bluuebunny/crossref_metadata_2025_split huggingface dataset:
Robotic radiosurgery for the treatment of one to three brain metastases: A pragmatic application of cost-benefit analysis using willingness to pay.
Authors: Greenspoon Jeffrey Noah , Sharieff Waseem , Whitton Anthony , Whelan Timothy Joseph , Wright Jim R. , Sussman Jonathan , Gafni Amiram 
Published: February 2017

17 Background: With the emergence of radiosurgery as a new radiotheraputic technique, health care decision makers are required to incorporate community need, cost and patient preferences when allocating radiosurgery resources. Conventional patient utility measures would not reflect short term preferences and would therefore not inform decision makers when allocating radiosurgery treatment units. The goal of this article is to demonstrate the feasibility of cost-benefit analysis to elicit the yearly net monetary benefit of robotic radiosurgery. Methods: To calculate the yearly incremental cost of robotic radiosurgery as compared to fixed-gantry radiosurgery we used direct local cost data. We assumed a standard 10 year replacement and 5% amortization rate. Decision boards summarizing the clinical scenario of brain metastases and the difference between robotic and fixed-gantry radiosurgery in terms of immobilization, comfort and treatment time were then presented to a sample of 18 participants. Participants who preferred robotic radiosurgery were randomly assigned to either a low ($1) or high ($5) starting point taxation based willingness-to-pay algorithm. Results: The yearly incremental cost of providing robotic radiosurgery was $99,177. The mean community yearly willingness-to pay for robotic radiosurgery was $2,300,000, p=0.03. The calculated yearly net societal benefit for robotic radiosurgery was $2,200,823. Among participants who preferred robotic radiosurgery there was no evidence of starting point bias, p=0.8. Conclusions: We have shown through this pilot study that it is feasible to perform cost-benefit analysis to evaluate new technologies in Radiation Oncology. Cost-benefit analysis offers an analytic method to evaluate local preferences and provide accountability when allocating limited healthcare resources.
Erlotinib and patterns of pharmacogenomic (PGx) testing.
Authors: De Souza Jonas A. , Gleason Patrick P. , Starner Catherine I. , Qiu Yang P. 
Published: February 2017

182 Background: Erlotinib is an oral oncology drug that costs approximately $5,000 per month. Both the NCCN Guidelines (since March 2011) and ASCO (since April 2011) recommend PGx testing for tumor epidermal growth factor receptor (EGFR) mutation in patients with advanced non-small cell lung cancer prior to erlotinib use in the first line setting. Insight into early utilization patterns of PGx testing is crucial as new reimbursement methods, care models and evidence-based clinical pathways are developed. Methods: Using integrated medical and pharmaceutical data from four Blue Cross Blue Shield plans, we retrospectively identified members who received erlotinib between 01/2011 and 06/2011 and identified the date of the first erlotinib claim (index date). A new erlotinib user was defined as having no erlotinib claims filed in the prior 180 days. Among members who received erlotinib, medical claims were queried for the presence of ICD-9 codes for malignant neoplasm of trachea, bronchus and lung and for any current procedure terminology (CPT) code indicating PGx testing and other chemotherapy in the prior 24-month period and 1-month post the index date. Total paid amounts from all PGx test codes were obtained. The closest PGx testing date to the index date was used to calculate days between PGx testing and index date. Further analyses examining lines of therapy, monthly patterns of erlotinib usage and PGx testing pre- and post-guidelines recommendations, as well as a description of differences in utilized PGx CPT codes per individual patient, were performed. Results: Among 3,357,936 members insured, 125 (40 per million) received erlotinib, and 102 (81.6%) of those patients had a lung cancer diagnosis. Sixty (48%) were new erlotinib users, and 47 had a diagnosis of lung cancer. Of these, 36 (76.5%) had a PGx CPT code claim. The time between the PGx test and erlotinib start ranged from 4 days to 22 months. A total of $30,391 was spent on all PGx testing with an average of $844 per member tested. Conclusions: In a privately insured cohort of members who newly initiated erlotinib for lung cancer, 23.5% had no prior PGx testing. There is an opportunity for consensus guidelines, care management programs and a single PGx CPT code to possibly reduce variation regarding PGx testing patterns.
Reducing unnecessary testing on admission in autologous stem cell transplant (SCT) patients.
Authors: Glotzbecker Brett , Yolin-Raley Deborah , Close Sara , Soiffer Robert , Antin Joseph H. , Jacobson Joseph O. , Alyea Edwin 
Published: February 2017

