results: During the study period 957 patients had breast conserving surgery and 229 required ≥ 1 re-excision procedures (24%). Re-excision rates varied widely among surgeons (10-36%). Stage 0 disease (ductal carcinoma in situ) was associated with an increased frequency of re-excisions (p<0.0001). These parameters will be re-evaluated in patients undergoing breast conserving surgery with adjunctive intraoperative use of the MarginProbe device. Re-excision rates and the accuracy of intraoperative assessment of lumpectomy margins will be compared with the historical cohort. Conclusions: The necessity for multiple surgical procedures to complete breast conserving surgery results in an added burden to the patient and the health care system. Improved intraoperative assessment of lumpectomy margins represents an opportunity to improve the quality of breast cancer surgery. A critical analysis of the impact of a new device on re-excision rates will be important to understand its potential benefit to the conduct of breast conserving surgery.
Outcomes of cancer patients who do not satisfy conventional clinical trial eligibility criteria (CTEC).
Authors: Cheung Winson Y. , Rasool Javaheri Khodadad , Speers Caroline
Published: February 2017

128

Background: Trials have stringent inclusion and exclusion criteria to maintain internal validity. However, study findings are often applied to patients in routine practice who do not meet CTEC. Our aim was to characterize the outcomes and magnitude of treatment benefit in these patients. Methods: Patients diagnosed with stage III colon cancer from 2006 and 2008, referred to 1 of 5 regional cancer centers in British Columbia, and assessed for adjuvant chemotherapy (AC) within 12 weeks of surgery were analyzed. Patients were considered trial-eligible (TE) if aged 18 to 79 years, ECOG 0/1, CEA <10, did not receive prior chemotherapy or radiation, and had adequate blood counts and normal cardiac, liver and kidney function. All other patients were deemed trial-ineligible (TI). Results: A total of 820 patients were identified: median age was 69 years (range 60-76), 423 (52%) were men, 365 (45%) were ECOG 0/1 and 592 (72%) received AC. Among patients treated with AC, 370 (63%) were TE and 222 (37%) were TI. Compared to TI patients, those who were TE were younger (63 vs. 70 years, p < 0.01) and more likely to receive combination regimens rather than single agent AC (56 vs. 33%, p < 0.01). Outcomes were significantly different among patients who were TE, TI, and those who did not receive AC (Table). In multivariate analyses that adjusted for known prognostic factors such as age, ECOG and T and N stages, both TI patients and those not treated with AC had worse outcomes than TE patients (HR for colon cancer death 1.32, 95%CI 0.86-2.02 and 2.77, 95%CI 1.92-3.99, respectively, p trend < 0.01; HR for all cause death 1.24, 95%CI 0.85-1.80 and 2.95, 95%CI 2.17-4.00, respectively, p trend < 0.01). Conclusions: In this population-based cohort, colon cancer patients who did not fit CTEC were frequently treated with AC. Outcomes in this TI group were inferior to those in the TE group, but they were better than the subset that did not receive AC. Broadening CTEC to include a segment of the TI population should be considered as there appears to be benefit in selected individuals. [Table: see text]
A peer review quality assurance program for outpatient radiation treatments.
Authors: Ballo Matthew T. , Chronowski Gregory , Schlembach Pamela , Bloom Elizabeth S. , Arzu Isidora , Kuban Deborah A.
Published: February 2017

13

Background: Our outpatient radiation treatment centers implemented a peer review program in 2007 that required presentation of all definitive cases to a weekly peer review conference. The purpose of this review is to document compliance and determine how this program impacted care over 4 years. Methods: Between 9/2007 and 9/2011, 2,988 patients were eligible for peer review. Patient data was presented to a group of physicians, physicists, and dosimetrists via teleconferencing and the radiotherapy plan was reviewed. Details of any changes made to patient care were documented within a QA note dictated after discussion. Any changes recommended by the peer review process were categorized as changes to radiation dose, target, or major changes. Results: Breast cancer accounted for 47.9% of all cases, followed in frequency by H/N (14.8%), GI (9.9%), GU (9.3%), and thoracic (6.7%) malignancies. Of the 2,988 eligible patients, 158 (5.3%) were not presented for peer review. The number of missed presentations decreased over time; 2007-8.2%; 2008-5.7%; 2009-3.8%; and 2010-2.7% (p<0.001). The reason for a missed presentation was unknown, but varied by disease site and physician. Of the 2,830 cases presented for peer review, a change was recommended in 346 cases (12.2%) and categorized as a dose change in 28.3%, a target change in 69.1% and a major treatment change in 2.6%. When examined by year of treatment the number of changes recommended decreased over time: 2007-16.5%; 2008-11.5%; 2009-12.5%; and 2010-7.8% (p<0.001). The number of changes recommended varied by disease site and physician. H/N, GYN, and GI malignancies accounted for the majority of changes made. Conclusions: Compliance with this weekly peer review QA program was satisfactory and improved significantly over the 4 year study period. The QA program resulted in decreased treatment plan changes over time reflecting a move toward radiation treatment consensus and consistency. Weekly peer review directly improved care in all patients by creating a culture of QA where guideline adherence and discussion are part of normal practice.
Factors associated with unplanned breast cancer readmissions.
Authors: Gavankar Charuta , Gross Cary , Lilenbaum Rogerio , Chagpar Anees B.
Published: February 2017

