bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cancer therapy and heart failure: Successful management through collaborative interdisciplinary practice.
Authors: Fadol Anecita P. , Durand Jean-Bernard , Summers Barbara L. , Woods Myrshia L. , Lewis Katie , Johnston Patty , Tomczak Nancy , Estrella Joylynn Mae , Kidin Lisa M. , Browning Douglas 
Published: February 2017

123 Background: Heart failure (HF) is a clinical problem of emerging importance in cancer care. The advances in cancer detection and complex treatment regimens have resulted in increased cancer treatment induced HF. The literature indicates that more than 50% of all patients exposed to anthracyclines will show some degree of cardiac dysfunction either acutely or 10 to 20 years after treatment, and 5% of those patients will develop overt HF. Successful management requires a collaborative, interdisciplinary approach. The purpose of this presentation is to discuss how the “Heart Success Program” (HSP) resulted in cost effective and clinical quality outcomes in patients with cancer and HF. Methods: The HSP was piloted in the emergency center and telemetry units with high volume admission of HF patients. The HSP includes comprehensive education of patients, families, and health care providers regarding HF management in cancer patients. HSP implementation includes a HF order set, patient education booklet, and educational videotape specific for patients with cancer and HF. Weekly interdisciplinary clinical rounds provide a forum for discussion of identified patient’s problems and formulation of solutions. Endpoint outcomes include compliance with the Center for Medicare and Medicaid Services (CMS) core measures for HF, as well as decreasing HF readmissions. Results: The pilot implementation of the HSP resulted in decreased hospital length of stay by 57%, and average hospital admission cost by 60%. Despite multiple co morbid conditions, patients were discharged with improved functional status and compliance with CMS HF core measures. Conclusions: The findings from this quality improvement project showed significant impact in clinical and cost outcomes for patients with cancer and HF. The multidisciplinary team approach that provided support to patients and their families and allowed for patients to continue their cancer treatment resulting in improved outcomes. As we move toward value-based purchasing, the HSP provides an example of how collaboration and standardized process improvement impacts cost and quality in the oncology population.
Oncology quality improvement as a cornerstone of the transition to accountable care.
Authors: Ruckdeschel John C. , Sause William T. , Belnap Tom , Jones Cory , Rowley Braden D. 
Published: February 2017

141 Background: Accountable care is defined as moving the incentives for health care from a system that rewards volume and procedures to one that rewards improvements in the quality of care for a defined population. To prevent this process from deteriorating into solely a cost reduction exercise, physicians, and hospitals need to develop a valid, reproducible, and effective means of measuring quality and impacting behavior to reduce variation and improve quality of care. The Intermountain Healthcare Oncology Clinical Program’s (OCP) experience with Oncology Quality Improvement (OQI) offers several key lessons for enabling this process. Methods: OQI initiatives are developed by a multidisciplinary physician-based team tasked with directing standardization and ensuring optimal care delivery. The team uses clinical knowledge, peer-reviewed literature, and data from an enterprise data warehouse to develop goals. Performance is measured against a goal which focuses on variation between physicians and facilities. Individual physician data is compared to de-identified data of peers, facilities, and the system. A physician champion performs academic detailing for physician groups across the system and is critical to the success of the program. Results: Over the past decade, the OCP initiated over 30 projects designed to measure and improve quality of oncology care delivery. Breast cancer projects included breast conservation in surgical management, reducing axillary dissection for ductal carcinoma in situ and sentinel node biopsy rather than axillary dissection. The OCP also explored standardizing lymph node resection during colorectal cancer surgery and subsequently the utilization of adjuvant chemotherapy. Imaging based goals included improving mammography callback rates and using PET/CT during preoperative assessment of lung cancer. In most instances the process resulted in significant, sustainable OQI. Conclusions: The investment in program and clinician staff is significant, and the requirements and costs for a sophisticated data system are real. However, an OQI program can provide meaningful improvements in the quality of cancer care and is an important step to facilitate the transition to accountable care.
Improving quality of early breast cancer care with a predictive test for taxane response.
Authors: Bodnar Carolyn , Brown Ruth , Knopf Kevin B. 
Published: February 2017