185 Background: Health care institutions are identifying strategies to reduce unnecessary testing, employ better utilization of resources, and decrease risk. At Dana-Farber Cancer Institute (DFCI), patients admitted for autologous SCT have standard testing, including CXR, completed within 42 days of hospital admission. Despite previous work-up, routine CXR is often ordered on admission. We questioned if this repeat CXR was clinically necessary. A retrospective review from 2010 showed that 69 of 130 (53%) asymptomatic SCT patients had CXR obtained on the day of admission. Two patients had findings of possible atelectasis vs. infiltrate on admission CXR. No further work up or antibiotics were initiated. After count recovery, one of the two patients had a chest CT for evaluation of fevers, showing only atelectasis. Based on these results, we aimed to reduce admission CXR without clinical indication to less than 5% by July 1, 2012. Methods: A multidisciplinary group was formed to map existing processes leading to admission CXR. Areas where previous standard testing were not readily available and areas of redundancy were identified. Changes to the EMR allowing easier access to pre-transplant results were made and a written and oral education program for PAs and nocturnists was created. Study Population: All elective patients admitted to the bone marrow transplant PA service (BMT-PA) for autologous SCT for multiple myeloma or lymphoma between 11/1/11-5/30/12. Results: The intervention (changing the EMR and establishing an education program) resulted in a reduction of admission CXR in asymptomatic patients from 53.3% to 5.5% (target 5.0%). During the study period, 144 patients were admitted to the BMT-PA service. Of those, 8 had CXR without indication. All CXR were ordered by Nocturnists, two prior to the intervention and six in the last four weeks of the observation period. Conclusions: The reduction of unnecessary CXR in asymptomatic SCT patients has had a considerable reduction in overall costs, nearly $58,000 to date, as well as reduced delays in initiating chemotherapy, radiation exposure, overall resource utilization, and patient inconvenience. Through this simple intervention, this reduction was easily obtained.
Evaluation of process control in radiation oncology treatment planning.
Authors: Wagner Henry , Singer Maria , Knipple Jamie , Aurand Amy , Repella Paulette , Ferenci Michele 
Published: February 2017

186 Background: ROTP extends from simulation (SIM) through the start of treatment and constitutes a sequence of processes. Accurate implementation of each of these is essential for proper treatment. Prior guidelines had been proposed in our department for conformal treatment and intensity modulated radiation therapy (IMRT) or Volumetric Modulated Arc Therapy (VMAT); these were often not met leading to dissatisfaction by staff and patients. To improve this we evaluated the current steps in ROTP in an effort to improve our process. Methods: We analyzed the records of 157 eligible patients who underwent CT simulation from 1/1/12 through 3/30/12, excluding patients treated for benign disease, brachytherapy, or patients who never started treatment. The departmental standard was for urgent cases to start within 4 days (d), non-IMRT cases to start in 5d and IMRT/VMAT/SBRT cases to start in 10d. We defined three intervals, from SIM to start of treatment, SIM to approval of the plan by the physician, and approval to treatment start. Results: The median interval between planning landmarks in work-days and the % exceeding planning standards plus 2 days are shown below. Almost half of cases exceeded departmental standards for timeliness of ROTP. Much of the variability occurred after the physician had approved the plan. Conclusions: To improve timeliness of ROTP we have introduced changes in our planning process: 1. Strict definition of urgent cases. 2. Assigning a start date at the time of simulation. 3. Case planning review by the Radiation Oncologist, dosimetrist (+/- Physicist) at SIM. 4. Daily review of task list by Chief of Physics and Department Chair. These changes have been implemented in our department and results of the first two months of their use will be presented. [Table: see text]
Categorization of measures of quality in radiation treatment.
Authors: Cao Jeffrey Quoc , Donaldson Holly , French John , Gillan Caitlin , Milosevic Michael , Lam Catarina , Dunscombe Peter 
Published: February 2017