131

Background: Unplanned hospital readmission within 30 days (UHR) has been used as a quality metric, but data are limited for breast cancer patients. We sought to determine factors associated with UHR in these patients. Methods: The National Cancer Database is a program of the American College of Surgeons and American Cancer Society that captures 70% of newly diagnosed cancer cases in the US. Factors relating to UHR were analyzed using univariate and multivariate analyses. Results: Data from 2003-2010 were used; 28,861 patients who had UHR were compared to 1,380,433 patients who were never readmitted. Planned readmissions were excluded. Factors correlated with UHR included age, race, ethnicity, region, facility type, education, insurance status, income, urban/rural location, neoadjuvant tx, lymph node status, tumor size, Charlson/Deyo score, and margin status (all p < 0 .005). On multivariate analysis, all factors but ethnicity and urban/rural remain significant (see table). Conclusions: Few breast cancer patients have UHR, but sociodemographic, clinicopathologic, and regional factors can be found that are associated with an increased risk. These may guide interventions to reduce UHR. [Table: see text]
Transition care clinic: Evidence-based survivorship care.
Authors: Deol Raman , Cheung Matthew C. , Del Giudice Elisabeth M. , Boudreau Angela , Miller Debbie , Singh Simron
Published: February 2017

141

Background: The Odette Cancer Centre (OCC) is the sixth largest comprehensive cancer centre in North America. In 2012/2013 fiscal year it is projected there will be 19,633 new cases and 82,293 follow-up visits, of which 16% of new and 24% of follow-ups will be for gastrointestinal (GI) and hematology disease sites. Current specialty cancer clinics are not well equipped to provide evidence-based survivorship care. Methods: The Transition Care Clinic (TCC) was developed for colorectal cancer and lymphoma patients transitioning from acute care at OCC back to their primary care provider (PCP) for follow-up, assessment, and surveillance after completion of active treatment. Patients are seen by a family medicine physician and advanced practice nurse and receive comprehensive survivorship care, individualized treatment summaries, and post-treatment care plans. An accompanying web resource continues to connect patients to OCC after discharge and provides survivorship specific information. Results: An eight month pilot resulted in 66 visits and 28 discharges, of which 53% of visits and 93% of discharges were for GI patients and 47% and 7% respectively for hematology. The 28 discharges resulted in resource utilization savings of 122 OCC clinic visits and 118 hospital CT scans. Symptom screening results across the domains of anxiety, depression, pain, and tiredness were on par with other cancer patients, dispelling concern that these patients experience different/more symptoms after treatment and during transition. Finally, patient feedback indicated that those that found it difficult to attend OCC appointments appreciated knowing guidelines were available and were comfortable with PCP follow-up, while others whose PCP missed initial presenting symptoms preferred cancer centre “specialists” and were not comfortable. Conclusions: There is need for inter-disciplinary development of survivorship and transition programs with buy-in from disease sites, multimodality consensus, revision of eligibility criteria for lymphoma, and efficiencies to complete comprehensive treatment summaries. Short and long-term outcomes to be measured include recurrences and secondary cancers, adherence to guidelines, patient quality of life, and satisfaction.
Palliative care checklist: A documentation improvement tool.
Authors: De la Cruz Maxine , Reddy Akhila Sunkepally , Tanco Kimberson , Vidal Marieberta , Azhar Ahsan , Silvestre Julio , Chisholm Gary B. , Williams Janet L. , Bruera Eduardo
Published: February 2017

