bluuebunny/crossref_metadata_2025_split 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.