187 Background: The Canadian Partnership for Quality Radiotherapy (CPQR) has revised an outdated version of quality assurance (QA) guidelines for use in Canadian radiation treatment (RT) centres. This updated document contains concise, specific quality statements against which program structure and performance can be evaluated. Our objective was to review available international guidelines for quality in RT, categorize them according to a defined taxonomy, and inform a modified Delphi process for further evaluation of the guidelines. Methods: We identified 8 relevant standards documents issued by jurisdictions internationally. Taken together, 454 statements, or groups of statements, describing measures of quality were identified. These disparate quality statements were consolidated into a limited number of manageable groups using an appropriate classification scheme. A decision tree with two major categories was developed. Category 1 was based on the classification proposed by Donabedian as to whether the statement addressed a structure, process, outcome, or other. Category 2 addressed whether the statement referred to activities directed towards the organization, patients, staff, equipment/clinical processes, or other. Five reviewers assigned each of the 454 statements independently to one of these 20 (4 x 5) category decision tree endpoints. Results: A free marginal kappa analysis of agreement between the 5 reviewers in all 20 endpoints yielded a value of 0.38 which is fair agreement. Restricting analysis to Category 1, there is better agreement with a kappa of 0.54. Alternatively, 3 or more of the 5 reviewers agreed on their assignments 93% of the time for Category 1 and 76% for Categories 1 and 2. There were 290 statements with less than 100% agreement in Category 1 extracted for a second mapping using additional descriptive qualifiers. Subsequently, the overall free-marginal kappa increased to 0.71, considered substantial agreement. Conclusions: Kappa values varied among the 8 documents reviewed, possibly indicating differences in clarity of the descriptions. The 454 standards identified have been categorized and provide a manageable input to our ongoing effort to maintain appropriate, up-to-date Canadian quality guidelines for RT.
Primary care providers’ evaluation of survivorship care plans.
Authors: Mayer Deborah , Dittus Kim , Dulko Dorothy , Pace Clare , Sprague Brian , Gerstel Adrian , Davies Janine M. , Geller Berta , Hawkins Nikki 
Published: February 2017

188 Background: Survivorship care represents a distinct phase of the cancer care and addresses surveillance, the physical and psychosocial sequelae of the cancer and treatment, and health promotion. Survivorship care plans (SCP) were recommended in the 2005 IOM From Cancer Patient to Cancer Survivor as a tool to address these issues and will be required by the Commission on Cancer in 2015. As part of two studies implementing SCP using the JourneyForward (JF-SCP) template, we evaluated primary care providers (PCP) perspective on their use. Methods: JF-SCP were developed and delivered to patients and PCP at the end of treatment. We collected information about usability, comprehension, barriers to use, and respondent demographics. Results: Of the 61 PCP who responded: 86% were physicians, 60% were women, had an average of 20 years in practice. PCP strongly agreed/agreed that SCP were easy to understand (95.7%), the right length (73.9%), addressed the right topics (95.7%), would be useful in talking with patients about survivorship plans (91.3%), would improve communication with oncologists (74.4%) and with patients (74.4%). Significant barriers interfering with the PCP providing follow-up care included: limited access to survivors as they stay with oncologists (59.5%), insufficient knowledge of issues (53.4%), inadequate recommendations from the oncologist (43.9%), lack of survivor care guidelines (42%), lack of time (38%), and poor reimbursement (16.6%). Specific suggestions about the JF-SCP included making it shorter and being clear about which provider was responsible for obtaining recommended testing. PCP commented on the importance of ongoing primary care provided throughout the cancer continuum. Conclusions: PCP reported ease of SCP use but did identify areas for improvement. Many PCP were frequently not included or did not stay involved with the cancer patient when being seen by oncologists. The SCP was viewed as a tool to facilitate communication with oncologists and patients.
Investigation of gastrointestinal stromal tumor (GIST) care management in GIST patients (pts) receiving short-term versus long-term imatinib (IM) adjuvant therapy: A chart review analysis.
Authors: Conley Anthony Paul , Guérin Annie , Sasane Medha , Gauthier Geneviève , Schwiep Frances , Keir Christopher Hunt , Wu Eric Q. 
Published: February 2017