142

Background: Palliative care (PC) encompasses medical, psychosocial and spiritual domains. Checklists are utilized for standardization and improvement in care, service, and safety. We implemented a PC checklist for patient encounters with the aim of improving clinical documentation. Methods: A PC checklist was drafted based on a consensus of 12 palliative care specialists. Dictations from 25 encounters for 13 clinical staff 3 months prior and 3 months post implementation of the checklist were compared using 10 items on the checklist. Improvement in documentation is not considered as a change in the delivery of care as all physicians followed the same practice patterns reinforced by academic activities like conferences, grand rounds, and interdisciplinary team meetings. Results: There were improvements in the documentation before and after the checklist for scores on Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire: 38% vs. 81% (p=0.0014), psychosocial history: 69% vs. 95% (p=<.0001) and overall documentation (defined as 6 out of 10 items on the checklist): 78% vs. 95% (p=<.0001). There is a trend for improvement in documentation of ECOG (p=0.009) and Memorial Delirium Assessment Scale (MDAS) (p=0.07). There was no significant improvement in the documentation for advance care planning (ACP) (p=0.328). Conclusions: The implementation of the checklist has shown improvement in overall documentation. Serial reminders to the clinical staff may be needed to further improve documentation practices. [Table: see text]
Patient involvement in multidisciplinary treatment planning (MTP).
Authors: Prabhu Das Irene , Rozjabek Heather , Fennell Mary L. , Mallin Katherine , Gay E. Greer , Castro Kathleen M. , Stewart Andrew K. , Clauser Steven
Published: February 2017

145

Background: Patient involvement in treatment decision-making has been well-studied. However, little is known about how patients are involved in the MTP process prior to their consideration of treatment options. Methods: An online survey was administered to 1,261 Commission on Cancer (CoC)-accredited programs to describe current MTP practice. Survey items addressed team structure and process, case presentation, and patient involvement. A total of 797 (63%) facilities responded. Multiple aspects of patient involvement focusing on the initial case presentation and post-meeting follow-up regarding information provision and communication are examined. Initial descriptive analyses are presented. Results: 97% of facilities reported patients are not invited to attend MTP meetings. Reasons for not inviting patients included: patients may find it overwhelming (62%), physicians not able to speak freely (58%), liability (43%) and privacy (42%) concerns. Of the facilities that do invite patients, 1/3 reported that patients often or always attend. Treatment recommendations from MTP meetings are shared with patients at 75% of facilities, 42% share treatment plans, and 28% give a meeting summary to patients. Nine percent of facilities do not give patients any information from the meeting. Prior to treatment, a written treatment plan is developed at 43% of facilities, and among these, 15% give the plan to patients. Regarding communication about MTP meetings, facilities reported pre-meeting discussions with attending physicians (95%) and patient navigators (21%). Post-meeting follow-up by 93% of facilities is usually done by physicians, 26% by patient navigators and 16% by PA/NPs, and 66% follow-up within 1 week. Conclusions: Initial findings suggest that even if facilities do not invite patients to MTP meetings, they engage patients in various ways at pre- and post-MTP meetings, providing information and having discussions. Physicians are integral in communicating with patients throughout the MTP process. Further study on the multiple facets of patient involvement in MTP is needed to better understand its influence on treatment decision-making.
Patients as partners in defining outcomes.
Authors: Summers Barbara L. , Albright Heidi Wied , Tatum LaToi Shanel , Bassett Elizabeth , Feeley Thomas W.
Published: February 2017

148

Background: The aim of this project was to develop an understanding of how patients conceptualize the term “outcomes” as it relates to their cancer experience and to determine patient preference for receiving and using outcomes-related information. When asked to rank cancer outcomes, most health care professionals suggest survival is the most significant outcome metric. We sought to determine if patients felt the same way. Methods: Focus group methodology was used in cancer patients with one of five major disease sites: breast, colon, lung, prostate, and head and neck. Participants were diverse with respect to age, ethnicity, income level, education level, and gender. Participants received semi-structured questions intended to elicit the patient’s personal conceptualization and use of outcomes information during their cancer continuum. Results: Patients identified a range of phenomena as their preferred definition of outcome and were sometimes confused by the term. Participants reported finding it difficult to interpret survival data without a basis for comparison or medical knowledge. Results of the focus groups will be presented and will address the wide variety of outcome definitions defined by patient participants. Conclusions: We found a large disconnect between what providers consider important and what patients consider important. We are continuing to evaluate patient perceptions of outcomes information by conducting further focus groups, and these qualitative findings will be used to develop a rigorous survey tool that can be administered to a greater number and wider variety of patients. Ultimately, the finding from these focus groups will allow for the creation of useful tools that educate patients and empower them to be full partners in their care.
Incorporating patient satisfaction metrics in assessing multidisciplinary breast cancer care quality.
Authors: Harper Jennifer L. , de Costa Anna-Maria A. , Garrett-Mayer Elizabeth , Sterba Katherine W.
Published: February 2017

