Delivering Patient-Centered Care in the Setting of Advanced Cancer: What Does a Clinical Risk-Prediction Model Have to Do With It?

In2013, the InstituteofMedicine (IOM)releasedaconsensusreport entitled “DeliveringHigh-QualityCancerCare: Charting a NewCourse for aSystem inCrisis,”1whichprovides ablueprint for improving the quality of cancer care in the United States. Inparticular, itscentral focus is theneedfordeliveringpatient-centeredcancercareand ensuring thatpatientshaveanopportunity to receiveeffective, high-value, and safe treatments that are consistent with their individual needs, values, and preferences.2 The IOM report’s goals and recommendations are hierarchical and move from thoseperceivedtobemostachievable—thosedirectlyassociated withthepatient-clinicianencounter—tothose thataremoredifficult toaccomplish,suchastheeliminationofdisparities incare andcomprehensivedelivery-systemreform, includingnewpaymentmodels.The first 2 recommendedgoalsof the IOMreport focusonthe importanceofengagedpatients.Goal 1emphasizes thecritical roleof thecancercare teaminprovidingpatientsand their familieswithunderstandable informationoncancerprognosis, treatmentbenefits andharms,palliative care, psychosocial support, andestimatesof the total andout-of-pocket costs of cancer care.Goal 2 stresses the importance, in the settingof advancedcancer,ofprovidingpatientswithend-of-lifecareconsistent with their needs, values, and preferences.1 Inthis issueofJAMAOncology,Brooksetal3describethedevelopment of a clinical predictionmodel to assess the risk for chemotherapy-relatedhospitalization(CRH) inpatientswithadvancedcancer initiatingpalliativechemotherapy.Themodelwas developedusingaretrospectivelydesignednestedcase-control studydrawingondata fromasingle communityhospital clinical registry. The authorsmake the case for the potential value of information regarding the risk for CRH in this patient population, noting that the ability of oncologists topredictCRHrisk with standard indicators (eg,performance status) ispoor.They propose that being able to identify the profile of patientsmost at risk for this clinically adverse eventmay “improve the chemotherapy informed-consent process, allow formodification of treatment regimens to reduce the risk of toxic effects, and identify patientswhomay benefit fromaggressive supportive carearoundthe timeof chemotherapy initiation.”3Theauthors acknowledge that therehasbeenconsiderable researchalready focused on development of strategies to assess the risks associatedwithchemotherapytoxiceffects;however, theyposit that therisksandburdensassociatedwithCRHmakeitamoremeaningful endpoint thana laboratoryvalue in the toxic range.That being said,whether ahospital admissionwas related to recent (within thepast 30days) administrationof chemotherapywas determinedbyadjudicationandconsensusof a teamofoncologycare clinicians, including representatives frommedical oncology, nursing, and pharmacy. The clinical registry used in this study was developed for quality-improvementpurposes,andtheauthorshadtoretrospectivelycollectdemographicandmedicaldatafromtheclinicalrecordsofcaseandcontrolpatients todeveloptheir riskmodel. Importantdatathatshouldhavebeenprovidedinthisreportinclude thenumberofmedical oncologists treatingpatientsduring the registryobservationperiodandtheirdistributionbetweencases andcontrols, thematchingof thecasesandcontrols in termsof year of treatment, and whether cases and controls received guideline-concordantsupport forwhitebloodcell (WBC)growth factorduring treatments.4A largepopulation-basedstudyconductedduringthissameperiodshowedbothunderuseandoveruseofWBCgrowth-factor support inpatients receivingchemotherapy for lung and colorectal cancer.5 Related article page 441 Opinion Editorial