195 Background: Although optimal duration of adjuvant IM therapy in Kit+ GIST pts is unknown, the NCCN guidelines recommend treatment for ≥36 months in high-risk pts based on clinical trials showing reduced risk of recurrence and mortality in pts receiving long-term adjuvant IM. The objective of this study was to investigate clinicians’ recurrence risk assessment and GIST management in patients receiving adjuvant IM for short- (6-12 months) vs. long-term (≥24 months) in community practice. Methods: GIST-related and treatment characteristic information on adult pts with primary resectable Kit+ GIST initiating IM ≤84 days after surgery (short-term: 411 pts; long-term: 408 pts) was collected from 320 U.S. oncologists using an online data collection form. In addition, physician prescribing patterns and perception of risk assessment and IM duration were collected. Results: Indicators of risk (tumor size, mitotic count, and tumor location) were significantly associated with IM treatment duration. Tumor rupture status did not impact IM duration, except when unknown, in which case pts had longer IM duration. About 50% of pts had not been tested for Kit mutation; 31% of physicians reported that it would not have changed therapy/management or were not aware of how results should have impacted GIST management. Among short-term pts for whom physicians reported a reason for IM discontinuation, main reasons included non-severe adverse events, completion of the 1-year treatment scheduled, economic constraint/health plan coverage change, and pts’ preference. Overall, 77.8% of surveyed physicians reported that pt risk profile drove their decision of continuing IM over an extended period of time. However, in practice 39.9% of the short-term pts and 48.8% of the long-term pts had a high risk profile as assessed by Fletcher classification; suggesting a lack of consistency between treatment related opinions and practice. Conclusions: These observed discrepancies highlight the need for standardization of risk assessment practices and education among community oncologists and pts.
Impact of a multidisciplinary cancer care program and nurse navigation on pancreatic adenocarcinoma treatment.
Authors: McCahill Laurence E. , May Mary , Martinez Coralyn , Taylor Wendy K. , Davis Alan T. 
Published: February 2017

200 Background: Treatment of pancreatic adenocarcinoma (PanCa) is complex and requires input from multiple physicians. We developed a unique gastrointestinal (GI) cancer program utilizing a multidisciplinary conference, a multidisciplinary clinic (MDC), a GI nurse navigator (NN) and continuous quality assessment with a nurse clinical auditor. The impact of this program, which requires significant additional resources, on adherence to evidence based cancer treatment for newly diagnosed PanCa patients is unknown. Methods: The GI (NN) interviews patients, coordinates staging and biopsies, physician visits and subsequent adjuvant care in the first year of diagnosis. A clinical quality specialist abstracted all treatment received (surgical, radiation, chemotherapy, palliative), and data was entered into a GI Quality database. Treatment received by patients in first year of diagnosis was compared to NCCN guidelines. Results: From January 2010 to April 2012, 68 patients with newly diagnosed PanCA were evaluated/treated. Overall compliance with NCCN treatment guidelines was 83.4%. Compliance was highest for stage I (almost all underwent surgical resection) and stage IV (none underwent surgery). Utilization of adjuvant therapies was 80% (16/20) for patients with stageI/II disease. Eight patients with stage I/II disease did not undergo surgery, due to comorbidities or disease progression. Conclusions: A novel GI cancer program utilizing a multispecialty MDC and a dedicated GI NN demonstrates very high compliance with evidence based therapy for first line treatment for PanCa patients. Although resource intensive, this level of adherence to evidence-based medicine is encouraging and higher than prior reports for PanCa. The relative contribution of the GI MDC clinic format versus the NN warrants further study. [Table: see text]
Adherence to head and neck cancer guidelines: Multidisciplinary conference recommendations and care delivered.
Authors: Nurgalieva Zhannat , Weber Randal S. , Lai Stephen Yenzen , Sturgis Erich M. , Beadle Beth Michelle , William William , Lewis Carol M. 
Published: February 2017