151

Background: The Medical University of South Carolina implemented a “patient-centered” multidisciplinary breast clinic program (MDBC) in August 2012. The structure of this care model facilitates a coordinated set of specialist visits, diagnostic studies, and care plan development on the day of initial consultation. In this study, we examined patient satisfaction with MDBC care delivery and communication with health care providers to inform the refinement of the MDBC program. Methods: During the first 10 months of the MDBC, patients were asked to complete a post-consultation telephone survey assessing overall satisfaction with care quality and the MDBC clinical team as well as satisfaction with various aspects of the MDBC model (e.g., time, explanation of treatment options, communication about practical and psychosocial factors). A statistical analysis was performed to explore potential associations between age (linear regression), race (Wilcoxon rank sum test), and stage (Fisher's exact test) with overall patient satisfaction scores. Results: Overall, patients (N=52, 56% W, 42% AA, 2% H; mean age=61 yrs) were highly satisfied with the MDBC consultation visit (mean=4.7, range 1-5), felt comfortable with their plan of care (mean= 4.4, range 1-5) and were satisfied with explanations about the cancer and treatment options (mean=3.7, range 1-4). Communication with treatment staff was scored highly. No statistically significant differences in overall satisfaction were found by age, race, or stage. However, patient responses were commonly “No” or “Yes, but not as much as I would like,” when asked if the care team addressed the impact of their diagnosis on their personal relationships (40.4%) or emotional health (28.9%). Conclusions: Results demonstrate that patients were highly satisfied with the care they received in the MDBC program. Participants were highly satisfied with practical care delivery factors such as time spent with clinical team and physician-patient communication. Findings suggest that this model is well suited to a diverse patient population and have highlighted potential quality improvement targets such as increased emphasis on provider's communication about psychosocial issues.
Embodying patient-centered communication: An eHealth prototype and evaluation.
Authors: Haas Niina , Yang DerShung , Lopez Ana Maria
Published: February 2017

152

Background: An eHealth prototype was developed to embody the principals of Patient-Centered Communication espoused by National Cancer Insitute (NCI). The prototype provides patients with features that support access to their “care” (medical records, symptom reporting and monitoring tools, calendar, treatment schedule), “team” (bio, roles, contact info for care team), “education” (reputable articles, videos, tools), and “community” (local classes, events, support groups, forums). This prototype was evaluated in terms of its usefulness and usability. Methods: The prototype was evaluated through two usability evaluation sessions. 13 cancer patients, 4 caregivers, and 12 cancer health care providers were recruited. During a 30-45 minute session, each subject viewed the prototype and completed a survey about the prototype’s usability and usefulness. The survey included 29 items with Likert scales ranging from 0 (Strongly Disagree) to 4 (Strongly Agree). Descriptive statistics were generated. Results: The results were categorized according to group (patient, caregiver, and provider) and section of prototype (overall, care, team, community, education). The patients rated the prototype higher in terms usefulness and usability across all user groups/sections except for the education section, which was rated highest by providers (Table). Conclusions: The positive feedback on several aspects of the prototype from different user groups indicates that our prototype met our objectives of being useful, easy-to-use, and adding value to the cancer patient’s care journey. Interestingly, there is a difference in the perceived value of the prototype’s different sections among each user group. The patients placed higher value on the “Care” features (medical records, symptom reporting and monitoring tools, and treatment schedule) and “Team” features (bio, roles, contact info for care team) than providers, and caregivers. Whereas providers most valued education content as opposed to patients and caregivers who ranked the team content as most important. [Table: see text]
Quality of life among breast cancer survivors treated with breast-conserving therapy in Hawaii.
Authors: Conde Francisco A. , Wilburn Andrea R.
Published: February 2017