146 Background: Patients (pts) with high-risk early breast cancer (BC) frequently have adjuvant taxane (TAX) treatment, but only 22% experience benefits in disease-free survival and many experience toxicities which impact quality of life (QoL) and increase costs. Research is underway to develop biomarkers which predict TAX response and hence identify pts who will benefit from the regimen and pts who will not, avoiding futile treatment and associated toxicities. Methods: A predictive economic model estimated the potential avoided toxicities and related costs of testing 100 BC pts with a biomarker to guide therapy selection compared to no pretesting. The no biomarker test group all received AC-T (AC-T) (doxorubicin 60mg/m2, cyclophosphamide 600mg/m2, followed by weekly paclitaxel 80mg/m2) for 12 weeks ($572). The model included rates and costs of 3 associated side effects (average $2024/patient): neutropenia (14%), thrombocytopenia (1%), and peripheral neuropathy (1%). In comparison, all pts were biomarker tested ($950) pre-treatment initiation and only those with biomarker overexpression were treated with AC-T versus AC, accruing the appropriate related costs plus the biomarker test cost. The model assumed the biomarker test was 70% to 90% predictive of expression. Results: The model found the biomarker group identified 55 to 70 non-expressing pts who would likely not have an increased benefit from the addition of TAX. For this group, 55% to 70% of the 3 AE toxicities and the associated impacts on QoL would be avoided producing $110,505 to $142,078 cost offsets. Between $25,792 and $60,304 of treatment expenditures could be avoided and better used. Budget neutrality occurred when neutropenia rates were reduced to 7%. The biomarker group identified 30–45 expressing pts who likely would benefit from AC-T. Conclusions: Applying a biomarker test to identify BC pts likely to respond to TAX may improve quality of care, particularly for non-expressers who could avoid QoL decrements of futile therapy and instead be managed with a less toxic and more beneficial therapy. Further development of such a biomarker should assess all pt impacts and healthcare system costs for both biomarker-identified expressers and non-expressers.
Systematic improvement of SBRT dose gradients.
Authors: Gagnon Patrick James , Weintraub Sheri , Scott Amanda , Schofield Deborah , Kumar Tushar , Mulvey Therese M. 
Published: February 2017

154 Background: Stereotactic body radiation therapy (SBRT) offers excellent local control for early stage lung cancer. SBRT utilizes high fractional doses of radiation in 5 or fewer treatments. Normal tissue risk is substantial necessitating steep dose gradients and conformal plans. The Radiation Therapy Oncology Group (RTOG) has established quality metrics for conformality and dose gradients for SBRT. The conformality ratio is the prescription isodose volume to the planning target volume (PTV). Dose falloff is represented by the ratio of the 50% prescription isodose volume to PTV volume (R50%). We evaluated our approach and identified a systematic method to improve our SBRT plans in a community cancer center setting. Methods: 26 lung nodules were treated with SBRT over 30 months at our institution. RTOG 0915 benchmarks were evaluated. Conformality ratios were excellent in all cases. Dose falloff was measured by the R50% and the 7 cases with the largest R50% were re-planned systematically. The technique included creation of a customized ring structure: PTV volume was multiplied by the maximum allowable ratio to establish an ideal 50% isodose volume and a 2 cm ring structure was created around this: the 50 IDV Ring. Intensity modulated radiation therapy (IMRT) optimization specified a max dose to the 50 IDV Ring of 50% of the prescription. Beam geometry and IMRT objectives were held constant from the initial plan. Results: Conformality ratios were maintained and were excellent in all cases. The 50 IDV Ring resulted in R50% improvements in 5 of 7 cases, 4 of which had at least a 15% improvement (15%, 20.6%, 19.2%, and 20.4%) and 1 of which had a 3.3% improvement. Two cases resulted in 1.8% and 0.5% increases in the ratio representing a small deterioration in dose falloff. Conclusions: A strategically designed ring structure can have an impact on dose falloff around a target volume resulting in improvements in dose gradients for SBRT plans. Whether this benchmark is clinically significant is uncertain but it does provide a useful metric for comparison and quality assurance of SBRT plans. A systematic approach to SBRT planning may help provide the highest possible therapeutic ratio in the setting of optimal beam geometry.
Toward proven and prioritized quality measures: Which ASCO QOPI and other supportive care measures associate with improved quality of life (QOL)?
Authors: Kamal Arif , Bull Janet , Abernethy Amy Pickar 
Published: February 2017