202 Background: Adherence to clinical guidelines, such as those developed by the National Comprehensive Cancer Network (NCCN), can serve as a quality measure for delivered care. We aimed to determine NCCN guideline compliance of and concordance between multidisciplinary conference (MC) treatment recommendations and treatment received. Methods: A retrospective review of 71 consecutive previously untreated patients from 1/1 to 4/1/2006 evaluated whether MC recommendations were compliant with 2006 NCCN treatment guidelines, what treatment was actually provided, and whether this treatment was congruent with MC recommendations and/or adhered to 2006 NCCN guidelines. Results: TNM staging was documented in 94.4% of MC notes and treatment recommendations were documented for 98.6% of patients. Of enrolled patients, 53% had oropharyngeal cancer, 22.7% had oral cavity cancer, 18.2% had laryngeal cancer, and 6.1% had nasopharyngeal cancer. The mean age at presentation was 57.4 years. Forty-eight patients (72.7%) were men. MC recommendations were not compliant with NCCN guidelines in 7 (10.6%) patients. Reasons for non-compliance were recommended definitive radiation alone for T1/2N2 oropharyngeal cancer (3 patients), recommended over-use of induction chemotherapy (2 patients) or adjuvant therapy (1 patient), and incomplete documentation (1 patient). Actual treatment deviated from MC recommendations in 25 (38.5%) patients, although in 14 of these patients, treatment remained guideline-adherent. Actual treatment was not compliant with guidelines in 9 patients; 4 of these patients had treatment congruent with MC recommendations, which were not NCCN guideline-compliant. Reasons for guideline-discordance in the remaining patients were individual. Conclusions: Discordance with NCCN guidelines for head and neck cancer treatment planning and delivery was observed in this cohort; while some deviations were due to incomplete documentation, areas for improvement were identified. Further study is warranted to determine whether treatment deviating from NCCN guidelines impacts patient outcome.
The negative impact of prior reprimand on radiation therapists’ and dosimetrists’ comfort in reporting errors: Results from a national survey of more than 500 respondents.
Authors: Church Jessica A. , Adams Robert D. , Hendrix Laura H. , Holmes Jordan A. , Marks Lawrence B. , Chen Ronald C. 
Published: February 2017

204 Background: The presence of a "just culture" is often noted to be critical in optimizing safety, since workers need to feel comfortable reporting errors. We performed a national survey of radiation therapists and medical dosimetrists to assess their comfort in reporting errors. We herein quantify the impact of workers’ perceptions of their workplace culture (based on prior experiences in reporting errors) on their comfort in reporting safety concerns. Methods: In 2011, a survey was mailed to 1,500 therapists and 528 dosimetrists assessing their comfort in reporting errors. The metric used to assess their perceptions of their workplace culture was if they had, or knew of staff who had been, reprimanded in the past for reporting errors. Comfort in reporting new errors among workers who have (vs. have not) experienced prior reprimand were compared using Fisher’s exact test. Results: Overall, 356 therapists from 47 states (24% response rate) and 190 dosimetrists from 35 States (36% response rate) responded to the survey. 16% of therapists and 5% of dosimetrists reported that they have been personally reprimanded for reporting an error. The proportion of workers comfortable reporting errors was lower among those with prior personal reprimand vs. those without such reprimand (47% vs. 90%, p<.0001). Similarly, 29% of therapists and 8% of dosimetrists reported that other staff members have been reprimanded for reporting, and these reprimands had a similar deterrent effect on reporting errors. On multivariate analysis, previous personal reprimand for reporting errors (OR 4.13, p=.001) and reprimand of other therapists/dosimetrists (OR 2.55, p=.03) were significantly associated with discomfort in error reporting. Conclusions: A sizable proportion of respondents in our study has been personally reprimanded or knows of staff in their facility reprimanded for reporting errors. Prior reprimand has a dramatic detrimental impact on workers’ comfort to report future concerns regarding safety. A potential opportunity for future improvement in radiation oncology treatment facilities is to encourage a culture that allows error reporting without fear of reprimand.