154

Background: Aim of this study was to compare quality of life (QOL), treatment-related side effects, and needs of recent and long-term breast cancer survivors following breast-conserving therapy. Methods: Surveys were sent to 750 women with Tis, T1 – T4 breast tumors without lymph node involvement who received lumpectomy followed by radiotherapy at a large, tertiary care facility in Hawai‘i from January 2001 to December 2010. To assure adequate representation across years, 75 women were randomly selected from each year. Surveys included demographic items, City of Hope Quality of Life – Breast Cancer Instrument, and Breast Cancer Prevention Trial Symptom Scales. Completed surveys were received from 265 (35.3%) women, and findings were analyzed for long-term survivors (diagnosed from 2001-2003, n=76), mid-range survivors (diagnosed from 2004-2007, n=95), and recent survivors (diagnosed from 2008-2010, n=94). Results: Overall, respondents reported high QOL. Similarly to recent breast cancer survivors, long-term survivors reported slight to moderate side effects, including hot flashes, vaginal problems, musculoskeletal pain, and cognitive dysfunction. After controlling for age, ethnicity, and cancer stage, there was no significant differences in QOL physical, psychological, and social well-being subscale scores across time periods. Long-term survivors were more likely than shorter-term survivors to want information regarding nutrition (p<.01), physical activity (p=.018), and ways to restore strength, mobility, and cognition (p<.01). Conclusions: Breast cancer survivors treated with breast conserving therapy report relatively good QOL between 2 and 12 years post-treatment, although they continued to experience physiological issues (which could be exacerbated by age), and anxieties about their cancer. Healthcare professionals should continually assess for ongoing cancer-related side effects even years after completing treatment. Funding: This research was supported by ‘Imi Hale Native Hawaian Cancer Network (U54 CA153459).
Satisfaction evaluation of medical attention at breast cancer service at National Cancer Institute Mexico.
Authors: Ramirez-Morales Rebeca , Santamaria-Galicia Julieta , Aldama Lucy , Bautista-Leon Alejandra , Aguilar Cristina , Alvarado Miranda Alberto , Calderillo Ruiz German , Arce Salinas Haydee Claudia
Published: February 2017

156

Background: Breast cancer is the leading cause of attention at the INCan. In 2012, 44,761 medical consults were given therefore 19,584 (44%) of those by breast cancer oncologists. The increasing percentage of patients could be associated with a quality attention deficit, crowded waiting room and a shorter time for consultations affecting patient communication and education. The goal of this study was to evaluate the quality attention given by breast cancer service with the purpose to design different strategies in order to improve quality and cordiality with our patients. Methods: Self-response surveys had been applied to patients with breast cancer at INCan. The variables investigated were demographic characteristics including age, education level, marital status and date of diagnosis. Also variables related with the quality of our medical and paramedical attention, global care support and the waiting time before consultations were asked. Results: 259 patients were interviewed, the median age was 50 years old (17-88), only 18% of them achieved university degree and 28.7% had less than elementary education. One third of our population lived in Mexico City; the rest of them came from different states from the center and south of the country. The waiting time in average was 2 hours (10 min -7 hours). Regarding to attention quality, 28% considered that waiting time should be shorter, 22% answered that doctor-patient relationship needs to improve. In this aspect, the main aspects to improve are: give information in detail including the patient and their relatives; a better explanation about their disease and treatment and also information about diet and physical activity, among others is needed. Finally, 9.3% suggested improvement in nursery service. Conclusions: The results showed that our effort is satisfactory. However our main goal is to improve our medical assistance. It has been proven that patient education and higher satisfaction level improves their adherence and the knowledge related to handle adverse effects of their treatment. Our proposals include psycological-educative strategies easy to understand. Enhance medical services to improve physician-patient relationship. We will keep looking forward about the efficiency of these strategies.
Patients’ and caregivers’ views on the timing and benefits of early palliative care: A qualitative study.
Authors: Hannon Breffni , Swami Nadia , Pope Ashley , Leighl Natasha B. , Krzyzanowska Monika K. , Moore Malcolm J. , Oza Amit M. , Rodin Gary , Zimmermann Camilla
Published: February 2017