165 Background: An expanding array of quality measures, including the Quality Oncology Practice Initiative (QOPI) metrics, is being developed for oncology. To date, evidence demonstrating the impact of each metric on outcomes, ultimately aiding in prioritization of individual measures, remains immature. We investigated the relationship between conformance with quality measures and higher patient QOL among cancer patients receiving palliative care. Methods: A comprehensive systematic review of PUBMED and the gray literature (1995-2012) identifed all described supportive care quality measures. Patients receiving palliative care in 4 community-based programs were entered into a longitudinal quality registry; analyses focused on cancer patients registered between 6/08-10/11. To find predictors of higher QOL, conformance cohorts were examined for demographic variables, performance status (measured by palliative performance scale, PPS) and provider estimation of prognosis and included in univariate and multivariate regression. Results: The systematic review yielded 303 quality measures. Of these, 18 measures, representing components of the ASCO QOPI, Hospice PEACE, and Cancer-ASSIST measure sets, were evaluable using registry data. 460 cancer patients were included. 60% of patients had weeks to 6 months expected prognosis. Among QOPI measures, conformance with two measures was significantly associated with better QOL: constipation assessment at time of narcotic prescription and emotional well-being assessment (both p<0.05). Other significant findings were conformance with screening of symptoms at first visit (p=0.017), timely treatment for uncontrolled dyspnea (p=0.005), and assessment of fatigue (p=0.007). In a multivariate model predicting higher QOL, measures involving emotional well-being assessment (OR 1.60; p=0.026) and screening of symptoms (OR 1.74, p=0.008) remained significant. Conclusions: Clinical care that conforms to quality measures reflecting regular symptom and emotional assessment is significantly associated with better patient experiences (QOL) and should be prioritized in quality assessment efforts.
Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting (CINV) in U.S. community oncology practice: INSPIRE study.
Authors: Gilmore James W. , Peacock Nancy Walker , Gu Anna , Szabo Stephen , Rammage Melissa , Sharpe Joyce , Haislip Sally , Perry Toni S. , Boozan Tim Lee , Meador Katherine , Cao Xiting , Burke Thomas A. 
Published: February 2017

167 Background: Electronic Health Records (EHRs) are a valuable source to evaluate the quality of oncology care, particularly when combined with patient outcomes data. Our objective was to evaluate the impact of guideline consistent/inconsistent chemotherapy prophylaxis (GCCP, GICP) on the incidence of no CINV after cycle 1 of highly or moderately emetogenic chemotherapy (HEC or MEC). Methods: INSPIRE (Impact of NCCN Antiemesis Guideline Usage on Patient Reported Emesis) was a prospective observational, multicenter study that enrolled chemotherapy-naive adults initiating single-day HEC or MEC. Results from the MASCC Antiemesis Tool, administered 5 to 8 days after HEC/MEC, were merged with EHR data. The primary endpoint, no CINV (no emesis and no clinically significant nausea), was compared between groups using logistic regression. Results: 1,295 patients (mean age=59.3, 30.0% male, 35.5% HEC) were enrolled from Georgia Cancer Specialists (53.0%), Tennessee Oncology (38.1%), Florida Cancer Specialists (5.7%), and Cancer Specialists of N. Florida (3.2%). The prevalence of GCCP was 57.3% (28.7% HEC; 73.1% MEC). If corticosteroids were prescribed to all HEC patients on days 2-4, GCCP for HEC would increase from 28.7% to 89.8%. If NK1-receptor antagonists (NK1-RA) were prescribed to all MEC patients, GCCP for MEC would increase from 73.1% to 97.8%. GCCP and GICP-treated patients differed by age, (p=0.010), HEC/MEC (p<0.0001), primary cancer site (p<0.0001), practice site (p<0.0001). The percent with no CINV, no emesis, and no clinically significant nausea was significantly higher for GCCP patients. Conclusions: Increased GCCP could significantly reduce CINV after HEC or MEC. The main reasons for guideline inconsisteny were lack of corticosteroids in the delayed phase for HEC and lack of NK1-RA for MEC. There remains room for improvement in nausea control. [Table: see text]
Guideline-concordant surveillance and follow-up care among low-income patients with breast cancer: The role of primary care medical homes.
Authors: Wheeler Stephanie B. , Kohler Racquel Elizabeth , Goyal Ravi K. , Lich Kristen Hassmiller , Moore Alexis , Smith Timothy , Melvin Cathy , Reeder-Hayes Katherine Elizabeth , Domino Marisa E. 
Published: February 2017