157

Background: Early palliative care referral can improve quality of life and satisfaction with care, and is increasingly encouraged. However, little is known about patients’ and caregivers’ attitudes towards early referral. We conducted qualitative interviews seeking the opinions of advanced cancer patients (who had been randomized to an early palliative care intervention) and their caregivers, to determine whether they perceived a benefit, and if so in which domains. Methods: We recruited participants from medical oncology clinics at a comprehensive cancer centre, following completion of a randomized controlled trial comparing early palliative care referral with standard oncology care. Selective sampling was employed to ensure equivalent numbers of participants based on study arm, age, gender, high vs. low quality of life scores, and high vs. low satisfaction with care. A grounded theory approach was used to explore emerging themes. Results: Twenty-six patients and 14 caregivers completed interviews. Several benefits of early referral were noted. These included: prompt attention to symptom needs; timely, sensitive information about prognosis and end-of-life care options; and destigmatization of palliative care through routine referral. Although some participants did not feel they currently needed palliative care, they did feel comforted that early referral had provided them with a “safety net” that could quickly be put into place if they required future support. Conclusions: Early referral was perceived as useful in several domains, including immediate symptom control, and preparation for the future.
Prognostic information (PI), psychological well-being, and quality of life for advanced cancer patients (ACP) in phase I trials and their spousal caregivers (SC).
Authors: Hlubocky Fay J. , Cella David , Sher Tamara , Ratain Mark J. , Daugherty Christopher
Published: February 2017

16

Background: The impact of the physician’s (MD) disclosure of PI on the psychological well-being and quality of life (QoL) of clinical trial subjects with terminal disease on phase I trials has not been formally evaluated. Methods: A prospective cohort of ACP enrolling in phase I trials was assessed at baseline (T1) and one month (T2) utilizing various measures including: state-trait anxiety (STAI-S/T), depression (CES-D), quality of life/QoL (FACIT-Pal), and global health (SF-36). Semi-structured interviews of ACPs also evaluated MD-Pt communication re prognosis and worry about ACP death. Results: 100 subjects (50 Phase I ACPs and 50 SC) were separately interviewed at T1 and T2. For the population as a whole: median age 62 (28-78y); 51% male; 100% married; 88% Ca; 68% > HS educ; 56% GI dx; 54% income <$65,000 yr. At T1, 45% of ACPs acknowledged having a discussion re life expectancy with MD; 35% stated the MD gave a prognostic timeframe; and 41% reported worry re death. For SC at T1, 62% recalled a prognosis discussion with the MD; 50% stated MD gave a timeframe; 53% reported PI disclosure was initiated by the MD; 66% reported worry re ACP death. At T2, rates remained consistent for both ACP and SC with the exception of increased reported worry re ACP death at 55% and 70% respectively. At T2, ACP who denied a prognosis was given by the MD had higher STAI-S (35 ± 10 v 29 ± 9, p=0.03) and CES-D scores (16 ± 12 v 7 ± 4, p=0.01); and lower FACT-Pal scores (128 ± 18 v 153 ± 24, p=0.01). SC with acknowledgement of a prognostic timeframe given by the MD had higher STAI-S anxiety (39 ± 16 v 36 ± 16, p=0.04) at T2. Regression analyses revealed that ACP with acknowledgement of a prognostic timeframe given by the MD had poorer FACIT-Pal QoL over time. Also, SC with acknowledgement of a prognostic timeframe at T2 was negatively associated with SF-36 scores. ACP and SC qualitative responses re PI disclosure revealed salient themes: hope for a positive outcome or prolonged survival; stabilization of disease; emotional distress; ambivalence/fear; acceptance. Conclusions: Physician disclosure of a prognostic timeframe is negatively associated with QoL among clinical trial subjects and SC in phase I trials.
Improving oncology quality through the implementation of evidence-based clinical pathways in a payer’s oncology network.
Authors: McCrone Daniel , Gill Dudley , Tran Cecilia , Sturgill Michael
Published: February 2017

161

Background: Physicians and health plans are collaboratively exploring clinical pathway strategies to improve patient outcomes, reduce treatment variation, and reduce oncology cost. One landmark study found that 33.2% of insured patients did not receive guideline cancer therapy. Additional studies have demonstrated that the use of pathways can lower the cost of care and that oncologist participation is a critical element for success. New Century Health (NCH), in partnership with a leading health plan and one of its Midwestern oncology networks, had two quality goals with the implementation of a chemotherapy prior authorization system: review all chemotherapy regimens for all patients and measure treatment plan adherence to evidence-based clinical pathways. Methods: As one component of a mandatory chemotherapy prior-authorization program, an online prior authorization system was used by oncology practices to submit chemotherapy treatment plans to NCH for approval. The system captured detailed patient clinical information and measured compendium and preferred pathway adherence rates. These data were shared with participating oncology practices on a quarterly basis. For analysis, an average Baseline compendium adherence rate was determined reflecting participating practices for six cancer diagnoses (Breast, Colon, Lung, Lymphoma, Multiple Myeloma, and Prostate). The Baseline rate was compared to the Review period rate. Results: A comparison of the Review and Baseline period metrics indicated a statistically significant increase in the level of compendium-based chemotherapy treatment plans submitted by participating providers. Conclusions: Implementation of an oncology prior authorization system that measures compendia-based adherence rates is associated with increased levels of evidence-based chemotherapy treatment plans by participating providers. [Table: see text]
Comparison of QOPI measure conformance between oncology fellows and attending physicians.
Authors: Zhang Tian , Kamal Arif , Kelley Michael J.
Published: February 2017

162

Background: Quality improvement measures are uniformly applied to all oncology providers, regardless of their positions. Little is known about differences in conformance to these measures between oncology fellows and attending physicians. In order to tailor improvement interventions to these groups, we investigated conformance across QOPI measures for oncology fellows and attending physicians at the Durham VA Medical Center (DVAMC). Methods: Using data collected from the Spring 2013 QOPI cycle, we abstracted information from patients who had received care at the DVAMC between 2011 and 2013 and separated them based on their provider. To validate the data, we abstracted a subset of patient charts, limited to oral chemotherapy quality measures. Descriptive statistics and the Chi square test were calculated for each measure between the two groups. Results: A total of 97 patients were reviewed at DVAMC. Of these, 21 had a fellow and 47 had an attending as their main provider. Fellows and attendings performed similarly on 119 of 125 QOPI measures (core, end of life, symptom, colorectal, and NSCLC modules). Fellows were less likely to assess pain on the most recent visits when compared to attendings (52% vs. 77%, p=0.046) but more likely to document a management plan if the patient had moderate or severe pain (86% vs 75%, p=0.09). Attendings documented the plan for oral chemotherapy more often (93% vs. 60%, p=0.07). However, after the chart audit, we found that fellows actually documented the plan for oral chemotherapy 80% of the time (p=0.21). Fellows were more likely to document smoking status (95% vs. 64%, p=0.007) and to address smoking cessation (86% vs. 62%, p=0.048). Conclusions: Patient care practices tend to be similar between attendings and fellows overall; some of the significant differences may not remain significant after chart audit. Fellows generally mirror behaviors of attending physicians, and attendings have an important role in modeling best practice behaviors for fellows. Different quality measure standards may not be necessary between fellows and attendings.
Feasibility and utility of influenza vaccination in hematology/oncology clinics.
Authors: Uppal Navjeet , Tobin Swanee , Cape Jennifer , Muller Matthew , Hicks Lisa K.
Published: February 2017

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Background: Seasonal influenza vaccination is recommended for cancer patients. However, many cancer clinics do not routinely offer flu shots. Early in January, 2013, Toronto experienced widespread influenza activity. Approximately 25% of hospitalizations on the hematology/oncology ward at St. Michael's Hospital (SMH) during this time were for suspected influenza. A large number of patients were noted to be unvaccinated. In-response, influenza vaccination was organized in parallel with regular hematology/oncology clinics at SMH. Aims: To determine the feasibility and utility of influenza vaccination in a cancer clinic. Methods: All patients seen in the SMH hematology/oncology clinic between January 14 and February 1, 2013, were eligible for influenza vaccination. A brief survey was administered to obtain vaccination history, willingness to receive flu vaccination, and beliefs about flu vaccination. Information regarding diagnosis, treatment, and family physician was obtained from the medical record. Univariate testing was completed with the Chi-squared and Fisher’s exact tests as appropriate. Results: 555 patients were seen during the period of interest; 206 completed the survey (37% response rate). Median age of respondents was 63 years, 42% were male, and 81% had cancer. 107(52%) of respondents had not received seasonal influenza vaccination of whom 41 (38%) accepted vaccination when offered. Among vaccinated patients, most received the flu shot from a family physician (70%). Reasons for not receiving the flu shot were personal preference (24%), belief that it was not necessary (19%), inconvenience (14%), concerns about side effects (8%), believe that it was contraindicated during chemotherapy (7%) and a perception that a medical practitioner advised against it (7%). Patients without a registered family physician were less likely to have received the seasonal flu shot (p=0.03). Patients with a malignant diagnosis and patients receiving IV chemotherapy tended to have lower rates of seasonal flu vaccination (p=0.09 and p=0.12 respectively). Conclusions: Administering influenza vaccination during hematology/oncology clinics is feasible and may address a care gap in this population.
A single center, retrospective analysis evaluating aberrant drug behavior stratification utilizing the opioid risk tool in patients with cancer.
Authors: Ma Joseph D. , Horton John M. , Hwang Michael , Atayee Rabia S. , Roeland Eric
Published: February 2017