171 Background: Community Care of North Carolina (CCNC) initiated an innovative medical home (MH) program in the 1990s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes, but has not been evaluated in the context of cancer care. We sought to determine whether MH enrollment was associated with guideline-concordant surveillance and follow-up care among breast cancer survivors. Methods: Using state cancer registry records matched to Medicaid claims, we identified women ages 18-64 diagnosed with stage 0, I, or II breast cancer from 2003-2007 and tracked their CCNC enrollment. Using published American Society for Clinical Oncology breast cancer survivorship guidelines to define our outcomes, we employed multivariate logistic regressions to examine correlates of receipt of surveillance mammogram and at least two physical exams within 15 months post-diagnosis. Results: In total, 840 women were included in our sample. Approximately half were enrolled in a CCNC MH during the study period, 38% were enrolled for more than 7 months post-diagnosis. Enrollment in a MH for at least 7 months post-diagnosis was strongly associated with receiving guideline-recommended surveillance mammogram (p<0.01) and at least 2 physical exams (p<0.01) within 15 months post-diagnosis. Conclusions: Results suggest that MH enrollment is associated with higher quality breast cancer survivorship care among women insured by Medicaid. Given the growing population of cancer survivors and increased emphasis on primary care MH, more research is needed to explore how medical homes can enhance and ensure the provision of guideline-recommended care during cancer survivorship.
Socioeconomic and clinical factors associated with delayed initiation of adjuvant chemotherapy for stage III colon cancer.
Authors: Haynes Alex Bernard , Chiang Y. Sabrina , Boland Genevieve Marie , Xing Yan , Massarweh Nader N. , Chang George J. , You Y. Nancy , Feig Barry W. , Cormier Janice N. 
Published: February 2017

173 Background: We have previously described an association between a greater than 8-week interval to initiation of adjuvant chemotherapy after resection of stage III adenocarcinoma of the colon and an approximately 20% increased risk of mortality. We sought to understand the factors that lead to delay in chemotherapy initiation. Methods: Patients who received adjuvant chemotherapy after resection of stage III colon cancer between 2003 and 2007 were identified from the National Cancer Data Base. Delayed chemotherapy was defined as the first date of chemotherapy administration being eight weeks or more after surgical resection. Comorbidity was categorized using the Charlson/Deyo index. Prolonged length of stay and unplanned readmission were used as surrogates for surgical complications. Multivariate logistic regression was performed to examine the associations between various clinical and socioeconomic variables and delay in the receipt of adjuvant chemotherapy. Results: 33,011 stage III colon cancer patients who received chemotherapy after surgery were identified. 8,036 (24.3%) initiated chemotherapy more than eight weeks after surgical resection. Unplanned readmission (OR 1.76, 95% CI 1.58-1.95), prolonged postoperative stay (OR 1.56, 95% CI 1.48-1.65), and comorbidity (OR 1.18, 95% CI 1.12-1.25) were all independent predictors of delay. Nonclinical factors, including African-American race (OR 1.34, 95% CI 1.24-1.45), lack of insurance (OR 1.63, 95% CI 1.43-1.87), and residence more than 100 miles from treating center (OR 1.23, 95% CI 1.01-1.51) were also independently associated with delayed chemotherapy. Conclusions: Delay in the initiation of adjuvant therapy for colon cancer beyond 8 weeks has previously been found to be an independent predictor of increased mortality. While some delays may result from patient frailty or postoperative complications, these data suggest that nonclinical factors may also contribute to delays. Increased focus on overcoming barriers to coordinated care should be prioritized to ensure that those patients who may benefit from adjuvant therapy receive it in a timely fashion to optimize survival advantages.
Effect of national recommendations on hepatitis B virus screening in a large U.S. cancer center.
Authors: Hwang Jessica , Fisch Michael , Lok Anna , Zhang Hong , Vierling John , Suarez-Almazor Maria 
Published: February 2017