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Background: Historically, it was believed that cancer patients could not have aberrant drug behaviors. However, clinical experience suggests otherwise. The prevalence of aberrant drug behaviors of cancer patients is unknown as screening is uncommon. Consequently, the UCSD Moores Cancer Center outpatient palliative care clinic initiated screening of aberrant drug behaviors utilizing the opioid risk tool (ORT) on new consultations. The purpose of this retrospective analysis was to identify key risk factors of aberrant behaviors of cancer patients and formulate a routine approach to follow-up and medications quantities. Methods: The treating oncologist referred new consultations to the outpatient palliative care clinic. A cohort of 93 cancer patients was evaluated from July 2012 to February 2013. Patients completed a 10-item, provider-administered, ORT during the consultation visit. Based on the ORT, patients were stratified into high-, moderate-, or low-risk for abarrent drug behavior and follow-up appointments and opioid quantities were adjusted accordingly. Results: Of the 93 patients, 48% were men and 52% women. Most patients had metastatic cancer (n=50; 54%) of gastrointestinal primary (n=27; 29%). Fifty-six (60%) patients were stratified as low-, 15 (16%) moderate-, and 22 (24%) high-risk based on ORT score. The most common risk factors for aberrant behaviors were a history of depression (women=25; men=17) and family history of alcohol abuse (women=22; men=18). There was no difference in the prevalence of depression (p=0.17) or family history of alcohol abuse (p=0.57). The least common risk factor was a personal history of prescription drug abuse (n=1) in women and history of preadolescent sexual abuse in men (n=0). Conclusions: Screening of cancer patients suggests risk factors for aberrant drug behavior exist. Stratifying patients based on a standard, routine tool can help identify cancer patients at risk for aberrant drug behaviors. Moderate and high-risk patients can then be followed closely with limited quantities of opioids until trust is established.
Outpatient documentation of advance care planning (ACP).
Authors: Obel Jennifer Carrie , Brockstein Bruce , Benfield Tiffany , Konchak Chad , Robicsek Ari , Raymond Michael , Tabachow Cory , Kharasch Maureen , Marschke Michael , Hensing Thomas A.
Published: February 2017

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Background: To increase and systematize outpatient ACP, our quality improvement team developed enhancements in 2 oncologists’ cohorts of newly diagnosed, incurable cancer patients (pts). At 1st consultation, an ACP form is given to pts; a nurse assesses knowledge about medical POAs and goals of care. Pts return for chemotherapy teaching and ACP education session conducted by a nurse utilizing an ACP workbook describing end-of-life (EOL) scenarios. After reviewing the workbook, the nurse or social worker fills out an Advance Directive Note (ADN). At next visit, the oncologist reviews the plan, cosigns the ADN and inputs code status orders (CSOs). Alternatively, oncologists may choose to create the ADN. Methods: An EOL quality database of 9 metrics was created via the Electronic Health Record to measure quality of EOL care for cancer patients. Before pilot implementation, baseline assessment of ACP documentation in deceased cancer pts was obtained utilizing the EOL database for a 3 month time frame (12/12-2/13) for 2 oncologists (GI and thoracic oncology). These rates are compared to ACP documentation for newly diagnosed incurable cancer patients in the outpatient clinic during the 3 month pilot occurring from 3/13-5/13. Results: During the pilot, 5/13 (38%) new thoracic oncology patients and 13/17 (76%) GI patients had outpatient ADNs. The average days to ADN placement from 1st visit, was 14 and 10 in thoracic and GI, respectively. GI oncology placed 6/13 ADNs on the 1st visit; 12/13 GI pts had ADNs placed less than 10 days from 1st visit. GI oncology also placed 10/17 outpatient CSOs of which 8/10 were less than 10 days from 1st visit. In the same thoracic oncologist’s deceased patients during the baseline period, 2/20 (10%) had outpatient ADNs compared to 7/20 who had inpatient ADNs; 2/20 thoracic patients had outpatient CSOs compared to 15/20 with inpatient CSOs. In two comparable practices which did not participate in the pilot from 3/13-5/13, 0/26 and 1/26 new patients had outpatient ADNs and CSOs, respectively. Conclusions: Outpatient ACP is feasible early in the care of cancer patients through systematic improvement in work flow and motivated providers. Future research will focus on whether ACP soon after a cancer diagnosis affects downstream metrics of quality and cost of care during EOL.