175 Background: National organizations recommend screening for hepatitis B virus (HBV) before chemotherapy but differ regarding which patients should be screened. We aimed to determine changes in screening rates at a cancer center after national recommendations were published between 2008 and 2010. Methods: We conducted a retrospective cohort study of HBV screening in cancer patients registered 1/2004 through 4/2011. Screening was defined as HBsAg and anti-HBc tests ordered around initial chemotherapy. We compared screening rates for 3 periods: before publication recommendations, during the period of publication of CDC, NCCN, AASLD, IOM, and ASCO recommendations, and after publication of recommendations. Logistic regression models were used to identify predictors of screening. Results: Of 139,981 new patients, 18,688 received chemotherapy, and 3,020 (16.2%) were screened. HBV screening rates increased over the 3 periods (14.8%, 18.2%, 19.9%; p<0.0001), but <19% of patients with HBV risk factors were screened. Among patients with hematologic malignancies, over 66% were screened during the entire study period, and odds of screening nearly doubled after publication of recommendations (p<0.0001). Less than 4% of patients with solid tumors were screened during the entire study period despite 70% increase in odds of screening after recommendations (p=0.003). Other predictors of screening included younger age, planned rituximab therapy, and known risk factors for HBV infection. Conclusions: HBV screening increased after publication of national recommendations, yet most patients with solid tumors or HBV risk factors remained unscreened. Efforts are needed to increase awareness of the importance of HBV screening prior to chemotherapy and antiviral prophylaxis to prevent HBV reactivation.
The effect of gaps in chemotherapy on survival in patients with high-risk stage II and stage III colon cancer.
Authors: Sada Yvonne , Duan Zhigang , El-Serag Hashem , Davila Jessica 
Published: February 2017

180 Background: Current guidelines recommend six months of chemotherapy (CT) for stage III colon cancer and consideration for high-risk stage II colon cancer. No previous studies have examined the impact of CT gaps on survival. This retrospective study examines determinants of CT gaps and the effect of gaps on survival. Methods: Using national Surveillance, Epidemiology, and End Results registry-Medicare linked data, high-risk stage II and stage III colon cancer patients diagnosed between 2000-2007 who received surgery and CT were identified. CT duration and gaps were calculated. CT gap was defined as 30 to 90 days between two CT claims. Data on demographics, clinical factors (comorbidity, tumor grade), and treatment factors (time to CT initiation, toxicity, hospitalization) were collected. Multivariable regression was used to examine factors associated with gaps. Cox proportional hazards analysis examined the effect of gaps on risk of mortality. Results: 7,371 patients were identified. Median age was 75 (IQR: 71-79); 47% were male. Among all patients, 1,803 (24%) had a gap. 2,674 patients (36%) received 5 to 7 months of CT, of which 469 (18%) had a gap. Multivariable regression analysis showed that patients who were black (OR 1.3, 95% CI: 1.1-1.7), stage III (1.2, 1.0-1.3), had toxicity (1.3, 1.1-1.4), or had 3 to 4 months of CT (vs. 5-7 months, 2.6, 2.3-3.0) were more likely to have a gap, while patients with a more recent diagnosis in 2007(vs. 2000, 0.6, 0.5-0.8) were less likely to have a gap. 3-year cancer-specific survival was the same in all patients with CT gaps compared with no gaps (80%, 95% CI: 78%-82% vs. 81%, 95% CI: 80%-82%). Cox proportional hazard models showed that patients with gaps did not have increased risk of mortality (HR 0.99, 0.89-1.1) adjusting for patient and clinical factors. Among those who received 5 to 7 months of CT, 3-year survival was 8% lower in patients with gaps compared to those with no gaps (80%, 95% CI: 75%-83% vs. 88%, 95% CI: 87%-90%). Conclusions: Nearly 25% of high-risk stage II and III patients who received CT had a gap. CT gaps were associated with worse survival in patients who received 5 to 7 months of CT. Interventions to improve CT toxicity management and reduce gaps are needed to maximize the benefit of CT.